The pervasiveness of multigenerational conflict in the nursing workforce is seen in the recent number of papers published and sessions presented at professional conferences, as well as Swearingen and Liberman’s (2004) comprehensive literature review using conflict theory and cohort theory perspectives. Management literature in nursing and other fields considers conflict from the perspective of the manager’s responsibility in dealing with the conflict. Yet individual employees, such as nurses, also have a responsibility to learn to work cooperatively with peers representing generational cohorts different than their own. The challenge to move toward shared accountability between professional staff nurses and managers has been issued (Kupperschmidt, 2004). If professional nurses are unwilling to assume shared accountability for creating environments consistent with the values of the profession, i.e., environments that encourage respectful interactions with colleagues, should they continue to assert that caring is the essence of nursing? This author argues that professional nurses must care enough about their patients, their profession, their multi-generational colleagues, and themselves to carefront disrespectful behavior from other professional nurses.

In this article, examples of conflict between the four generations comprising today’s nursing workforce, along with characteristics and selected strengths each generation brings to the workplace, are described. Additional literature addressing these characteristics and strengths is readily available in the management literature and elsewhere. Next it is argued that treating each other with respect is the individual nurse’s ethical responsibility. Carefronting, a model of communication used when professional nurses care enough about themselves and their patients to confront disrespectful behavior face-to-face (Kupperschmidt, 1994), is presented as a strategy to foster mutual respect among professionals who pride themselves on being members of a profession that cares. First, however, a brief review of literature addressing conflict in the nursing workforce is offered.

Conflict in the Nursing Workforce

Manion and Bartholomew (2004) conceptualized effective intergenerational relationships as community, noting that the desire for a sense of community at work, a community in which conflict is addressed gracefully, is universal. Yet far too often this graceful addressing of conflict is missing in the general workforce including the health care workforce. This lack of peer cohesion and poor working relationships has been noted as a factor in nurse burnout (Garrett & McDaniel, 2001). Bernstein and Fundner (2002/2003) reported that innumerable examples of disrespectful behavior are both ubiquitous and insidious in their erosion of productive collaborative approaches to patient care among hospital workers. They pointed out it would be naïve to think that noble institutions like hospitals would have any better track record than other complex organizations. Hutton (2006) also reviewed the literature of incivility, defined as a violation of workplace norms for mutual respect, asserting that the literature indicates incivility pervades workplaces, including health care organizations.

Research specifically connects conflict in the workplace with nurse retention. Negative, non-supportive, unpleasant, and uncooperative peers and co-workers are key impediments to nurses’ ability to find joy in their work (Manion, 2003). Anthony et al. (2005) found teams that work together, support one another, and resolve conflicts are critical factors in staff nurse retention. Strachota, Normandin, O’Brien, Clary, and Krukow (2003) reported that employee friendliness and cooperation are listed among the most favorable reasons why nurses stay with their jobs. Sumner and Townsend-Rocchiccoli (2003) presented a moving paper addressing the reasons why nurses leave nursing. They asserted that nurses’ intrinsic or existential need to be validated as consummate professionals frequently is not being met; professional nurses need to be rewarded with peer recognition and respect as well as recognition by patients for the special gift of self they give. They cited lack of respect for the gift of self as a cause of the exodus of nurses from nursing.

Researchers who have explored workplace stress specifically related to generational differences have reported connections between generational conflict and workplace stress. Santos and Cox (2000) and Santos et al. (2003) noted marked differences between Boomer and Generation X colleagues’ perceptions of this conflict and related stress, with Boomers reporting considerable conflict with Generation X nurses’ attitudes and behaviors. Boomers are angered by Generation X nurses’ perceived arrogance, lack of commitment, and slacker attitude. However, Generation X staff nurses did not agree with the Boomers’ perceptions of their behaviors. They felt their attitudes portrayed self-reliance rather than arrogance and that their commitment to the profession and the organization was greater than that of the Boomer RNs (Santos & Cox). In another study, newly graduated nurses reported that difficult peer relationships, described as lack of acceptance and respect, made their transition into the RN role more difficult (Casey, Fink, Krugman, & Propst, 2004). DeMeglio et al. (2005) reported that the novice nurses in their study also described subtle instances of lack of professional respect and support. Although a recent national survey of 1,783 RNs reported markedly improving relationships between RNs (Ulrich, Buerhaus, Donelan, Norman, & Dittus, 2005), generational conflict is still alive and well among the four generations of nurses in today’s nursing workforce. Lancaster and Stillman (2002) noted that this generational conflict can be poignant, painfully funny, or just plain painful. In nursing, it is painful and cries out for attention.

Differences Between Generational Cohorts

Perhaps one of the earliest documented cases of generational conflict is presented in I Kings, Chapter 12, of the Holy Bible. In this situation, Rehoboam, the young King of Israel, rejected the advice of his elders (men of his father’s generation) and took the advice of younger men (his generation). This generational conflict split the nation of Israel. More recently, lyrics of the song “In the Living Years” have portrayed movingly a major cause of generational conflict as different worldviews, worldviews formed during childhood that shape a generation’s adult values and expectations. Selected lyrics from this Song (See Figure) are especially pertinent to nursing. For example, consider the lyric line noting that talking in defense is like talking in a different language which results in a bitterness that lasts.

Figure. Selected Lyrics from In the Living Years

The four generations of professional RNs in today’s workforce have very different worldviews that are described below. The birth years for the different generations used in this article are the birth years used by Strauss and Howe (1991); the term professional is used to emphasize that registered nurses (RNs) are professionals; and the title descriptors for the four generations, Traditional, Baby Boomer, Generation X, and Net Generation Nurses, are based upon the author’s continued study of, and interaction with multi-generational nurses.

Dismayed Traditional Professional RNs (Birth Years pre 1944)

Traditional colleagues were raised primarily in a Judeo-Christian culture that embraced transcendent moral truth and extolled the virtue of the Protestant Work Ethic. Thus, they value hard work and commitment to organizations and ‘bosses’ (Hu, Herrick, & Hodgin, 2004; Kupperschmidt, 2000; Strauss & Howe, 1991). Members of the Traditional Generation entered nursing because they wanted to make a difference in peoples’ lives, and many viewed nursing as a ‘calling’ (Kupperschmidt, 2000). Although educated predominantly in hospital-based diploma programs, Traditional generation RNs embrace the Nightingale Pledge and thus consider themselves to be professionals. Strengths they bring to the workplace include their belief in hard work, doing a good job, and working together (Kupperschmidt, 2000; Strauss & Howe, 1991). They are dismayed by, and struggling with, the perceived lack of professionalism among younger nurses as evidenced by younger nurses’ dress, behavior, and what they, as traditional nurses, perceive to be vastly different work values. Traditional RNs are also discouraged by the age-related demeaning remarks younger colleagues make about their fellow Traditional colleagues, as individuals and as a generational cohort. Traditional RNs are dismayed by the lack of attention to their ergonomic needs and perceived lack of respect for their cumulative wisdom, wisdom they will take with them upon retirement, which may occur earlier than expected if their needs are not addressed (Cyr, 2005; Gerke, 2001; Letvak, 2002).

Disappointed Baby Boomer Professional RNs (Birth Years 1944 -1960)

Baby Boomers are credited with challenging and changing many of the values held by the Traditional generation. They redefined family and childhood and embraced values fostered by a personalized economy and spirit of free agency (Holtz, 1995; Russell, 1997). Their parents heeded Dr. Benjamin Spock’s advice and raised them to be independent, critical thinkers (Holtz, 1995). Boomer generation RNs embrace the sense of professionalism, viewing nursing as a career with their self-worth closely tied to their work ethic (Kupperschmidt, 2000). They are disappointed by the lack of available mid-level management positions; lack of attention to their ergonomic and life cycle needs; Generation X and Net Generation colleagues’ age-related demeaning remarks, and what they perceive as a lack of professionalism by these younger colleagues (Ulrich, 2001). Baby Boomer generation nurses perceive they are carrying the greatest share of the work in acute care settings (Santos & Cox, 2000); and they are experiencing high levels of role overload, role insufficiency, and interpersonal strain (Santos et al., 2003). Although they are disappointed that health care organizations are not evolving into the kind of professional environment in which they prefer to, and need to, work (Cyr, 2005), they maintain their strengths as process-oriented, team, and consensus builders and mentors (Kupperschmidt, 2000; Ulrich et al., 2005).

Disillusioned Generation X Professional RNs (Birth Years 1961-1980)

Generation X members are described as Baby Boomers’ children who inherited Boomers’ social debris: divorce and dual-career parents resulting in Latch Key Kid experiences (Holtz, 1995; Howe & Strauss, 1993). Generation X RNs were raised in an anti-child culture in which it was unpopular to be a child (Holtz, 1995; Howe & Strauss, 1993; Kupperschmidt, 1998). Many Generation X Nurses watched their parents, who had sacrificed time with their children to advance their careers, receive pink slips in their later years (Holtz, 1995; Howe & Strauss, 1993). Zemke, Raines, and Filipczak (2000) have noted that employees’ first job experiences significantly impact their values and expectations of the workplace, including the nature of the work itself and relations with co-workers and managers. Many Generation X nurses first work experiences occurred during a period of national recession and the reorganization and restructuring of health care organizations. Thus, they learned there is no such thing as job security. They have concluded that long term commitment to jobs and organizations, to paying dues, and to hierarchical reverence are to be avoided. Rather they believe that attaining and maintaining marketability is the key to personal success (Bradford & Raines, 1992; Holtz, 1995; Kupperschmidt, 1998; Tulgan 1995). Strengths Generation X colleagues bring to the workplace include their techno-competence, multi-tasking, and ability to work well alone (Holtz, 1995; Howe & Strauss, 1993; Kupperschmidt, 1998). Generation X RNs are disillusioned by Traditional and Boomer colleagues’ perceived unwillingness to become technologically competent; frequent negative comments about them as individuals and about their generation (Tulgan 1995), and health care organizations that are not evolving into the kind of professional environments in which they expected to work (Bradford & Raines, 1992; Howe & Strauss, 1993; Swearingen & Liberman, 2004; Tulgan 1995).

Disengaging Net Generation Professional RNs (Birth Years 1981-2000)

Net Generation colleagues were raised enmeshed in digital technology with computer games at nursery school. They were raised in the ‘Era of the Child’ when it was popular to be busy, protected children chauffeured by Soccer Moms (Howe & Strauss, 2000; Tapscott, 1998). Many have adopted the philosophy of moral relativism and consider truth as relative. Net Generation RNs may perceive nursing as an occupation rather than a profession as literature about the current and impending nursing shortage consistently refers to available jobs in nursing. Strengths Net Generation professional RNs bring to the workplace comprise their techno-competence, openness to and expectation of virtual teams, and collective action (Howe & Strauss, 2000; Kupperschmidt, 2001; Tapscott, 1998). Net Generation nurses may be disengaging from nursing, however, because of Boomer and Generation X colleagues’ negative attitudes, media reports about negative conditions in acute care settings and nurses leaving nursing (Shaver & Lacey, 2003), and the lack of cutting-edge technology (Kupperschmidt, 2001). Thus, many of today’s health care organizations may not be the kind of environment in which the Net Generation RNs expect and desire to work.

The Challenge

Much more could be and has been said about each generation. It is important, however, not to stereotype individuals. Gerke (2001) has asserted that the health care work environment needs a huge overhaul to successfully use the strengths of professional nurses from each of these highly diverse generations. Gerke (2001), and Duchscher and Cowin (2004), have stressed the importance of all staff learning about colleagues’ differences and dialoguing about how generationally determined values and expectations are being played out in their organizations. Ulrich (2001) has emphasized that colleagues’ workplace behaviors legitimately derive from their generational values, and has tied strengths and values together in a humorous example of how values influence how work gets done. Traditional colleagues value hard work and respect authority whereas Boomers value team work. Generation X Nurses value self-reliance and Net Generation colleagues value achievement. In the workplace, a Traditional nurse might say, “Do it because I say so,” and a Boomer nurse might say, “Let’s get together and reach a consensus about how to do it.” The Generation X staff nurses might say they will do it themselves; and Net Generation staff nurses might not care who does it as long as the work gets done. It is important to stress that professional RNs do not have to adopt colleagues’ generational values; but they do have to recognize, allow, and respect these different values. Lancaster and Stillman (2002) referred to these differences as clash points whereas Kalisch and Begeny (2005) referred to the differences as idiosyncrasies. Lancaster and Stillman (2002) asserted that professionals must be aware of and allow for these clash points and idiosyncrasies and respect colleagues’ generationally influenced strengths in order to enhance effective teamwork.

The Role of Respect in Multigenerational Relationships

It is the contention of this author that mutual respect could reduce multi-generational conflict among professional nurses in the workplace. Although no research studies were found which demonstrated a direct, positive correlation between generational lack of respect and workplace conflict, related literature and anecdotal reports are available to support this contention as described below.

DeLellis (2000) stressed the important role of respect in professional relationships and developed an integrated typology addressing various aspects of the concept. In a later paper, DeLellis and Sauer (2004) contended the need to be respected is universal among human beings and is an essential element in bringing good into human life. They discussed respect as a function of individual behaviors, values, and perceptions and built the case for respect as the ethical foundation for all employee relations. DeLellis and Sauer proposed that respectful communication has many faces: respect as active listening; respect as assertive speech; respect as avoidance of passive-aggressive communication; and respect during conflict.

DeLellis (2004) studied respect in various work settings including health care settings and reported that 79% of those surveyed felt workplace respect was lacking in the United States to the extent that it was a serious problem. Regarding respect in hospitals, respondents believed that the quality of work life for hospital employees, including nurses, would improve if employees would care about and respect each other as much as they do their patients. Ulrich et al., (2005) conceptualize respect as a concept comprised of four key elements: attention, deference, valuing, and appropriate conduct. They expressed concern over the dearth of studies addressing staff nurses’ perceptions of respect. However, they acknowledged the considerable number of anecdotal comments about the lack of respect, adding that these comments are made because mutual respect is a vital aspect of effective working relationships among a multi-generational nursing workforce.

Because of this author’s interest in generational issues, colleagues have shared personal examples of disrespectful treatment. For example, Traditional and Boomer colleagues have shared that younger colleagues disrespect them with remarks such as, “These old bitches take forever to learn technology.” Boomer colleagues have difficulty understanding that from the perspective of moral relativism, because someone (a Boomer colleague) finds the word ‘bitch’ offensive doesn’t mean a Net Generation colleague finds it offensive, as evidenced by a Net Generation colleague saying, regarding this word, “It is really no big deal.” Younger students complained that ‘older’ faculty are disrespectful when they make remarks such as, “Younger students just want the grade and don’t care about the content nor how they get the grade.” Additionally, Generation X nurses have offended Boomers by saying, “Boomers take forever to make decisions; they just want to process and process,” and Boomer colleagues have reported younger nurses disrespect their need to carefully weigh all the facts and achieve consensus, by openly remarking, “Only old people take this long to make a decision!”

This author has also heard both undergraduate and graduate students, primarily Generation X and Net Generation students, describe how the different generations perceive respect and disrespect. Both generations have described maintaining eye contact, paying attention, and being polite (please, thank you, and using titles such as Mr. and Mrs.), as respectful behaviors; whereas interrupting a speaker, gossiping, not paying attention, rolling one’s eyes when disagreeing with a speaker, and not responding to telephone calls and e-mail messages were described as disrespectful by both of these generations.

If treating each other with mutual respect was a mandate from a regulatory agency, nursing would figure out an effective way to meet the mandate. Yet, in essence, nursing does have an ethical mandate clearly stated in the American Nurses Association’s Code of Ethics (American Nurses Association [ANA], 2001). The Code of Ethics, Provision 1, states that nurses in all professional relationships practice with respect for the inherent dignity, worth, and uniqueness of all individuals

Carefronting Disrespect as Strategy

This section will begin with a description of Augsburger’s Model of Carefronting. Then Kupperschmidt’s adaptation of carefronting for nursing will be presented.

Augsburger’s Model of Carefronting

Flowing from his years of experience as a family therapist, Augsburger (1973) coined the word carefronting to describe a model of communication. He asserted that carefronting, caring enough to confront, is the key to effective relationships and the way to communicate with impact and respect in interpersonal relationships and work-related situations. Augsburger has built the case for this model by noting that conflict itself is natural and normal. It is the way people view, approach, and work through conflicted situations that influence their relationships. He asserted that silent withdrawal to disrespectful comments or behaviors is self-defeating because the relationship is only as good as the communication. He added that for carefronting to occur, both parties must be willing and able to state how they feel and what they value; they need to know that the other person is able and willing to work to understand them. Augsburger acknowledged that carefronting, i.e., making “I” statements and receiving the carefronting, requires courage. He asserted that failure to honestly and fully state one’s real feelings and viewpoints is not kindness; rather “it is a form of benevolent lying” (1973, p. 25). Augsburger explained that when a person is angered by disrespect, anger energies can become the creative force which enables the person to carefront the disrespectful behavior. Carefronting disrespectful behavior comprises negotiating differences in clear, respectful, truthful ways.

Augsburger (1981) has continued to develop carefronting by integrating the concept of forgiveness. The main thesis of this work is that when people forgive each other, they are both set free to meet genuinely and be fully present with each other. As Augsburger has explained, forgiveness lets go of anger, blaming, and avoidance; it comes to terms with the past and allows it to be truly past, thus allowing right and just relationships to evolve.

Kupperschmidt’s Adaptation of Carefronting

Although Augsburger’s model of carefronting was published more than three decades ago, it remains relevant and pertinent today. In a 1994 publication, Kupperschmidt adapted carefronting to nursing, noting that carefronting means caring enough about one’s self and goals to confront in a caring, self-asserting, responsible manner. She pointed out that carefronting considers nurses’ failure to confront as dishonest communication, a form of communication which negates the importance of relationships and goals. Kupperschmidt noted that carefronting is honest communication because in carefronting one states what should be stated (I want and deserve to be treated with respect) and what needs to be/should be stated (You and I have an ethical imperative to treat each other with respect); and it refuses to confuse the ‘should’ and the ‘need.’ In this article Kupperschmidt provided examples of ways to carefront, questions to be avoided, and strategies that allow colleagues to save face when being carefronted, stressing that carefronting embodies forgiveness, a complex process of restoring caring and valuing, addressing the anger engendered by previous disrespectful behavior, and focusing on the here and now.

Professional nurses of all generations must acknowledge they are currently or have been angered and/or hurt by disrespectful treatment at the hands of another professional RN. Professional nurses must learn to carefront in order to become the caring professional nurses they purport to be. Provision 1.5 of the Code of Ethics (ANA, 2001), page 9, states that the professional nurse must treat colleagues with respect and maintain a commitment to resolving conflicts with colleagues. In other words, each professional nurse has an ethical duty to resolve workplace conflicts. Becoming skilled in carefronting should assist individual nurses to embrace this ethical imperative and more skillfully address and resolve conflicts.

Several scholars have identified how carefronting can strengthen relationships among professional nurses. DeMarco (1998) asserted that caring enough to confront in the workplace is an ethical imperative for nurses. She shared findings from two studies in which staff nurses reported they chose not to confront nursing colleagues’ unacceptable behaviors because they were concerned that confronting colleagues would damage the relationships and engender reprisals, such as unwillingness to provide needed assistance and refusing to offer collegial help. In 2003 DeMarco and Roberts expressed their belief that if nurses will find ways to support one another socially and care enough about each other to be direct and confront, professional relationships among nurses will improve and respect will be heightened. Thus carefronting holds great promise as a strategy to help nurses representing various generational cohorts come to understand each other more fully.

Recently Patterson, Grenny, McMillan, and Switzler (2005) endorsed crucial confrontation, a concept similar to carefronting, in conflict situations when the stakes are high. These authors stressed the need to start with the heart by asking the following three questions:

• What do I want for me out of this relationship?
• What do I want for others out of this relationship?
• What do I want for the relationship?

They explained that professional nurses’ answer to these questions should be, “I want the ability to work together to provide safe patient care in an environment based upon mutual respect.” Patterson et al. added that confrontation involves holding someone accountable by confronting them face-to-face, in situations involving disrespect.

Nursing Management’s Responsibility for a Respectful Environment

The ANA Code of Ethics notes it is the responsibility of both individual staff nurses and nursing management to facilitate an environment of respect. Provision 6 of the Code notes that managers and administrators are responsible for setting standards and managing the environment of care to assure that each employee is treated fairly and is able to practice in an environment conducive to the provision of quality health care consistent with the values of the profession (ANA, 2001). Adoption and enforcement of a zero tolerance policy for disrespectful behavior clearly communicates the expectation that “the nurse in all professional relationships practices with…respect for the inherent dignity, worth and uniqueness of every individual....” (ANA, 2001, p. 7).

Rowe and Sherlock (2005) conducted a study to identify the types and frequency of verbal abuse nurses experienced. Respondents reported that the most frequent source of abuse was other nurses. Rowe and Sherlock noted that this disrespectful behavior increased job stress and decreased job satisfaction. They decried the fact that nurses have been taught to simply ‘grin and bear it,’ pointing out that disrespect in the form of verbal abuse is quite costly to the individual nurse, the hospital, and the patients. They charged managers and administrators to adopt a zero tolerance policy for disrespectful behavior.

Managers can adapt cultural diversity educational offerings to address generational diversity. Kupperschmidt (2000) described an array of generationally savvy management strategies based on the ACORN business model. Strategies within this acronym include: Accommodating employee difference; Creating workplace choices; Operating from a theoretically-sound, sophisticated management style; Respecting employees’ competence and initiative; and Nourishing retention. Laschinger (2004), and Laschinger and Finegan (2005), noted that when nurse managers provide access to information, support and resources, and opportunity for development, employees perceive they are respected.

In a short article directed toward managers, Sanford (2005) presented a particularly poignant vignette. She described a toxic work environment that was allowed to continue for 14 years because professional nurses (staff and managers) refused to carefront the disrespectful behavior of an RN named Mary. Sanford asserted that allowing Mary’s behavior to continue provided a model and gave other nurses permission to be disrespectful. She stressed the importance of managers, as well as staff nurses becoming competent in confrontation skill, thereby setting the expectation for mutual respect.

Summary

In summary, each generation of professional nurses brings different generationally influenced strengths and values to the workplace. It is a professional responsibility to become knowledgeable regarding these differences in strengths and values, and to use them as a fulcrum to increase mutual respect (Kalisch & Begeny, 2005). Selected questions professional nurses might use to assist them to identify and effectively use colleagues’ generationally influenced strengths are included in the Table. If all professional nurses assume their ethical responsibility to treat others with respect and to carefront disrespectful behavior, their practice will be consistent with their professional values. Assuming this responsibility will create environments conducive to the provision of quality health care and workplaces having a minimum of multigenerational disrespect and conflict.

Author

Betty R. Kupperschmidt, EdD, RN, CNAA
E-mail: Betty-kupperschmidt@ouhsc.edu

Dr. Kupperschmidt holds a Master’s degree in nursing and a Doctorate in Higher Education Administration. She has held a variety of leadership roles, including Clinical Director at a major medical center in Tulsa and Head of two Baccalaureate Programs. She is completing her 14th year as Associate Professor at the University of Oklahoma - Tulsa, teaching the theory and clinical content of the Administration Pathway. A request from local nurse executives for help with leading and managing Generation X staff nurses led her to develop expertise in this area which is now recognized at state, national, and international levels.

American Nurses Association. (2001). Code of ethics for nurses with interpretive statements. Washington: American Nurses Association.