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Generational differences in factors influencing job turnover among Japanese nurses: An exploratory comparative design
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International Journal of Nursing Studies 46 (2009) 957–967 www.elsevier.com/ijns
Generational differences in factors influencing job turnover among Japanese nurses: An exploratory comparative design Miyuki Takase *, Keiko Oba, Noriko Yamashita Tottori University, School of Health Sciences, 86 Nishi-Machi, Yonago-City, Tottori 683-8503, Japan Received 14 August 2007; received in revised form 17 October 2007; accepted 20 October 2007
Abstract Background: Although nurse turnover is a serious problem, the fact that each nurse has different work-related needs/values, and leaves their job for different reasons makes it difficult for organisations to develop effective countermeasures against it. Understanding nurses’ needs and the reasons for job turnover by the generation in which they were born may provide some feasible solutions. Objectives: The purpose of the study was to identify specific work-related needs and values of nurses in three generations (born in 1946–1959, 1960–1974, 1975–present). The study also aimed to explore generation-specific reasons that might make nurses consider leaving the jobs. Settings: The study was conducted in three public hospitals in Japan. Participants: A convenience sample of 315 registered nurses participated in the study. Methods: A survey method was used to collect quantitative and qualitative data. Quantitative data were analysed by ANOVA, and qualitative data were analysed by content analysis. Results: Nurses born between 1960 and 1974 embraced high needs and values in professional privileges such as autonomy and recognition, while those born after 1975 expressed low needs and values in the opportunities for clinical challenge. For nurses born between 1960 and 1974, the imbalance between their jobs and personal life made them consider leaving their jobs. For those born after 1975, losing the confidence to care made them consider turning over. Nurses born after 1960 tended to value economic return and job security more highly compared to those born between 1946 and 1959. Conclusions: Nurses in different generations have different sets of needs/values and reasons for job turnover. Understanding generation-specific needs and values of nurses may enable organisations and Nurse Managers to develop feasible and effective countermeasures to reduce nurse turnover. # 2007 Elsevier Ltd. All rights reserved. Keywords: Personnel turnover; Named groups by birth year; Nursing management; Nurse attitudes; Descriptive statistics; Content analysis
What is already known about the topic? Nurse turnover has negative impacts on nurses, the organisations they work for, and society. The reasons for nurses leaving their jobs are diverse. * Corresponding author. Tel.: +81 859 38 6317; fax: +81 859 38 6310. E-mail address: [email protected] (M. Takase).
Demographic generations shape the needs, values and attitudes of people. What this paper adds Nurses in different generations embrace different sets of work-related needs and values. The factors that make nurses consider leaving their jobs differ according to generation.
0020-7489/$ – see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2007.10.013
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Understanding nurses according to generation may enable organisations to develop age-specific and sensible countermeasures against nurse turnover. 1. Introduction Nurse turnover is a serious problem that has been plaguing health care organisations in many countries. In Japan, a survey of 2158 hospitals reported an annual turnover rate of 12.1% in 2004 (Japan Nursing Association, 2006a), and another survey revealed that 34.4% of 5688 nurses surveyed (or 45.8% excluding participants who did not respond to this particular question) had once left their jobs (Japan Nursing Association, 2006b). A similar turnover rate of 10.5% has been reported in the UK NHS trusts in 2005–2006 (Review Body for Nursing and Other Health Professions, 2007). The rate is even higher in the US (the average national turnover rate of 21.3% in 2000, according to American Organisation of Nurse Executives, 2002). Problems associated with nurse turnover are multifaceted. The turnover costs the organisations in recruiting and training new staff for replacement (Jones, 2004). The turnover also induces a temporary production loss and excess workloads on existing staff until newly hired staff become fully functional (Jones, 2004). More importantly, turnover exacerbates the current nursing shortage in that if appropriate replacement staff are not found, the public’s right to receive an appropriate level of nursing care is threatened (Hayes et al., 2006). The reasons for nurse turnover are diverse. Some of the reasons include nurses losing commitment to the organisations, or being dissatisfied with their jobs/organisational management (Hayes et al., 2006), both of which could result from the organisations not adequately reinforcing nurses’ work-related needs (i.e., what they want at work) and values (i.e., what they feel is important at work) (Lofquist and Dawis, 1991). Other reasons include overriding family responsibilities (Hayes et al., 2006), health problems (Sjo¨gren et al., 2005), or simply wishing to try other jobs (Gardulf et al., 2005). Difficulties in alleviating nurse turnover lie in the diversity of their reasons for leaving. Of course, it is not practical for the organisations to comprehend each individual nurse’s work-related needs and values nor their reasons for leaving. However, by grouping nurses into meaningful cohorts, the organisations might be able to understand the dispositions of each group, the specific needs and values held by the group members, and the characteristic reasons for their turnover. One such method of grouping nurses is by generations. A generation consists of people who not only share birth years, but also share distinctive characteristics, needs, values and attitudes as a result of experiencing the same social and historical events during their life-course and being influenced by the generation of their parents (Oda, 2006). This means that understanding the generations of nurses may enable organisations to develop sensible countermeasures to alleviate nurse turnover for each generation.
2. Generations in Japan There are several ways of classifying generations in Japan. This study used the following generation scheme to communicate with international readers: those born between 1946 and 1959; between 1960 and 1974; and between 1975 and the present. These generations comprise about 17%, 39% and 42% of the hospital nursing workforce in Japan, respectively (Ministry of Health, Labour and Welfare, 2006). 2.1. Born between 1946 and 1959 This generation is equivalent to the ‘‘baby boomers’’ in the US, who were born between the 1940s and the 1960s (Weston, 2001; Martin, 2004; Swearingen and Liberman, 2004). Unlike their US counterparts, Japanese baby boomers were born in a narrower year range of 1946–1949 (or 1945–1952) (Oda, 2006). This generation is called the ‘‘Dankai generation’’ (meaning a mass generation) in Japan. The Dankai generation were raised by parents who not only lost World War II, but also lost their traditional beliefs and values in the process of a postwar reformation led mainly by the US government. Along with the introduction of Western culture in Japan, the Dankai generation were inclined to explore a new lifestyle that was not constrained to a Japanese traditional style. They also tended to challenge authorities, society and politics, and participated in student rebellions influenced by anti-war movements (RICCL, 1997; Oda, 2006). Once they left school and entered the workforce, however, they became the committed members of organisations called ‘‘corporate warriors’’ (known as ‘‘Kigyousensi’’ in Japan). They enjoyed the wave of economic growth, in which their efforts were almost always rewarded with success and positive recognition. Corporate lifetime-employment and promotionby-age policies also encouraged them to devote their life to the organisations and to work without making a distinction between jobs and private life (Research Institute on Continuity and Change in Life (RICCL), 1997; Oda, 2006). Later in their work life when severe economic recession (i.e., the burst of an economic bubble/asset inflation) hit Japan in 1991, however, many of the Dankai generation lost their jobs due to corporate downsizing and the collapse of lifetime-employment system (Oda, 2006). Nurses in the Dankai generation received nursing education according to the 1968 curriculum reformation, in which the components of clinical practicum was reduced from 5632 to 1770 h, and more components for general and specialised subjects were introduced (Sasaki, 2006). Recognition of nursing was however low in this period, and thus their education was placed outside the tertiary education scheme (Sasaki, 2005). 2.2. Born between 1960 and 1974 This generation is equivalent to the US version of ‘‘Generation X’’ (Swearingen and Liberman, 2004; Apos-
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tolidis and Polifroni, 2006). In Japan, this generation includes two distinctive age cohorts: ‘‘Shinjinrui’’ (meaning a new mankind) and ‘‘Dankai juniors’’ (the second wave of baby boomers). Shinjinrui were born in the first half of the 1960s and enjoyed a life of consumption in the time of the economic bubble (RICCL, 1997). They are known as being irresponsible, indifferent, uninspired and cynical, and only interested in themselves and how to obtain life at an upper rank in class society. They are avaricious for everything that makes their life comfortable. For them, the fulfilment in their private life is the motivation to work, and thus extra hours of work are not appreciated (RICCL, 1997). Dankai juniors were born between 1971 and 1974 (Shiozaki, 2000), and are the children of the Dankai generation (RICCL, 1997; Oda, 2006). Being raised by Dankai parents, they were shaped into being anti-traditional, openminded, and revolutionary (Oda, 2006). In contrast to their Dankai parents who hold a sense of solidarity, however, Dankai juniors are self-centred individuals (RICCL, 1997). Their commitment to organisations is low after experiencing difficulties themselves in finding jobs and/or their parents being made redundant due to the burst of the economic bubble. As a result, they draw a solid line between work and private life (RICCL, 1997; Oda, 2006). They are also known to desire money and freedom for a comfortable life, and for being competent in information technology (IT) (RICCL, 1997). Shinjinrui nurses were educated under the 1968 nursing curriculum reformation, while Dankai junior nurses did so under the 1989 curriculum reformation. In the latter reformation, ‘‘nursing as a profession’’ was emphasised, and the curriculum was designed to furnish students with theoretical evidence in nursing care. The advent of four nursing areas (i.e., adult, aged care, paediatric and maternity nursing) in the curriculum also positioned nursing as a specialised profession (Sasaki, 2005; Sugimori and Funashima, 2004). As for clinical practicum, the total hours were reduced to 1035 (Sasaki, 2006). 2.3. Born between 1975 and present This generation is equivalent to ‘‘Generation Y’’ in the US (Kupperschmidt, 2001; Martin, 2004), and is called ‘‘Post Dankai juniors’’ in Japan (Japan Consumer Marketing Research Institute, 2005). They were born during the economic bubble, and were pampered by parents and many adults due to a decreasing number of children as a result of a low birth rate (Oda, 2006). Being brought up by parents in the Dankai generation in a way that fosters individuality, they value the self over the public and act in accordance with their own sense rather than the commonsense held by society (RICCL, 1997). They grew up surrounded by the Internet and convenience stores, and are accustomed to instant acquisition of materials and information. They are also competent users of IT (Tamesada, 2005).
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While they enjoyed a materialistically abundant environment and indulgence, they also experienced some hardships. Due to an escalating number of school-bullying incidents, they are afraid of standing out among others and of being alienated. They are also victims of the burst of the economic bubble, and thus their loyalty to organisations is low and they opt to acquire specialised skills to survive in a world with a low employment rate (Tamesada, 2005). Nurses in this generation were educated under the 1996 nursing curriculum reformation. An emphasis was placed on structuring nursing as a discipline, and equipping students with scientific thinking. Two areas of nursing, home care and mental health nursing, were added to the curriculum, making a total of six areas of nursing to be established. Many nursing courses that were offered previously at polytechnic schools were transferred to tertiary institutions to promote the quality of nurses (Sasaki, 2005; Sugimori and Funashima, 2004). The total hours of clinical placement remained the same (Sasaki, 2006). However, university education tended to place more emphasis on theories and on the thinking process, and less on practical skills.
3. Research on the generations of nurses The literature review suggested that people belonging to different generations may embrace different values and characteristics because of their experiences of going through distinctive social, economic and educational events. However, there are only a handful of studies that investigated how these differential values can be translated into the values held by nurses. McNeese-Smith and Crook (2003), for instance, surveyed 412 US nurses to compare work-related values held by nurses in different generations. The findings showed that nurses born between 1925 and 1942 held significantly lower values in having variety in their tasks than those born between 1943 and 1960, and those born between 1961 and 1980. The oldest group of nurses were also found to attach lower values to economic return in their work than the other groups of nurses. Stuenkel et al. (2005) also conducted a similar study on 272 US nurses. The results showed that nurses born between 1960 and 1980 embraced higher values in having autonomy and variety in their tasks than those born between 1943 and 1960. Other researchers tended to conduct small-scale studies. With a sample of US hospital employees (42 RNs, 16 nurse technicians and 4 nursing secretaries), Hu et al. (2004) found that hospital employees born between 1922 and 1960 tended to demonstrate higher commitment to employment longevity than those born after 1961. This finding was reinforced by a study of Palese et al. (2006), who interviewed 10 Italian chief nurses regarding their perceptions of their staff nurses in different generations. In contrast, Apostolidis and Poli-
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An explanatory comparative design with a cross-sectional survey method was used to examine the workrelated needs and values of nurses between the three generations, and the events that make them consider leaving their jobs. This is part of a larger study that investigated the antecedents of nurses’ intentions to leave their jobs. Other parts of the study results are reported elsewhere (Takase et al., in press).
and an open-ended question asking about the events that make nurses consider leaving their jobs. The job orientation questionnaire originally developed by Manhardt (1972) and his colleagues included 25 statements that characterise aspects of work environment and a job. This questionnaire was used to measure nurses’ workrelated needs and values, with rating scales devised by Cable and Edwards (2004). The needs were measured by asking nurses ‘‘how much do you need each of the following 25 job characteristics?’’, and the responses were made on a 5-point Likert scale ranging from 1 (none) to 5 (a very large amount). The values were measured by asking ‘‘how important do you think about each of the following 25 job characteristics?’’ and the responses were made on a 5-point Likert scale of 1 (not important at all)–5 (extremely important). This questionnaire was translated into Japanese and modified in accordance with the nursing context in Japan. To re-establish the validity and the reliability of the questionnaire, a principal component analysis and an internal consistency test (Cronbach’s alpha) were conducted. A principal component analysis revealed four factors: ‘‘working conditions’’; ‘‘professional privilege’’; ‘‘clinical challenges’’; and ‘‘social rewards’’. The overall reliabilities of the instrument were 0.90 for measuring the work-related needs, and 0.92 for the values. Two weeks after the distribution of the questionnaires, reminder letters were sent to each ward of the three hospitals in order to encourage the return of the survey. Any nurse who misplaced the survey questionnaire was also asked to contact either the principal researcher or the Director of Nursing to obtain a replacement. A total of 4 weeks was allocated for the return of the questionnaires using reply-paid envelops provided.
5.2. Participants
5.4. Ethical considerations
Participants were recruited from three public hospitals (one university, one prefectorial and one city hospital) in the western region of Japan. These hospitals are medium to large in size, accommodating 430–700 beds, and play a central role in treating patients who require a high level of medical care in this region. From these hospitals, a total of 849 registered nurses were invited to participate in the study. Midwives, enrolled nurses, and registered nurses working in outpatient departments, and those who were not directly involved in patient care (e.g., directors of nursing and educational consultants) were excluded, as they held different roles, responsibilities and work-related values from those working in the wards.
Prior to data collection, approval to conduct the study was obtained from the University Review Board and the Directors of Nursing in all participating institutions.
froni (2006) did not find much difference in work-related values of nurses between two age cohorts (i.e., those aged over and below 41 years old, based on a total sample size of 98 US nurses). Although the findings of the above studies suggest that nurses in different generations have different sets of values and needs, the absence of any Japanese studies make it difficult to determine what kind of expectations Japanese nurses in each generation have. Moreover, small sample sizes in some of the studies may limit their generalisability to other populations.
4. The purposes of the study The purpose of the present study was therefore to explore the work-related needs and values held by Japanese nurses in the above three generations. The study also aimed to identify factors that could make nurses consider leaving their jobs.
5. Methods 5.1. Study design
5.3. Data collection Questionnaires were distributed to potential respondents through the Directors of Nursing in the three hospitals upon the request of the researchers. The questionnaires included demographic questions, the job orientation questionnaire,
5.5. Data analysis Descriptive statistics were used to illustrate the needs and values held by nurses in the three generations. Their needs and values were then compared using ANOVA. When a significant difference was observed, a post hoc comparison was conducted to compare the strength of needs and values between the three generations. For this analysis, a Bonferroni test was used to control for an overall type I error rate. A significance level was set at p < 0.05. For the open-ended question, a thematic analysis was conducted to identify themes of the events that made nurses consider leaving their jobs, using the methods described by Rice and Ezzy (1999). These themes were then used for content analysis, in which the frequencies of the themes identified across the three generations were computed.
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Fig. 1. Descriptive statistics on work-related needs of nurses in three generations.
6. Results A total of 332 nurses returned the questionnaires—a return rate of 39%. Among them, 17 nurses provided incomplete questionnaires, which were excluded from further analysis.
Therefore, in total 315 usable questionnaires were analysed (a final response rate of 37%). Of 315 nurses, 56 nurses were born between 1946 and 1959 (17.8%), 97 between 1960 and 1974 (30.8%) and 162 were born after 1975 (51.4%). The mean age of the parti-
Fig. 2. Descriptive statistics on work-related values of nurses in three generations.
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cipants was 34.3 years, and the average years of working as a nurse was 12.1 years. The composition of the participants was 98.7% female, 54.9% single, 83.2% working as clinical staff, 16.8% working as head nurses and 90.2% working in permanent full-time positions. Forty percent of nurses had at least one child. As for their educational backgrounds, the majority (63.2%) had nursing diplomas, followed by 23.2% having associate degrees, 11.7% Bachelor of Nursing and 1.9% higher degrees. The mean scores of nurses’ work-related needs and values in 25 job characteristics are presented in Figs. 1 and 2. In these figures, the first eight items from the left comprise ‘‘working conditions’’, the next eight ‘‘professional privilege’’, the next five ‘‘clinical challenges’’, and the last four ‘‘social rewards’’. The results of ANOVA and post hoc comparisons by these four sub-scales are presented in Table 1. As for the working conditions, nurses in all three generations indicated high needs in having good job conditions, and there was no significant difference amongst the means. When the degree of importance they attached to this factor was asked, however, those born between 1946 and
1959 rated this factor significantly lower than those born between 1960 and 1974, and those born after 1975. In particular, nurses born between 1960 and 1974 and born after 1975 rated the importance in ‘‘having ample leisure time’’ higher than those born between 1946 and 1959. With regard to ‘‘professional privilege’’, nurses born between 1960 and 1974 rated their needs in having privileges such as autonomy, recognition and variety in duties significantly higher than those born after 1975. The same trend was observed in their values of obtaining professional privileges. The tendency for nurses born after 1975 to rate both needs and values lower than the others was also seen in the dimension of ‘‘clinical challenges’’. As for the needs, the youngest nurse group (i.e., born after 1975) rated their needs for having clinical challenges significantly lower than those in other generations, especially in the areas of utilising professional backgrounds and the opportunities to be creative. Regarding the values, those born after 1975 again rated on this dimension significantly lower than those born between 1960 and 1974, in particular to the opportunities for being creative and for problem-solving.
Table 1 Results of AVOVA and post hoc comparisons Factors
Generations
Means (S.D.)
ANOVA
Bonferroni
1946–1959 1960–1974 1975–present
3.882 (0.599) 4.044 (0.531) 3.994 (0.538)
F = 1.559 p = 0.212
N/A
Professional privilege
1946–1959 1960–1974 1975–present
3.333 (0.576) 3.423 (0.537) 3.198 (0.532)
F = 5.436 p = 0.005
1960–1974 > 1975–present, p = 0.004
Clinical challenges
1946–1959
3.431 (0.481)
F = 7.703
1946–1959 > 1975–present, p = 0.008; 1960–1974 > 1975–present, p = 0.003
1960–1974 1975–present
3.407 (0.622) 3.173 (0.525)
p = 0.001
1946–1959 1960–1974 1975–present
3.656 (0.642) 3.567 (0.729) 3.596 (0.616)
F = 0.330 p = 0.719
N/A
1946–1959
3.719 (0.647)
F = 3.617
1975–present > 1946–1959, p = 0.039; 1960–1974 > 1946–1955, p = 0.046
1960–1974 1975–present
3.952 (0.559) 3.939 (0.547)
p = 0.028
Professional privilege
1946–1959 1960–1974 1975–present
3.257 (0.535) 3.400 (0.520) 3.191 (0.571)
F = 4.392 p = 0.013
1960–1974 > 1975–present, p = 0.010
Clinical challenges
1946–1959 1960–1974 1975–present
3.237 (0.541) 3.330 (0.564) 3.100 (0.539)
F = 5.555 p = 0.004
1960–1974 > 1975–present, p = 0.004
Social rewards
1946–1959 1960–1974 1975–present
3.473 (0.672) 3.655 (0.628) 3.556 (0.547)
F = 1.764 p = 0.173
N/A
Needs Working conditions
Social rewards
Values Working conditions
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Fig. 3. Events that made nurses in three generations consider leaving their jobs. Note: The line graph indicates the frequencies of the events indicated by nurses in all three generations (n = 214).
With regard to ‘‘social rewards’’, nurses in all generations rated high needs in having good pay and job security, and less in receiving respect. There was no statistically significant difference amongst their needs. The results of ANOVA also indicated no difference in terms of how they value having social rewards. However, a closer examination revealed that nurses born after 1960 valued pay and job security particularly higher than those born between 1946 and 1959. Fig. 3 shows the results of a content analysis on the events that made nurses consider leaving their jobs. A total of 214 nurses responded to the open-ended question (36 nurses born between 1946 and 1959, 67 born between 1960 and 1974 and 111 born after 1975). Themes and categories that emanated from a thematic analysis and were used to content-analyse the data are presented in Table 2. ‘‘Excess workloads’’ and ‘‘issues in interpersonal relationships’’ were the first and third factors of why nurses consider leaving their jobs, and was indicated frequently by nurses in all generations. The second most frequently indicated factor was ‘‘imbalance between work and life’’. As shown in Fig. 3, this factor was the most frequently raised by nurses born between 1960 and 1974, and least raised by those born between 1946 and 1959. ‘‘Lacking motivation to work’’, ‘‘dissatisfaction with organisational system’’ and ‘‘losing confidence to care’’ occupied the fourth to sixth positions, indicated most frequently by nurses born after 1975. In particular, the youngest age group rated ‘‘lacking motivation to work’’ higher than those born between 1946 and 1959, ‘‘dissatisfaction with organisational system’’ higher than those born between 1960 and 1974 and ‘‘losing confidence to care’’ higher than the rest of the nurses. The last factor was nurses being ‘‘attracted to
other jobs’’. This reason was indicated by a small number of nurses born after 1960, but by none of the oldest age group.
7. Discussion Among the four factors of work characteristics, the need for comfortable working conditions was rated highest by nurses in all generations. In particular, having ample leisure time was valued highly by those born between 1960 and 1974, and after 1975. These findings suggest that the intrusion of their jobs into their private lives would certainly discourage these two age cohorts in continuing their jobs. Indeed, the results of a content analysis indicated that the imbalance between work and life made nurses born between 1960 and 1974 consider leaving their jobs most frequently, followed by those born after 1975. This trend is understandable, as Shinjinrui and Dankai juniors value the fulfilment in private life and have a tendency to draw a definite line between work and private life (RICCL, 1997). As for nurses born between 1946 and 1959, the importance they attached to having comfortable working conditions was moderate, although they too indicated high needs in this dimension. The Dankai generation is known as ‘‘corporate warriors’’ and work hard without distinguishing work and private life (RICCL, 1997; Oda, 2006). This tendency was observed in the findings of a content analysis, where they indicated the least numbers of responses in regard to the imbalance between work and life. These findings suggest that nurses born between 1946 and 1959 may be more robust to harsh working conditions, such as
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Table 2 Results of thematic analysis Category
Descriptions
Excess workloads
Excess workloads (both quantitative and qualitative) Many auxiliary tasks Physiological and psychological stress by work
Workloads exceeding one’s capacity in terms of the amounts and abilities; long working hours (extra hours of work often required after the shift) Many auxiliary tasks (i.e., those not relating to nursing care) imposed on nurses (e.g., being involved in work committees, participating in nursing research and seminars) Physiological and psychological stress, fatigue, feeling of burnout caused by hard work schedules and excess workloads
Imbalance between work and life
Invasion of work into a private life Family matters Scheduling holidays/days-off
Off-time consumed by work (e.g., encouraged to participate in nursing research, attending ward meetings, work committees and nursing seminars, etc. on a day-off) Being unable to attend to family matters sufficiently; need to compromise family roles for work Difficulty with scheduling holidays/days-off to meet own/family needs; being unable to take sick leave
Issues in interpersonal relationships at work
Relationships with nurse managers Relationships among nursing staff Relationships with other health professionals Relationships with patients and their families
Stressful relationships with nurse managers (e.g., difficulty communicating with nurse managers; nurse managers not understanding staff needs, not showing respect to staff, and being unsupportive and authoritative) Stressful relationships between co-workers and with senior nurses (e.g., being alienated by other staff, working with arrogant or less motivated nurses) Stressful relationships with physicians and other professionals (e.g., a power relationship between physicians and nurses) Stressful relationships with patients and their families (e.g., patients bullying nurses, need to comply to irrational patients’ requests)
Lacking motivation to work
Discrepancy between ideal and actual roles Losing motivation to work Losing own goals
Being unable to provide the level of care nurses want Being unable to find rewarding and satisfying aspects of the job; feeling unaccomplished at work Losing own professional goals or role models
Dissatisfaction with organisational systems
Lack of professional rewards Introduction of new technology/system Issues with organisational management Lack of opportunities to grow
Inadequate pay and recognition provided to nurses by the organisations Finding it difficult to cope with new technologies and systems (e.g., electronic patient record system) introduced by the organisations Issues relating to insufficient staff allocation and inadequate working conditions (including shift schedule); the organisational decisions not reflecting the current situation Feeling a lack of opportunities for professional growth in the current organisations
Losing confidence to care
Fear of committing medical errors Losing confidence to care
Being afraid to commit (or have actually committed) a medical error on a patient; feeling that big responsibilities rest on nurses Losing confidence to care as a nurse; being unable to save a patient’s life; being unable to meet the job requirements due to a lack of knowledge, skills, and abilities as a nurse
Attracted to other jobs
Nursing jobs in other organisations Jobs other than nursing
Attracted to nursing jobs at other organisations that provide better working conditions Attracted to a non-nursing job, which is more suitable for self
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sacrificing their private time for their work, than other generations of nurses. This, however, does not necessarily mean that their needs deserve the least organisational attention. Excess workloads and issues in interpersonal relationships were the two most frequently cited causes that made nurses in this generation consider leaving their jobs. When problems with workloads and interpersonal relationships go beyond nurses’ capacities to deal with them, these problems will certainly contribute to even the most experienced nurses leaving their jobs. In order to avoid work intruding on nurses’ private time, the current workloads of nurses need to be alleviated. A recent study has revealed that nurses spend approximately 60% of their time in activities that directly benefit patients and 15% doing unnecessary work such as locating equipment and persons (Upenieks et al., 2007a). Another study also suggests that organisational factors such as shift schedules and the organisational skills of nurse managers impact more on nurses’ workloads than the acuity of the patients assigned to them (Spence et al., 2006). Hence, nurse managers should first review the contents of staff activities, work environment, and other work-relevant tasks that nurses carry out, as well as their own management strategies, and then identify areas for improvement. Employing assistant personnel is another way to alleviate nurses’ workloads (Upenieks et al., 2007b). In addition, nurse managers should also show their understanding of nurses’ needs to have quality days-off. Such quality time would allow nurses to recover from work stress and catch up with their family issues. In regard to professional privilege, nurses born between 1960 and 1974 rated their needs and values more highly than other generations. Significant differences between the needs and values of nurses in this generation and those born after 1975 may be attributable to a low score given by the latter in response to supervising others. It is understandable why the youngest group of nurses attached the least need and value to this factor, as their lack of clinical experience does not motivate them to assume this role. However, the fact that nurses born between 1960 and 1974 rated consistently high needs and values in having professional privileges, such as autonomy, recognition and intellectual stimulation, is noteworthy. As has been mentioned, nurses in this generation tend to seek a life at an upper rank (RICCL, 1997). It appears that their tendency to pursue a prestigious life is also reflected in their professional life. These findings suggest that providing a good amount of professional privilege could motivate these nurses to stay in their current jobs. There are several interventions possible to provide nurses in this generation with a sense of professional privilege. For example, the organisations and nurse managers can provide these nurses with more responsibilities and freedom in the conduct of their work. This kind of intervention would improve their sense of autonomy. Nurses in this generation may also feel privileged if they are asked to participate in the unit management and decision-making. In addition, providing immediate praise for a good nursing practice is an excellent way for nurse managers
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to express their recognition of the contribution that nurses in this generation make to patient care (Smith et al., 2005). While nurses born before 1974 tended to seek the clinical challenges, those born after 1975 neither sought nor valued professionally challenging opportunities. This low motivation of the youngest group of nurses may be attributed to their lack of confidence as nurses. Those born after 1975 received nursing education in which Japanese nursing had been experiencing a transitional period from a traditional clinically oriented style of education to an academic education. Many of the previously provided nursing courses have been taken over by universities where nurse educators are struggling to establish nursing as an academic discipline rather than just as an occupation. An emphasis on the theoretical component of nursing and the reduction in a clinical practicum are the characteristics of tertiary nursing education, which contributed to graduates entering the workforce without being equipped with an adequate level of clinical abilities and skills. Furthermore, the complexity of nursing roles, coupled with heightened recognition of patient safety, has prevented students from applying their skills in real clinical settings (Ministry of Health, Labour and Welfare, 2007). As nursing education has been more and more academically oriented, the gap between skills required at work and those taught in the schools tends to be wider. According to a national survey conducted by the Japan Nursing Association, this gap was the most prominent factor causing newly graduated nurses to lose their confidence to work as a nurse, and leave their jobs (Kanoya, 2005). Although not ranked highest, this tendency was also visibly observed in our qualitative findings. The findings of this study thus render support for the previous findings, and highlight the importance of providing junior nurses with an adequate level of clinical education so as to boost their confidence to care. A study by Tokiwa et al. (2004) showed that the level of exposure to nursing skills in clinical settings was correlated to the level of confidence nursing students have in their clinical skills. Thus, the extension and the expansion of a clinical practicum component in the nursing curriculum are essential to boost the confidence of students as well as newly graduated nurses. A solid nursing skill education in classrooms and in clinical sites is also important, as it allows students and graduates to practise their nursing skills on each other or using simulation models. Some of these suggestions were made by a recent nursing curriculum proposal by the Ministry of Health, Labour and Welfare (2007), and are expected to be implemented in tertiary institutions in Japan. With reference to social rewards, nurses in all three generations indicated high needs for receiving a good pay and job security. When it came to the importance they attached to these factors, nurses born between 1946 and 1959 were more modest than those in other generations. The reason why nurses born after 1960 held high values in pay and job security can be explained by their experiences during the economic recession. Having experienced hardship entering the workforce due to shrinking employment opportu-
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nities, these younger generations have tended to develop an aspiration for a stable and solid life. Money and job security are two indispensable tools for them to achieve this end. These findings are consistent with those of the US studies, where Generations X and Y were found to value economic return (McNeese-Smith and Crook, 2003; Hu et al., 2004) as a result of experiencing corporate downsizing. For the organisation, providing high remuneration to all employees is a difficult task, and thus they may not be able to satisfy nurses’ needs in this factor. Considering a high demand for nurses in Japan at present, however, the organisation can assure their work positions as long as their performance meets the organisational goals. The organisation and nurse managers may not discuss job security with their incumbents on a daily basis, but a simple verbal assurance or a statement such as ‘‘we need you here’’ may be enough for nurses to consider staying in the current jobs. Whereas there were differences in the needs, values and reasons for considering turnover among nurses in the three generations, there were also commonalities. Nearly half of the nurses in each of the three generations identified excess workloads and issues in interpersonal relationships to be the reasons that made them consider leaving their jobs. These two problems need to be attended to with extra care in order to alleviate workload burdens. The findings of this study emanated from the responses made by 315 Japanese nurses. As a result of a low return rate, our findings may not be generalised to other nursing populations in Japan. Nevertheless, our findings provide implications that understanding generations may help to identify needs and values of nurses in specific age groups, and their reasons for considering leaving their jobs. The findings of this study could also have implications for other countries. For example, Japanese nurses in the three generations share some characteristics and history with baby boomers, Generation X and Generation Y in the US. Baby boomers are described as not respecting authority (Weston, 2001), yet they are dedicated and loyal members of organisations (Watson, 2002) and define themselves through their jobs (Swearingen and Liberman, 2004). Unfortunately, they too faced redundancies due to downsizing later in their life (Watson, 2002). Likewise, Generation X are described as being cynical (Kupperschmidt, 1998), disloyal to organisations (Watson, 2002) and inclined to draw a line between work and private life (Weston, 2001), attributes that are also commonly seen in Japanese in this age cohort. Generation Y are also known to have grown up during the time of an expansive economy (Martin, 2004), prefer teamwork (Kupperschmidt, 2001) and are competent in IT. Therefore, US nurses may embrace similar needs, values and reasons for turnover as described by Japanese nurses.
8. Conclusions Nurses go to work with a different set of needs and values, and leave their jobs for different reasons. Under-
standing why individual nurses are not satisfied with their jobs, and thus leave their organisations is difficult. On the other hand, treating nurses as a unified professional group who hold the same values and needs may be insensitive. By grouping nurses in meaningful cohorts, the organisations and nurse managers might be able to understand specific expectations held by each group of nurses, and act to reduce turnover in a feasible and an appropriate manner. Generations provide such an insight into the expectations and values of different nurses. However, the varying values held by nurses in different generations were often considered as a source of an intergenerational conflict (Hu et al., 2004; Martin, 2004; Swearingen and Liberman, 2004), the solving of which is a challenge for nurse managers (Watson, 2002). The present study shed light on the positive aspect of the effect of each generation, and suggested that it holds key information that can be used to create a fulfilling work environment for nurses in each generation, and thus alleviating nurse turnover.
References American Organisation of Nurse Executives, 2002. Acute care hospital surveys of RN vacancy and turnover rates in 2000. Available at: http://www.wha.org/workForce/pdf/aone-surveyrn vacancy.pdf. Apostolidis, B.M., Polifroni, E.C., 2006. Nurse work satisfaction and generation differences. J. Nurs. Adm. 36 (11), 506–509. Cable, D.M., Edwards, J.R., 2004. Complementary and supplementary fit: a theoretical and empirical integration. J. Appl. Psychol. 5, 822–834. Gardulf, A., So¨derstro¨m, I., Orton, M., Eriksson, L.E., Arnetz, B., Nordstro¨m, G., 2005. Why do nurses at a university hospital want to quit their jobs? J. Nurs. Manag. 13, 329–337. Hayes, L.J., O’Brien-Pallas, L., Duffield, C., Shamian, J., Buchan, J., Hughes, F., Lachinger, H.K.S., North, N., Stone, P.W., 2006. Nurse turnover: a literature review. Int. J. Nurs. Stud. 43, 237–263. Hu, J., Herrick, C., Hodgin, K.A., 2004. Managing the multigenerational nursing team. Health Care Manag. 23 (4), 334–340. Japan Consumer Marketing Research Institute, 2005. Generation Y. Available at: http://www.jmrlsi.co.jp/menu/yougo/my10/my 1020.html (in Japanese). Japan Nursing Association, 2006a. Nurse demand–supply survey in hospitals in 2005: overall results (a prompt report). News Release. Available at: http://www.nurse.or.jp/home/opinion/ newsrelease/2006pdf/20060602.pdf (in Japanese). Japan Nursing Association, 2006b. The circumstances of nursing employees in 2005: overall results (a prompt report). News Release. Available at: http://www.nurse.or.jp/home/opinion/ newsrelease/2006pdf/20060705.pdf (in Japanese). Jones, C.B., 2004. The costs of nurse turnover. Part 1. An economic perspective. J. Nurs. Adm. 34 (12), 562–570. Kanoya, Y., 2005. Why do new graduates leave their jobs?: exploring the determinants of their turnover from data analysis. Kango Tenbo 30 (10), 17–23 (in Japanese). Kupperschmidt, B., 1998. Understanding generation X employees. J. Nurs. Adm. 28 (12), 36–43.
M. Takase et al. / International Journal of Nursing Studies 46 (2009) 957–967 Kupperschmidt, B., 2001. Understanding net generation employees. J. Nurs. Adm. 31 (12), 570–574. Lofquist, L.H., Dawis, R.V., 1991. Essentials of Person-Environment-Correspondence Counselling. University of Minnesota Press, Minneapolis. Manhardt, P.J., 1972. Job orientation of male and female college graduates in business. Pers. Psychol. 25, 361–368. Martin, C.A., 2004. Bridging the generation gap(s). Nursing 34 (12), 62–63. McNeese-Smith, D.K., Crook, M., 2003. Nursing values and a changing nurse workforce. J. Nurs. Adm. 33 (5), 260–270. Ministry of Health, Labour and Welfare, Statistics and Information Department, 2006. Statistical Report on Public Health Services: the 91st table. Available at: http://wwwdbtk.mhlw.go.jp/toukei/ data/130/2006/toukeihyou/0005924/t0132822/ HAR0910_001.html (in Japanese). Ministry of Health, Labour and Welfare, 2007. A report examining the enrichment of basic nursing education (a proposal). Available at: http://www.mhlw.go.jp/shingi/2007/03/dl/s0323-6a.pdf (in Japanese). Oda, T., 2006. Six Generations in Japan. Seiun-Sha, Tokyo (in Japanese). Palese, A., Pantali, G., Saiani, L., 2006. The management of a multigenerational nursing team with different qualifications. Health Care Manag. 25 (2), 173–193. Research Institute on Continuity and Change in Life, 1997. The feelings of the times, the feelings of generations. NHK Books, Tokyo (in Japanese). Review Body for Nursing and Other Health Professions, 2007. Twenty-second report on nursing and other health professions 2007. Available at: http://www.ome.uk.com/downloads/361072 _Cm7029_WEB.pdf. Rice, P.L., Ezzy, D., 1999. Qualitative Research Methods: A Health Focus. Oxford University Press, South Melbourne. Sasaki, H., 2005. The historical perspectives on nursing education in our country: the light and shadow. Seizansha, Kanagawa (in Japanese). Sasaki, H., 2006. An examination on of the changes in the post-war educational hours and its impacts: what the reformation of
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nursing education brought. Integr. Stud. Nurs. Sci. 8 (1), 1–9 (in Japanese). Shiozaki, J., 2000. How to capture Dankai juniors. NRI Research News 78, 1–2 (in Japanese). Sjo¨gren, K., Fochsen, G., Josephson, M., Lagerstro¨m, M., 2005. Reasons for leaving nursing care and improvements needed for considering a return: a study among Swedish nursing personnel. Int. J. Nurs. Stud. 42, 751–758. Smith, H.L., Hood, J.N., Waldman, J.D., Smith, V.L., 2005. Creating favourable practice environment for nurses. J. Nurs. Adm. 35 (12), 525–532. Spence, K., Tarnow-Mordi, W., Duncan, G., Jayasuryia, N., Elliott, J., King, J., Kite, F., 2006. Measuring nursing workload in neonatal intensive care. J. Nurs. Manag. 14, 227–234. Stuenkel, D.L., Cohen, J., de la Cuesta, K., 2005. The multigenerational nursing work force. J. Nurs. Adm. 35 (6), 283–285. Sugimori, M., Funashima, N., 2004. Nursing Education. IgakuShoin, Tokyo (in Japanese). Swearingen, S., Liberman, A., 2004. Nursing generations: an expanded look at the emergence of conflict and its resolution. Health Care Manag. 23 (1), 54–64. Takase, M., Yamashita, N., Oba, K., in press. Nurses’ leaving intentions: Antecedents and mediating factors. J. Adv. Nurs. Tamesada, A., 2005. Generation Y. Nikkei BookDirect, Tokyo (in Japanese). Upenieks, V., Kotlerman, J., Akhavan, J., Esser, J., Ngo, M.J., 2007a. Assessing nursing staffing ratios: variability in workload intensity. Policy Polit. Nurs. Pract. 8 (1), 7–19. Tokiwa, Y., Matsuoka, H., Ito, M., Kanda, K., 2004. The level of attainment for basic nursing skills in the practice of fourth year nursing students. J. Gumma Univ. Health Sci. 24, 149–156. Upenieks, V., Akhavan, J., Kotlerman, J., Esser, J., Ngo, M.J., 2007b. Value-added care: a new way of assessing nursing staffing ratios and workload variability. J. Nurs. Adm. 37 (5), 243–252. Watson, D.S., 2002. Wanted: a few good nurses. AORN J. 76 (1), 8–11. Weston, M., 2001. Coaching generations in the workplace. Nurs. Adm. Q. 25 (2), 11–21.
International Journal of Nursing Studies 46 (2009) 957–967 www.elsevier.com/ijns
Generational differences in factors influencing job turnover among Japanese nurses: An exploratory comparative design Miyuki Takase *, Keiko Oba, Noriko Yamashita Tottori University, School of Health Sciences, 86 Nishi-Machi, Yonago-City, Tottori 683-8503, Japan Received 14 August 2007; received in revised form 17 October 2007; accepted 20 October 2007
Abstract Background: Although nurse turnover is a serious problem, the fact that each nurse has different work-related needs/values, and leaves their job for different reasons makes it difficult for organisations to develop effective countermeasures against it. Understanding nurses’ needs and the reasons for job turnover by the generation in which they were born may provide some feasible solutions. Objectives: The purpose of the study was to identify specific work-related needs and values of nurses in three generations (born in 1946–1959, 1960–1974, 1975–present). The study also aimed to explore generation-specific reasons that might make nurses consider leaving the jobs. Settings: The study was conducted in three public hospitals in Japan. Participants: A convenience sample of 315 registered nurses participated in the study. Methods: A survey method was used to collect quantitative and qualitative data. Quantitative data were analysed by ANOVA, and qualitative data were analysed by content analysis. Results: Nurses born between 1960 and 1974 embraced high needs and values in professional privileges such as autonomy and recognition, while those born after 1975 expressed low needs and values in the opportunities for clinical challenge. For nurses born between 1960 and 1974, the imbalance between their jobs and personal life made them consider leaving their jobs. For those born after 1975, losing the confidence to care made them consider turning over. Nurses born after 1960 tended to value economic return and job security more highly compared to those born between 1946 and 1959. Conclusions: Nurses in different generations have different sets of needs/values and reasons for job turnover. Understanding generation-specific needs and values of nurses may enable organisations and Nurse Managers to develop feasible and effective countermeasures to reduce nurse turnover. # 2007 Elsevier Ltd. All rights reserved. Keywords: Personnel turnover; Named groups by birth year; Nursing management; Nurse attitudes; Descriptive statistics; Content analysis
What is already known about the topic? Nurse turnover has negative impacts on nurses, the organisations they work for, and society. The reasons for nurses leaving their jobs are diverse. * Corresponding author. Tel.: +81 859 38 6317; fax: +81 859 38 6310. E-mail address: [email protected] (M. Takase).
Demographic generations shape the needs, values and attitudes of people. What this paper adds Nurses in different generations embrace different sets of work-related needs and values. The factors that make nurses consider leaving their jobs differ according to generation.
0020-7489/$ – see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.ijnurstu.2007.10.013
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Understanding nurses according to generation may enable organisations to develop age-specific and sensible countermeasures against nurse turnover. 1. Introduction Nurse turnover is a serious problem that has been plaguing health care organisations in many countries. In Japan, a survey of 2158 hospitals reported an annual turnover rate of 12.1% in 2004 (Japan Nursing Association, 2006a), and another survey revealed that 34.4% of 5688 nurses surveyed (or 45.8% excluding participants who did not respond to this particular question) had once left their jobs (Japan Nursing Association, 2006b). A similar turnover rate of 10.5% has been reported in the UK NHS trusts in 2005–2006 (Review Body for Nursing and Other Health Professions, 2007). The rate is even higher in the US (the average national turnover rate of 21.3% in 2000, according to American Organisation of Nurse Executives, 2002). Problems associated with nurse turnover are multifaceted. The turnover costs the organisations in recruiting and training new staff for replacement (Jones, 2004). The turnover also induces a temporary production loss and excess workloads on existing staff until newly hired staff become fully functional (Jones, 2004). More importantly, turnover exacerbates the current nursing shortage in that if appropriate replacement staff are not found, the public’s right to receive an appropriate level of nursing care is threatened (Hayes et al., 2006). The reasons for nurse turnover are diverse. Some of the reasons include nurses losing commitment to the organisations, or being dissatisfied with their jobs/organisational management (Hayes et al., 2006), both of which could result from the organisations not adequately reinforcing nurses’ work-related needs (i.e., what they want at work) and values (i.e., what they feel is important at work) (Lofquist and Dawis, 1991). Other reasons include overriding family responsibilities (Hayes et al., 2006), health problems (Sjo¨gren et al., 2005), or simply wishing to try other jobs (Gardulf et al., 2005). Difficulties in alleviating nurse turnover lie in the diversity of their reasons for leaving. Of course, it is not practical for the organisations to comprehend each individual nurse’s work-related needs and values nor their reasons for leaving. However, by grouping nurses into meaningful cohorts, the organisations might be able to understand the dispositions of each group, the specific needs and values held by the group members, and the characteristic reasons for their turnover. One such method of grouping nurses is by generations. A generation consists of people who not only share birth years, but also share distinctive characteristics, needs, values and attitudes as a result of experiencing the same social and historical events during their life-course and being influenced by the generation of their parents (Oda, 2006). This means that understanding the generations of nurses may enable organisations to develop sensible countermeasures to alleviate nurse turnover for each generation.
2. Generations in Japan There are several ways of classifying generations in Japan. This study used the following generation scheme to communicate with international readers: those born between 1946 and 1959; between 1960 and 1974; and between 1975 and the present. These generations comprise about 17%, 39% and 42% of the hospital nursing workforce in Japan, respectively (Ministry of Health, Labour and Welfare, 2006). 2.1. Born between 1946 and 1959 This generation is equivalent to the ‘‘baby boomers’’ in the US, who were born between the 1940s and the 1960s (Weston, 2001; Martin, 2004; Swearingen and Liberman, 2004). Unlike their US counterparts, Japanese baby boomers were born in a narrower year range of 1946–1949 (or 1945–1952) (Oda, 2006). This generation is called the ‘‘Dankai generation’’ (meaning a mass generation) in Japan. The Dankai generation were raised by parents who not only lost World War II, but also lost their traditional beliefs and values in the process of a postwar reformation led mainly by the US government. Along with the introduction of Western culture in Japan, the Dankai generation were inclined to explore a new lifestyle that was not constrained to a Japanese traditional style. They also tended to challenge authorities, society and politics, and participated in student rebellions influenced by anti-war movements (RICCL, 1997; Oda, 2006). Once they left school and entered the workforce, however, they became the committed members of organisations called ‘‘corporate warriors’’ (known as ‘‘Kigyousensi’’ in Japan). They enjoyed the wave of economic growth, in which their efforts were almost always rewarded with success and positive recognition. Corporate lifetime-employment and promotionby-age policies also encouraged them to devote their life to the organisations and to work without making a distinction between jobs and private life (Research Institute on Continuity and Change in Life (RICCL), 1997; Oda, 2006). Later in their work life when severe economic recession (i.e., the burst of an economic bubble/asset inflation) hit Japan in 1991, however, many of the Dankai generation lost their jobs due to corporate downsizing and the collapse of lifetime-employment system (Oda, 2006). Nurses in the Dankai generation received nursing education according to the 1968 curriculum reformation, in which the components of clinical practicum was reduced from 5632 to 1770 h, and more components for general and specialised subjects were introduced (Sasaki, 2006). Recognition of nursing was however low in this period, and thus their education was placed outside the tertiary education scheme (Sasaki, 2005). 2.2. Born between 1960 and 1974 This generation is equivalent to the US version of ‘‘Generation X’’ (Swearingen and Liberman, 2004; Apos-
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tolidis and Polifroni, 2006). In Japan, this generation includes two distinctive age cohorts: ‘‘Shinjinrui’’ (meaning a new mankind) and ‘‘Dankai juniors’’ (the second wave of baby boomers). Shinjinrui were born in the first half of the 1960s and enjoyed a life of consumption in the time of the economic bubble (RICCL, 1997). They are known as being irresponsible, indifferent, uninspired and cynical, and only interested in themselves and how to obtain life at an upper rank in class society. They are avaricious for everything that makes their life comfortable. For them, the fulfilment in their private life is the motivation to work, and thus extra hours of work are not appreciated (RICCL, 1997). Dankai juniors were born between 1971 and 1974 (Shiozaki, 2000), and are the children of the Dankai generation (RICCL, 1997; Oda, 2006). Being raised by Dankai parents, they were shaped into being anti-traditional, openminded, and revolutionary (Oda, 2006). In contrast to their Dankai parents who hold a sense of solidarity, however, Dankai juniors are self-centred individuals (RICCL, 1997). Their commitment to organisations is low after experiencing difficulties themselves in finding jobs and/or their parents being made redundant due to the burst of the economic bubble. As a result, they draw a solid line between work and private life (RICCL, 1997; Oda, 2006). They are also known to desire money and freedom for a comfortable life, and for being competent in information technology (IT) (RICCL, 1997). Shinjinrui nurses were educated under the 1968 nursing curriculum reformation, while Dankai junior nurses did so under the 1989 curriculum reformation. In the latter reformation, ‘‘nursing as a profession’’ was emphasised, and the curriculum was designed to furnish students with theoretical evidence in nursing care. The advent of four nursing areas (i.e., adult, aged care, paediatric and maternity nursing) in the curriculum also positioned nursing as a specialised profession (Sasaki, 2005; Sugimori and Funashima, 2004). As for clinical practicum, the total hours were reduced to 1035 (Sasaki, 2006). 2.3. Born between 1975 and present This generation is equivalent to ‘‘Generation Y’’ in the US (Kupperschmidt, 2001; Martin, 2004), and is called ‘‘Post Dankai juniors’’ in Japan (Japan Consumer Marketing Research Institute, 2005). They were born during the economic bubble, and were pampered by parents and many adults due to a decreasing number of children as a result of a low birth rate (Oda, 2006). Being brought up by parents in the Dankai generation in a way that fosters individuality, they value the self over the public and act in accordance with their own sense rather than the commonsense held by society (RICCL, 1997). They grew up surrounded by the Internet and convenience stores, and are accustomed to instant acquisition of materials and information. They are also competent users of IT (Tamesada, 2005).
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While they enjoyed a materialistically abundant environment and indulgence, they also experienced some hardships. Due to an escalating number of school-bullying incidents, they are afraid of standing out among others and of being alienated. They are also victims of the burst of the economic bubble, and thus their loyalty to organisations is low and they opt to acquire specialised skills to survive in a world with a low employment rate (Tamesada, 2005). Nurses in this generation were educated under the 1996 nursing curriculum reformation. An emphasis was placed on structuring nursing as a discipline, and equipping students with scientific thinking. Two areas of nursing, home care and mental health nursing, were added to the curriculum, making a total of six areas of nursing to be established. Many nursing courses that were offered previously at polytechnic schools were transferred to tertiary institutions to promote the quality of nurses (Sasaki, 2005; Sugimori and Funashima, 2004). The total hours of clinical placement remained the same (Sasaki, 2006). However, university education tended to place more emphasis on theories and on the thinking process, and less on practical skills.
3. Research on the generations of nurses The literature review suggested that people belonging to different generations may embrace different values and characteristics because of their experiences of going through distinctive social, economic and educational events. However, there are only a handful of studies that investigated how these differential values can be translated into the values held by nurses. McNeese-Smith and Crook (2003), for instance, surveyed 412 US nurses to compare work-related values held by nurses in different generations. The findings showed that nurses born between 1925 and 1942 held significantly lower values in having variety in their tasks than those born between 1943 and 1960, and those born between 1961 and 1980. The oldest group of nurses were also found to attach lower values to economic return in their work than the other groups of nurses. Stuenkel et al. (2005) also conducted a similar study on 272 US nurses. The results showed that nurses born between 1960 and 1980 embraced higher values in having autonomy and variety in their tasks than those born between 1943 and 1960. Other researchers tended to conduct small-scale studies. With a sample of US hospital employees (42 RNs, 16 nurse technicians and 4 nursing secretaries), Hu et al. (2004) found that hospital employees born between 1922 and 1960 tended to demonstrate higher commitment to employment longevity than those born after 1961. This finding was reinforced by a study of Palese et al. (2006), who interviewed 10 Italian chief nurses regarding their perceptions of their staff nurses in different generations. In contrast, Apostolidis and Poli-
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An explanatory comparative design with a cross-sectional survey method was used to examine the workrelated needs and values of nurses between the three generations, and the events that make them consider leaving their jobs. This is part of a larger study that investigated the antecedents of nurses’ intentions to leave their jobs. Other parts of the study results are reported elsewhere (Takase et al., in press).
and an open-ended question asking about the events that make nurses consider leaving their jobs. The job orientation questionnaire originally developed by Manhardt (1972) and his colleagues included 25 statements that characterise aspects of work environment and a job. This questionnaire was used to measure nurses’ workrelated needs and values, with rating scales devised by Cable and Edwards (2004). The needs were measured by asking nurses ‘‘how much do you need each of the following 25 job characteristics?’’, and the responses were made on a 5-point Likert scale ranging from 1 (none) to 5 (a very large amount). The values were measured by asking ‘‘how important do you think about each of the following 25 job characteristics?’’ and the responses were made on a 5-point Likert scale of 1 (not important at all)–5 (extremely important). This questionnaire was translated into Japanese and modified in accordance with the nursing context in Japan. To re-establish the validity and the reliability of the questionnaire, a principal component analysis and an internal consistency test (Cronbach’s alpha) were conducted. A principal component analysis revealed four factors: ‘‘working conditions’’; ‘‘professional privilege’’; ‘‘clinical challenges’’; and ‘‘social rewards’’. The overall reliabilities of the instrument were 0.90 for measuring the work-related needs, and 0.92 for the values. Two weeks after the distribution of the questionnaires, reminder letters were sent to each ward of the three hospitals in order to encourage the return of the survey. Any nurse who misplaced the survey questionnaire was also asked to contact either the principal researcher or the Director of Nursing to obtain a replacement. A total of 4 weeks was allocated for the return of the questionnaires using reply-paid envelops provided.
5.2. Participants
5.4. Ethical considerations
Participants were recruited from three public hospitals (one university, one prefectorial and one city hospital) in the western region of Japan. These hospitals are medium to large in size, accommodating 430–700 beds, and play a central role in treating patients who require a high level of medical care in this region. From these hospitals, a total of 849 registered nurses were invited to participate in the study. Midwives, enrolled nurses, and registered nurses working in outpatient departments, and those who were not directly involved in patient care (e.g., directors of nursing and educational consultants) were excluded, as they held different roles, responsibilities and work-related values from those working in the wards.
Prior to data collection, approval to conduct the study was obtained from the University Review Board and the Directors of Nursing in all participating institutions.
froni (2006) did not find much difference in work-related values of nurses between two age cohorts (i.e., those aged over and below 41 years old, based on a total sample size of 98 US nurses). Although the findings of the above studies suggest that nurses in different generations have different sets of values and needs, the absence of any Japanese studies make it difficult to determine what kind of expectations Japanese nurses in each generation have. Moreover, small sample sizes in some of the studies may limit their generalisability to other populations.
4. The purposes of the study The purpose of the present study was therefore to explore the work-related needs and values held by Japanese nurses in the above three generations. The study also aimed to identify factors that could make nurses consider leaving their jobs.
5. Methods 5.1. Study design
5.3. Data collection Questionnaires were distributed to potential respondents through the Directors of Nursing in the three hospitals upon the request of the researchers. The questionnaires included demographic questions, the job orientation questionnaire,
5.5. Data analysis Descriptive statistics were used to illustrate the needs and values held by nurses in the three generations. Their needs and values were then compared using ANOVA. When a significant difference was observed, a post hoc comparison was conducted to compare the strength of needs and values between the three generations. For this analysis, a Bonferroni test was used to control for an overall type I error rate. A significance level was set at p < 0.05. For the open-ended question, a thematic analysis was conducted to identify themes of the events that made nurses consider leaving their jobs, using the methods described by Rice and Ezzy (1999). These themes were then used for content analysis, in which the frequencies of the themes identified across the three generations were computed.
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Fig. 1. Descriptive statistics on work-related needs of nurses in three generations.
6. Results A total of 332 nurses returned the questionnaires—a return rate of 39%. Among them, 17 nurses provided incomplete questionnaires, which were excluded from further analysis.
Therefore, in total 315 usable questionnaires were analysed (a final response rate of 37%). Of 315 nurses, 56 nurses were born between 1946 and 1959 (17.8%), 97 between 1960 and 1974 (30.8%) and 162 were born after 1975 (51.4%). The mean age of the parti-
Fig. 2. Descriptive statistics on work-related values of nurses in three generations.
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cipants was 34.3 years, and the average years of working as a nurse was 12.1 years. The composition of the participants was 98.7% female, 54.9% single, 83.2% working as clinical staff, 16.8% working as head nurses and 90.2% working in permanent full-time positions. Forty percent of nurses had at least one child. As for their educational backgrounds, the majority (63.2%) had nursing diplomas, followed by 23.2% having associate degrees, 11.7% Bachelor of Nursing and 1.9% higher degrees. The mean scores of nurses’ work-related needs and values in 25 job characteristics are presented in Figs. 1 and 2. In these figures, the first eight items from the left comprise ‘‘working conditions’’, the next eight ‘‘professional privilege’’, the next five ‘‘clinical challenges’’, and the last four ‘‘social rewards’’. The results of ANOVA and post hoc comparisons by these four sub-scales are presented in Table 1. As for the working conditions, nurses in all three generations indicated high needs in having good job conditions, and there was no significant difference amongst the means. When the degree of importance they attached to this factor was asked, however, those born between 1946 and
1959 rated this factor significantly lower than those born between 1960 and 1974, and those born after 1975. In particular, nurses born between 1960 and 1974 and born after 1975 rated the importance in ‘‘having ample leisure time’’ higher than those born between 1946 and 1959. With regard to ‘‘professional privilege’’, nurses born between 1960 and 1974 rated their needs in having privileges such as autonomy, recognition and variety in duties significantly higher than those born after 1975. The same trend was observed in their values of obtaining professional privileges. The tendency for nurses born after 1975 to rate both needs and values lower than the others was also seen in the dimension of ‘‘clinical challenges’’. As for the needs, the youngest nurse group (i.e., born after 1975) rated their needs for having clinical challenges significantly lower than those in other generations, especially in the areas of utilising professional backgrounds and the opportunities to be creative. Regarding the values, those born after 1975 again rated on this dimension significantly lower than those born between 1960 and 1974, in particular to the opportunities for being creative and for problem-solving.
Table 1 Results of AVOVA and post hoc comparisons Factors
Generations
Means (S.D.)
ANOVA
Bonferroni
1946–1959 1960–1974 1975–present
3.882 (0.599) 4.044 (0.531) 3.994 (0.538)
F = 1.559 p = 0.212
N/A
Professional privilege
1946–1959 1960–1974 1975–present
3.333 (0.576) 3.423 (0.537) 3.198 (0.532)
F = 5.436 p = 0.005
1960–1974 > 1975–present, p = 0.004
Clinical challenges
1946–1959
3.431 (0.481)
F = 7.703
1946–1959 > 1975–present, p = 0.008; 1960–1974 > 1975–present, p = 0.003
1960–1974 1975–present
3.407 (0.622) 3.173 (0.525)
p = 0.001
1946–1959 1960–1974 1975–present
3.656 (0.642) 3.567 (0.729) 3.596 (0.616)
F = 0.330 p = 0.719
N/A
1946–1959
3.719 (0.647)
F = 3.617
1975–present > 1946–1959, p = 0.039; 1960–1974 > 1946–1955, p = 0.046
1960–1974 1975–present
3.952 (0.559) 3.939 (0.547)
p = 0.028
Professional privilege
1946–1959 1960–1974 1975–present
3.257 (0.535) 3.400 (0.520) 3.191 (0.571)
F = 4.392 p = 0.013
1960–1974 > 1975–present, p = 0.010
Clinical challenges
1946–1959 1960–1974 1975–present
3.237 (0.541) 3.330 (0.564) 3.100 (0.539)
F = 5.555 p = 0.004
1960–1974 > 1975–present, p = 0.004
Social rewards
1946–1959 1960–1974 1975–present
3.473 (0.672) 3.655 (0.628) 3.556 (0.547)
F = 1.764 p = 0.173
N/A
Needs Working conditions
Social rewards
Values Working conditions
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Fig. 3. Events that made nurses in three generations consider leaving their jobs. Note: The line graph indicates the frequencies of the events indicated by nurses in all three generations (n = 214).
With regard to ‘‘social rewards’’, nurses in all generations rated high needs in having good pay and job security, and less in receiving respect. There was no statistically significant difference amongst their needs. The results of ANOVA also indicated no difference in terms of how they value having social rewards. However, a closer examination revealed that nurses born after 1960 valued pay and job security particularly higher than those born between 1946 and 1959. Fig. 3 shows the results of a content analysis on the events that made nurses consider leaving their jobs. A total of 214 nurses responded to the open-ended question (36 nurses born between 1946 and 1959, 67 born between 1960 and 1974 and 111 born after 1975). Themes and categories that emanated from a thematic analysis and were used to content-analyse the data are presented in Table 2. ‘‘Excess workloads’’ and ‘‘issues in interpersonal relationships’’ were the first and third factors of why nurses consider leaving their jobs, and was indicated frequently by nurses in all generations. The second most frequently indicated factor was ‘‘imbalance between work and life’’. As shown in Fig. 3, this factor was the most frequently raised by nurses born between 1960 and 1974, and least raised by those born between 1946 and 1959. ‘‘Lacking motivation to work’’, ‘‘dissatisfaction with organisational system’’ and ‘‘losing confidence to care’’ occupied the fourth to sixth positions, indicated most frequently by nurses born after 1975. In particular, the youngest age group rated ‘‘lacking motivation to work’’ higher than those born between 1946 and 1959, ‘‘dissatisfaction with organisational system’’ higher than those born between 1960 and 1974 and ‘‘losing confidence to care’’ higher than the rest of the nurses. The last factor was nurses being ‘‘attracted to
other jobs’’. This reason was indicated by a small number of nurses born after 1960, but by none of the oldest age group.
7. Discussion Among the four factors of work characteristics, the need for comfortable working conditions was rated highest by nurses in all generations. In particular, having ample leisure time was valued highly by those born between 1960 and 1974, and after 1975. These findings suggest that the intrusion of their jobs into their private lives would certainly discourage these two age cohorts in continuing their jobs. Indeed, the results of a content analysis indicated that the imbalance between work and life made nurses born between 1960 and 1974 consider leaving their jobs most frequently, followed by those born after 1975. This trend is understandable, as Shinjinrui and Dankai juniors value the fulfilment in private life and have a tendency to draw a definite line between work and private life (RICCL, 1997). As for nurses born between 1946 and 1959, the importance they attached to having comfortable working conditions was moderate, although they too indicated high needs in this dimension. The Dankai generation is known as ‘‘corporate warriors’’ and work hard without distinguishing work and private life (RICCL, 1997; Oda, 2006). This tendency was observed in the findings of a content analysis, where they indicated the least numbers of responses in regard to the imbalance between work and life. These findings suggest that nurses born between 1946 and 1959 may be more robust to harsh working conditions, such as
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Table 2 Results of thematic analysis Category
Descriptions
Excess workloads
Excess workloads (both quantitative and qualitative) Many auxiliary tasks Physiological and psychological stress by work
Workloads exceeding one’s capacity in terms of the amounts and abilities; long working hours (extra hours of work often required after the shift) Many auxiliary tasks (i.e., those not relating to nursing care) imposed on nurses (e.g., being involved in work committees, participating in nursing research and seminars) Physiological and psychological stress, fatigue, feeling of burnout caused by hard work schedules and excess workloads
Imbalance between work and life
Invasion of work into a private life Family matters Scheduling holidays/days-off
Off-time consumed by work (e.g., encouraged to participate in nursing research, attending ward meetings, work committees and nursing seminars, etc. on a day-off) Being unable to attend to family matters sufficiently; need to compromise family roles for work Difficulty with scheduling holidays/days-off to meet own/family needs; being unable to take sick leave
Issues in interpersonal relationships at work
Relationships with nurse managers Relationships among nursing staff Relationships with other health professionals Relationships with patients and their families
Stressful relationships with nurse managers (e.g., difficulty communicating with nurse managers; nurse managers not understanding staff needs, not showing respect to staff, and being unsupportive and authoritative) Stressful relationships between co-workers and with senior nurses (e.g., being alienated by other staff, working with arrogant or less motivated nurses) Stressful relationships with physicians and other professionals (e.g., a power relationship between physicians and nurses) Stressful relationships with patients and their families (e.g., patients bullying nurses, need to comply to irrational patients’ requests)
Lacking motivation to work
Discrepancy between ideal and actual roles Losing motivation to work Losing own goals
Being unable to provide the level of care nurses want Being unable to find rewarding and satisfying aspects of the job; feeling unaccomplished at work Losing own professional goals or role models
Dissatisfaction with organisational systems
Lack of professional rewards Introduction of new technology/system Issues with organisational management Lack of opportunities to grow
Inadequate pay and recognition provided to nurses by the organisations Finding it difficult to cope with new technologies and systems (e.g., electronic patient record system) introduced by the organisations Issues relating to insufficient staff allocation and inadequate working conditions (including shift schedule); the organisational decisions not reflecting the current situation Feeling a lack of opportunities for professional growth in the current organisations
Losing confidence to care
Fear of committing medical errors Losing confidence to care
Being afraid to commit (or have actually committed) a medical error on a patient; feeling that big responsibilities rest on nurses Losing confidence to care as a nurse; being unable to save a patient’s life; being unable to meet the job requirements due to a lack of knowledge, skills, and abilities as a nurse
Attracted to other jobs
Nursing jobs in other organisations Jobs other than nursing
Attracted to nursing jobs at other organisations that provide better working conditions Attracted to a non-nursing job, which is more suitable for self
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sacrificing their private time for their work, than other generations of nurses. This, however, does not necessarily mean that their needs deserve the least organisational attention. Excess workloads and issues in interpersonal relationships were the two most frequently cited causes that made nurses in this generation consider leaving their jobs. When problems with workloads and interpersonal relationships go beyond nurses’ capacities to deal with them, these problems will certainly contribute to even the most experienced nurses leaving their jobs. In order to avoid work intruding on nurses’ private time, the current workloads of nurses need to be alleviated. A recent study has revealed that nurses spend approximately 60% of their time in activities that directly benefit patients and 15% doing unnecessary work such as locating equipment and persons (Upenieks et al., 2007a). Another study also suggests that organisational factors such as shift schedules and the organisational skills of nurse managers impact more on nurses’ workloads than the acuity of the patients assigned to them (Spence et al., 2006). Hence, nurse managers should first review the contents of staff activities, work environment, and other work-relevant tasks that nurses carry out, as well as their own management strategies, and then identify areas for improvement. Employing assistant personnel is another way to alleviate nurses’ workloads (Upenieks et al., 2007b). In addition, nurse managers should also show their understanding of nurses’ needs to have quality days-off. Such quality time would allow nurses to recover from work stress and catch up with their family issues. In regard to professional privilege, nurses born between 1960 and 1974 rated their needs and values more highly than other generations. Significant differences between the needs and values of nurses in this generation and those born after 1975 may be attributable to a low score given by the latter in response to supervising others. It is understandable why the youngest group of nurses attached the least need and value to this factor, as their lack of clinical experience does not motivate them to assume this role. However, the fact that nurses born between 1960 and 1974 rated consistently high needs and values in having professional privileges, such as autonomy, recognition and intellectual stimulation, is noteworthy. As has been mentioned, nurses in this generation tend to seek a life at an upper rank (RICCL, 1997). It appears that their tendency to pursue a prestigious life is also reflected in their professional life. These findings suggest that providing a good amount of professional privilege could motivate these nurses to stay in their current jobs. There are several interventions possible to provide nurses in this generation with a sense of professional privilege. For example, the organisations and nurse managers can provide these nurses with more responsibilities and freedom in the conduct of their work. This kind of intervention would improve their sense of autonomy. Nurses in this generation may also feel privileged if they are asked to participate in the unit management and decision-making. In addition, providing immediate praise for a good nursing practice is an excellent way for nurse managers
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to express their recognition of the contribution that nurses in this generation make to patient care (Smith et al., 2005). While nurses born before 1974 tended to seek the clinical challenges, those born after 1975 neither sought nor valued professionally challenging opportunities. This low motivation of the youngest group of nurses may be attributed to their lack of confidence as nurses. Those born after 1975 received nursing education in which Japanese nursing had been experiencing a transitional period from a traditional clinically oriented style of education to an academic education. Many of the previously provided nursing courses have been taken over by universities where nurse educators are struggling to establish nursing as an academic discipline rather than just as an occupation. An emphasis on the theoretical component of nursing and the reduction in a clinical practicum are the characteristics of tertiary nursing education, which contributed to graduates entering the workforce without being equipped with an adequate level of clinical abilities and skills. Furthermore, the complexity of nursing roles, coupled with heightened recognition of patient safety, has prevented students from applying their skills in real clinical settings (Ministry of Health, Labour and Welfare, 2007). As nursing education has been more and more academically oriented, the gap between skills required at work and those taught in the schools tends to be wider. According to a national survey conducted by the Japan Nursing Association, this gap was the most prominent factor causing newly graduated nurses to lose their confidence to work as a nurse, and leave their jobs (Kanoya, 2005). Although not ranked highest, this tendency was also visibly observed in our qualitative findings. The findings of this study thus render support for the previous findings, and highlight the importance of providing junior nurses with an adequate level of clinical education so as to boost their confidence to care. A study by Tokiwa et al. (2004) showed that the level of exposure to nursing skills in clinical settings was correlated to the level of confidence nursing students have in their clinical skills. Thus, the extension and the expansion of a clinical practicum component in the nursing curriculum are essential to boost the confidence of students as well as newly graduated nurses. A solid nursing skill education in classrooms and in clinical sites is also important, as it allows students and graduates to practise their nursing skills on each other or using simulation models. Some of these suggestions were made by a recent nursing curriculum proposal by the Ministry of Health, Labour and Welfare (2007), and are expected to be implemented in tertiary institutions in Japan. With reference to social rewards, nurses in all three generations indicated high needs for receiving a good pay and job security. When it came to the importance they attached to these factors, nurses born between 1946 and 1959 were more modest than those in other generations. The reason why nurses born after 1960 held high values in pay and job security can be explained by their experiences during the economic recession. Having experienced hardship entering the workforce due to shrinking employment opportu-
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nities, these younger generations have tended to develop an aspiration for a stable and solid life. Money and job security are two indispensable tools for them to achieve this end. These findings are consistent with those of the US studies, where Generations X and Y were found to value economic return (McNeese-Smith and Crook, 2003; Hu et al., 2004) as a result of experiencing corporate downsizing. For the organisation, providing high remuneration to all employees is a difficult task, and thus they may not be able to satisfy nurses’ needs in this factor. Considering a high demand for nurses in Japan at present, however, the organisation can assure their work positions as long as their performance meets the organisational goals. The organisation and nurse managers may not discuss job security with their incumbents on a daily basis, but a simple verbal assurance or a statement such as ‘‘we need you here’’ may be enough for nurses to consider staying in the current jobs. Whereas there were differences in the needs, values and reasons for considering turnover among nurses in the three generations, there were also commonalities. Nearly half of the nurses in each of the three generations identified excess workloads and issues in interpersonal relationships to be the reasons that made them consider leaving their jobs. These two problems need to be attended to with extra care in order to alleviate workload burdens. The findings of this study emanated from the responses made by 315 Japanese nurses. As a result of a low return rate, our findings may not be generalised to other nursing populations in Japan. Nevertheless, our findings provide implications that understanding generations may help to identify needs and values of nurses in specific age groups, and their reasons for considering leaving their jobs. The findings of this study could also have implications for other countries. For example, Japanese nurses in the three generations share some characteristics and history with baby boomers, Generation X and Generation Y in the US. Baby boomers are described as not respecting authority (Weston, 2001), yet they are dedicated and loyal members of organisations (Watson, 2002) and define themselves through their jobs (Swearingen and Liberman, 2004). Unfortunately, they too faced redundancies due to downsizing later in their life (Watson, 2002). Likewise, Generation X are described as being cynical (Kupperschmidt, 1998), disloyal to organisations (Watson, 2002) and inclined to draw a line between work and private life (Weston, 2001), attributes that are also commonly seen in Japanese in this age cohort. Generation Y are also known to have grown up during the time of an expansive economy (Martin, 2004), prefer teamwork (Kupperschmidt, 2001) and are competent in IT. Therefore, US nurses may embrace similar needs, values and reasons for turnover as described by Japanese nurses.
8. Conclusions Nurses go to work with a different set of needs and values, and leave their jobs for different reasons. Under-
standing why individual nurses are not satisfied with their jobs, and thus leave their organisations is difficult. On the other hand, treating nurses as a unified professional group who hold the same values and needs may be insensitive. By grouping nurses in meaningful cohorts, the organisations and nurse managers might be able to understand specific expectations held by each group of nurses, and act to reduce turnover in a feasible and an appropriate manner. Generations provide such an insight into the expectations and values of different nurses. However, the varying values held by nurses in different generations were often considered as a source of an intergenerational conflict (Hu et al., 2004; Martin, 2004; Swearingen and Liberman, 2004), the solving of which is a challenge for nurse managers (Watson, 2002). The present study shed light on the positive aspect of the effect of each generation, and suggested that it holds key information that can be used to create a fulfilling work environment for nurses in each generation, and thus alleviating nurse turnover.
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