For the first time in history, today’s nursing workforce is composed of nurses from four different generational groups.  It can be challenging for nurse leaders to guide their teams to get past their conflicts and communication issues to work together in harmony.   If you are an emerging leader, it is likely that you are either from Generation X or Generation Y.  You may find yourself supervising nurses from a generational group that is different from your own.  As a nurse leader, you will play a key role in setting the tone and culture of the units or departments that you lead.  The journey of building a culture of inclusion and respect begins with insight into your own generational beliefs and biases.  The research that has been done with generational groups indicates that generational cohorts share birth years and a collective life experience that helps to shape their values, work ethics, attitudes toward authority and professional aspirations.  Generational profiles should not be considered infallible but they help to explain the life experiences of a generation that help to shape their personal core values.

The Veterans  (born 1925-1945)

Many nurses in the veteran generational cohort have already retired but some continue to work in both staff and leadership positions. The Veterans grew up in difficult times with life experiences that included World War II and the Great Depression.
The economic and political uncertainty that they experienced has led them to be hard working, financially conservative, and cautious.  Veterans value the lessons of history. When facing new challenges, they look to the past for insight into what has worked and what hasn’t. Organizational loyalty is important to this generation, and they feel seniority is important to advance in one’s career. They tend to be respectful of authority, supportive of hierarchy, and disciplined in their work habits.  For some nurses in this generational cohort, the transition to a high technology environment and use of electronic medical records has proved challenging.

The Baby Boomers  (born 1946-1964)

Baby Boomers grew up in a healthy post-war economy. Nuclear families were the norm. They were encouraged to value their individualism and express themselves creatively. Often described as the most egocentric generation, they have spent their lives rewriting the rules.  The Baby Boomer generation is the largest cohort in the nursing workforce and currently occupies many nursing leadership positions.  Baby Boomers are known for their strong work ethic, and work has been a defining part of both their self worth and their evaluation of others.   Significant numbers of Baby Boomer nurses are eligible to retire but many either want to continue working or have to because of the economic recession.

Generation X  (born 1965-1980)

The structure of the American family changed during the formative years of Generation X. Divorce rates increased significantly and many members of Generation X were raised in single parent households.  This was the first generation where both parents were likely to work outside the home and many were raised as latchkey children. Their formative experiences including exposure to massive corporate layoffs have led them to value self reliance and work-life balance; they are described as less loyal to the corporate culture. Technology underwent major advances during their formative years and has became an important part of their lives.  The Generation X cohort is significantly smaller than the Baby Boomers. During the 1990s, the profession of nursing had significant problems attracting Generation X members who saw nursing as not offering the career growth and entrepreneurial opportunities available in other jobs. However, many Generation Xers have now entered nursing as a second career and significant numbers are in leadership positions.

Generation Y   (born 1981-2000)

The Millennials are the second largest generational cohort in the general population and over the next ten years will be the largest cohort in the nursing workforce.  They were raised in a time where violence, terrorism, and drugs became realities of life. Raised by parents who nurtured and structured their lives, they are drawn to their families for safety and security. They are a global generation and accept multiculturalism as a way of life. Generation Y are the first true digital natives.  Technology and the instant communication made possible by cellular phones have always been part of their lives.  This generation is often compared to the Veterans in their values. A higher level of interest in nursing among this generation has been noted  and applications to nursing programs significantly increased as they entered college.

Understanding Your Team

An interesting exercise is to  do a generational profile of the team you work with.  See if you have a mix of all age groups and whether there are differences on various work shifts.  As a leader, your team will closely observe how you manage generational differences.  Do you try to understand differences and build synergy or do you complain about the differences in values and skills with technology.  Although there are differences in values, attitudes and beliefs in generational cohorts, there are also many similiarities.  All staff want to be respected, recognized and remembered for their work.  Team members should be able to agree on the common purpose of patient-centered care.

Each generational group has unique strengths that you as a leader can tap into to improve the work environment.  Some examples include the following:

Veterans – bring wisdom to their teams and also a historical perspective on their organizations.  Their insight can be valuable on task forces and committees. 

Baby Boomers – have significant clinical and organizational experience.  They make great mentors and should be engaged in helping with succession planning. 

Generation X – are known for their independence but are also keen observers of their environments.  They will bring creativity and innovation to solving problems.  They are also outcomes oriented which is an important skill in today’s healthcare environment.

Generation Y – are optimists and technologically savvy.  They should be part of technology selection teams and make excellent coaches for their more seasoned colleagues in how to use technology in the workplace.  They grew up volunteering and are civic minded.  They make great leaders for United Way drives and Going Green Initiatives. 

We know from research is that team performance is stronger when members have different attitudes, perspectives and experience.  Diverse work teams also tend to be more creative and better able to handle complexity and challenges.  As a nurse leader, it is important to honor these generational strengths and help teams to manage the conflicts that are inevitable when there is a diversity of opinion.

Many nurses find it difficult to delegate tasks to other members of their health care team.  It is not uncommon to hear a nurse say that they could finish the task themselves in the time that it takes to explain it to someone else.  While this may be true, it is shortsighted.  When done well, delegation can be a very effective management tool.  It frees professional nurses to attend to more complex patient needs.  At the same time, delegation helps to develop the skills of nursing assistive personnel and it is also more cost-effective for the organization.  By the end of the decade, this skill will become critical when there is a shortage of both professional nurses and nurse leaders. 

Ineffective delegation or the lack of follow-up for tasks delegated can result in errors or omissions of care.  As part of professional standards and licensure, specific guidance is often provided to nurses about the delegation of nursing care.  In the United Kingdom, qualified nurses who are registered by Nursing and Midwifery Council (MCN) delegate care to Health Assistants but retain responsibility for care delegated (advice on delegation).  In the United States the National Council of State Boards of Nursing (NCSBN) has a position paper that describes delegation as the transfer of authority by a qualified nurse to a competent individual for the purpose of completing selected tasks or activities.  This assignment should be based on the assessment of the patient’s needs and the scope of practice and skills of the individual to whom care is delegated.  This could be to another Registered Nurse, Licensed Practical Nurse or Patient Assistant.  Follow-up guidance and supervision of care is expected.  In most US states, activities that include the use of the nursing process (nursing assessment, diagnosis, plan of care, reassessment and evaluation of patient outcomes) can only be delegated to a Registered Nurse.

Prior to delegating in any setting, nurses need to understand the practice act or professional responsibilities that are part of their licensure.  In addition to this information, it is also important to review the policies that a health care agency has regarding delegation.   The following framework (NCSBN) can be then be used in the delegation process:

Step One – Assessment and Planning Questions to Ask

Goal – Give the Right Task under the Right Circumstance to the Right Person

• What are the needs and condition of the patient?
• What level of clinical decision making and assessment is needed?
• What is the predictability of the patient’s response to care?
• What is the potential for adverse outcomes associated with the delegated performance of tasks and functions?
• What are the cognitive and technical abilities needed to perform the activity/function or task?
• Which team member has the scope of practice, skills, competencies and experience to perform the task needed?
• What is the context of the situation and the environment – was the patient just admitted, is it a high acuity environment?
• What level of interaction/communication is needed in the care of the patient and with whom?

Step Two – Communication Questions to Ask

Goal – Give the Right Direction

• How is the task to be accomplished?
• When and what information should be reported?
• What is the process for seeking clarification about delegated care?
• What are the communication expectations in emergency situations?

Step Three – Supervision Questions to Ask

Goal – Provide the Right Supervision

• What level of supervision and observation needs to be provided?
• What should be the frequency of monitoring and observing care?
• How will the completion of care be verified and documented?
• How will unexpected changes in a patient’s condition be managed?

Step Four – Observation and Feedback Questions to Ask

Goal – Assess the Effectiveness of Delegation

• Was the delegation successful?
• Is there a better way to meet the needs of the patient?
• Is there a need to adjust the plan of care?
• Were there learning moments for staff or the nurse who delegated care?
• Was appropriate feedback and follow-up provided?
• Was positive feedback given when appropriate?

Delegation is both a science and an art.  The science to delegation involves understanding professional responsibilities from a legal standpoint.  The art involves making sure that good communication takes place during the delegation process.  Part of being a good leader is help professional nurses understand the need to develop their team members through delegation rather than demonstrating a lack of confidence in others or a need for control.

Everyone thinks of changing the world, but no one thinks of changing himself”   Leo Tolstoy

Many nurse leaders today will readily admit that one of their most significant challenges is dealing with the rapid changes occurring in the health care environment.  This change is happening on many levels.  Organizations are introducing new technologies and electronic medical records that are forcing a change in practice.  Insurers are moving to reimbursement models that are based on pay for performance on a wide variety of measures, many of which are nursing sensitive.  The workforce is comprised of four generations with different values, attitudes and beliefs – and some tried and true approaches in human resource management are no longer working well.  The level of uncertainty during these difficult economic times makes future planning difficult.  We know that the future will require that we take some bold action but resistance to change in times of uncertainty can be challenging.

Accepting Change

In most situations where we are asked to change, we are substituting new and unfamiliar behaviors or practices for old comfortable ones.  This can make us feel insecure about our work and is often personally exhausting.  That is why the reaction to change can be quite emotional.  A good example of this is what is happening with in many institutions with the introduction of the electronic medical record.  Seasoned nurses who have worked their entire careers with paper charts are now being asked to do their charting electronically.  Some are not secure with their technology skills and are having difficulty mastering the new systems that are purchased by their health care agencies.  Initially, their work is taking much longer because of their lack of proficiency with these new systems.  They feel like novices in clinical environments where they once felt quite proficient.  In contrast, many younger nurses who are part of the digital age are quite happy with the transition to electronic medical records.  They have always had technology as part of their life.  Their clinical patterns of working are not as well established because they are early in their careers.  It is important to keep in mind that resistance to change is often a manifestation of insecurity.

The Role of the Nurse Leader in the Change Process

As a leader, reflecting on your own reaction to the change and what you are projecting to others is an important first step.  You may be demonstrating resistance yourself in subtle ways that are both verbal and nonverbal.  Leaders play a key role in framing the context of change for their staff.  This is especially true in uncertain environments.  You must help to manage change in a way that employees can cope with it.  To be successful, change cannot be imposed but rather the leader should look for ways to enable and involve staff.  John P. Kotter, a Harvard Business Professor, is a highly regarded expert in the field of change management.  He proposes the following 8 step model that leaders can use to understand and manage change:

1. Create a sense of urgency about the need for change– inspire staff to see the need for the change and make the change objectives real and relevant.
2. Build a team to help guide the change–  get the right people in place (skills, abilities and attitude) to make the change happen.
3. Develop and communicate the change vision– a simple, clear strategy of what the change is and how the change will occur.
4. Communicate for buy-In-involve as many people as possible, keep them informed and respond to their needs.
5. Empower action– remove obstacles, provide feedback and reward progress.
6. Create short-term wins– establish some easy to reach goals – manage the change in bite-size chunks.
7. Don’t let up– build and encourage determination and persistence – report on the progress.
8. Make the change stick– this is the most challenging part of change -weave the change into the culture and practice in tangible ways.

Change can be hard but altering the pace of change in our environments is not likely to be a leadership option now or in the future.  What is within our control is how we personally respond to change, and how we frame and facilitate change for our followers.

As is true with many nurse leaders, they feel like they have too much on their plate to do and are constantly feeling stressed.  These feelings are a way of life in today’s work environment and in modern life.  All of us have stress.  It is how well we manage it that is important.

There are five strategies that are especially important in nursing leadership and they include the following:

1.  Have self-compassion

Most nurses are compassionate people but often their compassion does not extend to themselves.  Nurse leaders often expect perfection in themselves and forget that to err is human.  Halvoson observes that research has shown that people with self-compassion are more optimistic, less anxious and less prone to depression.

2.  Take at least five or ten minutes during every work day to do something that you find interesting

It is important to look for things in your work environment that you can incorporate into your day to make it more interesting.  This will replenish your energy.  It could be having lunch with colleagues, mentoring a young nurse or visiting with a patient.  For some leaders, it might taking time each day to catch up on a few journal articles.  Whatever it is that can help energize you – find it and plan it into your day.

3.  See your work in terms of progress, not perfection

It is easy to begin to doubt yourself when things don’t seem to be going well.  We often measure ourselves by what we have not done versus our accomplishments.  The truth is that leadership is a journey.  I am a great believer in networking.  Leadership can at times feel lonely but when you talk with other leaders, you are likely to gain a better perspective on your progress in your work.

4.  Use if-thens for positive self-talk

Often the best way to deal with stress is to be proactive and anticipate it.  Planning if-then scenarios can be very helpful.  Anticipate a worst case scenario and then think about how you will react.  Decide your response in advance.  As an example if you will be attending a very stressful budget meeting to discuss staffing, plan in advance how you will react if you are put on the defensive.  If you need to do a very difficult employee counseling, think about how you will handle it if things do not go well.

5.  Always keep in mind the bigger picture

Within the context of our day to day work, it is easy to forget that work is just one aspect of our lives and all of us are replaceable.  There are so many things in today’s health care environment that are beyond our control and stressing about it won’t change it.  Steve Job’s the former CEO of Apple Computer may have had the best advice of all.  During a 2005 commencement address, Jobs spoke about how remembering that he would soon be dead is the most important tool that he had encountered to help him make the big choices in life.  He told these graduating students that “all external expectations, all pride, all fear of embarrassment or failure – these things just fall away in the face of death, leaving only what is truly important.  Remembering that you are going to die is the best way I know to avoid the trap of thinking that you have something to lose.  You are already naked.  There is no reason not to follow your heart”.  

Managing time is very challenging for nurse leaders in today’s environment.  A colleague recently told me that she had little time to do work because most of her time was spent in meetings.  Many of the meetings had no clear outcome, and she was not even sure why she was being asked to attend them.  I was struck by a Harvard Business Review Blog posted by Elizabeth Beth Saunders last week.  In this block, she urged leaders to break their addiction to meetings in order to have more time to do clear strategic thinking.

The Meeting Addiction

Sometimes leaders believe that the only way they can stay in the loop in their organizations is to personally attend all the meetings that are scheduled.  It is true that for some leaders attending meetings will be the core of their work.  But most leaders have a vast array of other responsibilities that get pushed to the side as they attend often lengthy meetings with no clear goals.  A good exercise that we used in one organization that I worked in was to calculate the cost of a meeting in terms of the time of participants.  We found that were few meetings that we could honestly say that there was a positive return on investment.

Saunders offers the following decision tree that leaders can use to make the decision whether to attend the meeting.

Breaking the Addiction

Saunders suggests that your new default should be to choose the least “costly” time investment that still accomplishes the end goal.  Always ask for the agenda in advance.  Perhaps the meeting could be attended by another staff member or maybe you only need to be present for part of the meeting.

She also suggests that leaders should avoid being the ones who convene unnecessary meetings. Good meeting management skills are important.  She recommends that  you don’t schedule a meeting for something that you can solve in a phone call, and don’t make a phone call for something that can be communicated in an e-mail. If you must schedule meetings, she urges that you challenge yourself to make them leaner. Try out 30-minute or even 15-minute meetings, and set a goal to finish early. If you find you consistently need more time, you can increase the meeting length in the future, but often with increased focus, you won’t need it.

There are nurse leaders who measure their value by how many meetings they are invited to attend and feel insulted when they are not in the loop on everything.  While going to a lot of meetings may make you feel important, but it’s not a good way to allocate your time.  You need to give yourself permission to decline meetings.  A good exercise to use to help break your addiction is to review each meeting on your calendar for the previous month and then use the above decision tree to determine whether you really needed to be there.