The average age of Registered Nurses (RNs) in the United States is 51 yearsThe average age of Registered Nurses (RNs) in the United States (U.S.) is 51 years (National Council of State Boards of Nursing [NCSBN], 2021). With many RNs approaching traditional retirement age and nursing school leaders facing barriers to increasing student enrollment, a substantial nursing shortage in the United States is anticipated (American Association of Colleges of Nursing [AACN], 2020). The greatest deficit of nurses is predicted in the southern and western U.S. regions (Zhang, Tai, Pforsich, & Lin, 2018). National nursing school enrollment increases of 5.1% in 2019 are insufficient to meet expected future nursing service needs, with nursing faculty shortages contributing to limited student admissions to nursing schools (AACN, 2020).

...retention of the nursing workforce is needed to meet projected future nursing care demands...In addition to educating new nurses, retention of the nursing workforce is needed to meet projected future nursing care demands, particularly with respect to the chronic conditions of the aging U.S. population and subsequent complex healthcare needs (Uthaman, Lert, & Yuh, 2016). Many RNs experience psychological distress due to job-related stress and burnout (Ross, Letvak, Sheppard, Jenkins, & Almotairy, 2020) and job dissatisfaction can lead to nurses leaving the profession (Chen et al., 2019).

Inability to retain older nurses represents a potential loss of valuable expertise...Research to examine experiences of nurses during the COVID-19 pandemic is ongoing and the literature on nurse experiences of working during the pandemic has rapidly expanded (Arnetz, Goetz, Arnetz, & Arble, 2020; Chen, Lae, & Tsay, 2020; Fernandez et al., 2020; Galehdar, Toulabi, Kamran, & Heydari, 2020; LoGiudice & Bartos, 2021). Yet, there has been limited research to understand perceptions of older, experienced RNs as they work during the COVID-19 pandemic. Inability to retain older nurses represents a potential loss of valuable expertise in the profession (Buerhaus, Skinner, Auerbach, & Staiger, 2017).

Healthcare delivery practices in the U.S. continuously evolve with older nurses who have remained in the workforce through many changes (Uthaman et al., 2016). Their experiences may provide important insights to improve patient care through RN workforce retention during public health crises. To address this gap, the aims of our study were to: (1) Examine relationships between older nurse demographics and context of employment during the COVID-19 pandemic; (2) Explore older RN and Advanced Practice RN (APRN) perceptions of their work experiences during the pandemic; and (3) Identify facilitators and barriers in older nurses’ workplace environments that relate to nurse workforce retention.

Review of Literature

The COVID-19 pandemic has intensified the nursing retention crisis.Retention of RNs within organizations has been a persistent challenge. Prior to the pandemic, RNs had the highest turnover rate (140.7%) among U.S. nursing home personnel, and this trend has been most prevalent in lower-rated, one-star facilities (Gandhi, Yu, & Grabowski, 2021). The COVID-19 pandemic has intensified the nursing retention crisis. The pandemic negatively influenced new graduate nurses’ plans, by limiting employment opportunities and training both in school and clinical settings (Crismon, Mansfield, Hiatt, Christensen, & Cloyes, 2021). Frontline nurses who cared for COVID-19 patients have reported low levels of work satisfaction in Canada (Lavoie-Tremblay et al, 2021) and in Israel (Savitsky, Radomislensky, & Hendel, 2021), with high intention to leave the workplace described by some nurses (Lavoie-Tremblay et al, 2021). Nurse job insecurity concerns include reduction in hours and layoffs for nurses employed in primary healthcare settings (Halcomb et al., 2020) and issues with the availability of personal protective equipment (PPE) for nurses working in hospital (Bullington, 2021) and primary care (Halcomb et al., 2020) settings.

...it is important to consider how to incentivize delayed retirement for older nurses.Research on retention of nurses aged 50 years and older appears to be studied less than retention of nurses of any age. Registered nurses aged 50 years and older represent more than 40% of all RNs working in the U.S. (Health Resources & Services Administration [HRSA], 2018). Considering the large number of working older nurses and the increased need for nursing care, it is important to consider how to incentivize delayed retirement for older nurses. Prior to the pandemic, older nurses reported priority incentives they felt would delay their retirement from the profession. These incentives included the ability to work part-time and a show of respect for older nurses’ expertise through recognition of seniority (Myer & Amendolair, 2014).

Study Methods

Research Design
This feasibility study used a qualitative and descriptive approach to better understand the experiences of older nurses working in the COVID-19 pandemic to inform further research aimed at improving RN retention. Participants were asked to complete an online survey with both closed and open-ended questions designed to elicit older nurses’ experiences and perspectives of what implementations helped or hindered their abilities to provide quality patient care and remain in the nursing workforce during the pandemic. The survey was researcher-designed and informed by recent studies that describe older worker and nurse experiences during the COVID-19 pandemic (Halcomb et al., 2020; Kooij, 2020). The draft survey was piloted with six (6) working RNs aged 50 and older in North Carolina (NC) who were not part of the research team. Their feedback was used to inform the final survey.

Health and demographic questions were included in the final survey to further describe the sample population and give context to the nurses’ working environments. Demographic information collected included age, years of nursing experience, sex, race, level of nursing education, marital status, nursing employment status, rural status, living alone or with someone, and area of nursing practice. Participants were asked the following questions about their workplace environment with yes or no response options:

• Have you been working during the COVID-19 pandemic?
• Have you felt well-protected by your employer with respect to Personal Protective Equipment (PPE) and safety protocols?
• Have you been diagnosed with COVID-19 or believe you contracted COVID-19 as a result of work-related exposure?
• Has your employer offered psychological counseling to you during the current pandemic?
• If offered, did you participate in the counseling offered by your employer?

To solicit experiences and perceptions about workplace healthcare culture, the survey included the following open-ended questions:

• How has your mental and/or physical health changed during this pandemic?
• What steps, if any, has your employer implemented to improve RN retention and well-being for Registered Nurses?
• Is there anything you’d like to share about your healthcare system culture?

Data Collection
...study participants included RNs and APRNs aged 50 years and older...This research received Institutional Review Board approval from Western Carolina University. Inclusion criteria for study participants included RNs and APRNs aged 50 years and older who could read and speak English and were registered with the North Carolina Board of Nursing (NCBON) as an RN or APRN working in any of NC’s 100 counties.

The sampling frame was derived from the NCBON listing of RNs who work in NC; this registry is publicly available for a fee. After sorting by county name, the email address of every fifth entry on the registry was selected for inclusion on the final contact list. We used this method of systematic, stratified, random sampling to increase generalizability of our study findings. Email invitations were sent to 6500 RNs and APRNs on the final contact list until enrollment ended. Some emails (n = 27) were returned as undeliverable and 6473 RNs and APRNs across NC were ultimately contacted with a final analytic sample of 195 participants. Surveys were completed between August 2020 and January 2021 and participants received small remuneration in the form of an online store gift card. Survey responses were not linked to participant email addresses.

Trustworthiness and Credibility
Several strategies to ensure internal validity (Creswell & Creswell, 2018) were implemented during this study. Multiple team members analyzed the qualitative narrative data using emergent qualitative content analysis to identify codes and themes. Research team members independently reviewed the open-ended responses one question at a time to create an impression of the content and identify codes. We then met as a group to review and discuss the initial findings and early impressions of key thematic ideas. Three team members reviewed and compared initial findings of responses to all questions together and initial themes were developed and refined to reach consensus.

Data Analyses
A profile of our analytic sample is provided via descriptive statistics. Assumptions of Normality, absence of outliers, and homogeneity of variance were assessed for continuous variables (age and years of nursing experience) and were satisfied in testing. Pearson’s correlations were performed to examine associations between demographic characteristics and working environments. All tests were two-sided with significance set at the 0.05 level. Analyses were performed in SPSS v26.

Results

Aim 1: Examine Relationships
Of the 32.3% who reported that psychological counseling was offered to them, only 1.6% participated.Study Aim 1 was to examine relationships between older nurse demographics and context of employment during the COVID-19 pandemic. The study sample consisted of 195 RNs or APRNs who were employed throughout NC. Sample mean age was 59.8 ± 6.8 years with participants having an average of 30.4 ± 11.4 years of RN experience. Most participants were female (92.8%), White (90,3%), married (73.3%), and living with someone (83.1%). Nearly half (47.7%) of the sample population resided in rural areas (Table 1). Most respondents (86.2%) were working full-time as nurses during the COVID-19 pandemic in moderate-to-high patient acuity settings and felt their employers provided adequate PPE for employees (73.3%). Only 5.6% of participants reported being diagnosed with COVID-19 or having contracted COVID-19 through work-related exposure. Of the 32.3% who reported that psychological counseling was offered to them, only 1.6% participated.

Table 1

Demographic Information

Pearson’s correlation analyses showed significant relationships between participant demographics and context of employment during the COVID-19 pandemic (Table 2). Associations between years of nursing experience and educational level, marital status, employment status (full-time or part-time/retired from nursing), working during the pandemic, and work-related COVID-19 exposure emerged, although many were weakly correlated. This suggests that, in this sample, RNs who reported working during the pandemic had fewer years of nursing experience and lower levels of education. There was a weak relationship between rural status and level of education, with rural-dwelling RNs reporting lower levels of education compared to RNs residing in urban areas. A strong correlation emerged between having part-time/retired from nursing employment status and not working during the pandemic. Living alone was positively associated with feeling protected by one’s employer.

Table 2

Correlations of Sociodemographic and Employment Characteristics

Aim 2: RN and APRN Perceptions
Study Aim 2 was to explore older RN and APRN perceptions of their working experiences during the pandemic. Most participants (90.3%) responded to the question, “How has your mental and/or physical health changed during this pandemic?” Response rate to the question, “What steps, if any, has your employer implemented to improve RN retention and well-being for Registered Nurses?” was 82.6% and 60% of participants answered the question, “Is there anything you’d like to share about your healthcare system culture?” Five thematic ideas were identified in the data, expressed here as major codes and thereafter further described: Exposed, Exhausted, Seeking Balance, Timing of Employer Response, and Variation in Workplace Caring Culture (Table 3).

Table 3

Emerging Themes

Some participants (n = 28) reported no mental or physical health changes due to the pandemic. However, many reported feelings of being exposed, helpless, or vulnerable to the unknown or uncontrollable variables in the working environment, and experienced mental health effects such as depression, fear, worry, and anxiety. Related to the theme, Exposed, one participant described this as, “I have been exposed several times at work which causes me to worry about my family getting the virus.”

Reported tiredness and exhaustion was recurrent in participant responses...Reported tiredness and exhaustion was recurrent in participant responses, and supported the emerging theme, Exhausted. This included physical health impacts such as inability to fall asleep and/or stay asleep, increased blood pressure, headaches, body aches, inability to exercise, and in so many words, “Exhausted from mandatory extra shifts.”

Mental health impacts were reported related to social and work isolation during the pandemic. Several supporting quotes of this nature included, “My circle of support is dwindling” and “I don't want to talk to neighbors or friends.”

Nurses expressed their concern for their ability to care for patients while still protecting themselves and their loved ones during the pandemic. This led to the theme of, Seeking Balance, with one participant noting, “Always on the edge a little to ensure I am protecting myself & the patient/family.”

The theme Timing of Employer Response related to measures taken by the RNs’ employers and the timing of the assistance, if it occurred at all. When asked about the assistance offered to them by their healthcare employers during COVID-19, some participants reported that no employer assistance had been offered, one person stating: “They haven't. We voted in a union, but it hasn't helped yet, in fact it has made it harder so far.”

Some participants viewed policy changes or interpretations of policies as ageist.Some participants viewed policy changes or interpretations of policies as ageist. A few respondents indicated that a lack of employer assistance resulted in their unplanned retirement. Policies were implemented at some healthcare delivery systems that were perceived as discouraging older RNs to remain in practice, such as increasing weekly work hours with no options to work a reduced load. Several quotes directly addressing age included:

• My previous employer declined to offer a reduced hourly position, resulting in my retirement when I could no longer work a 40-hour job.
• Before I retired I did try for a different job within the hospital, but because of my Age I am Positive the only reason I was not able was because of my Age.
• All senior employees were basically forced out.
• Recently no longer used as PRN by another agency due to my age-
• Replaced with younger full time employee perceived ageism.

Others reported positive employer responses to the emergent needs of healthcare employees, as exemplified in this quote: “Promote wellness activities i.e. exercise programs, mindfulness activities, sleep support, emotional and financial well-being, resources for living, counseling, flexible work schedules, and encouraging employees to take time away from work.”

Finally, the theme, Variation in Workplace Caring Culture, was apparent through the aid provided or not provided by employers for the RNs. An interesting finding involved communication. Many participants described a lack of communication in their workplaces, while others described open and frequent communication as one of the best aspects of their workplace culture, including these examples below:

• The supervisor and nurses on our team are supportive of one another. We have telephone team meetings and weekly individual reflection with our supervisor.
• We have had many great nurses leave to take jobs at other hospitals and nothing was done to try and keep them.
• …is soulless and continues to lay off and eliminate positions and departments. They just decreased security staff by half!!

Aim 3: Facilitators and Barriers
Study Aim 3 was to identify potential facilitators and barriers in older nurses’ workplace environments that relate to nurse workforce retention. Facilitators for RN workforce retention included work flexibility and/or resources and implementing ways that made experienced, older RNs feel included, valued, supported, and protected. Barriers to RN workforce retention were inadequate workplace orientation; unsafe patient assignments; micromanaging; implementing policies perceived as ageist; and making pay and benefit-related policy changes without RN input or feedback (Table 4).

Table 4

Facilitators and Barriers in the Workplace

Discussion

...older nurses who have less time in the nursing workforce may financially need and/or want to work as long as possible. Compared to RNs with less nursing experience, those with more nursing experience had higher levels of education, were unmarried, worked part-time or not at all during the pandemic, and reported less work-related COVID-19 exposure. While the average study participant had more than 30 years of nursing experience, these results indicate that participant RNs who worked the most during the COVID-19 pandemic constituted a lower educated and less experienced workforce. It is important to note that age was not significantly associated with years of nursing experience, as one might expect. This finding may reflect new pathways to enter the nursing profession later in life than the 4-year traditional student pathway. As nursing is increasingly becoming a second career for many (AACN, 2020), older nurses who have less time in the nursing workforce may financially need and/or want to work as long as possible. Finding lower levels of education for rural RNs compared to RNs living in urban areas aligns with previous evidence (Probst, McKinney, & Odahowski, 2019). Despite statistical significance, many of the Pearson r values in this feasibility study did not indicate strong relationships between measured variables of participant demographics and context of employment. Further research is warranted in larger, more diverse RN populations.

Several RNs indicated the need to balance duty-to-help with duty-to-protect oneself and family...Several RNs indicated the need to balance duty-to-help with duty-to-protect oneself and family, as previously reported in a systematic review (Fernandez et al., 2020). Similar to other studies of RNs of all ages working during the COVID-19 pandemic (Arnetz et al., 2020; Chen et al., 2020; LoGiudice & Bartos, 2021), RNs in our study described initial feelings of being exposed to more recent mental and physical exhaustion with most mental health impacts centered on fear, stress, depression, and anxiety. Given that psychological stress symptoms are related to nurses exiting the profession (Chen et al., 2019), a situational specific theory, Systemic Assessment of Depressive Symptoms among Registered Nurses (SAD-RN), could be useful to guide future research aimed at improving the mental health of nurses and increasing nursing workforce retention (Ross et al., 2020). One of this theory’s key concepts is coping processes as protective factors against depressive symptoms in RNs (Ross et al., 2020).

Many older nurses in our study reported concerns for the quality of care they were able to deliver...The relationship between RN staffing and patient care quality has been examined, with higher patient loads related to higher hospital readmissions (Giuliano, Danesh, & Funk, 2016) and higher levels of missed patient care (Griffiths et al., 2018). Many older nurses in our study reported concerns for the quality of care they were able to deliver, given time constraints due to staffing levels. Some participants considered leaving the nursing profession due to their perceived inability to meet safe patient care needs related to inadequate nurse staffing.

Demand for nursing care and concern that growth estimates are inadequate to meet future healthcare needs reinforces the importance of retaining older nurses in the workforce (Uthaman et al., 2016). With an average nursing experience of 30 years, criticisms from some of this study’s participants are likely justified as they are based on substantial experience. Nursing intuition is supported by years of research that recognizes intuition as a form of knowledge that includes both experience and expertise (Chilcote, 2017; Green, 2012; Hassani, Abdi, & Jalali, 2016). Recognizing the value of intuitive knowledge based on experience and expertise in the nursing workforce is essential. Older nurses’ experiences and expertise could be tapped to identify solutions and strengthen the nursing workforce.

Recognizing the value of intuitive knowledge based on experience and expertise in the nursing workforce is essential. Some evidence of real or perceived ageism emerged from our data and this prejudice may threaten successful retention of older RNs and APRNs in the profession. It is important to acknowledge that older workforce retention situations may be complicated by the pandemic due to the vulnerability of some older adults to the COVID-19 virus (Ayalon et al., 2020).

Identified retention facilitators included proactive and protective measures taken by healthcare leadership, with many of these actions not attached to monetary resources but related to communication. Participants felt highly valued when included in decisions that impacted their workplace environment and ability to care for and protect their patients and themselves, as found in the COVID-19 related literature (Arnetz et al., 2020; Chen et al., 2020; LoGiudice & Bartos, 2021).

Participants felt highly valued when included in decisions that impacted their workplace environment...A general appreciative perspective of older RNs by healthcare leadership yielded positive and loyal feelings in older RNs towards their workplace. Interestingly, encouraging words and actions from leadership within healthcare workplace cultures were appreciated more than additional compensation by some older RNs. Having better communication strategies in place is a relatively easy and inexpensive implementation for employers to consider.

Some barriers have been reported pre-COVID-19 and may have been exacerbated by the pandemic.Barriers identified from the data naturally organized into implementations (or lack of) that either negatively impacted patient and/or RN safety or implementations (or lack of) that negatively impacted the employment experience. Implementations that negatively impacted safety included inadequate workplace orientations and inadequate staffing, which concurred with earlier findings (Chen et al., 2020). Implementations that negatively impacted the employment experience of older RNs were related to pay and benefits, micromanagement, and perceived ageist policies. Some barriers have been reported pre-COVID-19 (Ryan, Bergin, White, & Wells, 2018; Uthaman et al., 2016) and may have been exacerbated by the pandemic.

Implications for Nursing

Many facilitators and barriers to keeping older RNs in the nursing profession do not require monetary resources...The RN workforce requires supportive protection for its pivotal role in responding to public health crises. Considering global aging trends, findings from this study can inform ways for healthcare delivery systems to retain experienced, older RNs for improved patient care and simultaneously develop experienced mentors for newly educated RNs. Many facilitators and barriers to keeping older RNs in the nursing profession do not require monetary resources, but rather point to good communication strategies, thoughtful, appreciative, and respectful behaviors, and a flexible mentality to meeting the needs of older RNs and APRNs.

Study Limitations

Participants were recruited from one U.S. southern state Board of Nursing registry for this study. Recruitment and enrollment were limited to individuals who were English-speaking and had online email access. The sampling frame used was limited to RNs and APRNs, which excluded other nurses, such as Licensed Practical Nurses who may have perspectives and experiences that differed. With a 3% online survey completion rate, the final recruited study sample included mostly white and female participants, thus limiting the presented perspectives. One explanation for the low response rate may be that nurses during the COVID-19 pandemic were too busy providing care or too tired after working to take the time to complete the email surveys. Another possible explanation contributing to the online study’s response rate may be that the older participants in this study represent Generation X and Baby Boomer populations, with both groups known to have lower technology adaptation levels compared to other generations (Vogels, 2019). The research team was unable to analyze responses of RNs and APRNs separately due to unequal group sizes, with most respondents being RNs. The data were considered as group data that included both RNs and APRNs. There may be unknown specific differences between the groups of RNs and APRNs to explore in future research.

Conclusion

Mental and physical health of many older RNs and APRNs has been negatively impacted during the COVID-19 pandemic...The goal of our study was to examine older RN and APRN perceptions of their work experiences during the COVID-19 pandemic to identify potential facilitators and barriers in their workplace environments that relate to RN workforce retention. Mental and physical health of many older RNs and APRNs has been negatively impacted during the COVID-19 pandemic, with greater emphasis on mental health. Our results show facilitators and barriers gleaned from nurse participants’ words that focus on improving the valuation of older RNs and APRNs and the expertise they bring to quality patient care and to mentoring new nurses to the profession. The information resulting from this study may assist healthcare delivery system leadership in nursing workforce retention efforts to meet growing nursing needs for the best patient care outcomes.

Author Note

We have no known conflict of interest to disclose. Correspondence concerning this article should be addressed to Francine H. Sheppard, College of Health and Human Sciences, School of Nursing, 3971 Little Savannah Road, Cullowhee, NC 28723; phone 704-466-1250 or at the email below.

Authors

Francine H. Sheppard, PhD, RN, CNE, CDP
Email: fsheppard@wcu.edu
ORCID ID: 0000-0001-8145-3084

Francine Hebert Sheppard is an Assistant Professor in Western Carolina University’s School of Nursing. She received an MSN in Education from Gardner-Webb University and a PhD in Nursing from The University of North Carolina Greensboro. In 2021, Dr. Sheppard was named a Distinguished Educator in Gerontological Nursing by the National Hartford Center of Gerontological Nursing Excellence. Her clinical practice specialties are in mental health and geriatrics. Dr. Sheppard’s research examines mental and physical health outcomes of older adults during life transitions with her publications, grants, and presentations focusing on the transition of retirement and older workforce concerns, including holistic health and ageism. She has presented her research regionally, nationally, and internationally.

R. Turner Goins, PhD
Email: rtgoins@email.wcu.edu
ORCID ID: 0000-0001-6875-1263

R. Turner Goins received an MS and PhD in Gerontology from the University of Massachusetts-Boston and completed a National Institutes of Aging’s research post-doctoral fellowships at Duke University’s Medical Center in Epidemiology. For the last 22 years, Dr. Goins’s research has focused on American Indian and Alaska Native aging-related issues. She has had the pleasure of working with many tribal communities across the U.S. in the area of elder health. Dr. Goins’s research adopts a community-based participatory research approach, wherein her research examines issues of local importance. In 2018, she was a J. William Fulbright Scholar at the University of Auckland which allowed her to examine physical and cognitive health issues among older Māori. Dr. Goins has received over 5.7 million dollars in support of her research program, including funding by the National Institutes of Health, Centers for Disease Control and Prevention, Health Resources and Services Administration, the Claude Worthington Benedum Foundation, the National Council on Aging, the Reed Foundation, and the Cherokee Preservation Foundation. She is a fellow in the Gerontological Society of America and served as the President of the Southern Gerontological Society (2016-17).

Ratchneewan Ross, PhD, RN, FAAN
Email: ratchneewan.ross@louisville.edu
ORCID ID: 0000-0003-2005-341X

Ratchneewan Ross is a professor at the University of Louisville, was the Cone Health Distinguished Professor at the University of North Carolina at Greensboro, and was PhD nursing program director at Kent State University in the USA. She was Assistant President for Academic Affairs at Burapha University, Thailand. Her areas of expertise include mental health, measurement, and mixed methods. She has numerous publications and serves on editorial teams for several journals in Brazil, Thailand, and the USA.

Kathleen Conte, PhD
Email: kathleen.conte@sydney.edu.au
ORCID ID: 0000-0002-5429-429X

Kathleen Conte holds a PhD in Public Health and a Masters in Bioethics and Medical Humanities. She has over 7 years’ experience and training in qualitative research in a variety of methods, and currently teaches masters-level courses in Qualitative Research and Research Methods at DePaul University. She has over 15 years’ experience working in health promotion and community contexts, as well as clinical settings.

Nicole Zonin, MSN, RN
Email: nzonin@gmail.com

Nicole Zonin is a Director of Utilization and Care Management. She received a bachelor’s degree from Western Carolina University and Master’s in the Nursing Leadership program. Her clinical practice specialties are in mental health, acute rehab and geriatrics. As a Graduate Assistant for the Baccalaureate programs at Western Carolina University, Mrs. Zonin assists with nursing research and nursing geriatric courses with a focus on cultural diversity and mental health.