Literature Map Overview Contents

1 NARRATIVE ARGUMENT: RESEARCH PROBLEM ........................................... 3 1.1 Argument ............................................................................................................ 4 1.2 Problem ............................................................................................................. 11 2 BACKGROUND ...................................................................................................... 12 2.1 Nursing Shortage .............................................................................................. 12 2.2 Economic Rationalism ...................................................................................... 14 2.3 Impact of Nursing Shortage on Quality Outcomes of Care .............................. 16 IMPACTING CONCEPTS ........................................................................................... 18 2.4 Organisational Environment ............................................................................. 18 2.4.1 Workload................................................................................................... 20 2.4.2 Skill Mix / Casualisation ........................................................................... 21 2.4.3 Risk Factors .............................................................................................. 23 2.4.4 Work Excitement ...................................................................................... 25 2.5 Leadership ......................................................................................................... 28 2.5.1 Communication/Team Function/Peer Cohesion ....................................... 28 2.5.2 Flexibility .................................................................................................. 30 2.5.3 Supervision / Supportive / Trust ............................................................... 31 2.5.4 Autonomy / Empowerment ....................................................................... 33 2.5.5 Mentorship ................................................................................................ 34 2.5.6 Commitment ............................................................................................. 35 3 Professional Status and Remuneration...................................................................... 36 3.1.1 Professional Job Design ............................................................................ 36 3.1.2 Professional Pay Structure ........................................................................ 38 3.1.3 Professional Development Opportunities ................................................. 39 3.1.4 Boomers versus Xers ................................................................................ 40 4 RESULTANT ISSUES ............................................................................................. 41 4.1 Retention, Resign or Retirement ....................................................................... 41 4.1.1 Job Satisfaction ......................................................................................... 42 4.1.2 Decision Making Ability / Valued Expertise ............................................ 43 4.1.3 Unique Needs ............................................................................................ 44 4.1.4 High-Effort/Low Reward .......................................................................... 49 5 IMPLICATIONS FOR RESEARCH /PRACTICE .................................................. 51 6 REFERENCES ......................................................................................................... 53 7 APPENDIX 1 Terms and Definitions ....................................................................... 54

1 NARRATIVE ARGUMENT: RESEARCH PROBLEM

The following contextual narrative clarifies the problem emerging for the following themes. The research will utilise the three major factors which may influence nurses decision to end their career. These are organisational environment,

leadership and professional status and remuneration. The paper will develop an in-depth understanding of these factors and how they impact on the end-of-career nurses (EOCN) view of job satisfaction which is required before any intervention is designed to effect the decision to leave. For the purpose of this paper, end-ofcareer nurses are aged from 45 years onwards regardless of when the entered the profession and is limited to registered nurses only.

In Context
As an experienced nurse educator in the Australian Healthcare system, I have worked for 10 years in a School of Nursing. We provide professional

development opportunities for all registered nurses within a large metropolitan tertiary and teaching hospital. An organisational priority is the professional

development of the nurse leadership team who consist of nursing officers 3 to 7 culminating in the middle and upper management group. In order to support future nurse leaders through succession management, the inclusion of nursing officer 2s, the lower management group, has recently occurred. A major component of the professional development initiative is a supportive transition program targeted for the new graduate and has come as a result a nursing shortage in the acute setting. This program focuses on the consolidation and advancement of the new graduate nurses beginning skills which is supported through a preceptor model over approximately twelve months. This preceptor support is provided by a select group of experienced staff.

For experienced nursing staff, preceptor training is delivered over two days with other complimentary programs such as Leadership and Management, Mentoring, Preceptorship and Business Planning being offered, however attendance to these programs are limited due to the heavy workloads and insufficient staff to provide backfill during program times regardless of flexible delivery times and options. In addition to their designated role as preceptor, the experienced nurse is expected to cope with workplace issues such as perceived lack of leadership support and minimal of off-line time to attend professional development. For example, their daily workload would include preceptoring the new graduates/staff and student nurses, continue a normal case load of patients and often manage the shift coordination. As a result of these workload demands, burnout and possibly

attrition rates for the EOCN is increased.

In order to fill staffing vacancies, the organisational focus has been on recruitment, yet minimal effort is provided to support retention of the EOCN. At this point, there appears little effort to retain the EOCN cohort in the profession, thus prematurely reducing their participation in the workforce. As a consequence, it is expected 22,000 nurses will leave their jobs from 2002 until 2006 (National Review of Nursing Education, 2002). EOCN have gathered considerable

corporate knowledge and experience which is invaluable in support of the less experienced nurse. Little is known about the reasons for their exit and what are the resilience factors for the EOCN who choose to remain?

1.1 Argument
The attrition of EOCN contributes to the nursing shortage that provides a backdrop which will influence the quality outcomes. Conversely it is the

healthcare systems challenge to put aside economic consideration and influence the ECONs decision on their employment status. During this global nursing

shortage, Australia has predicted a shortage of 31,000 nurses by 2006 (National Review of Nursing Education, 2002). By 2010 it is forecast that almost all of the baby boomers, of which the EOCN belongs, will be at prime retirement age

(Buchan, 1999; Duffield & O'Brien-Pallas, 2002; Minnick, 2000), yet no strategies are in place to retain this group. With 47% of the workforce over 46 years of age and 20% in the 56 year cohort, there is limited time to ensure the environment is conducive to meet the needs of the patient and the EOCN (Forster & Queensland Health, 2005).

Other contributing factor to nursing shortages such as declining school enrollments and disillusionment with nursing as a profession have contributed to fewer nurses at the bedside, often choosing other more satisfying career options (Norman et al., 2005). While numerous Government reports have recommended strategies to address the current shortage (Australian Health Ministers' Conference, 2004; National Review of Nursing Education, 2002), none have specifically viewed the value of retaining the most experienced practitioners who are on the brink of retirement the EOCN (Buchan, 1999). Retention of the EOCN could rebalance the registered nurse population in a time of shortage, however strategies are not in place to modify current trends of exit.

The current shortage is of concern to most health professionals and it is questionable if staff supply can keep pace with an increasing demand for quality healthcare in an environment of limited resources. To provide quality care, job redesign requires a renewed look at the under-utilisation of the EOCN (Australian Health Ministers' Conference, 2004; Duckett, 2005). Cognisant of nursing

shortages and resultant imbalanced of skill mix, this is an opportunity to consider issues such as workforce substitution with the potential to better utilise and consequently retain the experienced EOCN (Duckett, 2005; National Review of Nursing Education, 2002).

Contemporary healthcare services are moving away from cost containment towards an emphasis on quality outcomes (Donley, 2005; Ferlie & Shortell, 2001). Within this environment, the benefits of EOCN becomes evident when research has identified a positive association between higher levels of staffing by registered

nurses and lower rates of adverse outcomes (Fagin, 2001; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002). Therefore, with a diminishing nurse

workforce taxed with heavy workloads, evidence of adverse outcomes linked to disproportionate nurse-patient rations, highlights a need for quantifying the demands placed on nursing staff (Capuano, Bokovoy, Hitchings, & Houser, 2005). Employers will soon face an older and smaller registered nurse workforce and the increasing demands will weigh heavily on this ageing cohort. The focus must ensure that strategies are in place to retain the valuable resource of EOCN ensuring that the effects of the staffing reductions do not negatively impact on quality outcomes (Buerhaus, Staiger, & Auerbach, 2000b). If nurses do not have the resources or time to care for patients, no amount of public relations will convince patients that received good quality nursing care.

Organisational Environment
The context in which EOCN choose to work may be the most important decision related to leaving the organisation. Factors such as heavy workloads, risk factors and inappropriate skill mixes can have a significant negative impact on staff and their health outcomes.

An Australian review reports that nurses often find they belong to a profession controlled in a paternalistic manner and one that is not held in high regard by other health care team members. This review, while not specific to EOCN, did suggest that nurses experienced endless shift work, low pay, horizontal violence, social isolation, risk of injury and disease (National Review of Nursing Education, 2002, p. 180). Numerous authors have identified that excessive workloads are a major stressor causing dissatisfaction, which negatively affects turnover figures (Cyr, 2005; Forster & Queensland Health, 2005; National Review of Nursing Education, 2002; Needleman et al., 2002; Strachota, Normandin, O'Brien, Clary, & Krukow, 2003).

From a quality perspective, services are dependant on appropriate numbers of competent, skilled clinicians. A recent review documented unsustainable

workload levels which was exacerbated by an increase of unqualified workers and a reduction in the numbers of qualified nurses (Forster & Queensland Health, 2005). Consequently, due to their experience, EOCNs were expected to manage heavy workloads, provide direct patient care, act as shift coordinator while holding a mentor portfolio to junior staff (O'Brien-Pallas, Duffield, & Alksnis, 2004).

As a consequence of unrelenting workloads, nurses are increasingly susceptible to injuries. Time and cost constraints may minimise the use of supportive

equipment such as manual handling devices, causing higher musculoskeletal and needle-stick injuries reported in the older cohort (American Nurses Association, 2001; Buerhaus, Staiger, & Auerbach, 2003; Chandra, 2003). Damaging effects of work related injury range from mental health problems to coronary disease (DeVries & Wilkerson, 2003). The literature also indicates a strong correlation between sick leave and overtime (Norman et al., 2005). The personal cost to staff from these injuries may have a direct impact on the inability to recruit and retain experienced nurses (Creegan, Duffield, & Forrester, 2003; Demerouti, Bakker, Nachreiner, & Schaufeli, 2000). With exploding costs to the individual and the organisation, a report from United Kingdom estimated that job stress cost 3.8 billion pounds and lost approximately 13 million work days per year (Laurence, 2003). Under stressful conditions, nurses are considered particularly susceptible to burnout. Studies suggest that these compounding issues are negatively

associated with satisfaction and turnover (Aiken, Clarke, Sloane, Sochalski, & Silber, 2002).

With increased turnover and insufficient quality staff, gaps in services are temporarily filled by a variety of methods (Creegan et al., 2003; Forster & Queensland Health, 2005). One such method is casualisation, particularly if

personal and professional needs are not met (Hart, 2006). Seen as a cost saving device, unqualified workers present a quality risk, due to no minimum standard

and consequently places enormous supervisory pressure on the experienced nurse (National Review of Nursing Education, 2002). A frequent outcome of

inappropriate skill mix may cause full-time staff to resign or reduce employment hours, as they undoubtedly will be left with less desirable shifts.

Known to be a volatile and hostile environment, a heightened risk of violence in the workplace may include issues such as bullying, harassment or condescending behaviour. The climate may influence nurses mobility and their decision to leave the profession (Queensland Nurses' Union of Employees, 2004). In 2000, an Australian study concluded that workplace bullying is a result of a stressful environment. The violence varies from intimidation to stabbings and the

perpetrators range from colleagues, physicians, patients and family members (Rosenstein, Russell, & Lauve, 2002; Stevens, 2002). Bullying affects one in four employees with costs incurred from productivity losses, increased absenteeism, turnover and law suits, which were estimated at $12 billion per year (Mayhew & Chappell, 2001).

Leadership
It has been argued that a portfolio of leadership approaches which is modified to meet the needs of different groups or individuals energises staff to excel (Sofarelli & Brown, 1998). Leadership is understood in this context as the behaviours, knowledge and skills that are pivotal to the development of a social climate which is sensitive and supportive of the need to nurture and retain quality staff (Garrett & McDaniel, 2001). These behaviours may create a sense of ownership for the nurse without being fearful of risk taking in this constantly changing environment. Transformational style is argued to have the ability to empower staff to embrace innovation and change.

While the literature provides examples of optimal leadership qualities and styles, many organisations are stuck in bureaucratic hierarchical models of the past,

missing the opportunity to provide a more open and flexible leadership approach (McDaniel, 1997). The risks for hierarchical institutions is their inflexibility which blocks the necessary responses required in a changing environment (Sofarelli & Brown, 1998). This bureaucratic structure was evident in a public health review, which identified the inflexibility and inequitable practices imposing unreasonable demands on staff (National Review of Nursing Education, 2002). The EOCN

often described as the sandwich generation, as a result of their diverse responsibilities outside the work environment. With a predominately female led profession (80%), these demands on work-life balance of the EOCN is a significant issue which organisations should consider.

Consequently, as a result of the demands placed upon the EOCN, trust in leadership has become an increasingly critical element in influencing the organisational culture, employee performance and commitment to the

organisation (Allen & Meyer, 1996). Nurses struggle to provide quality care within cost constraints, supervise increased numbers of unlicensed care givers and yet continue to have little influence in their practice setting (Laschinger, Finegan, & Shamian, 2001c). Lack of consistency and credibility of healthcare leaders

dealing with labile budgets further compromise the supportive and trusting relationship needed to retain quality staff (Malloch, 2002). The literature does indicate dissatisfaction of nurses across the age spectrum and although few studies have focused specifically on the EOCN, what literature is available is limited to descriptive studies (Cyr, 2005).

Another leadership strategy aimed to value and develop staff which is positively linked to satisfaction, higher levels of commitment, productivity and reduced turnover is the availability of a mentoring relationship (Alleman & Clarke, 2000). The relationship may be either a development role for the EOCN (mentee) or a facilitator position (mentor). The literature on mentorship however, is focused on the new graduate (Nelson, Godfrey, & Purdy, 2004) and nurse executives (Savage, 2001), with no studies or recommendations targeted to the EOCN. This

is an opportunity for leadership to value the professional knowledge of this group, ensuring an avenue to transfer their diverse experiences and the opportunity for the EOCN to receive mentorship guidance.

Leaders are often guilty of not developing or valuing knowledge, particularly of the experienced group and work environments do little to promote autonomy of practice with clinical decision-making is often initiated away from the bedside. EOCN expect to earn increased autonomy, recognition and opportunities (Hanson, Jenkins, & Ryan, 1990; Ritter-Teitel, 2003), however autonomous practice is the exception rather than the rule. This is a missed leadership

opportunity as autonomy is found to be the strongest correlate of job satisfaction and intention to remain in the current position (Kramer & Schmalenberg, 2003).

Professional Status and Remuneration

Professional issues such as status, professional development opportunities and remuneration may also significantly influence the nurses decision to leave (Duckett, 2005; Minnick, 2000). Educational preparation in healthcare has

remained static as professions have continued to train and work in silos rather than reorganising the professional boundaries to meet the changing demands of contemporary healthcare. To provide interdisciplinary quality care, a stronger

emphasis on workforce substitution with the potential of expanded roles is needed with an intent to eliminate the under-utilisation of the EOCN (Australian Health Ministers' Conference, 2004; Duckett, 2005).

Providing relevant professional development not only supports quality outcomes, but has positive links to retention (Tanner, 2002). These development

opportunities are an organisational priority for the new graduate, yet this same emphasis is not offered to the EOCN. Regardless of the practice role, there is a personal and professional need to maintain contemporary skills and knowledge. Education models discuss life long learning for all staff (Queensland Health, 2004), however due to limited resources, allocation of professional development

opportunities are targeted towards the nurse with more years to serve. Struggling with high acuity, the continuation of professional development opportunities for nurses becomes a distant thought rather than a professional and personal requirement (Giorgianni, 2005; National Review of Nursing Education, 2002; Tanner, 2002).

It is unclear if there is an association with remuneration and the decision to leave. A national survey found that 95% of younger nurses as opposed to 80% of the older cohort indicted that increased salary and benefits would encourage recruitment and retention (Norman et al., 2005). However if insufficient pay

structures coupled with heavy workloads and emotional demands is the norm, nurses may question their intent to stay (Capuano et al., 2005).

1.2 Problem
The benefits of retaining the EOCN is not being realised and is at risk of exacerbating an already crisis nursing shortage. It is time to focus on the

evidence concerning staff satisfaction and resultant turnover rates. There is little evidence in satisfaction studies to allow for the consideration of the unique needs of EOCN, but rather indicate that nurses merely respond to the environment which is an erroneous belief (Fagermoen, 1997).

As the workforce ages, nurse leaders often fail to recognise the value of this experienced cohort and due to general assumptions, certain age biases develop to the detriment of the EOCN (Cofer, 1998). The preference for long-term

relationships with the employer rather than advancement and job mobility increases as nurses age (Beatty & Burroughs, 1999). While valuing the EOCN expertise is not reflected in organisational workforce practices or policy, nurse leaders are ideally positioned to ensure this knowledge is utilised in management processes.

Additionally, lack of recognition is evident due to the limited opportunities for experienced nurses to practice autonomously. Nurses who have more decision making and empowerment in how they practice tend to experience greater job satisfaction and commitment to the role which consequently reduces the effortreward imbalance (Kluska, Laschinger, & Kerr, 2004). However resource

constraints, high acuity and bureaucratic organisational structures limit nurses opportunities for inclusion in decision making (Laschinger & Shamian, 1994). Similarly, nurse leaders have the ability to create a climate which fosters autonomy of practice, particularly for the EOCN.

The pressure to provide efficient and effective services with fewer resources will continue and will be at the expense of the retention of the EOCN if negative influences are not minimised. Organisations are neglecting an experienced

resource who is able to contribute to the sustainability of healthcare. While it is possible to identify probable influences from general studies across the age spectrum, there remains limited data to inform interventions for the EOCN influencing their decision to leave.

From this previous discussion of possible influences on EOCN turnover, there is clearly insufficient and specific data to determine interventions designed to effect the EOCN decision to leave. Therefore in light of this problem, the purpose is to: Explore how organisational environment, leadership and professional issues influence retention of the end-of-career nurse.

2 BACKGROUND
2.1 Nursing Shortage
Nursing shortages have gained considerable attention since World War II both nationally and internationally (Coile, 2001; Fagin, 2001; Minnick, 2000), predicting an Australian shortage of 31,000 nurses by 2006 (Buchan, 1999; Creegan et al.,

2003; Lee & Mills, 2005; National Review of Nursing Education, 2002).

An

additional complication of the shortage is an ageing society requiring increasing demand for healthcare services, yet the supply of EOCN are prematurely reducing their participation in the workforce (National Review of Nursing Education, 2002).

The baby boomer nurses will begin to reach the age of 58 years by 2006. More commonly, 55 years is seen as a time when they begin to reduce their labour participation (Buchan, 1999; Duffield & O'Brien-Pallas, 2002; Minnick, 2000). If this large cohort chooses to retire in the short term, there is potential to put pressure on wages and in turn on the costs of health services which is already a significant problem (Minnick, 2000).

Nurses are entering the profession at an older age and there is a prediction of decreased career longevity due to generational factors (Bednash, 2000; Duffield & O'Brien-Pallas, 2002; Fagin, 2001; Norman et al., 2005). In addition, numbers of new graduates are insufficient to meet demand and numbers are not being sustained in the workforce (Duffield & O'Brien-Pallas, 2002; Minnick, 2000; National Review of Nursing Education, 2002).

School leavers and others who may potentially choose nursing as a career are favouring other options which may be partially due to the image nursing has portrayed in recent times (Handcock, Campbell, Bignell, & Kilgour, 2005). Media coverage of long hours including shift work, unrelenting workloads (Buerhaus et al., 2000b; Steinbrook, 2002), violence in the workplace and increasing health care errors have caused concern about nursing as a career choice (Cavanaugh & Huse, 2004; Donner & Wheeler, 2001b; Duffield & O'Brien-Pallas, 2002; Letvak, 2002; National Review of Nursing Education, 2002; Nevidjon & Erickson, 2001). The work stress caused by increasing acuity and complexity of care requirements (Fagin, 2001; Marcum & West, 2004) is further exacerbated by dissatisfaction as nurses feel they cannot provide the level of care that patients require (Fagin, 2001; Letvak, 2002).

A significant increase in enrollments would not elevate the problem as educational and clinical placement services are insufficient to cope with the current demand (Minnick, 2000; National Review of Nursing Education, 2002). As a short-term remedy, unregistered assistants, agency and travel nurses are filling the gaps although it is not without significant quality control issues (Buerhaus, Staiger, & Auerbach, 2000a; Lee & Mills, 2005).

While addressing issues of supply are needed, review of how to retain and maximise the effectiveness of EOCN is essential. Strategies need to focus on both short and long term actions and to effectively remedy this public dilemma (O'Brien-Pallas et al., 2004). A current strategy to increase nursing numbers has focused on recruitment of the new nurse graduate with minimal attention has been granted to the EOCN. While definition and methodology collection of

turnover data is inconsistent, it has been suggested that forcing the older nurse to retire in preference of recruitment of younger nurses, will have a devastating effect on the organisation and the profession by the loss of their corporate knowledge (Carlisle, 1997).

2.2 Economic Rationalism

In a climate of increasing demand on costly services, the efficiency and effective provision of healthcare is vital due to the enormous public investment in healthcare (Fagin, 2001; National Review of Nursing Education, 2002). The

ageing population with increasing demands and consumer expectations on the health system, continued expansion of new technologies and the rising costs of healthcare all influence the way healthcare allocates essential services. As the largest professional group in healthcare (40%) (Forster & Queensland Health, 2005), nurses hold a unique position which places them in a continuous role beside the bed, yet they are the most vulnerable to the economic razor (National Review of Nursing Education, 2002).

Due to the impact of managed healthcare budgets, there is an imperative to improve each facilities financial performance. Erosion of revenue streams has lead to organisational restructuring and in many instances, savings have been made by downsizing or eliminating staff development units (Nevidjon & Erickson, 2001; Sumner & Townsend-Rocchiccioli, 2003; Tanner, 2002). Despite other

efforts to reduce costs through shortened hospital stays and early discharge, in 2002 there was an increase of 9.5% in hospital spending. This increase in costs was associated with salaries, benefits and malpractice premiums (Levit, Smith, Cowan, Sensenig, & Catlin, 2004). Additional costs to service provision can be attributed to the use of casual or agency staff and overtime due to insufficient quality staff. This type of staff usage increases the risk of adverse events for staff and patients, loss of productivity and continuum of care which may attract legal costs (Duffield & O'Brien-Pallas, 2003; Levit et al., 2004). While there should be a balance between allocated expenditure and quality in healthcare (Nevidjon & Erickson, 2001), this is not routinely being achieved.

The pressures to meet organisational goals and professional demands increases stress which consequently increases turnover rates and associated costs (Hayes et al.; Waldman, Kelly, Arora, & Smith, 2004). Depending on the nurses

specialty, costs may extend to $42,000 for a medical-surgical nurse and $64,000 for a specialty nurse. These figures are inclusive of recruitment, orientation and preceptoring of new staff (Hayes et al., 2006; Thorgrimson & Robinson, 2005). While retirement or turnover costs absorb the health dollar, economists suggest that these costs are necessary in an efficient labour market allowing employees to transfer to jobs where their productivity and aligning wage is greatest (Gray, Phillips, & Normand, 1996).

Many organisations are vulnerable to criticism that economics have driven their labour policy. The introduction of higher wages to remedy the nursing shortage will not provide a sustainable solution as the profession is plagued with diverse

organisational and professional problems requiring action. Some issues include a decreased attraction into the profession, the average nurses age is 46 years with a trend to reduce work hours or early retirement resulting in further compromise of the nursing shortage. There are increasing family demands on nurses, and a plateau effect on wages unless nurses transfer from the clinical area to management careers (Coile, 2001). The evidence also suggests that

compensation will not attract nurses who work in other fields, as many are considered secondary workers. Nursing is more likely than most occupational groups to respond to changes in the total family income or the home situation through their participation in the workforce (Buerhaus et al., 2003; Minnick, 2000).

It does appear that business and economic principles have replaced the healthcare norms and many professional values. Ironically, the diminishing

professional and human values in healthcare have not reduced healthcare costs due to increased infection rates, iatrogenic effects and litigation. Sobering

statistics from the HeathGrades Report (2004) estimated that in the past 3 years medical errors in United States contributed to 600,000 preventable patient deaths. To place a more accurate and quantifiable figure to this would be difficult, if not impossible. This business model of healthcare has not improved access to care or enhanced quality outcomes and has not inspired current nurses or enticed new nurses to the profession (Donley, 2005).

2.3 Impact of Nursing Shortage on Quality Outcomes of Care

One of the most serious consequences of the nursing shortage, including inappropriate or inadequate staffing and skill mix, is the resultant issue of vicarious liability. There is an increased risk to patients, staff and organisations if employees are delegated work beyond their scope of practice and skill level (Council, 2005). Negligence is a costly experience for all parties (Duffield &

O'Brien-Pallas, 2003). Registered nurses are acutely aware of increased liability faced by supervising less qualified workers due to possible medical errors which

is exacerbated by the nursing shortage and high attrition rates (Capuano et al., 2005; Cavanaugh & Huse, 2004; Coile, 2001; Hayes et al., 2006; Letvak, 2002). Quality orientation programs and a preceptorship model for staff support have been demonstrated to reduce the errors made by new staff. However, this model is expensive due to high turnover and is not a routinely offered in all facilities (Cavanaugh & Huse, 2004).

The Institute of Medicine suggested that work environments may in fact support error making (Institute of Medicine of the National Academics, 2001). This may be evidenced by erosion of nurses trust in administration, lack of nursing leadership, minimal opportunity for clinical decision making, unsafe skill mix, extended hours and inadequate professional development to support clinical and professional practice (Diers, 2004). Clearly, there is a link between nurse staffing, work environment and quality patient outcomes.

The nursing shortage will also compromise access to health services, increase patient waiting times and reduce the quality services and outcomes. Increased patient acuity and nurses responsibilities have further taxed workloads when coupled with a deteriorating work environment adversely affecting patient outcomes (Aiken et al., 2001; Nicklin & McVeety, 2002). Overtime is unavoidable in emergency situations, although may also pose an increased safety risk to staff and patients. A study of nurses who worked at least a 12.5 hour shift were three times more likely to make an error than those who worked an 8.5 hour shift (A. Rogers, Hwang, Scott, Aiken, & Dinges, 2004). Costs of hiring additional quality nurses may be offset if patients have fewer complications and adverse events, therefore leaving the hospital sooner (Cavanaugh & Huse, 2004; Duffield & O'Brien-Pallas, 2003). This may be a solution but is short term and costly. Would maximising the benefits of better utilisation of the EOCN prove more effective?

As the nursing shortage peaks, many facilities have opted to increase the use of agency staff and to employ traveling nurses as a buffer. Using nurses who may

not stay long enough to adjust to the workflow and standards of the facility, can compromise the care and add to turnover expense and training costs (Stein & Deese, 2004). Other attempts to remedy the shortage have included increased use of unlicensed assistant personnel. With an increase in patient complexity and acuity, healthcare requires more skilled nurses rather than substitution of unskilled workers which brings concerns of increased medical errors (Buerhaus et al., 2005b; Nevidjon & Erickson, 2001). An increased focus on the retention of

experienced staff would provide a more economical and efficient solution.

Sobering statistics from the HeathGrades Report (2004) estimated that in the previous three (3) years medical errors in United States contributed to 600,000 preventable patient deaths. It is worthy of note that although the adverse or error figures may be alarming, it could be the tip of the iceburg (Balas, Scott, & Rogers, 2004). Due to fears about reprisal from management and regulatory bodies,

nurses only report a marginal number of drug administration errors (Osborne, Blais, & Hayes, 1999). Leape et al (1995) suggests that only the life threatening or approximately 5% of significant errors are reported. Minor errors or those

identified prior to occurring are almost never reported (Leape et al., 1995; Osborne et al., 1999). Certainly, a number of recurrent issues exacerbate the incidence of errors and include interruptions and distractions, poor

communication, inadequate staffing levels, high patient acuity, and heavy workloads (Balas et al., 2004). Given the current health environment, these

influencing factors should to be considered in workforce planning.

IMPACTING CONCEPTS
2.4 Organisational Environment
While leadership is important, structural and contextual factors such as organisational environments are also likely to exert influences, so it should be

cautioned that strong leadership is not all that is required to implement effective healthcare processes (Ferlie & Shortell, 2001).

With little power to make clinical decisions, many nurses suggest that they are not valued. Long and inflexible shifts are rendered more difficult due to the need to clinically support casual or agency staff (National Review of Nursing Education, 2002; Norman et al., 2005). These complexities project an image of a profession in turmoil, unpredictable and an unsafe career option (Nevidjon & Erickson, 2001). Repeated job mobility, if directly attributed to the organisational environment, may have devastating long-term effects and organisations need to identify and control the factors which influence this mobility (Chandra, 2003).

A supportive workplace environment which considers the professional and personal needs of the individual is vital to ensure a sustainable workforce. Throughout a National review, components of a supportive environment were suggested as: o professional skills and knowledge recognised o time to care for their patients o supported through professional development o autonomy in practice o a family friendly workplace o safe environments and better remuneration. This review identified that nurses practiced in a profession of paternalistic influence and struggled to gain respect or status by other healthcare professionals. They experienced unfriendly shift work, low remuneration,

horizontal violence, social isolation, and increased risk of injury and disease (National Review of Nursing Education, 2002). Although these comments

originated across general nursing services, they are similarly significant for the experienced EOCN, leaving little to encourage their retention.

2.4.1 Workload
When nursing shortages occur, there is an increase in workload for those who remain, minimising the time available to accomplish both personal and professional needs. The persistent and excessive workloads has been

consistently documented as a major cause of stress and dissatisfaction within the nursing profession, which consequently increases the likelihood of turnover (Cyr, 2005; Forster & Queensland Health, 2005; Hegney, Plank, & Parker, 2003; National Review of Nursing Education, 2002; Needleman et al., 2002; Strachota et al., 2003). This increasing dissatisfaction is associated with reports of A study across five countries reported insufficient

questionable quality care.

registered nurses to provide quality care and complete the necessary work due to excessive workloads (Aiken et al., 2001). Most nurses choose the profession to care for patients and not because of the high professional status or remuneration. With excessive workloads, nurses professional needs are often unmet, eliminating one of the most rewarding components of their role rendering turnover a favourable option (Chandra, 2003).

Shortfalls from the high turnover rates have been exacerbated by cost containment and failure to recruit nursing numbers in line with increasing demand (Buchan, 2000; Forster & Queensland Health, 2005). Without an adequate basis for projecting nursing care hours, nurse managers are in a vulnerable position to defend appropriate nurse allocation requirements. Workload measurements

should capture the complexity of the patient situation however, unpredictable patient events which directly impact on the nurses working situation is not reflected in current measurements (O'Brien-Pallas, 1988; O'Brien-Pallas, Irvine, Peereboom, & Murray, 1997; Steinbrook, 2002). The Business Planning

Framework (BPF) is a tool developed to balance nursing workloads with service provision (Queensland Health, 2001). Some facilities have employed the use of BPF, however the emphasis has been on meeting budget integrity rather than manageable nursing workloads (Queensland Nurses' Union of Employees, 2004).

Balancing the workloads and service provision is made more complex with high numbers of unfilled nursing vacancies. Additionally, with a reported 53.7% of nurses choosing to work part-time, there is still a requirement to continue to provide the same level of care (Forster & Queensland Health, 2005). Replacement of planned leave becomes unmanageable in these circumstances and may compromise quality services. Strategies to manage leave relief include paid or unpaid overtime, double shifts, part time staff increasing hours worked, canceling services and bed closure (Baumann et al., 2001; Queensland Nurses' Union of Employees, 2004; A. Rogers et al., 2004).. Risks of making an error were found to be three times higher when overtime, twelve hour shifts and over 40 hour weeks were worked. This study identified that the probability of making an error was not altered by the age or experience of the nurse (A. Rogers et al., 2004). These ineffective and unsafe strategies may further exacerbate

recruitment and retention opportunities.

With the constant struggle to manage staffing issues with mounting workloads, nurses are forced to prioritise their work, often sacrificing invisible work such as emotional support for more obvious tasks. Rather than reducing expected tasks such as medication administration, nurses compensate by donating their time which may compromise nurses well being demonstrated by fatigue, burnout and moral distress. The reality is that nurses are often left to compensate for the inadequate systems (Rodney & Varcoe, 2001).

2.4.2 Skill Mix / Casualisation

The ability to provide the right skill mix and numbers of nurses over the 24 hour period seven days per week is complex due to the difficulties faced with retention of experienced EOCN (Buchan, 2000; Duffield & O'Brien-Pallas, 2002; Forster & Queensland Health, 2005; Minnick, 2000). A critical imbalance in the supply of qualified nurses and a move to escape persistently high workloads has initiated a trend for nurses to chose part-time or casual employment over full-time

(Australian Health Workforce Committee, 2004; Duffield & O'Brien-Pallas, 2002, 2003). With a predominately female workforce (88%) (Forster & Queensland

Health, 2005), seeking casual work allows nurses to combine paid work with family responsibilities, to study and pursue other interests, to ease out of the workforce as they near retirement and to supplement the family income (Kryger, 1999).

As a consequence of the trend for casualisation, remaining nurses are required to increase their workload by clinically supporting a floating population of agency or traveling nurses to bridge the gaps in the workforce (Creegan et al., 2003; Lee & Mills, 2005; Stein & Deese, 2004). Unregulated workers similarly add to the

enormous stress placed on the supervisory role of the registered nurse (National Review of Nursing Education, 2002). Study results have found consistent

evidence between higher levels of staffing by registered nurses and lower rates of adverse events (Needleman et al., 2002). However, selected organisations

compromise staff allocations with potential increase in liability due to increasing numbers of less-qualified workers delivering care without the level of skill required to work unsupervised (Forrester & Griffiths, 2001).

While efforts to provide appropriate and safe skill mixes, the profession must also reconcile with the generational differences. As the Net generation focuses on work-life balance, they are likely to opt for casual status, which will leave the EOCN to juggle commitments of work and diverse family issues. As a

consequence, the EOCN work-life balance may be reduced which presents a dissonance in their values as they place priority on fulfilling work commitments. Resultant dissatisfaction with the environment may prompt the EOCN to further reduce participation or retire from the profession prematurely.

2.4.3 Risk Factors

As a result of high workloads complicated by insufficient experienced staff, nurses are susceptible to musculoskeletal injuries. An American Nurses Association

(ANA) survey results indicated that 88% of health and safety concerns influenced nurses decision to stay (American Nurses Association, 2001). As the most

frequently reported injury, back injuries continue to plague nurses health and well-being (American Nurses Association, 2001; Buerhaus et al., 2003; Chandra, 2003).

An ANA survey reported nurses concern of contracting HIV or hepatitis from a needlestick injury the next major health and safety risk (45%) (American Nurses Association, 2001; Worthington, 2001). Shift work research indicated the

cumulative effects of fatigue and recognised that the bodys circadian rhythms indicate that 12MN to 6am are regular sleeping times. Loss of sleep will lead to accumulation of fatigue and heighten the risk of error (Queensland Nurses' Union Submission, 2001).

2.4.3.1 Organisational Stress / Burnout

High workloads combined with the inability to recruit and retain experienced nurses, personal and professional imbalances contribute to the susceptibility of nurses suffering from work stress and consequently burnout (Creegan et al., 2003; Cyr, 2005; Demerouti et al., 2000; National Review of Nursing Education, 2002).

Empirical evidence suggests that each additional patient per nurse is associated with a 23% increased chance of burnout and a 15% increased chance of job dissatisfaction (Aiken et al., 2002). Poor working conditions and disillusionment with work stress was shown to result in increased turnover (Webster, 2001b). Nurses who claimed high job demands such as demanding interactions with patients, high physical and cognitive workloads had strong influences on

emotional exhaustion. Nurse leadership can not deny their role in fostering nurse satisfaction within the work environment, since more satisfied employees rise to the challenges of the workplace and are more resistant to job strain and burnout (Garrett & McDaniel, 2001; Gelsema et al., 2006; Laschinger, Finegan, & Shamian, 2001d).

As a consequence of continued burnout, treating patients in detached or even a dehumanized manner may result. The nurses feelings are exposed by

demonstrating cynical or negative view point, leading to derogatory comments about the patient (Maslach, 1976; A. M. Pines & Kanner, 1982). There is little doubt that burnout is a significant component in poor delivery of health care (Leiter, Harvie, & Frizzell, 1998; Leveck & Jones, 1996).

It is also recognised that if the social environment is supportive, burnout is less likely to occur, even if the work is stressful (Demerouti et al., 2000; A. Pines & Maslach, 1978). Work conditions such as reward systems (Demerouti et al.,

2000; Gelsema et al., 2006) and sound communication flow and processes are also associated with health and well being for nurses (Decker, 1997; Gelsema et al., 2006). By lowering the work pressure, physical demands and providing

sufficient time to provide quality care may prevent serious health consequences for nurses (Gelsema et al., 2006; Joiner & Bartram, 2004), however job demands may become too high to be buffered within ordinary supporting limits related to work situations (Lindholm, 2006).

Mid-career nurses defined as those aged between 35 and 54 make up threequarters of health care employees in United States. One third of these employees report working 50 or more hours per week and dissatisfaction rates are high. Over a third report they are in dead-end jobs with 40% reporting feelings of being burnout. Baby Boomers are a component of the mid-career and EOCN group and are often torn between the responsibilities of the younger children and older family members. The stress of trying to manage their personal and professional life,

particularly if the work environment is inflexible can often create a burnout situation.

Healthcare simply can not afford to loose staff to this epidemic, when the development of management practices could reduce occupational stressors and should be seen as a fundamental part of leadership. Implementing strategies to manage workplace stress is primarily a leadership role, however is reliant on leaders and staff collaboratively working to identify work stressors (Collins, 2006). Strategies to manage the effects of stress are only part of the puzzle as the workplace environment is likely to be exacerbating the causes of stress. Work relationships influencing retention decisions for the EOCN are pivotal in evolving a working culture that engenders trust and encourages creativity in an emotionally intelligent environment.

2.4.4 Work Excitement

The nursing shortage has two focal points: inadequate numbers entering the profession and increasing numbers of nurses leaving the profession, often prematurely. Just one of many influences why nurses may be leaving is the effects of burnout. Work excitement is defined as personal commitment and enthusiasm for work (Bruffey, 1997, p. 203; Sadovich, 2005; Simms, ErbinRoesemann, Darga, & Coeling, 1990; Zavodsky & Simms, 1996). Together with work frustration, work excitement provides insight into the interrelationships between these concepts and job satisfaction. Four significant predictors of work excitement include work arrangements, a learning environment that fosters individual growth and development; variety of experiences; and positive working conditions (Simms et al., 1990). An enabling environment reaches full potential when it fosters continuous learning of all employees, stimulating work excitement. Internal locus of control becomes a key component in the creation of empowered work environments which was found to correlate significantly with work excitement (Erbin-Roesemann & Simms, 1997).

If nurse leaders were to develop and support such a work environment, what influence would this have on the EOCN as they contemplate retirement? As disengagement is said to increase with time in the job, it is timely to consider how this influences those considering retirement, particularly if they have been in the same position or organisation for many years (McNeese-Smith, 2000).

2.4.4.1 Occupational Violence

Work relationships an be compromised as a result of internal violence most common in organisations where dominant/subordinate hierarchical interactions exist. This results in significant productivity losses, higher absenteeism, turnover and law suits. Workplace violence has been found to be characterised more by gender differences with female victims experiencing higher levels of verbal and sexual abuse, while male victims tend to receive more overt threats and physical assaults. Violence against females in the workplace has increased while This is a significant

decreasing for the males (Fisher & Gunnison, 2001). consideration within a female dominant profession.

This internal violence is evident in disruptive behaviours such as disrespect, berating colleagues, use of abusive language and condescending behaviours by physicians towards nursing staff. Regardless of an organisational code of

conduct, these behaviours were witnessed by over 90% of study participants. Often in the presence of colleagues, patients or family members, there was found to be a direct relationship between disruptive physician behaviour, nurse satisfaction, morale and retention (Greenfield, 1999; Rosenstein, 2002; Rosenstein et al., 2002). A perception variance in the role of nursing and failure to communicate effectively is described as the cause of the nurse/physician problem. This was demonstrated by physicians and nurses varied views on the extent to which collaboration and joint decision-making are valued, what constitutes appropriate inter-professional communication and defined areas of

responsibility (Larson, 1999).

The physician dominant role and the nurse

subservient role is reinforced by gender, education and remuneration. Collaboration raises concerns of erosion of power and authority for the physician, however while physicians expect nurses to perform as their extensions, experienced nurses such as EOCN, expect to use their knowledge to contribute to optimal patient outcome (Greenfield, 1999; Larson, 1999).

Integral in some areas of nursing, bullying and intimidation of nurses by nurses was evident at all levels with the victims feeling powerless to stop the behaviour (Stevens, 2002). Study participants (44%) indicated that reporting violence of any degree or source has barriers which include intimidation, fear of retaliation, lack of confidentiality and physician lack of awareness or unwillingness to change (Aiken et al., 2001; Greenfield, 1999; Rosenstein, 2002; Rosenstein et al., 2002). It is difficult to accurately quantify the extent of the violence as many incidences do not result in time off work. The recording of some incidences are sited in the patients file and not recorded for WorkCover purposes (Queensland Nurses' Union Submission, 2001).

Client initiated violence is more common with workers of face-to-face contact with clients and families, particularly if they are distressed, frightened or in pain, therefore nurses working in emergency departments and mental health are high risk for injury (Mayhew & Chappell, 2001). As a health care professional, one of the most difficult situations is to be confronted by one of the patients for whom they have dedicated their career to assisting (Hinson & Shapiro, 2003).

No nurse is exempt from the possibility of violence in healthcare regardless of the experience or time in the role, however many organisations present the problem as an employees skill defect and consequently assign conflict management training. Rather than conflict training, the author suggests a radical cultural shift is needed. Taking organisational responsibility for this problem should be

recognised and supported by leadership, policy and cultural refocus (Hinson & Shapiro, 2003; Paterson, Leadbetter, & Miller, 2005).

2.5 Leadership
The complexities of leadership can not be contained within a discrete list of skills and behaviours, however selected specific components are considered to influence the impact on the decision of the EOCN intent to stay.

Studying the cascading effect of leadership styles through role-modelling across hierarchical levels confirmed the positive influences of transformational

leadership, yet it was found that transformational leadership between hierarchical levels was lacking in this study (Stordeur, Vandenberghe, & D'Hoore, 2000). Is the lack of leadership representative of healthcare settings and how does this impact on the EOCN and their intent to stay EOCN?

2.5.1 Communication/Team Function/Peer Cohesion

A comprehensive literature review found the scope of the current nurse turnover problem and associated factors was significantly influenced by leadership style (Hayes et al., 2006). Supportive communication from leaders and colleagues is particularly relevant in buffering nurses from job stressors and provide nurses with informational and emotional resources to cope with the workplace stress. Additionally, this was found to assist in the enhancement of an environment in which nurses build communication skills that enable them to performs effectively in their role (Laschinger et al., 2001d).

Reduced nurse turnover and higher levels of staff satisfaction has been found to be positively effected when associated with an emphasis on communication between leadership and staff, professional autonomy, commitment to flexibility in a decentralised organisational structure. Exemplary communication promotes a sense of belonging and identification with a group or organisation, allowing

employees to learn desirable identity characteristics and make decisions congruent with the group norms and values. Demonstrated through the

interaction of the experienced and less experienced nurse, the latter is able to identify with the role and what it means to be a nurse (Apker, Ford, & Fox, 2003; Apker & Fox, 2002; Buchan, 1994; Meyer, Stanley, Herscovitch, & Topolnytsky, 2001; Scott et al., 1999). The notion of enhancement of the less experienced nurse identity adds significant value to the EOCN and their ability to contribute to this development.

Sound communication ability and listening skills are often overlooked and may influence the EOCN decision to stay. Unfortunately, many leaders do not believe that staff by the bed have the ability to create innovative ideas at an organisation level, giving no opportunity to develop through participation. This style of

leadership is unlikely to be able to facilitate change, sustain continued commitment of employees or manage conflict which is common within changing organisations (Grossman & Valiga, 2000). The successful leader will encourage genuine communication with all employees, especially the EOCN who can effectively support the less experienced staff to develop a sustainable workforce, and will celebrate problems and innovative initiatives (Kerfoot, 2000a). Nurturing a culture conducive to open communication and safety in challenging the status quo is needed if leaders are to engage EOCN in their role (Edens, 2005).

Positively linked with staff communication and job satisfaction, effectively functioning teams are generally associated with higher quality of care (Aiken, Sochalski, & Lake, 1997; Amos, Hu, & Herrick, 2005; Upenieks, 2002). However the real challenge is in the development of the team. Doctors, nurses and unions were found to be in power conflicts related to inadequate allocation of resources by governments, however resulting in a constant struggle for control between stakeholders, with management and clinical professionals in opposition (Farrell, 2003). Other leadership studies highlight an association with autonomy and

group cohesion reducing job stress and increasing job satisfaction, which in turn

was directly linked with the intent to stay (Anderson, Corazzini, & McDaniel, 2004; Boyle, Bott, Hansen, Woods, & Taunton, 1999).

While generally, loyalty to organisations may be diminishing, that is not true of collegial loyalty. Encouraging social ties among key employees such as the

EOCN can often significantly reduce turnover. Staff will not hesitate in leaving an organisation, however will find it difficult to leave their teammates. In order to retain EOCN, leaders should implement strategies which create cohesive work teams (Cappelli, 2000; Kerfoot, 2000a).

Modeling a nursing practice environment to investigate the effectiveness of leadership practices found where nurses perceived a participatory leadership style, they reported higher levels of group cohesiveness and lower job stress. Perceiving they were valued team members, this may compensate for other frustrations within a complex environment (Leveck & Jones, 1996). EOCN who are satisfied with the work environment will want to remain in the current role, which will minimise direct and indirect turnover costs and optimal patients outcomes (Leppa, 1996).

2.5.2 Flexibility
The most attractive employer is a flexible work environment which recognises the personal and professional needs of the nurse while still meeting the needs of the organisation (Leavitt, 1996). However, as a consequence of the nursing shortage and unacceptable work situations such as heavy workloads, roster scheduling is constantly challenged leading to nurse resentment, burnout, low morale, absenteeism and turnover. Self-scheduling was found to be a potential

empowerment tool recognising individuality and encouraging participation and accountability while promoting high job satisfaction and the maintenance of staffing standards (Hung, 2002; Strachota et al., 2003). A review of a public health system found rostering practices as inflexible and inequitable. Some

issues raised included unreasonable demands; full-time staff perceived being disadvantaged through undesirable scheduled shifts; no backfill availability dictated that no study or special leave was possible; lack of experimentation of varying shift lengths and lack of rostering principles or guidelines (Queensland Health, 1999). While a Rostering Framework principles were developed

anecdotally, rostering issues continue to plague work unit management (Queensland Health, 2001).

The EOCN may not only be caring for offspring attending university or grandchildren, but also may be taking a major role in the care of their older family members. Other family situations such as single parent families will also impact on the work and life balance. For a female dominant profession, increase in work and life demands calls for greater flexibility in scheduling practices that reflects the need for work and life balance (Chandra, 2003; Hung, 2002; National Review of Nursing Education, 2002). This however is not commonly found. As most health care is delivered in the acute hospital setting, these facilities are commonly described as bureaucratic hierarchical organisations. Criticised as inflexible and lacking in innovation (McDaniel, 1997), this bureaucratic structure and leadership style prevents nurses responding appropriately to the continually changing environments (Sofarelli & Brown, 1998).

2.5.3 Supervision / Supportive / Trust

Public trust and respect for nurses has never been questioned, although this can not be said for the relationship between nurses and their leaders (Sofarelli & Brown, 1998). Issues such as lack of consistency in leadership and financial limitations may limit the ability to build trusting relationships particularly as the winning side is often the business component of healthcare rather than clinical needs (Laschinger et al., 2001c; Malloch, 2002; McKenna & Maister, 2002).

As a means to build trusting relationships, nurse leaders should express their trust and stand back to allow EOCN to develop and at times, make mistakes in a non judgmental and learning environment. Trust was found to be the best predictor of feelings of autonomy and empowerment (Kramer & Schmalenberg, 1993). EOCN also should reflect on the relationship they have with nurse leaders to consider if they are utlising the opportunities of affirming their leadership and contributing to a collegial and trusting workplace (Daly, Speedy, & Jackson, 2005; Kerfoot, 2000b). If nurse leaders can influence the work environment which fosters trust, provides support and empowers nurses to accomplish their goals, this will increase job satisfaction and organisational commitment, which will in turn positively affect retention (Laschinger et al., 2001c; McNeese-Smith, 1993). Would this finding be accurate for the EOCN cohort?

The philosophy of some nurse leaders is to do to rather than to work with staff. This type of assertion can generate anger and mistrust with minimal creativity or initiative being demonstrated resulting in employee resignation. Alternatively, the leader who is able to communicate a genuine need for success, the employee will likely be empowered to excel past all expectations. Success is credited to the nurses ability to clearly define the expected outcomes and provide a nurturing, motivating and coaching environment (Jones, Stasiowski, Simons, Boyd, & Lucas, 1993; Kerfoot, 2000b).

Empowerment is a means of social support to reconcile stress in the workplace. The social support from the leader or colleagues is crucial in positively influencing affect, coping mechanisms and well-being. As staff perceive a decrease in their level of collegial support, they perceive an increase in job stresses (Laschinger, Finegan, Shamian, & Wilk, 2001b). It is evidenced that satisfied and retained nurses are choosing to work in environments that value social support and empower nursing practice (Upenieks, 2002).

The greatest risk to health care is the compromise of integrity, but how can nurse leaders build trusting relationships in this climate? To what degree can the EOCN expect their leader to provide the appropriate resources to deliver quality of care? It is time to leave past negativity and work collaboratively to own and shape effective organisations (Malloch, 2002). The EOCN has gained valuable

experiences and should be a major component in this collaboration.

2.5.4 Autonomy / Empowerment

One method to engender trust within the profession is to attract staff with the promise to empower nurses to develop and utilise their professional skills. As autonomy was found to be the strongest predictor of nurse organisational and professional identification, nurses who perceived that their role offered sufficient autonomy were more likely to experience feelings of membership and loyalty towards their employer and profession (Apker et al., 2003; Bednash, 2000). However, the work environment does not always allow autonomous practice at the bedside, with many decisions being made from a distance. A professional dilemma as autonomy was also found to be the strongest correlate of job satisfaction and retention (Hanson et al., 1990; Kramer & Schmalenberg, 2003; Laschinger et al., 2001d; Nedd, 2006; Ritter-Teitel, 2003).

EOCN may question if the emphasis on life-long learning is to allow staff to develop and influence work processes, or is it contrasted by controlled information and centralised power? Are staff rewarded by inclusion in decision-making

without fear of retribution within the team to support enhanced communication processes? (Laschinger et al., 2001b; Laschinger, Shamian, & Thorgrimson, 2001a; L. Rogers, 2005). The exercising of autonomy can not occur if there is no freedom with which to practice (Kramer & Schmalenberg, 2003; Laschinger, Wong, McMahon, & Kaufmann, 1999).

Empowerment is the single most critical component of effective change within organisations and is pivotal that leaders empower nurses across the spectrum of generations, considering each individuals needs (Cooper, 2003). The importance of strong facilitative leaders who have the capacity to revitalise staff to become committed, accountable employees is essential in a climate aiming to retain quality experienced staff such as the EOCN (Laschinger et al., 1999). However, it has been suggested that it is the leadership team who need to change from their traditional practices to one of shared governance (Edens, 2005). The empowered organisation functions with peers, partners, colleagues and collaborators, but no bosses and uses mentors, coaches and people who can in spire, challenge and create synergy among equals (Kerfoot, 2002).

2.5.5 Mentorship
As a leadership strategy, mentoring reflects the development of culture and values from one who the mentee aspires to resemble. Within this interaction, a mentor provides an enabling relationship which facilitates another nurses personal growth and development assisting with career development guiding the mentee through organisational, social and political networks (Morton-Cooper & Palmer, 1993) .

As a consequence of nursing shortages made more critical by the ageing workforce, graduate nurses need to be better prepared prior to entering the workforce. Nurse leaders can persist in a losing battle to develop staff with

minimal resources or work towards a self-sufficiency model to support their staff with mentorship as other industries have done. The already strained workforce can limit the leaders ability to roster experienced nurses such as the EOCN away from patent care to facilitate, preceptor or mentor new staff (Greene & Puetzer, 2002; Stein & Deese, 2004). The flow of mentees can negatively impact on the EOCN with burnout often as a result (Greene & Puetzer, 2002).

Support for a mentor relationship should be balanced with resources to achieve the goal of professional development and retention. Recognition for the mentor role has been offered by some facilities through remuneration, job redesign and professional status (Greene & Puetzer, 2002), however this has not routinely been the case and in many instances, this role is in addition to an already heavy workload (Graham, 2000; Kent, 2001; Savage, 2001). Throughout the nurses career, work skills and attitudes are developed through experiences which can not be replicated for the new nurse through training. Mentorship may provide this opportunity through role modeling and counsel (Leavitt, 1996). While the EOCN is aptly qualified to provide this development opportunity, little training if any is provided for the role. The opportunity for the EOCN to enter this relationship in a mentee capacity is also limited. If the literature indicates positive correlation

between satisfaction and mentor relationships, this could significantly influence the EOCN decision to stay.

2.5.6 Commitment
Nurses attachment to a facility has been explained by consisting of three variations of organisational commitment. Affective commitment related to the

nurses connection with the organisation which was found to be positively associated to job satisfaction, job involvement, job performance and

organisational citizenship behaviour (Allen & Meyer, 1996).

Secondly,

continuance commitment reflects a nurses acknowledgment of the costs of leaving the organisation. If continuance commitment is high, the nurse believes the benefits of staying with the organisation outweigh the consequences of leaving. Lastly, normative commitment is the nurses sense of obligation for It is argued that collectively these themes

remaining with the organisation.

represent components of commitment and each nurse has an individual commitment profile of their need, desire and obligation to remain with the current organisation (Meyer & Allen, 1991).

Organisational behaviour is of significant importance as EOCNs aim to maintain high quality patient care with fewer resources. It would therefore be

advantageous for leaders to promote factors that encourage affective commitment while minimising those of continuance commitment (Allen & Meyer, 1996; Meyer et al., 2001).

Organisational commitment can also be enhanced without requiring loyalty to the organisation. One such strategy is to delegate the control of practice to the

nurses which will act as a catalyst to increasing their commitment. The resultant benefits is satisfaction, recognition and status (Cappelli, 2000). Nurses are more likely to commit to an organisation if their leader challenged the job, questioned the status quo, managed stress effectively and took risks within their practice (McNeese-Smith, 1993). practice to the EOCN? To what extent do leaders delegate the control of

3 Professional Status and Remuneration

3.1.1 Professional Job Design
While the Australian health workforce has changed significantly during the last decade (Australian Institute of Health and Welfare, 2005), an Australian review highlighted a lack of long term workforce planning with fragmentation of components of nursing and education (National Review of Nursing Education, 2002), which has not contributed to the continued commitment of nurses. With a health professional shortage, it is argued that future workforce planning should have a stronger focus on a different mix of responsibilities between health professionals. An expanded role for nurses could assist in retaining nurses such as the EOCN or attracting those seeking better career options (Duckett, 2005).

The transition to university education and curricula refinement has provided increased opportunities to undertake more complex roles for those with broader

education and experienced background, particularly so for the EOCN. As roles such as nurse practitioner becomes integral to healthcare, clearly health professionals can undertake substitution roles of other providers (Queensland Nursing Council, 2005). Midwives take a significant role in maternity care, while the rural nurses expanded role has supported outback areas where there is minimal medical support. Educational preparation for health has developed niche professions rather than reorganising the professional boundaries to meet the demands of this changing health environment. It is suggested that job redesign is required with a fresh look at providing quality care across all health care professions, with a renewed look at the under-utilisation of the EOCN (Duckett, 2005). If workplace challenges are not provided, dissatisfaction may result which in turn may affect retention (Australian Health Ministers' Conference, 2004; Duckett, 2005).

As further role expansion of non-medical professional develops, relationships will move from less subservient to one of collegial. educational programs to facilitate professional There are calls for shorter career mobility, career

advancement and retraining through nurses entire career. This is long overdue if organisations are to meet the future demand with appropriate professional mixes (Duckett, 2005) with the EOCN being a major stakeholder . Unfortunately, often the front line nurse has little influence in the redesigning of roles of meaningful work (Kerfoot, 2000a).

For this redesign to occur, leaders need to be cognisant of the environment in order to anticipate and recognise the need for change whether by workplace reorganisation or job redesign (Edens, 2005). An example of delivery model

redesign demonstrated an increase in patient, staff and physician satisfaction, cost savings and overall improvement in efficiency. The success was contributed to a clear understanding by all staff of the mutually valued roles of staff and the model was based on concepts such as nurse experience, competence and individual preference. Marginalising of experienced staff to non career posts

because they choose to reduce from full-time capacity is a waste of valuable resources. This situation is reflective of what commonly presents for the EOCN (Buchan, 2000). The challenge for redesign is the valuing of expertise of the EOCN in order to optimise their contribution (Nevidjon & Erickson, 2001).

3.1.2 Professional Pay Structure

While many strategies such as challenging professional roles aim to attract and retain nurses, the economy has a significant influence on the profession. In a strong economy, numerous career options may appeal to students who may otherwise have chosen nursing if the remuneration was competitive (Minnick, 2000). Reviewing the United States labour market demonstrated hospital

registered nurses wages increased 5% above inflation rates in 2002 and 1.8% in 2003. A subsequent surge of registered nurses employment over the age of 50 and international nurses as a result of the wage increase. In addition, a

weakening of the national economy which threatened employment of many Registered Nurses spouses, making nursing work favourable (Buerhaus, Donelan, Ulrich, Norman, & Dittus, 2005a). Most nurses are considered

secondary workers and it is more likely that they respond to the total family income and the general economy (Buerhaus et al., 2003; Minnick, 2000). If

stagnation or insignificant increase of nurses wages continues, there is little reason to believe that nursing can make a strong economic case to retain those considering retirement (Buerhaus et al., 2005a).

With a high global demand, nurses seek employers who pay higher rates (Formella & Rovin, 2004a, 2004b; Webster, 2001a). The perception of poor

monetary rewards and lack of recognition for excessive roles contributes to increased turnover (Aiken et al., 2001; Fagin, 2001). Loosing knowledge workers such as the EOCN is in itself a crisis, but it also poses a financial burden on western countries due to the favouring of a lowered retirement age as many are leaving at 50 to 55 years. The burden is acknowledged by high societal costs

through loss of tax revenues, increase of retirement costs and the growing health care due to continued increase in life expectancy (Kilbom, 1999).

3.1.3 Professional Development Opportunities

In an environment where nurses struggle to respond to high acuity and little monetary rewarded, the availability of professional development opportunities has become a distant thought rather than a professional and personal requirement (Giorgianni, 2005; National Review of Nursing Education, 2002; Tanner, 2002). High-quality staff education is one of the most effective ways to attract, motivate and retain talented staff (Tanner, 2002). If nurses intend to remain on the front lines as they progress through their 60s, education and professional development will be a necessity around their mid 40s, bringing a new and revitalising challenge in preparation for the next 20 years of their working life (Giorgianni, 2005).

As the ageing population is growing at a faster rate than the younger population, the impact for healthcare demand will escalate. This will in turn increase the requirement for nurses to continue to develop their skills necessary to manage chronic disease (Duckett, 2005).

Clarity of the role of the nurse has historically been difficult to gain consensus and consequently it is then difficult to forecast curricula and projected numbers to meet the increasing demand. The shortage has provided opportunities for the profession as broader educational foundations allow nurses to accept the challenge of more complex roles such as the nurse practitioner (Heartfield, 2006; Queensland Nursing Council, 2005). If these challenges are not forthcoming, dissatisfaction will result. The issues of substitution, as discussed in Professional Redesign, could be a solution to support the nursing shortage and the appropriate utilisation of the EOCN (Duckett, 2005).

What often is not considered is the specific stage of personal and professional development of the EOCN. This group has pursued study, developed in their career and fulfilled the parent role. Some begin to question their future both personally and professionally (Donner & Wheeler, 2001b). An inclusive and

supportive development environment with consideration to their changing needs has not historically been met, as the priority has been focused on training the new nurse. The challenge for organisations is to not to offer a one stop shop of ongoing professional development or retraining for EOCN, but to provide opportunities to meet their own agendas while ensuring that the employers needs are also meet (Donner & Wheeler, 2001b; O'Brien-Pallas et al., 2004).

3.1.4 Boomers versus Xers

To consider recruitment and retention strategies without multigenerational factors would be limiting. Each generation considers core values differently and

prioritises accordingly. Baby Boomers born between 1946 and 1964, sometimes referred have multiple responsibilities and the EOCN is characterised within the Boomer group. They absorb themselves in work, however strive for early

retirement and financial freedom. They seek an environment which assists them juggle personal responsibilities while continuing to meet their professional commitments (Hart, 2006; Minnick, 2000). As the EOCN is preparing to reduce participation in the workforce, extended retention up to and past the traditional retirement age would make a substantial contribution to the quality and quantity of the workforce (O'Brien-Pallas et al., 2004).

Generation Xs born between 1965 and 1978 consider work just one component of their life with leisure and family as their priorities (Hart, 2006). A preference to work as individual contributors rather than team members, they generally do not intend to remain with the same organisation throughout their career (Creegan et al., 2003). Generation Y born from 1979 have core values which include

confidence, achievement, diversity and recognition of professional status. Once

employed, this group expects immediate authority with influential decision making. Generation X and Y, as the future nursing workforce do not share the work ethic and sense of loyalty to the employer as the Baby Boomers demonstrate (Donley, 2005; Hart, 2006; Thorgrimson & Robinson, 2005). While labeling is a superficial way of describing these groups, it does allow some understanding of their trends which should be considered when shaping workforce policy in recruitment and retention practices (Creegan et al., 2003; Donley, 2005; Stuenkel, Cohen, & de la Cuesta, 2005).

The challenge for nursing is to reconcile the reality of the clinical environment, including the bureaucratic control which is in direct contrast with the expectations of the Generation X and Y. If these characteristics are not considered in

management processes, the best that can be expected is that Xs and Ys will elect to work casually in order to maintain the balance of work and lifestyle (Creegan et al., 2003; Stuenkel et al., 2005; Thorgrimson & Robinson, 2005). This situation will leave the EOCN to shoulder the responsibility as the other generations balance their lives. The sustainability of this situation is unattainable.

4 RESULTANT ISSUES
4.1 Retention, Resign or Retirement
As the nursing shortage worsens and influences threaten to loose experienced EOCNs, organisations need to consider the resilience factor of why nurses remain in organisations, and why they decide to leave (Bruffey, 1997). While there is a plethora of literature discussing the reasons why nurses leave, there is little evidence to support the resilience factor specifically for the EOCN. Sustainability of healthcare depends on how the retention issue is managed.

The Australian retirement age ranges between 55 to 65 years with 55 years commonly seen as when labour participation begins to reduce (Duffield & O'Brien-

Pallas, 2002), however as life expectancy increases so too should the retirement age. Individuals who are financially viable will not extend their work participation even though the retirement age has been extended. There are however, older employees who may continue working if the conditions were flexible and met their individual and professional needs (Leavitt, 1996).

Efforts are beginning to focus on retention of current staff, with strategies such as sign-on bonuses, inflating the pay scales or promises of flexible rostering (Hart, 2006). Promises are often not realised and short-term strategies such as sign-on bonuses merely gravitate current staff to other organisations. Few organisations have managed the difficult components of work climate frequently highlighted as a major influence of the decision to stay (Forster & Queensland Health, 2005). Creating a positive climate results in satisfied staff who often stay committed to the organisation over a longer term. High-performing organisations make optimal use of staff such as the EOCN and their unique abilities (Snow, 2002).

Few studies have explored strategies for different age cohorts, which has resulted in a one-size fit all approach to planning initiatives, cautioning leaders not to generalise data or make assumptions based on ageist attitudes. While studies have provided recommendations to retain nurses nearing retirement, there is no evidence to support these strategies are effective. There is however a potentially large cohort of highly skilled nurses available if the best-fit retention strategies are practiced (Kilbom, 1999; O'Brien-Pallas et al., 2004).

4.1.1 Job Satisfaction

Job dissatisfaction and turnover are reoccurring themes sited in the literature and have regained interest due to the nursing shortage (Takase, Maude, & Manias, 2005). Throughout this paper, authors have identified associations between

specific variables, job satisfaction and the intent to stay. What is lacking is the

evidence of specific predictors for the EOCN. It is uncertain if general satisfaction data can be transferred to the EOCN cohort.

Much of the satisfaction literature assumes that nurses are receptacles merely waiting to respond to the environment. Researchers have ignored how nurses actually interpret and judge their environment within the context of their professional needs. What has not been addressed in past studies is the degree to which EOCN seek these environmental characteristics to satisfy their professional needs, to compare nurses needs with their perception of environment and to seek how this comparison affects nurses job satisfaction and turnover intention (Takase et al., 2005). Each nurse will have unique professional and personal needs indicating that it is unlikely that generalisation of data is satisfactory (Fagermoen, 1997).

A significant association found was between job satisfaction and organisational commitment. The notion of job stages highlights the time nurses disengage will vary due to nurses individual and organisational circumstances. The predictors for disengagement increased with time on the job due to boredom and indifference to the job, rather than age or time as a nurse. The stage of mastery is described as advanced beginning skills moving towards advanced practice. The nurse at the mastery stage describe themselves as feeling a sense of accomplishment, challenge and purpose (McNeese-Smith, 2000). Therefore the challenge for nurse leaders is to maintain EOCN in the mastery stage, which should include the valuing of their expertise.

4.1.2 Decision Making Ability / Valued Expertise

Nurses who have more discretion and decision making in how they perform their role tend to experience greater job satisfaction and commitment (Allen & Meyer, 1996; Kluska et al., 2004; Ritter-Teitel, 2003). The valuing of nurses expertise through a high degree of autonomy in their practice creates a bond to the

organisation and profession. Nurses may be influenced to leave an organisation if they were unable to exercise decision making based on their professional judgment (Kluska et al., 2004).

Due to resource cutbacks and high patient acuity, nurses autonomy has been limited by reducing the opportunity for inclusion in decision making exacerbated by time constraints (Apker et al., 2003; Hanson et al., 1990; Ritter-Teitel, 2003). An Australian review collaborated these results, suggesting nurses had little influence over the health system or inclusion in decision making. Ultimately

nurses are forced to reallocate time to undertaking more supportive duties rather than direct patient care (National Review of Nursing Education, 2002). A separate review identified too many layers of bureaucracy and lack of decision making (Forster & Queensland Health, 2005). This convoluted, prolonged reporting

processes slowed down the nurses ability to mobilise resources in order to meet organisational goals in an effective and timely manner (Laschinger & Shamian, 1994; Snow, 2002).

Autonomy has been described as one of the most significant features explaining job satisfaction and retention among nurses. A comparative study of magnetic and nonmagnetic hospitals suggested that the former nurses had independence to deploy needed resources for care delivery and had relative freedom to make decisions about the care. These nurses indicted that their work environment was supported by administration including leadership visibility, support of an autonomous climate and commitment to professional practice (Upenieks, 2002). What level of decision making is delegated to EOCN? Is there consideration for the individuals knowledge and skills with regard to delegation responsibilites?

4.1.3 Unique Needs

There are major implications for the workforce due to the trends of the ageing society. When nurse leaders fail to recognise the value of older workers, certain

biases may arise (Cofer, 1998). These biases should inform nurse leaders and administrators in how to manage workforce issues for the EOCN (Beatty & Burroughs, 1999). The motivations for continuing employment shift as age

increases and should be considered when addressing individual needs of the EOCN. To optimise the usability of the ageing cohort, unique trends are

considered in Table 1.

Table 1 1st Preference 40-49 years 50-59 years 60 years or older Money Enjoyment of work Enjoyment of work and usefulness

Motivational Preferences by Age Motivational Preferences by Age 2nd Preference Enjoyment of work Usefulness 3rd Preference Usefulness Money Money

The changing preferences as a nurse ages favour long-term relationships with an employer over advancement and job mobility. If personal and professional needs of the EOCN are met, this would be a significant retention advantage to the organisation (Beatty & Burroughs, 1999).

Labour force participation begins to decline at approximately 50 years of age. Increased absenteeism with employment of the older cohort is unfoundered as the rates are equal for both young and older workers with more absences among the elderly being related to poor health. It is likely that those with poor health will take early retirement (Beatty & Burroughs, 1999). There is an age bias that some employers have of the ageing workforce, by suggesting their inability to manage the physical aspects of the role or that there is an increase in absenteeism. With no lift policies and appropriate lifting equipment, physical injury should be minimised (Beatty & Burroughs, 1999; Cofer, 1998; Giorgianni, 2005). Those remaining in the workforce are healthier than their retired counterparts, and those

continuing to work report higher life satisfaction than their non-working counterparts (Beatty & Burroughs, 1999; Giorgianni, 2005).

Reasons for employment vary with each individual and the EOCN is no exception. Customising positions, adjusting schedules and assignments around staff needs would seem a rational strategy (Cappelli, 2000; Nevidjon & Erickson, 2001).

4.1.3.1 Age Bias The age bias of an unproductive, dependant older nurse is moving to one of an active older nurse who desires and is often capable of working beyond the traditional retirement age. Rather than a sudden push into retirement, there

should be a redesign to provide a more flexible transition that allows nurses to balance work and leisure. Many economists are predicting a shortage of skilled workers resulting in a need for organisations to recruit older workers who possess valuable skills. The nursing shortage is escalating and there has been little action to encourage or support the EOCN to retain their place in the system (Steinhauser, 1999).

Leaders in general function from both positive and negative beliefs about the older workforce. They consider the older cohort is more loyal, dependable and possesses a positive work ethics, however, they also believe that this group has less competence in technology, less potential for learning and less flexibility than their younger counterparts. Hence, their positive characteristics are not utilised to their full potential with age biases inhibiting further growth (Beatty & Burroughs, 1999).

An investigation of the age which was considered too old to work found that young adults hold negative views towards the elderly and label those in their 60s as too old to work. While education can support the learning of realistic ageing issues, it does suggest difficulties for the experienced EOCN who will undertake

preceptor roles to support the younger nurses professional and personal development (Farney, Aday, & Breault, 2006). While people are healthier, these extra years are rendered less productive for a variety of reasons as nurses reduce their participation in the workforce prematurely (Giorgianni, 2005).

4.1.3.2 Retraining / Professional Development An area which has attracted little attention is that of professional development of the ageing nurse workforce. The younger employee who will receive a large proportion of the training resources to utilise their newly acquired skills to enhance their career moves, while the EOCN views training opportunities for enhancement of job-related skills (Buchan, 1999; Leavitt, 1996).

The clinical ladder was a concept developed in the 1980s to manage recruitment and retention issues, while later the program was focused to drive the retention of experienced nurses who could significantly contribute to quality care. The

retention of clinically competent nurses requires that workunit environments are supportive by allowing autonomy of practice and decision making. The concept was based on Benners work on professional development and utilised supports such as mentoring to facilitate career development. Incorporating peer review and role negotiation, it seems a valuable initiative for the EOCN to design their professional progress (Corley, Farley, Geddes, Goodloe, & Green, 1994).

Work skills and attitudes develop over the nurses career, which is invaluable to the employer. The transfer of experiences can not be replicated in programs to their younger counterparts. Organisations are slow to develop policies to promote variable career paths as nurses mature, including reduced working hours and post-retirement work opportunities (Beatty & Burroughs, 1999). How best can organisations provide quality education that achieves the desired outcomes of knowledge acquisition, demonstrated critical thinking and proficiency in interdisciplinary clinical skills? In the closing career years, how do organisations

ensure that there is an opportunity to transfer this wealth of knowledge before retirement or transfer? If these experts are not available, new and existing staff may not gain the critical experience needed to engage in interdisciplinary activity, which may compromise improved patient outcomes (Tanner, 2002).

Development of a life-long learning culture requires access to continued education for all staff to support minimum standards and career options (Donner & Wheeler, 2001a). Offering high quality staff development programs can be one of the most effective ways of attracting, motivating and retaining talented staff (Forrester & Griffiths, 2001; Tanner, 2002). However, it has been identified that cost cutting had a negative impact on professional development. Feedback

indicated that there was a lack of commitment by employers to ensure that nurses maintained best practice (National Review of Nursing Education, 2002). The

clinicians felt disempowered, undervalued and marginalised and reported inadequate training and professional development opportunities and insufficient time for teaching and research (Forster & Queensland Health, 2005, p. 205).

Organisations should be nurturing the continued development of the ageing workforce so that the gradual shift of otherwise productive employees into a stage of economic dependency. Policy initiative should foster flexible career paths

throughout the nurses working life; support personal decisions based on individual performance, productivity and potential for all employees and support flexible and progressive arrangements for retirement from the organisation (Mutschler, 1996).

4.1.3.3 Work-life Balance With projected increases in the demand for healthcare and concern that the nursing supply will be insufficient to cope with the demand, there is focus on retention strategies and more efficient utilisation of nursing resources. By

enabling nurses to combine work and non-work commitments, staff turnover concerning this issues could be positively influenced (Buchan, 2000).

Flexibility of work scheduling has historically been an issue as nurses care for their young children and maintain their position in the workforce. This flexibility is not equally granted to the EOCN who may hold multiple caring responsibilities over diverse age groups. In addition, the EOCN may require flexibility due to the accessing of educational programs, taking sabbaticals or a phased approach to retirement (Forster & Queensland Health, 2005).

Nurses continue to report overwork and poor working conditions, the climate is left increasing stressful as consumer expectations are raising, patient acuity increasing and EOCN reducing their participation in the workforce. The balance of work and home life becomes increasing important and as a result, many choose to leave the profession. The increasing turnover rates indicate that nurses are not willing to work within the current healthcare system. The work

environment and related conditions are fundamental to the retention, particularly those who possess the accumulated knowledge and skills of decades of experience (Chandra, 2003; National Review of Nursing Education, 2002). While reports indicate the inflexibility of management, turnover data indicates that attempts to action recommendations are generally unsuccessful.

4.1.4 High-Effort/Low Reward

In the 1990s, healthcare restructuring was a planned strategy to increase productivity and reduce expenditure while maintaining quality of care (Aiken, Clarke, & Sloane, 2000). The fall-out has left devastating effects for healthcare, leaving nurses feeling devalued and burnout (Laschinger et al., 2001d). The

effort-reward model is a balance in the work environment where high-cost/ low gain conditions are considered stressful (Siegrist, 1996). Two components of efforts and rewards are distinguished in this model: an extrinsic component which reflects distinct job conditions (effort: demands, obligations; rewards: money, esteem, career opportunities and security), and intrinsic component, the personal

coping style termed over-commitment (Hasselhorn, Tackenberg, & Peter, 2004). Some individuals will cope with stress more effectively than others for example, nurses with over-commitment or high intrinsic effort will over emphasis their efforts as they need approval. They will find the dissonance between efforts and rewards extremely stressful (Kuper, Singh-Manoux, Siegrist, & Marmot, 2002). Rewards are the degree to which nurses feel they have been recognised and congratulated for the job performance. The level of reward or recognition should match the level of the performance or risk of inequity may cause withdrawal from extra effort by the nurse (Snow, 2002).

Examination of the validity of Siegrists effort-reward imbalance model in Japanese workers found that the effort-reward imbalance was most prevalent in the 25-30 age employees. The effort-reward imbalance decreases with age,

however the level of over commitment increased with age (Tsutsumi et al., 2002) highlighting the need for the EOCN to receive feedback and recognition for their efforts.

A comparative study of the association of chronic work stress with adverse health outcomes among nurses found a strong association of effort-reward imbalance with not only burnout but also the intention to leave the profession (Hasselhorn et al., 2004). Further evidence from a survey of 36,000 public sector employees indicated that failed reciprocity in work may be associated with the co-occurrence of potentially preventable lifestyle-related risk factors that contribute to cardiovascular disease and other chronic diseases (Kouvonen et al., 2006).

Relationship study between nurses perceptions of workplace empowerment and their experiences of effort-reward imbalance established a link between nurses workplace empowerment and effort-reward imbalance. Having the access to

supports, autonomy, opportunity, information and resources may result in a positive match between self-appraised efforts and perceived rewards and prevent this imbalance (Kluska et al., 2004).

As the evidence demonstrates value of the effort-reward imbalance model, this strategy could be adopted by organisations to retain nurses in an improved workplace environment perceiving their value.

5 IMPLICATIONS FOR RESEARCH /PRACTICE

Conclusion
Within the healthcare sector, a decline in the retirement age of healthcare professionals has occurred which will contribute not only to the nursing shortage but will also complicate the availability of experienced and qualified nurses to provide quality care. The retention of the EOCN may provide part of the solution. The value of this group as valid contributors to continued work past current nominated retirement age should be recognised. As an under utilized cohort, the EOCN contribution can offer mentorship to the new generation of nurses as they become the future (Giorgianni, 2005).

Healthcare can achieve considerable savings if reduction of the current high and costly rate of turnover and trend through reliance on temporary staffing is minimised. Rather than shifting the nursing shortage from one facility to the next by attracting nurses with promises and bonuses, an examination of the factors which influence the retention of those with experience and organizational knowledge, the EOCN would better serve a long term solution. If organisations are willing to spend money to recruit staff, they could also allocate these resources to staff retention. Retention strategies targeted towards the EOCN, require diversity which focuses on their specific stage of personal and professional development and their unique needs.

Within the preliminary proposal,numerous factors have been identified which may influence retention. These factors have demonstrated dissonance between Given the

relationships, work unit environments and expectations of nurses.

lacking of research specific to the EOCN, this study aims to gain an in-depth understanding of resilience factors of the EOCN in an acute care, tertiary healthcare setting and explore how these factors influence this unique group affects the decision to stay.

Therefore in light of the problem, the purpose will be to: Explore how organisational environment, leadership and professional issues influence retention of the end-of-career nurse.

Possible questions for research may include: Do EOCN leave organisations prematurely? Do organisations support EOCN to encourage extended work

participation? Do current leadership and professional development programs benefit EOCN? Do current leadership and professional development programs offered to EOCN benefit the organisation? What strategies are needed to retain EOCN?

6 REFERENCES

7 APPENDIX 1

Terms and Definitions

Baby Boomers - born between 1946 and 1964, sometimes referred to as the sandwich generation having responsibilities of aging parents while dealing with teenage and university age children (Hart, 2006; Minnick, 2000).

Burnout - the syndrome of feelings of emotional exhaustion, depersonalization and reduced personal accomplishment (Demerouti et al., 2000).

Depersonalisation - the development of negative, cynical attitudes towards recipients of ones service or care (Demerouti et al., 2000).

Emotional exhaustion - energy depletion or draining of emotional resources (Demerouti et al., 2000).

End-of-career nurses nurses aged from 45 years onwards regardless of when they entered the profession. Additionally, this definition will also include nurses of who retire or leave the profession regardless of age.

Generation Xs - were born between 1965 and 1978 (Hart, 2006).

Generation Y - born from 1979 (Donley, 2005; Hart, 2006; Thorgrimson & Robinson, 2005).

Person-environment fit theories - an employees perceived compatibility with the organisation and with their environment and how the degree of congruence between them affects nurses occupational behaviour (Mitchell, Holtom, Lee, & Erez, 2001, p. 1104).

Traditionalists - born 1922 to 1945 (Hart, 2006).

Work excitement - personal commitment and enthusiasm for work as evidenced by creativity, receptivity to learning and ability to see opportunity in everyday situations (Bruffey, 1997, p. 203).

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