From baby boomers to Gen Zers, the question of how the four generations comprising today’s workforce can best work together gets a lot of attention. Personal and professional experiences, levels of training, employer expectations, and career outlook can vary across generations. In nursing, tenure is a particularly nuanced factor that adds complexity to the discussion on workforce dynamics and may be one of the more definitive features of employee experience and, ultimately, retention.
As healthcare organizations and other stakeholders refine their strategies for bolstering the nursing workforce, it is critical to incorporate the nuanced needs and preferences of nurses at different stages of their careers. To this end, we surveyed 5,772 nurses across tenures in October 2023 as part of an ongoing research collaboration between the American Nurses Foundation (the Foundation) and McKinsey (see sidebar, “About the research collaboration between the American Nurses Foundation and McKinsey”). The survey results provide insights into opportunities to bridge the experience gap and support nurses across their career continuum.
The survey analyzed three specific nurse cohorts: early-tenure nurses (less than five years of nursing experience), midtenure nurses (five to less than 21 years), and most-tenured nurses (21 or more years). When notable differences were reported within these cohorts, the specific tenure range was also noted.
Across all experience levels, intent to leave the bedside remains high for surveyed nurses. About 30 percent of survey respondents indicated they were at least somewhat likely to leave their positions in the next six months. This is particularly acute in the early-tenure population, where a greater proportion of surveyed nurses reported considering leaving (about 45 percent) compared with midtenure (31 percent) and most-tenured nurses (27 percent).
The early-tenure population is particularly important to retain as more experienced nurses reach retirement age. Supporting and retaining midtenure and most-tenured nurses is also crucial given the critical role they play in teaching and mentoring those newer to the profession. In fact, finding creative ways to enable not only nurses nearing retirement but also those already retired to participate in direct patient care activities or coaching could help fill part of the experience void—and this cohort appears open to doing so if their needs and preferences were met.
We asked nurses who indicated they were currently or previously retired what would make them consider returning to clinical nursing. Of the 179 survey respondents, 45 percent reported that having the ability to set their own schedule would make them consider returning to clinical nursing, 34 percent wanted the ability to serve as an educator, and 31 percent wanted the ability to mentor nurses. Surveyed nurses across tenures indicated that there is a need to enact structures that would enable more robust onboarding and training for new nurses, promote team building, and create safe working environments through policies designed to prevent incivility and bullying.
Understanding the common needs of the nursing workforce as well as unique tenure-specific qualities can help hospital leaders find tangible ways to create collaborative and sustainable environments that would benefit nurses across the entirety of their careers. In this article, we explore how a positive team environment, across and between all tenures, can promote well-being and holistic employee health.
How the work environment can affect nurses
It’s no surprise that a team environment can substantially affect both health and burnout. Positive team characteristics, such as a sense of belonging, psychological safety, opportunities to learn and grow, and coworker support, were among the top indicators of an employee’s holistic health, according to a global survey conducted by the McKinsey Health Institute (MHI) across industries last year. Negative team characteristics, such as toxic workplace behavior and interpersonal conflict, were strongly linked with burnout.
MHI’s findings were reflected in the sentiments of early-tenure nurses in our survey. These respondents indicated that they were looking for a work environment where they felt supported and could learn from more-tenured nurses, but reported sometimes experiencing a negative environment, which can contribute to burnout. While in our May 2023 survey, nurses overall reported that they were indeed feeling burned out and that their mental health was suffering, nurses with less than five years of experience more often reported lower satisfaction with their roles, greater intent to leave their roles, and experiencing burnout.
In our October 2023 survey, we examined how negative sentiments after working a shift may be affecting nurses’ intent to leave. We asked nurses to select an adjective or sentiment for how they felt after they finished working a shift with each nursing tenure, including their peer group. When we compared intent to leave with the sentiments each nurse shared, there was a positive correlation between those who reported more negative sentiments and those who reported a greater intent to leave. This is particularly salient for stakeholders, as it provides a glimpse into how culture and team dynamics may affect nurses and their likelihood to stay in their current roles.
Nurses’ sentiments about working with those of different tenures
To better understand the overall nursing experience, it is important to evaluate each tenure, including the unique needs, preferences, and experiences of the nurses in each tenure, as well as where there is common ground among tenures. Not surprisingly, we found some distinct nuances to each group’s professional experience but also many commonalities to build upon.
Our joint research highlighted that nurses’ experiences working with different tenures may affect how they feel at the end of their shifts (Exhibit 1)—even though nurses are likely to tell
you there is no such thing as a typical shift or day for them.
Surveyed nurses were asked to select the top sentiments they felt after working a shift. Early-tenure nurses more often reported feeling supported by midtenure nurses (29 percent) than feeling supported by most-tenured nurses (17 percent). Early-tenure nurses also more often said that they felt frustrated by their most-tenured colleagues (12 percent), compared with midtenure nurses (8 percent). Additionally, early-tenure nurses more often reported feeling intimidated by most-tenured nurses (12 percent) than by their midtenure coworkers (2 percent).
Despite these negative sentiments, however, about 75 percent of early-tenure nurse respondents reported that they agreed or strongly agreed that they enjoyed working with most-tenured nurses. More than 80 percent reported that they viewed most-tenured nurses as “a great resource to learn from” (Exhibit 2). These sentiments were consistent across early-tenure nurses with less than two years of experience and those with more than two years but less than five years of experience.
These two early-tenure nurse subsets differed, however, when reflecting on shifts with midtenure colleagues, most evidently on whether midtenure nurses “have the time and capacity to train and coach them.” About 25 percent of those with less than two years of experience reported that they disagreed or strongly disagreed, compared with about 11 percent of nurses with more than two years but less than five years of experience.
Midtenure and most-tenured nurses were fairly aligned with each other in terms of how they felt about working with early-tenure nurses. Midtenure and most-tenured nurses reported feeling hopeful, like a leader, and respected. Yet they also noted being exhausted and concerned after a shift with early-tenure nurses. In fact, only half of most-tenured and midtenure nurses reported that they got enough support from early-tenure nurses.
This response may indicate that midtenure nurses feel that early-tenure nurses entering the workforce require more support than they can provide (for example, if they are managing more complex patients while also training new joiners). Nonetheless, about 75 percent of both midtenure and most-tenured nurse respondents shared that they enjoyed working with early-tenure nurses (Exhibit 3). Greater than 70 percent of midtenure and most-tenured nurses said they felt energized or personally fulfilled by supporting early-tenure nurses in learning and developing, but more than 33 percent reported that they didn’t have the time or capacity to train or coach others.
Actions to improve collaborative work across tenures
To address the unique challenges facing each tenure and strengthen retention, it is imperative for organizations to evaluate how and where to deploy resources that best match the needs of nurses across their career continuum. To identify tactical, actionable solutions, organizations need a better understanding of what initiatives nurses think could improve the experience of a multitenure workforce and how to create environments that are more collaborative. We also looked at additional cross-cutting strategies for recruitment and retention, such as flexibility.
Ultimately, the interventions an organization chooses will depend on the makeup of its staff and the organization’s goals for its nursing pipeline. However, by using the preferences that the nurses in our survey shared, there are three potential avenues that organizations can consider.
Enhance flexibility for all
Providing schedule flexibility could be helpful not only for nurses who are currently practicing but also to potentially bring back retired nurses. Nearly a third
of respondents reported that their employers didn’t offer any type of shift flexibility. Among those who worked at places offering some schedule flexibility, more than 30 percent of early-tenure nurses reported feeling neutral to very dissatisfied with the available options, and 25 percent of midtenure and most-tenured nurses reported the same.
We asked nurses to select all the flexible-schedule options that mattered the most to them (Exhibit 4). Across all tenures, nurses expressed a desire for self-scheduling (for example, everyone gets to select the days and shifts they work for the entirety of the published schedule). This was particularly important for early-tenure nurses, with 46 percent selecting this as an important scheduling option. Additionally, all nurses wanted their employers to offer variable and flexible shift lengths (for example, four, six, eight, ten, and 12 hours). Among early-tenure nurses, 36 percent selected this as a desired scheduling option, while 32 percent of midtenure nurses chose this option. Early-tenure nurses also requested flexible and variable start times (for example, 7:00 a.m., 8:00 p.m., et cetera), while midtenure and most-tenured nurses opted for hybrid working options.
Some organizations have started utilizing technology to support flexible scheduling options. For example, Providence partnered with healthcare platform CareRev to provide unclaimed shifts to nurses or care providers in nontraditional increments, such as 9:00 a.m. to 2:00 p.m., which could then free up nurses to perform daytime activities such as dropping off and picking up their kids from school. Similarly, SSM Health partnered with the app ShiftMed to offer open shifts to its workforce. The partnership gave SSM Health the opportunity to pilot flexible shift options, start times, and roles and allowed them to fill more than 85 percent of their 25,000 posted shifts per quarter.
The exodus from the workforce of the many nurses nearing retirement age may mean the loss of decades of expertise and institutional knowledge. Some organizations have implemented programs that provide flexibility and schedule relief to these most-tenured preretirement nurses. Indeed, being able to set their own schedule was the top response among the 1,640 respondents who identified as eligible for retirement, with 46 percent sharing that this would encourage them to consider delaying their retirement. And 45 percent of nurses who were currently or previously retired indicated that this would make them consider rejoining the workforce.
Examples of organizations that have focused on bringing nurses back to their organizations by using flexibility include Henry Ford Health and Northwestern Memorial HealthCare. Henry Ford Health focused on outreach to nurses who left the workforce during the COVID-19 pandemic. It offered flexible opportunities, including internal travel nurse programs and weekend-only options. This strategy resulted in about 25 percent of nurses returning to the organization. Similarly, Northwestern Memorial HealthCare concentrated on opportunities it called “knowledge worker” roles, which may be less physically demanding than a bedside position and allow nurses to participate in its innovative nursing models, including remote intensive care unit care and virtual nursing.
Bolster mentorship opportunities
Asking nurses how they felt after working a shift revealed a road map of what they need, as well as the barriers they encounter when nurses don’t have the time or resources to follow this plan. Early-tenure nurses indicated they wanted to learn from their midtenure and most-tenured coworkers, with 18 percent ranking formal mentorship programs as a top initiative to support a positive work environment. About 72 percent of midtenure and most-tenured nurses shared that they felt energized and fulfilled when they could teach and coach their early-tenure colleagues. However, only about 60 percent of midtenure and most-tenured nurses shared that they had adequate time or capacity to coach and teach. This can lead to sentiments of confusion, burnout, intimidation, and frustration.
Although many nurses are already feeling stretched and mentally exhausted, there may be a key group of nurses with the expertise, bandwidth, and desire to support onboarding and mentoring programs. We asked nurses who had not yet retired to select the top three things that their employers could do for them to consider staying in their role. While the ability to set their own schedule was the top response (46 percent), 27 percent reported that being able to work as a nurse educator or in a virtual-nurse capacity would be attractive.
Among nurses who have retired or were previously retired, similar sentiments were shared (Exhibit 5). More than 30 percent reported that being able to serve as an educator or focus on mentoring newer nurses would be enough to make them consider rejoining the workforce.
As a growing number of nurses reach retirement age, organizations have an opportunity to create roles that honor the expertise of these often more-tenured nurses while promoting a work environment that is collaborative and positive for early-tenure nurses. Facilities within the Mass General Brigham healthcare system piloted a formal mentoring program in which early-tenure nurses meet every two weeks for three months with more-tenured nurses. The organization considers this to be paid educational time. Reviews from the pilot show that job satisfaction increased for both new and experienced nurses. Similarly, the AARP Center for Health Equity through Nursing is recruiting working and retired nurses for its mentorship program, which is focused on nursing students in underrepresented communities, as part of its Campaign for Action focused on health equity.
In addition, adequate support for new graduates entering the workforce was indicated as the number-one contributor toward a positive work environment among all three tenure cohorts. For example, the Practice Transition Accreditation Program, an evidence-based accredited registered nurse residency and fellowship program created by the American Nurses Credentialing Center (ANCC), demonstrated an 85.3 percent retention over 12 months, compared with the industry average of 71.3 percent.
Promote team building and safe spaces
Personal working styles in any work environment can vary greatly depending on the individual; however, in healthcare specifically, teams should work cohesively and collaboratively. When surveyed nurses were asked to choose the top three most important factors for creating a collaborative working environment, nurses across all tenures selected team building as a
top initiative.
Healthcare organizations may not need to look far to find processes to support better collaboration and understanding among team members. Many organizations use after-action reviews following patient safety events to assess and reflect on what went well and what needs to be improved to prevent such future incidents. Additionally, it may be beneficial for departments to conduct more frequent check-ins, huddles, and team-building exercises to give nurses and health professionals an opportunity to share experiences and establish norms for their working culture. Often conducted at the beginning of shifts, huddles may also allow departments to set up working models and provide a platform for staff to get to know one another more informally, which can build trust and professional collaboration.
Another example initiative that could help build a more supportive environment is the Schwartz Rounds program. It was established as a contrast to traditional patient rounding, which tends to focus on patient needs and barriers to care. Instead, the Schwartz Rounds program offers healthcare providers time and space to discuss the social and emotional issues they face while caring for patients and families. The benefits include improved teamwork, better interdisciplinary communication, and a greater appreciation for different roles and disciplines, as well as a decrease in feelings of stress and isolation.
Other actions that stakeholders can consider include establishing and enforcing policies that create space for nurses to feel safe at work. Among early-tenure and midtenure nurses, 12 percent reported that a top priority was formal policies and enforcement against bullying (Exhibit 6). Bullying, incivility, and verbal abuse can lead to a degradation of safe, quality care and affect an individual’s sense of well-being, creating an unhealthy work environment.
Supporting nurses across their career continuum
Addressing the complexity of this multitenure, multigenerational workforce is critical to supporting the healthcare workforce and ensuring an adequate pipeline of nurses eager and engaged in the profession. Many surveyed nurses expressed positive sentiments toward their peers and colleagues but also shared structural challenges that may be preventing them from fully appreciating the potential benefits of a multitenure workforce.
Bolstering cross-tenure relationships would increase trust and collaboration among nurses, not only increasing the likelihood that they stay in the profession but also improving productivity and engagement in real time. How to address these challenges will depend on the makeup of each specific workforce, but stakeholders can start by evolving their workforce strategies to ensure that tenure-specific needs and preferences are considered.
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