Fighting the Last War
Thirty-odd years ago, I read a book on a generational history of the U. S., 1 which has recently been re-capitulated and updated. 2 You have encountered this idea if you have heard the term “Gen X.” Their basic argument is population cohorts form a collective identity depending upon their age at the time of major crisis—either secular or religious—and that these recur in a cyclical pattern of four “turnings.” They define these as first, a high, then an awakening, then an unraveling, and finally a crisis. Howe argues we are in the fourth, or crisis, era of the cycle; “a decisive era of secular upheaval when the values regime propels replacement of the old civic order with a new one.” These turnings produce a predictable pattern of generational archetypes, depending on where in the cycle one is born. The children of the first turning are a prophet generation; those of the second turning
are a nomad generation; the third, a hero generation; and fourth an artist generation.
Although they develop their thesis over several hundred years, I will focus only on living cohorts. The last hero generation (GI), born 1901-1924 has essentially died and the next one (millennial), born 1982-2006(?) is just now completed entering the workplace. The nomad generations (silent), born 1925-1942) and Gen-Z, (born say 2006 or later), represent the elders and the children. The “Boomers,” born 1943-1960, are the prophet generation, followed by Gen X, born 1961-1981, who are a nomad generation.
Howe makes some predictions about the national mood, which will be much more unified and will be led by the Millennials (1982-2006). He predicts further emphasis on politeness, careful use of negative language, and adherence of low-risk lifestyles.
“Millennials will approach the Crisis climax showcasing many of the peer traits for which they are already well-known: compliance with authority, desire to contribute, instinct for teamwork, and patience in pursuit of long-term goals.”
I want to use this framework to re-examine the staffing crisis in healthcare. While the entire economy underwent post-pandemic re-shuffling, “The Great Resignation,” news reports suggest staffing levels have stabilized everywhere except health care. Why?
One reason may be a general malaise infecting the present workforce. Aiken and associates conducted a survey in 2021 of 5,312 doctors and 15, 738 nurses working magnet hospitals. 3 Despite restricting the survey to hospitals ranked as good places to work, 20% of physicians and 34% of nurses reported a poor work environment, and fewer than 10% of the clinicians described their workplace as “joyful.” The authors note:
Close to 90% of physicians and nurses reported that professional relations between them were good, and most reported that their care teams worked efficiently together.
These findings hold promise for clinicians acting together to bring about important
changes in their work environments. However, clinicians need management support
for change, and our findings on clinician-management relations were concerning.
Close to half of physicians and nurses were not confident that management would act
1 Strauss W, Howe N. Generations: The History of America’s Future, 1584-2069. (New York: William Morrow
and Co., 1991.)
2 Howe N. The Fourth Turning is Here. (New York: Simon & Schuster, 2023.)
3 Aiken LH, Lasater KB, Sloane DM, et al. Physician and Nurse Well-Being and Preferred Interventions to
Address Burnout in Hospital Practice. JAMA Health Forum. 2023;4(7):e231809.
doi:10.1001/jamahealthforum.2023.1809. Downloaded 20 November 2023 from jamanetwork.com.
to resolve problems that clinicians identify in patient care, and close to one-third of
clinicians reported that their values were not well aligned with those of management.
These are surprising findings in Magnet hospitals given that these issues may be even more pronounced in non-Magnet hospitals.
So how does the generations framework help us to understand the challenges? Much of “the way things are” took place in the years after 2001, or what Howe would label the third turning, an unraveling era, when Gen X, a nomad generation, was fully into the workforce. Now, Gen Xers, now 43-64, are the clinical leaders, and the Millennials are the bulk of the bedside care nurses. Gen X were the latch-key kids of the 80’s, entered the workforce when defined benefit pensions, and a 30-year career with the same firm became delusional objectives. In response, many have thought in terms of individual self-interest, with a focus on short-term, tangible results. Being “joyful” isn’t tangible and simply doesn’t make sense, especially compared with the challenges of this crisis era we are in now. But
recall the things Millennials value: “compliance with authority, desire to contribute, instinct for teamwork, and patience in pursuit of long-term goals.”
The generational framework, then suggests we won’t solve our workforce challenge by doing more of the same, and certainly won’t respond to hiring more free-agents. When I was in the Army, one criticism was we were always training to fight the last war, not the next. Ironically, the Army has an entire system designed to study and evolve tactics as dictated by combat experience anywhere in the world, but health care organizations do not.
What might we learn from our current situation in health care?
Successful organizations will need to harness can-do practicality (Gen X) to creation of more team oriented, joyful places to work (Millennials). I have no glib solutions for this, but one example might be to develop measures that improve “esprit de corps” oriented around clinical goals. Imagine a party to celebrate a year with no central line infections (CLABSI) compared to a “nurse of the year” award ceremony. Both are “good,” but the former celebrates the good work of the group, while the latter celebrates only the individual’s performance. Something like this isn’t bottom line oriented, and may not make sense to Gen X leaders, but might appeal to Millennial workers. Stated more broadly, we need leaders willing to see the care of the patient as the primary goal for everyone, and able to make that a palpable reality in their organizations. Sure, it is difficult, but are there
any better options?
23 January 2024
Addressing Health Care Culture
A contrary view of the culture changes needed in healthcare.
Advisory Report on Burnout, part 1
Health care worker burnout has become so prevalent, the US Surgeon General has issued an Advisory Report on immediate steps needed.
Advisory Report on Burnout, part 2
We are in a time of “bowling alone,” “working from home,” and other trends that result in a general stretching of the social bonds that hold our communities together. This means organizations must be intentional about creating healthy communities within the walls if they want to create healthy communities outside the walls.
Asking the Right Questions
Solutions for problems in health care abound, but are we asking the right questions?
What lessons does building cathedrals have for healthcare reform?
Redesigning Medical Care in Hospitals
Implementing changes designed to improve teamwork are hard and resource-intensive, and may not be as complete as desired. Supporting the effort must be, and must be seen to be, a top priority in these difficult financial times or staffing problems will get worse
.Redesigning Medical Care in Hospitals
Implementing changes designed to improve teamwork are hard and resource-intensive, and may not be as complete as desired. Supporting the effort must be, and must be seen to be, a top priority in these difficult financial times or staffing problems will get worse.