Never before has healthcare been so complex. Patients are going to the hospital sicker and leaving quicker. Technology is rapidly changing how we care for patients. Healthcare workers often hear ‘do more with less’ and this expectation becomes the norm rather than the exception. Adding to the dynamics of this multi-faceted work environment is the “cross-pollination” or the converging of multigenerational healthcare workers (Mercier, 2012).

A workforce that encompasses several generations must learn to work together, forming teams and recognizing the inherent diversity in order to deliver effective healthcare and meet desired patient outcomes. A workforce that encompasses several generations must learn to work together, forming teams and recognizing the inherent diversity in order to deliver effective healthcare and meet desired patient outcomes. The purpose of this article is to summarize generational traits, analyze characteristics of cohesive teams, and provide strategies to create an environment where teams thrive and patient outcomes flourish.  We first briefly define generational cohorts by characteristics, and discuss differing expectations for work/life balance and potential negative outcomes. Our discussion offers team strategies for positive outcomes, a case scenario, and resources for team building and organizational opportunities.

Generational Cohorts by Characteristics

Currently, there are four unique generational cohorts represented in the clinical workforce. A generational cohort is often grouped according to year of birth; events that occurred during their lifetimes; and life events, such as wars, technological advancements, or economic conditions (Smith, 2015). Interestingly, these events tend to create the personalities, values, and beliefs of a given generation. Blending the unique perspectives of these generations in the workforce can be perplexing at best.

 It is important to seek multigenerational understanding among the various cohorts. Rather than favoring one generation over another, institutions can benefit from celebrating differences and promoting strengths of the various generational cultures that currently comprise their workforce. It is important to seek multigenerational understanding among the various cohorts. Indeed, safety and positive working conditions demand mutual respect and cooperation. The patient and the institution both benefit by addressing team-building as a solution to shared understanding and reciprocal appreciation among different generations. Institutional leaders must capitalize on the attributes of each generation to meet the demands of their organization and create effective teams (Stanley, 2010).

Each generation has cultural values and traits, formed by defining events in their youth, which also manifest in the workplace. The current nursing workforce is made up of four generational cohorts that each have unique qualities. These cohorts span from 1925 to 2000 and are comprised of the Veterans, Baby Boomers, Generation Xers, and Millennials. Each generation has cultural values and traits, formed by defining events in their youth, which also manifest in the workplace (Cox & Holloway, 2011). The following tables highlight the multigenerational representation in the current workforce. Table 1 summarizes general information and traits for each of these cohorts. Table 2 outlines the current workforce percentage by age groups for certified nurse assistants (CNA), licensed practical nurses (LPN), and registered nurses (RN).

Table 1. General Characteristics by Cohort

Table created by the authors (Cox & Holloway, 2011; Douglas, Howell, Nelson, Pilkington, & Salinas, 2015).

Table 2. Workforce Demographics

Table created by the authors (U.S. Department of Health and Human Resources, 2011; U.S. Department of Health and Human Resources, 2013).

In addition to the characteristics inherent to individual generational cohorts listed in Table 1, research has demonstrated that individuals from different generations also have differing expectations regarding work/life balance (Roebuck, Smith, & El Haddaoui, 2013). The next section describes some of these differences, which may significantly impact workplace relationships, collaboration, and outcomes.

Work/Life Balance

What constitutes work/life balance changes at various stages of careers and different factors become significant to people as they age. Work/life balance is defined as, “the '‹amount of '‹time you '‹spend doing '‹your '‹job '‹compared with the '‹amount of '‹time you '‹spend with '‹your '‹family and doing things you '‹enjoy” (Cambridge Dictionaries Online, 2016, para. 1) What constitutes work/life balance changes at various stages of careers and different factors become significant to people as they age (Roebuck et al., 2013). A recent survey by the Society of Human Resource Management found that among all the generations, 89% of Americans are working longer hours and report work/life balance to be a problem (Roebuck et al., 2013).

Veterans, while small portion, are still in the workforce and may be dealing with their own health concerns. Many who have made poor financial plans find work a necessity rather than an option. This generational group may not possess the stamina to work long hours but may still want to or remain in the workforce. Work/life balance for this generation means working in a flexible environment that is less demanding to accommodate the desire to work with the reality of declining health (Life Directions, 2005; Workflow Management Coalition, n.d.).

Baby boomers live to work and will sacrifice personal interests until the job is complete (Johnson, 2015). Unfortunately, this group may be caring for elderly parents. This group of baby boomers is also known as the sandwich generation; these individuals may also have grown children living with them. Boomers may have drawn attention to the concept of the work/life balance but younger workers from Generation X and Generation Y place an even higher value on blending occupational demands with family pressures (Roebuck et al., 2013).

Generation X demands work/life balance as a backlash to baby boomers’ intense dedication to employers and long hours spent at the office (Johnson, 2015). Generation Xers often have a large amount of debt related to mortgages and student loans, and may also be caring for small children. Allowance of family needs is vital to this group in terms of work/life balance.

Millennials prefer flexible schedules, telecommuting, casual dress code, and other perks not enjoyed by previous generations (Bergstrom, 2015). Indeed, this generation is known for expecting flexibility from employers. Many millennials consider work/life balance an important criterion for selecting a place of employment. A survey completed by Kirschner (2015) indicated that more than one in four millennials were disillusioned with their current job and listed unproportioned work/life balance as the reason (Kirschner, 2015).

Nursing as an occupation is largely comprised of women, so organizations that wish to attract younger talent must be creative with ways to entice and retain this cohort. Since the millennial generation will encompass the largest generation in the workforce in 10 years, this aggregate will represent 75% of those employed (Johnson, 2015). Additionally, these millennial women will still bear the majority of caregiving responsibilities for children and ill family members, so it is vital to accommodate their life/work balance needs.

While maximizing the strengths, needs, and desires of these generational cohort...  can contribute to effective teams, failing to do so can lead to poor outcomes. While maximizing the strengths, needs, and desires of these generational cohort based on their differences can contribute to effective teams (Stanley, 2010), failing to do so can lead to poor outcomes. The next section briefly describes the potential for several common negative workplace outcomes, such as incivility, stressors and errors, and stereotyping.

Potential Negative Outcomes

Incivility

All individuals desire respect along with being valued within an organization. Understanding generational differences has the ability to decrease incivility in the workforce. Left unchecked, incivility disrupts patient care and erodes organizational morale. Incivility may put patients at risk. For example, tension in the workforce may lead to mistakes and carelessness in the care provided to patients. Generational differences, left misunderstood, have the potential to damage the workforce by increasing staff turnover, resulting in substandard patient care, poor outcomes, and higher costs to the organization (Stanley, 2010).

Stressors and Errors

... key negative outcomes of additional stressors, and even errors, may result from poor practices that have become routine. Effective communication is vital for an institution to succeed, and differences in priorities, skills, and perceptions inherent to generational cohorts may lead to miscommunication. In the first author's experiences, a large amount of anecdotal evidence has suggested that key negative outcomes of additional stressors, and even errors, may result from poor practices that have become routine. For example, older providers may sometimes delegate the task of medication order entry into the computer. This practice, which may arise from a lack of comfort and skills with technology, can create increased workload for already busy nurses. Using an additional person in the medication entry process offers an additional opportunity for error. Ultimately, poor practices which have become routine, and may be based on generational variances, may also create team based problems.

Stereotyping

Stereotyping generational characteristics leads to misconceptions and dysfunction (Stanley, 2010). Thus, it is prudent to note that, within each generational group, individuals bring their own unique personalities and cultural imprints. Often, an individual may be stereotyped by his or her generational cohort (e.g., Millennial = lazy, not motivated). However, it may more accurately be that these characteristics are typical to his or her personality, and not generational in nature. Recognizing and embracing the cultural diversity of the workforce, in general and by generational characteristics, can be a factor to consider when addressing retention and recruitment variables (Stanley, 2010).

The acknowledgement of generational strengths may result in improved orientation, mentoring, retention, and diminished peer conflict (Barry, 2014). In the long run, these efforts may then help organizations to avoid potential negative outcomes. They may improve patient safety and save revenue. Expert nurses, who have a depth of knowledge and experience, are able to mentor novice nurses. The wisdom and information that they can provide is often not taught in the classroom (Concordia, 2016). Novice nurses can be great assets in the area of testing new technology and subsequently mentoring nurses from older generations.

...to create a nonjudgmental, cohesive environment that minimizes the potentially negative organizational outcomes described above... leaders [need to] promote acceptance and understanding of all generations. In sum, to create a nonjudgmental, cohesive environment that minimizes the potentially negative organizational outcomes described above, we recommend that leaders promote acceptance and understanding of all generations. There is always an ongoing influx of novice nurses and impending retirement of expert nurses contributing to the mix of generational perspectives. Research suggests teams are stronger when members possess different experiences, attitudes, and perspectives (Sherman, 2015). Diverse teams also have a tendency to be more creative and adept at handling challenges. Therefore, it is imperative to develop and implement new strategies for all generations to work as cohesive teams. An organizational culture comprised of several generations has the potential to flourish if differences are understood and respected. In the next section, we describe evidence supporting teamwork and offer several teambuilding strategies to promote positive outcomes.

Team Building Strategies for Positive Outcomes

Evidence for Teamwork

Studies have demonstrated that teamwork leads to greater job satisfaction with present occupation and current position (Kalisch, Lee, & Rochman, 2010). Corrigan, Donaldson, Kohn, McKay, and Pike (1999) completed a study that directly links effective teamwork to patient safety. Organizational approaches vary. Successful organizations may support team-building via retreats or goal focused meetings. The purpose of such activities is to sustain and improve successful communication (Gonzalez & Rolman, 2010).

Positive organizational outcomes can be achieved by supporting good teamwork. Positive organizational outcomes can be achieved by supporting good teamwork (Gonzalez & Rolman, 2010). Equity and fairness ensure no generational cohort dominates and everyone’s view is perceived as important. Research has demonstrated that teamwork increases effectiveness because teams can achieve more than individuals alone. It is not simply due to the increase of people; the achievement is obtained through pooling of knowledge, skills, and creative energy (Gonzalez & Rolman, 2010).

Leadership is required to build a strong foundation for a team (Gonzalez & Rolman, 2010). This leadership must promote time and resources; clear goals and objectives; and trust. Ideally, team leaders are those members who can motivate others and have profound listening skills. Team leaders are empowering participants, communicating vision, providing resources, and helping members overcome adversity. Leaders need patience, honesty, and balance to create successful teams.

Organizations that promote team-building improve problem solving and morale, leading to healthier work environments. Organizational effectiveness enhances learning and openness. Amplification of energy and productivity are by products of successful institutions. Working collegially with members from various generations promotes acquisition of wisdom and new ways of thinking in an ever-changing environment. This effective team culture enhances the way patients receive care (Gonzalez & Rolman, 2010). For example, many times, seasoned nurses are able to provide prioritization, while younger counterparts can initiate technological advances.

Team-Building Concepts and Activities

Healthcare organizations and the patients who receive care within those facilities want nursing teams to work together and accomplish the goals of improved patient outcomes. Doing so results in a culture of synergistic ideas (Mercier, 2012). Four activities assist in building highly effective multigenerational teams: open communication, inclusion, trust, and conflict resolution (Cox & Holloway, 2011; Mercier, 2012). Successful multigenerational teams have engaged in activities that increased their ability to communicate, created an inclusive environment, built trusting relationships, and learned how to deal with conflicts.

Open communication. The ability to communicate is a cornerstone of effective intergenerational teams. Each generation has a different perspective of acceptable channels of communication (Cox & Holloway, 2011). Millennials will most likely view text messaging with the associated abbreviations as a preferred method of communication, while baby boomers favor face to face communication and may find text messaging impersonal and confusing (Cox & Holloway, 2011; Douglas et al., 2015). Effective teams work to develop an understanding of how each generation represented communicates by open discussion and agreement about modes of communication that the team will utilize. A skilled nursing leader will use several modes of communication. Meetings once a month are one option or communication via email. The use of a mailroom bulletin board may also reach others who prefer this method. Various methods of communication demonstrate respect for all. Multiple channels provide varied and effective communication.

All generations can agree that providing competent and safe care and being compassionate are paramount in the healthcare setting. The “Ask Me” team-building activity can facilitate learning about one another and improve communication. Have the group break down into small teams of five to ten. Assigning members to groups may ensure representation from multiple generations on each team. Have team members ask questions about one-another. Types of questions that may help understand the different generations include:

• What was your first car?
• Name the most popular music group or song when you were in high school?
• What was your favorite song in high school?
• Describe your typical Saturday activities when you were in school?

A representative of each team should then share what each group learned.

Inclusion. Teams comprised of multigenerational members need to be inclusive. Inclusion can be increased by objectively attempting to comprehend and assess behaviors of those from diverse generations (Cox & Holloway, 2011). Millennials and Generation X team members need to work to appreciate the affinity that baby boomers have for competition and group work, while baby boomers should admire the self-sufficiency and technological savvy of the younger generational teammates (Douglas et al., 2015; Sherman, 2015). Ultimately, inclusiveness permits team members to recognize and appreciate what they and others have to offer, esteeming and engaging each member of the team.

The “What do we have in common?” activity (Volunteer Power, 2016) can promote recognition of commonalities. Have the team form sub-groups of three. Allow five minutes to talk to one another and identify five things they have in common. Encourage them to stretch beyond the obvious. The five things should not be work-related or common (e.g., they are all nurses, work in the same place, or are the same gender). When the time is up, have each group share the identified commonalities.

Trust is built by team members who consistently perform with integrity and competence. Trust. It is vital to assume positive intent and common goals. All generations can agree that providing competent and safe care and being compassionate are paramount in the healthcare setting (Mercier, 2012). Intergenerational teams that work well together have developed a solid foundation of trust. The presence of trust allows team members to admit errors, discuss weakness, and voice concerns without the fear of reprisal (Douglas et al., 2015). Trust is built by team members who consistently perform with integrity and competence (Cox & Holloway, 2011). In addition, trust can be strengthened by team members who ask for assistance when needed, provide appropriate feedback, and appreciate all members’ expertise and experience (Douglas et al., 2015). It is important for a team to recognize that it only takes one incidence of substandard performance to instill the feeling of mistrust; mistrust leads to more distrust and ultimately to a dysfunctional team (Cox & Holloway, 2011).

The “Mine Field” is an activity that helps to develop trust, communication, and cooperation. Start with a room that has a large open floor space. Place obstacles, such as chairs, tables, or large soft objects, on the floor so that the teams have to navigate around and in between them. In pairs, one member directs a blindfolded teammate across the room without hitting any obstacles. After completion, the pair switches so that each experiences the two roles. This activity can be creatively altered if desired. For example, rather than negotiating a mine field, certain items can be placed around the room so that the blindfolded member can complete a certain task, such as finding a bottle of water, finding an empty glass, opening the bottle of water, pouring it into the glass, and delivering the glass of water to the person giving the directions (howdoyouplay.net, 2016).

High performing teams have developed an appreciation of generational approaches to conflict and have established guiding principles that frame conflict as beneficial. Conflict Resolution. Highly effective teams have established open communication, trust, and inclusion that then facilitates successful conflict resolution (Cox & Holloway, 2011). Conflict resolution includes measures of aggressiveness, opposition, teamwork, collaboration, accommodation, and avoidance. High performing teams have developed an appreciation of generational approaches to conflict and have established guiding principles that frame conflict as beneficial (Douglas et al., 2015). It is important for teams to recognize that the inability to constructively resolve or to avoid conflict leads to dysfunction where members just tolerate each other in lieu of trusting each other (Douglas et al., 2015).

Douglas and colleagues (2015) outlined several activities that can enhance an individual team member’s capacity for communication, inclusiveness, trust, and conflict resolution. One of the most important activities is to develop a team agreement that is formal, creates a safe working environment, and facilitates member and team accountability. Providing individual coaching (mentoring) can assist members to maximize their individual strengths. Organizing team-based communication workshops that focus on generational traits can build team unity. Finally, the acknowledgement of existing conflict, and underscoring its usefulness, can help teams to be successful in reaching goals or outcomes. Respecting individuals and asking for their feedback can enhance the working atmosphere. It is important to remember that everyone needs to feel valued for their contribution to the organization (Mercier, 2012).

The Four-Word Build exercise (Communicationandconflict.com, 2015) promotes conflict management and communication. The team should first divide into groups of at least four or more members (even numbers work best). Identify an idea or concept for exploration and discussion. This could be a difficult situation that is hard to talk about, a new training concept, or a new initiative within the institution. Each individual receives a sheet of paper and is asked to write four words that come to mind when they think of the concept or topic. Tell participants that there are no right or wrong words. They are not to confer before writing the words. Next, ask them to pair within their groups and share their list of four words with one another. The pair then identifies which four of the eight words they agree are the most pertinent to the concept. Then, ask the pairs to combine with another pair and share their four words (now a group of four with eight words). They should then, among the four of them, again identify the top four words they believe best represents the topic or concept. This process continues between groups. The final goal is to develop a list of four words about the topic or concept that represents the entire group. Each time individuals and groups share their words there will be discussion and thought sharing. This leads to greater understanding and deeper discussion by all. Once the final four words have been identified, inquire what this experience was like for them. Depending on the original concept or topic, this activity may lead to greater insight regarding a situation, a consensus agreement for solutions, or wider understanding of different views and opinions.

One or more of these team holding strategies can be useful to identify generationally-based differences and synergize multigenerational team efforts. Below we offer a case scenario to further illustrate the article concepts.

Case Scenario

A multigenerational group of nurses had experienced a difficult accreditation issue which resulted in stress, some resentment, and a general feeling of discord. Managers felt that team-building was needed to improve morale, and also encourage communication, and promote mutual respect and cooperation. A quick internet search for “team building activities” revealed multiple sites with information and ideas for activities.

The "Toxic Waste” activity was found at the Wilderdom website and chosen based upon its description to promote creative problem solving and communication in established teams (The Wilderdom Store, 2013). The referee for the activity, in this case one of the managers, collected and setup the materials as the website described. The setup included one large bucket, one small bucket, length of rope, eight bungee cords, and at least eight balls. One cord was tied into a loop to assist the team and perhaps decrease the time needed for problem solving.

The leader informed the team of nurses upon arrival that the small bucket of balls represented toxic waste, and the circle on the floor represented a toxic spill that would kill or injure anyone who crossed it. The large bucket located across the room represented a container to secure and seal the toxic waste. Dropping single balls would result in injury (such as the loss of the hand or foot that came in contact with it) and spilling the entire bucket of balls would result in death of the entire team. The leader instructed the team that they must use the bungee cords to devise a way to safely pick up the toxic waste balls and transfer them to the large bucket.

The first method the team tried was not at all successful; but it did result in laughter, and more importantly, communication and problem solving. A bit of discussion then ensued as the team talked about the best way to transfer the balls in the small bucket without touching them. The first method the team tried was not at all successful; but it did result in laughter, and more importantly, communication and problem solving. As this is a difficult activity, some questions and tidbits for guidance were both expected and provided. The team finally achieved success when they tied bungee cords to several sections of the small loop. Four or five individuals then each pulled on a section of bungee, resulting in the loop stretching open so it could be placed over the lip of the small bucket without having to step inside the circle. The small bucket was then carefully carried by the bungees over to the large bucket, and the entire bucket and attached bungees were dropped into it. Upon success, the group shared smiles and applause.

Debriefing followed the activity. Team members shared how interesting it was to discover one another’s ideas and creativity for approaching the problem. They also reflected on what they learned from the activity that could be used in the future when a problem arises; such as to listen to one another and give everyone a chance to share his or her idea, because it just might be the idea that works. In this case, when the one person who had been quiet throughout the activity finally spoke up, she had the idea that led to successfully moving the bucket without touching it or dropping any balls.

...effective relationships that capitalize on the strengths of multigenerational perspectives take time to develop. This case scenario illustrates many concepts important to success with multigenerational collaboration in the workforce. Effective communication was critical to the ultimate success, including time for listening and respect for each person’s suggestions. Perseverance was important; effective relationships that capitalize on the strengths of multigenerational perspectives take time to develop. Debriefing helps the team members to both identify and appreciate the various steps of the activity that led to the final successful attempt. Most importantly, this activity was initiated and supported by organizational leadership. This lets participants know that multigenerational collaboration in the workplace is expected and important to successful outcomes. Table 3 provides additional resources for teambuilding strategies.

Table 3. Additional Team-Building Resources

Conclusion: Organizational Opportunities

Respect and understanding can be outcomes of organizations that recognize generational differences. Multigenerational workforces can provide rich environments that support an atmosphere of diversity and growth (Mercier, 2012). Respect and understanding can be outcomes of organizations that recognize generational differences. For example, by acknowledging baby boomers' preference to work in teams, organizational leaders may suggest this generation form committees that promote success for the company. This may be accomplished by creating a retention committee. Technology skills of Millennial nurses might be tapped for mentoring to launch a new computer system. Gen Xers' strengths are ideal for clinical practice issues or matters dealing with quality assurance (Mercier, 2012).

On average, nurse turnover costs hospitals $82,000 to $88,000 per staff member. Thus, increasing the satisfaction of the workforce would result in cost savings at the very least (Kalisch et al., 2010). Retention strategies are important to every company and should now include flexibility and acknowledgement of a desired work/life balance. These include balancing personal and professional commitments, perhaps by job sharing and self-scheduling. Other nurses need and want assistance with development of their financial portfolios (Mercier, 2012).

We are all unique. Yet, there remains common ground that binds us. Some suggest it is not the differences in generational groups that cause division; rather it is fundamental organizational failures to communicate well with employees and issues of power in the workforce (Stanley, 2010). Nursing leaders have a responsibility and a unique opportunity to balance group maintenance and group tasks along with successful team-building. Leaders must respectively identify attitudes and behaviors that help or hinder the group (Mercier, 2012).

According to Birx, Lasalla, and Wagstaff (2011) positive changes that result from team-building activities are rarely long term. This is in alignment with Lewin’s Model of Change which highlights that lasting habits are created when consistently reinforced over time. Otherwise it is easy for individuals and teams to revert to old habits (Cherry, 2014). Therefore, to support positive outcomes in the workplace, it is beneficial to frequently revisit team-building exercises and reinforce their helpful effects.

Ultimately the purpose of team-building within multigenerational nursing teams is to promote patient safety and other positive organizational outcomes. Ultimately the purpose of team-building within multigenerational nursing teams is to promote patient safety and other positive organizational outcomes (Stanley, 2010) through improved understanding, communication, inclusion, trust, and respect. Both nursing administrators and individual team members have a responsibility to work toward these goals, however challenging. In today’s dynamic and fluid healthcare environment, it is prudent to attract and retain staff by appealing to and providing a supportive environment for nurses of all generations. Education regarding generational differences, similarities, and transparent communication along with successful team-building can help to make this happen.

Authors

Jill M. Moore, PhD, RN, CNE
Email: Jill.Moore@indstate.edu

Dr. Moore completed her Master’s in Nursing Education and her PhD in Higher Education Leadership at Indiana State University in Terre Haute, IN. She is the Nursing Education and Nursing Administration Program Director and an Assistant Professor in the Department of Advanced Practice Nursing at Indiana State University. Prior to transitioning to nurse education Dr. Moore practiced in the critical care and acute care environment working within teams of multigenerational healthcare workers.

Marcee Everly, DNP, ND, MSN, RN, CNM
Email: Marcee.Everly@indstate.edu

Dr. Everly completed her master’s and doctoral nursing education at the University of Colorado, Health Sciences Center, in Denver, CO. She is Department Chair and Associate Professor in the Department of Baccalaureate Nursing at the Indiana State University. The department is comprised of a variety of individuals across generations. Before practicing in academia, Dr. Everly worked as a labor and delivery nurse and was later a full-time full-scope Certified Nurse Midwife practicing in a busy Midwestern city.

Renee Bauer,PhD, MS, RN
Email: Renee.Bauer@indstate.edu

Dr. Bauer received her undergraduate degree, master’s degree and PhD from Indiana State University in Terre Haute, IN. She is an assistant professor and director for the accelerated nursing degree track at Indiana State University. She has taught psychiatric nursing for eight years at the University and has done patient care for over 23 years, working with colleagues of all ages.