Crit Care Nurs Q Vol. 33, No. 1, pp. 67–74 c 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins Copyright 

Generational Considerations in Providing Critical Care Education Tricia Paterson, RN With the current and predicted nursing shortage, much emphasis is placed on recruitment and retention. With an aging workforce, we must recruit, educate, and retain nurses from many different generations. As leaders and educators, we must be aware of generational differences and work with staff to appreciate potential preferences in communication, approach to learning and motivational factors. We are aware that over the next 15 years, many experienced nurses will retire. We must do all we can to recruit and retain nurses from all generations in order to provide a workforce able to meet the needs of our patients and families. Generational preferences should be considered when developing nursing education and in welcoming and accepting new staff into the culture of the nursing unit. Key words: Baby Boomers, Generation X, generational characteristics, Millennials

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OCIALIZATION of a nurse into a new work setting can be as important as establishing clinical competence. A new employee who does not feel like a valued member of the team or who feels that they do not have friends or a social network in the workplace is not likely to stay there. A nurse starting a nursing position may be fresh out of school, starting nursing as a second career, or returning to nursing after some time away. These nurses may come from many cultural and generational backgrounds. This article will focus on the importance of recognizing and understanding generational value development, characteristics and preferences, and how this influences our approach to communication and providing critical care education and training. Awareness of generational differences may require a change in how we conduct ourselves. Raines suggests that we follow what

Author Affiliation: Southeast Baptist Hospital, Baptist Health System, San Antonio, Texas. Corresponding Author: Tricia Paterson, RN, Southeast Baptist Hospital, Baptist Health System, 4214 E. Southcross Blvd, San Antonio, TX 78222 (tricia [email protected]).

she has coined the “Titanium Rule.” Instead of the “Golden Rule” of doing unto others as we would have done unto us, we should “do unto others, keeping their preferences in mind.”1(p34) This requires knowledge and insight into the generational differences that we encounter within our workforce, and our attitudes toward these differences. Generational differences in nursing have the potential to create unnecessary friction and conflict. When we see or hear an act that is not congruent with our own likes or thought processes, we may initially pass judgment that the other person is wrong or misguided. We may consciously or unconsciously search for other behaviors in that person to support our impression. We may even ignore other behaviors that discount our theory, in an attempt to selffulfill our initial impression. Friction and conflict may lead to unhealthy distractions from patient care, increasing the risk for error and increasing the likelihood of staff turnover. Education, the act or process of imparting or acquiring knowledge, occurs in many situations on a nursing unit. Educators, staff nurses, doctors, other team members, patients, and families are all involved in the process of providing and receiving education. 67

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Education can be planned as part of an orientation or continuing education program, can occur during daily rounds, can be incorporated into the plan of care, or can occur during those ever-important just-in-time teachable moments. The ability to communicate and to understand the needs and desires of the other person is the foundation for respect, and respect is a vital component for communicating at a professional level. Skilled and thoughtful communication includes the ability to anticipate and exceed the expectations of those with whom we interact. Educators who understand and consider generational differences can role model their approach to meeting the needs and expectations of various age groups. Educators who demonstrate these skills can help instill this approach in new employees and in their relationships with other coworkers, patients, and families. When dealing with critically ill patients, communication barriers can lead to fatal mistakes. In creating a culture of patient safety, a nurse must feel free to speak up and “stop the line,” essentially requiring all present to immediately stop what they are doing and ensure safety measures and processes are being followed. A team member who notices or suspects a problem has the obligation to speak up and should be able to do so without fear of repercussion. This is indeed daunting for many nurses. The open communication that comes from understanding and respecting one another will facilitate all members of the healthcare team to do the right thing more frequently. Educators often find themselves addressing a mixed audience, so they need to effectively communicate to a group of nurses in with very different styles, preferences, and expectations. Educators have to alter and adapt on the spot to meet the learning needs of the group, and one style or methodology often does not fit all. We cannot assume, for instance, that everyone is able to access information or complete training online. We may not appreciate that someone who has been out of the clinical setting for a while is looking at bedside technology that is very differ-

ent from when they last practiced. And, we cannot assume that an experienced nurse will be comfortable admitting in a public setting what they do not know. Understanding of generational differences can provide insight into these situations. The following discussion includes defining the generations, generational characteristics, preferences related to educational approaches and how an appreciation of these factors can positively influence an educator’s approach to communication and adult learning. It is important to identify with your own generational characteristics and then familiarize yourself with the other generational characteristics of others. Developing generational appropriate techniques can help you identify with another person’s values and present information in a manner that will encourage the other person to be receptive. A generationalsensitive approach will promote communication that will benefit the patient, the employee, and the educator. DEFINING THE GENERATIONS The generational differences we encounter today are more than just a matter of differences in likes, dislikes, and perspectives. They are gut-level differences in values that involve a person’s beliefs, emotions, and preferences. The values we develop in our youth are the foundation for what we believe as adults.2 This value development occurs in stages during the period from ages 1 through 20. We develop values by imprinting, modeling, and socialization in our childhood years. But, in early adulthood, we may find ourselves replacing some of these childhood values if we experience significant emotional events.2 As we think about generational characteristics, we must visualize the Bell curve, where on one extreme we have few members of the generation whose values deviate from the norm, the center with the normal values of society and thus the majority of the members, and then the other extreme where again, a few members of the generation find themselves.2 When studying a generation, we

Generational Considerations in Providing Critical Care Education assume that those whose ages cluster together in the height of the Bell curve will exhibit similar characteristics and reactions. This knowledge of common traits and characteristics helps us to determine the most effective way to communicate with a certain group or individual. It is important to note that we when talk about traits common to a generation, it is not meant to stereotype or neglect individual differences. It is only meant to provide a frame of reference that can lead to increased understanding and sensitivity. When does a generation start and stop? Stauss and Howe suggest in their book, Generations, that a generation is roughly 22 years in time.3(p31) Others will look at period of population increase and decrease, or defining events that affect a whole generation at a certain period in their life, such as the assassination of John F. Kennedy, the Challenger disaster, or the tragic events of September 11, 2001 when the Twin Towers in New York City were attacked by terrorists. Often, people identify with others born in the same decade. People born in the 1940s and 1950s are widely known as the Baby Boomer generation. Members of this generation are currently between 50 and 67 years old, and have a current U.S. population of approximately 76 million.2 Baby Boomers will continue to hold key leadership positions. The next generation, born from 1960 to 1979, is often referred to as Generation X. This age group includes 44 million people who are currently between the ages of 30 and 49 years.4 The generation born between 1980 and 1999 has been called by many names, including the Y Generation, Generation Next, the Net Generation, and the Millennials. The Millennial generation was born between 1980 and 1999, and that age group currently ranges between the ages 10 and 29 years. They have a population of approximately 80 million, which is larger than the Baby Boomer generation.2 Looking at the other end of the spectrum, it is also important to mention the Traditionalists, born between 1920 and 1939, now at the age of 68 to 89. Although 95% of this generation is retired,5 this generation produced

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leaders who demonstrated commitment to social concerns and greatly influenced the Baby Boomer generation. These individuals include Cesar Chavez, organizer of the United Farm Workers, and Martin Luther King, Jr., another great civil rights leader. UNDERSTANDING In nursing, the average age of registered nurses employed in hospitals in 2006 was 48, up a staggering 7 years, as compared to 2002. The breakdown of age groups provided by the Bureau of Labor Statistics reveals that 45% of the nursing population working in hospitals are Baby Boomers, 42% of the group are Generation Xers, and the Millennials make up a mere 10% of the registered nurse workforce.6 This poses a significant age imbalance. We are faced with an aging workforce who may have difficulty meeting the physical and emotional demands of the critical care environment or 12-hour shifts. Baby Boomers will be looking at retirement over the next decade. In order to pass on the experience and knowledge of this generation, we need to recruit younger nurses before the Baby Boomers retire. Educators must be able to help bridge the gap between these distinctly different generations while meeting the needs of both. In doing so, educators can positively impact both recruitment and retention. CHARACTERISTICS & PREFERENCES BOOMERS The Baby Boomers’ learning styles were directly influenced by their upbringing. Most commonly, 2 parents were present in the household. The mother often was at home and available to help them while they were learning to cook or complete their homework. Thus, the Boomer generation is generally comfortable with someone offering assistance during the learning process.7 This generation demonstrates remarkably high loyalty to companies and to their work. The Baby Boomers are seen as “workaholics” because they are willing to work more than the

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standard 40-hour work week.5 They believe that rewards will come in due time based on years of service. Baby Boomers have a willingness to sacrifice for success. They also crave individual recognition because of their sheer numbers, are highly respectful, see education as a birthright, and strongly favor personable communication to build rapport with peers and coworkers.8 Baby Boomers may desire a trainer who will offer activities where they can interact in teams and form relationships.1 They like trainers who come across as their equal, and they enjoy personal examples and sharing of the trainer’s vulnerability. Baby Boomers believe attention to training will help achieve on-the-job “star power,” which reflects their desire for recognition. Boomers may dislike role-play, as they may be apprehensive about demonstrating shortcomings in public. They enjoy generous positive reinforcement during the learning process. Boomers prefer training materials that are readily accessible and that can be examined in more detail on their own time. As an educator, we need to help Baby Boomers put their knowledge into practice. When we ask them how to solve a problem, this helps them assimilate the knowledge they already have with what they just acquired. A nonauthoritarian environment provides the Boomer the greatest chance of success for learning.1 GENERATION X The Generation Xers are now in their 30s and 40s. They were raised in an era of high divorce rates and single parenthood, and they were coined “latchkey children.” For this generation, their value development occurred during a time when their parent(s) were hard at work late in the day, so they were coming home after school and looking after themselves. Because of this, they are used to getting things done on their own. This translates into nurses who are willing and able to meet goals set before them. They demand that the goal or purpose is clearly stated because they begin formulating a plan as soon as the concept

is presented to them. They often will work through a task on their own, in their own way. For a Generation X person, how you get it done is not as important as the fact that it actually gets completed. Growing up, if it was their responsibility to make dinner, success occurred if food was on the table in time. It was completely irrelevant if it was hot dogs or a pot roast with vegetables. Guilt-ridden parents would come home and tell them how great they were for accomplishing the goal (ie, dinner on the table.) They desire praise from their leaders and educators when they reach desired outcomes. This group also experienced their parents being laid off from work in the 1980s after years of dedicated service. Because of this, they tend to be skeptical, independent workers who value a balance between their work and family life. This is supported by the fact that of the 44 million Generation X employees, 17 million change jobs every year.4 They are very comfortable with multitasking, are motivated to get the job done, and value efficiency, directness, and immediate responses. For example, if a Generation X has a question (and they are comfortable asking a lot of questions), they want a direct answer in a timely manner. Clearly stating goals, providing immediate feedback, and clarifying questions quickly will assist Generation X students in engaging in a learning activity. Generation Xers prefer a learning environment where they have the opportunity to explore different methods to attain a goal. The Generation X student grew up on the cusp of the technology age; they played with Atari instead of PlayStation 3. They enjoy visual learning with clear, simple images to illustrate the point. The educator would do well to choose CD ROM and videos as methods of teaching. The Generation X student wants to sample and try products and will enjoy role-playing. They are responsive to trainers that are succinct and demonstrate their expertise. If the educator can convince Generation Xers of the value of a lesson, they will not hesitate to jump in and try something even if it makes them look clumsy in front of others. This can

Generational Considerations in Providing Critical Care Education prove to be a great lead-in for the other generations who may be more hesitant to participate in role-playing. Members of Generation X like short activities followed by group interaction. They prefer short term challenging goals and appreciate the use of bullet points in presentations to highlight key concepts. Because of their independent style, you might consider establishing a relationship with an experienced nurse who can act as a coach. This way, the Generation X student knows who they can turn to in order to “bounce-off” ideas.9 They will appreciate references and resources such as Web sites, e-mail addresses, and telephone numbers. Generation X people enjoy learning by doing, are very flexible, and have a very strong desire for positive feedback. They are eager to learn once a useful purpose of the learning exercise has been presented to them. Importantly, Generation Xers want learning to be fun. They want the opportunity to connect with people and celebrate accomplishments. Having fun allows for people to learn about each other in an easy-going environment. It is important to find out from the students what they perceive as fun. Recall the “Titanium Rule”;do unto others, keeping their preferences in mind.1 Then, do your best to incorporate these ideas into the lesson while giving ample credit to the creators. When teaching, it is best to err on the side of freedom in the learning environment—for if you allow them to work out problems for themselves, they will thrive. MILLENNIALS The Millennials come from merged families that are highly collaborative and optimistic. They are the only generation that has grown up alongside technology and expect it to be part of their lives. As a generation, the Millennials have a clear focus on worklife balance and accept authority. Their upbringing was highly collaborative, with parents including them in family decisions, so it is of utmost importance that they be heard. Millennials may need more supervision than

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other generations. As a generation, Millennials like to look at positive creative options when solving problems. They subscribe to a strict moral code, they care about manners, and they strongly believe in civic action and in volunteering for their cause of choice. The Millennials also place a high priority on making money, both personally and for the company. It is important to tie course objectives clearly to economic impact. Educational strategies for Millennials may include providing digital education such as computer simulation or Internet Web sites. They will be easily bored if they are required to sit and listen to a lecture for a long period of time. Educational activities need to be interactive and engaging. Millennials prefer a learning environment that combines teamwork and technology. In a classroom setting, give everyone a task, and when a few have completed the task correctly, encourage them to help others.1(p140) The interaction with the other members of the class promotes their self-worth, which may be lacking due to inexperience. Technology, on the other hand, seems as natural as air. However, they expect the technology to be up to date. They will readily notice trainers who are not comfortable with current technology, and they have the tendency to stereotype that trainer’s generation as being behind the times and thus on a lower level than themselves. This initial reaction is difficult to reverse, and trainers must be aware of their own shortcomings where technology is concerned and identify them openly. Because Millennials grew up in highly scheduled environments (think “soccer moms”), they are used to being busy and prefer more structure than Generation X in their learning activities. They look for attention from the authority figure during the process of learning. Educators can get creative with music, art, and games, and incorporate lively and interactive training materials to keep them engaged. Millennials often enjoy reading, so the educator may want to provide both print and online articles and references. When training Millennials, encourage and reward technological creativity. Try to balance

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didactic and discovery activities with opportunities to ask questions. Present short and clear goals and objectives and use interactive sessions with teams and groups. A Millennial needs to be able to build on to skills they already possess, and be encouraged to be innovative when mastering new concepts. A Millennial student will benefit from a mentor or preceptor who is patient and will supervise them until they are competent. The preceptor can encourage interaction with other members of the team and facilitate team building. The Millennial generation is often more interested in being part of the team than leading it.9 MIXED With the hope of engaging all members of a mixed generational group in a learning activity, a skilled educator needs to be flexible. Anticipate your audience so you can develop and present your material accordingly. As nurses, we are used to adapting our communication style depending on whether we are speaking to a doctor, a colleague, or a patient’s family member. As an educator, appreciation of the need to adapt can be demonstrated by having a variety of tools, resources, and methodologies that address the learning needs and preferences of the target group. Before starting a learning activity, have an open discussion regarding the differences in generational preferences. By clearly stating that there are characteristics common to generations, the discussion becomes about the generations’ themselves, thereby avoiding the pitfall of the perception of an individual attack. It is best to encourage students to offer statements of positive traits that each generation may contribute to the group and thus collectively place all generations in a positive mindset. When forming groups, be aware that the learning style of one generation may benefit from sharing the style of another. This variation in backgrounds and perspectives can be presented as an opportunity that is beneficial to the students and the educator.1 An assessment tool that helps the learner identify their preferred learning style can be used

and the information gained shared among the group. This awareness of other style preferences helps the learner realize that a variety of methods can be used to meet learning goals. As each generation begins to understand the other generations, acceptance becomes possible. There are a number of ways you can offer diversity in your training sessions. Provide options in various formats: large and small group discussions, e-learning, videos, simulation, and role-play, to name a few. Ensure your training materials depict people of a wide variety of ages and ethnicities. Are there activities for introverts and extroverts, for kinesthetic, visual, and audio learners? Are your materials easy to read for those who are 50 and above? When training, be sure to use examples that include people from the various generations, highlighting the best about people. Successful trainers treat everyone knowing they have great things to offer and are motivated to do their best. Stuenkel10 offered an innovative approach to integrate the generations successfully. She presented case studies derived from actual stories found in newspapers. Attentiongrabbing headlines, such as “Man Goes 6 Days with Nail in Skull”and “Inadvertent Intracranial Nasogastric Tube Placement,” were brought to the classroom where small groups worked to develop a care plan based on the information provided in the article. The validity of the topic engaged the generations. The Baby Boomers were able to work in groups to obtain validation of their ideas, the Generation Xers were clearly given a goal to care for this patient, and the Millennials were initially captured by the “wow”factor of the event. Together, they were eager to work as a team and formulate a thorough care plan. Stuenkel used information about learning style preferences from each generation and provided an educational opportunity that proved beneficial to all. In another study, Walker et al11 evaluated generational differences in student’s preferences related to classroom teaching methods. They compared and contrasted Generation X preferences versus Millennial preferences

Generational Considerations in Providing Critical Care Education (n = 134, 25 Generation X, 105 Millennials). Both groups preferred lecture over group work for receiving conceptual information. When learning how to perform certain skills, both groups preferred demonstration/return demonstration over a lecture format. The data also showed that for the Generation X and Millennials, 72% learned from clinical stories, and 96% preferred handouts that coincided with a visual presentation. A surprising finding was that both generations enjoyed the benefits of face-to-face educational experiences, when generally these generations are perceived as technologically savvy with the assumption that they want everything computerized. ONLINE TRAINING FOR ALL GENERATIONS More and more training opportunities are being provided using a computer or Webbased format. Although we assume younger generations will be more comfortable with e-learning than their older coworkers, all generations may face challenges when navigating online education. Faculty, too, must adapt to the online environment. Faculty who have been most successful in this transition have exhibited the following traits: they are motivated to learn, are willing to lose control over class design and teaching style, are able to collaborate with experts, are willing to change roles, are able to build a support system, patient with technology, and are able to learn from others.8 One Australian study12 found that a group assignment via online learning was considered an active, social, and shared learning experience by the students. The use of bulletin boards allowed for active sharing of information. For students who are less likely to offer opinions in an open classroom forum, the online bulletin board allowed the student to reflect on his own opinions and then be able to freely share them in a comfortable environment.12 Hu et al13 studied 62 participants from various nursing units. They found that half of those in the Baby Boomer generation found computers “frightening and complicated.”Ed-

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ucators may need to assess for this level of discomfort and perhaps offer a basic computer skills course before any computer based learning activity is required. Also, when working online, Kenny12 found that students who are less computer savvy prefer working in small groups (6–8 students) with others who have approximately the same level of computer experience. She found that students who were experienced with computers did not generally have this same preference. Unfamiliarity and fear of the unknown can undermine a training program before it even gets started. The Baptist Health System began providing advanced cardiac life support in a Web-based format in January 2009. It is offered to nurses taking the course for the first time as well as to seasoned intensive care unit nurses who are renewing their certification. Initially, there was a great deal of anxiety voiced by the Generation Xers and Baby Boomers. Some opted to not even attempt the online course and chose to take the course in a live format outside of the system. The benefit of self-paced study was overpowered by the fear of online learning and/or the fear of not having face-to-face education. Over the course of the year, our education department has loaned hard copies of the course manuals on request, provided written instructions on how to navigate the program, offered a 30minute briefing session, provided telephone support, and offered live assistance as the learner was working through the program. Our employees seem relieved to know that these options are available, and anxiety has decreased. Providing nurse managers with a mini demonstration of new programs that are introduced also creates influential advocates. For the student, an up-front assessment of familiarity with online learning and remediation before an online course is assigned can promote a positive learning outcome. THE EDUCATOR Educators in today’s workforce represent all 3 generations. Many of them are Baby Boomers and early Generation Xers, but times have changed. Baby Boomers may be used to

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generational separation in the workplace. In the past, the older you were and the longer you were with a company, the higher your expected position. Management training was tiered accordingly so training occurred basically within the same generational group.12 Also, nursing school classes did not have a mix of generations. I called my nonagenarian grandmother to inquire about her nursing graduating class of 1941, and she readily remembered that all of the woman were about 20 to 21 years of age. Today, nursing classes consist not only of those who have progressed sequentially from high school to college or nursing school, but also of those who are entering nursing as a second career and as an older adult. The educator now is more likely to have to meet the needs of a multigenerational group. A great descriptor of the Millennial Generation is “digital native” which leaves the rest of us as “digital immigrants.”12 Many nurses and educators have had to embrace technology as a means of professional survival. As educators, we are constantly striving to master new technology. We may be providing educa-

tion about using new technology, or we may be using new training technology ourselves. Many educators were trained primarily in a live, lecture-oriented environment. Thus, it is important for the educator to expand their own technological skills and become more aware of the principles of computer-assisted learning. CONCLUSION Being respectful of generational differences requires knowledge about each generation as well as self-awareness. Larson said, “You can create synergy when you know what people’s strengths are.”14 An educator who has generational awareness, who uses that awareness to meet the needs of a mixed group of learners, and who can help others see the positive contributions each generation has to offer, can support the development of this synergy. And, in finding that element of understanding, the environment will be more conducive to learning, and the group will be more likely to work together, stay together, and produce a favorable outcome.

REFERENCES 1. Raines C. Connecting Generations: The Sourcebook for a New Workplace. Menlo Park, CA: Crisp Publications; 2003. 2. Hicks R, Hicks K. Boomers, Xers, and Other Strangers: Understanding the Generational Differences That Divide Us. Wheaton, IL: Tyndale House Publishers; 1999. 3. Stauss W, Howe N. Generations: The History of America’s Future 1584 to 2069. New York, NY: Harper Perennial; 1992. 4. Swearingen S, Liberman A. Nursing generations: an expanded look at the emergence of conflict and it’s resolution. Health Care Manag. 2004;23(1):54–64. 5. MacLaughlin FB. Leading by recognizing generational differences. Long Term Living. 2009:2:34–35. http:// www.ltlmagazine.com. 6. The aging RN workforce: Effective strategies to leverage and retain experienced nurses. Health Workforce Solutions LLC, Perspectives. http://www.healthws. com/perspectives3/index.html 2007. Accessed June 3, 2009. 7. Wieck LK. Generational approaches to current nursing issues—How younger and older nurses

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can coexist. Okla Nurse. March-May 2005:16– 19. Gibson S. Intergenerational communication in the classroom: recommendations for successful teacherstudent relationships. Nur Educ Perspect. 2009; 30(1):37–39. Stewart DW. Generational mentoring. J Contin Educ Nurs. 2006;37(3):113–120. Stuenkel DL. Consider this: straight from the headlines to the classroom. Nurse Educ. 2009;34(3):99– 100. Walker JT, Martin T, White J, et al. Generational (age) differences in nursing students’ preferences for teaching methods. J Nurs Educ. 2006;45:371–374. Kenny A. Issues and innovations in nursing education. Online learning: enhancing nurse education? J Adv Nurs. 2002;38(2):127–135. Hu J, Herrick C, Hodgin K. Managing the multigenerational nursing team. Health Care Manag. 2004; 23(4):334–340. Larson J. Exploring the Generation Gap in the Nursing Workforce, 2009. http://www.Nursezone.com. Accessed August 1, 2009.