Strife in the Time of COVID — Role of Leaders in Bridging Generational Gaps

It is the early days of the COVID-19 pandemic. You have been asked to counsel a junior physician who had entered the room of a patient under investigation (PUI) for COVID without the appropriate personal protective equipment (PPE). When asked about the incident, she stated that the (experienced) overnight physician had probably ordered testing as a knee-jerk reaction, and that based on her information, “all this stuff is really a waste of resources.”

How do you proceed? Is this a black and white situation that has nothing to do with generational differences, or are there shades of gray here?

COVID-19 has brought out the best and the worst in humankind. At best, it has helped us to rally against a common threat; at worst, it has amplified generational differences.

As thousands of physicians have come out of retirement(1) to join the fight against COVID-19, generational flashpoints are inevitable. What is the role of a physician leader in bridging generational gaps? We offer a way forward based on evidence-based practices from within and from outside medicine.

Today, five generations are in the healthcare workforce. Millennials represent the single largest generation in the U.S. workforce(2) and are increasingly assuming formal leadership roles in healthcare systems. Additionally, 44 percent of Millennials identify as being a minority(3) and thus comprise the most diverse adult generation in U.S. history. The complex generational divide has been dubbed the “racial generation gap.”(4) A majority of Millennial physicians are women, resulting in what can be described as a sex generation gap.(5) Key characteristics of the generations are listed in Table 1.(6)

The economic cost of the friction between generations is substantial; it has been estimated to cost the U.S. economy up to $820 billion(7) and the healthcare industry approximately $213 billion(8) annually in lost productivity. Ignoring generational differences may negatively affect the bottom line through high employee turnover and increased cost for recruitment, training, and retention.(9) In addition, poor clinical outcomes that result from a disconnect in inter-generational communication styles can lead to increased care costs from patient rehospitalizations.

For these reasons, many facilities are hiring generational consultants, often at great cost, to ostensibly create a more harmonious workplace environment.(10)

“Sticking Points” and a Way Forward

In his best-selling book Sticking Points: How to Get 4 Generations Working Together in the 12 Places They Come Apart, Haydn Shaw(11) describes the formative events and experiences or “ghost stories” of each generation that influence them in the workplace. The 12 sticking points Shaw outlines that lead to generational conflict are listed in Table 2.

Shaw proposes five steps to help leaders move through generational conflict and facilitate better working relationships:

1. Acknowledge generational differences rather than sweeping them under the rug.

2. Appreciate the differences; focus on why people are different.

3. Flex and adjust what you do and how you do it so everyone has what works best for them.

4. Leverage generational differences as opportunities to communicate more clearly, reach markets more effectively, and understand customers better.

5. Resolve to create a policy/resolution/answer so that everyone is on the same page moving forward.

Shaw’s seminal work can be applied in healthcare, where physician leaders should get comfortable putting hard feelings on the table, emphasizing the common need, and not fearing awkward silences. Such an approach can set the stage for a productive conversation between generations.

When colleagues or direct reports come with the “what” (the problem that is causing strife), leaders should make an effort to refocus them on the “why” to understand the other person's point of view. Once people acknowledge and appreciate differences, they can decide how to flex for each generation. In situations where flexing is not possible, clinical leaders should have a transparent decision-making process to resolve the issue at hand.

Building Bridges

Leaders who have the following traits are considered the most credible across all generations: trusted, listen well, farsighted, encouraging, dependable, focused, dedicated, experienced, and have good coaching skills.(12)

One of the most critical leadership roles is to promote a culture of learning and responsible risk-taking, which can sometimes be at odds with older generations’ need for preservation and imposition of the wisdom of their age. Institutional knowledge and cautionary tales are certainly helpful to set context, but they should be balanced with fostering employees’ creativity in rethinking tasks and workflows in the spirit of continuous improvement. In the current climate of uncertainty and rapid data obsolescence, the ability to improvise and course-correct has never been more vital.

As retiring or retired physicians are brought back into the workforce, leaders should consider Grey Guidance(13) or mentorship programs to promote sharing of knowledge and skills among generations. Interestingly, the majority of Millennials favor mentorship;(14) an impressive 94 percent state that their mentors give them valuable advice.

To be successful, such programs must be rooted in transparent goals, mutual respect, shared values, ongoing dialogue, and a free flow of information, not to mention steering clear of stereotypes,(15) which damage camaraderie and are often incorrect. For example, despite being depicted as self-entitled and complacent, young employees rank above all other generations in terms of collaboration and teamwork and rank high in self-development. Just as significantly, it is the Boomer generation that has shown the most recent growth in social media usage.

Furthermore, there may be similarities in workplace preferences between Boomers and Millennials,(16) such as flexible work options and a heightened sense of obligation to make a positive contribution to society and to the health of the planet. Perhaps it’s no surprise that Boomers and Millennials tend to seek each other out in the workplace, given that Millennials are usually the offspring of Boomers.

Clearly, leaders should respect employees as individuals without assumption, stay alert to generational tensions, and explore natural synergies among generational cohorts.

Another tool that increasingly is being utilized is generational awareness training (GAT). The components of GAT(17) are listed in Table 3. GAT also can be rolled into existing diversity training programs that are offered in many healthcare organizations.(18)

An Intentional Culture: Designing Workplaces for the 21st Century

Kristin Baird, RN, president and CEO of Baird Group, believes that healthcare companies can learn from Google’s overall deliberate approach(19) in creating a workplace environment.

“They create an intentional culture,” Baird says. “In other words, people are really defining ‘This is what we want our culture to be.’ ” An intentional culture starts with having a vision for the company environment, similar to the mission statement a company might make to guide its business goals. Once an organization defines its desired work culture, the leaders can strive to achieve and maintain that environment.

“It’s a sacred relationship that we enter into every single day,” Baird says. “Leaders of healthcare organizations have a responsibility to make sure they’re creating an environment very intentionally that’s going to engage people so they really feel connected to that greater purpose.”

New York University Winthrop University Hospital Research and Academic Center (NYUHRAC)(20) is one healthcare facility that has intentionally designed workspaces to foster collaboration. Its 95,000-square-foot facility comprises a mix of patient care, research, and educational space, and takes inspiration from Bell Labs.

Located in Murray Hill, New Jersey, Nokia Bell Labs (formerly Bell Labs) is a legendary facility that has served as the birthplace of numerous innovations that have shaped today’s world, including the transistor, communications satellites, the laser, and cellular phones. The policy at Bell Labs is to encourage, and even demand, cross-disciplinary collaboration. A culture of collaboration is supported not only by the company’s policies, but also by the architectural features of the facility.

Taking a cue from Bell Labs, the roles of proximity and connectivity were considered in the design of the NYUHRAC. Opportunities for spontaneous collaboration were integrated throughout the building, including several space types to accommodate different kinds of collaboration. Echoing the connecting corridors of Bell Labs, an open stair provides a vertical connection between departments, designed to encourage impromptu conversations and interactions among employees.

NYURAHC conducted a mixed-methods study that suggested that a thoughtfully designed environment could support employee engagement and increase collaboration, so long as it was in concert with a more positive attitude of medical professionals toward collaboration. It is unlikely that the implementation of one change will be wholly effective in isolation. Ultimately, they concluded, the ingrained culture of hierarchies in healthcare may be the most significant hurdle to a culture of collaboration.

Generational Gaps and Medical Education

Gupta(21) and colleagues explored the perspectives of physicians at three different stages in their careers: a resident, a mid-career physician, and a senior physician. The three viewpoints were written separately and included important conclusions that each generation wished to express to the next. Some basic tenets were underscored by each generation, such as the importance of balancing a personal life with medicine and accepting the unpredictability and inherent complexity of caring for patients; however, some perspectives highlighted how medicine has changed throughout the years and how this has served to perpetuate the disconnect among three generations.

The facilitated conversation approach(22) can be applied to any training program and can be incorporated into daily rounds, which typically consist of multigenerational groups. The most successful teams often clearly delineate expectations for each member of the team on the first day, which makes the hierarchy less intimidating and validates every team member’s opinions and perspectives.

As graduate medical education evolves, it embraces more experiential, self-directed learning with facilitators rather than dogmatic teaching styles.(2) The best learning occurs in clinical simulation when the facilitator does not know what is coming next in the scenario, but rather works with the students. Boomers are more likely to have the soft skills required for effective facilitation and mentoring; information leaders can use in the realm of healthcare education to better meet the needs of learners.

Generation Gaps and Technology — Boon or Bane?

The COVID-19 pandemic has highlighted the ability of healthcare systems to adopt newer technologies(23) to triage patients, facilitate virtual patient visits, and coordinate the workflows of decentralized healthcare teams.

Traditionally, technology adoption has been a generational “sticking point,” yet organizations are increasingly turning to technology and omni-channel communication to bridge generation gaps. Communication platforms such as Slack(24) have obtained HIPAA certification and have been adopted by healthcare organizations as a viable alternative to traditional emails. Organizations that have adopted such platforms attest to broader shared communications about operational issues and shared interests.

Another bonus is that content can be placed in specific arenas or “channels” that allow employees to prioritize consumption and relevance. As an example, a project team might use one channel to enable collaboration at a quick pace and use another to share sensitive patient information with providers in a secure manner.

An additional benefit of such software-as-a-service or “SaaS” communication platforms such as Slack is that they can integrate with clinical communications platforms that facilitate on-time alerts for patient care issues, escalate missed alerts to the next available provider,(25) and detect the sharing of sensitive health information.(26)

Such platforms are not without their drawbacks, however, some users complain that they are not effective for big-picture conversations, and that multiple conversations can exist within a single channel, defeating the purpose of the communication platform. Ultimately, dedicated solutions may need to be developed within the realm of healthcare, using multi-generational end-user feedback to address issues such as alarm fatigue, ease of use, and integration with existing technologies, such as electronic handoff and on-call scheduling systems.

Putting It All Together

Let’s reexamine the scenario that played out at the beginning of this article. The junior (Millennial) physician in question entered the room of a PUI for COVID-19 without donning appropriate PPE. When asked why, she states that the (experienced Boomer) overnight physician ordered testing as a knee jerk, and that, based on her information, “all this stuff is really a waste of resources and a drag on the environment.”

How could this confrontation have been avoided? The first step is to acknowledge generational differences with communication styles: Perhaps the Millennial physician prefers an electronic handoff, whereas the Boomer physician would have preferred a phone call or face-to-face interaction. A standardized process for handoffs that addresses the need for multi-channel communication may be helpful, such as a brief update of the electronic handoff tool augmented by a handoff in person or by videoconference. The latter option may mitigate problems posed by a noisy environment such as the nursing unit where there are frequent interruptions to workflow.

A thoughtfully designed semi-private or private space to receive handoff is another option to facilitate a free flow of communication and a detailed explanation about the need for testing.

Generational awareness training (GAT) might be helpful to create a foundation of trust and confidence (see Figure 1). Perhaps the senior doctor would have opened up and said, “I was very busy last night, and when the nursing supervisor came to me and said that the patient possibly might have been exposed, I told her that I would go ahead and order testing.” He may have gone on to say that while the risk of the patient having the illness was low, he tested for COVID-19 out of an abundance of caution.

Figure 1. Crosswalk to bridge generational gaps (taking into account values, context, and preferred communication channels)

The junior physician, in turn, may have offered to pick up the baton and review web-based electronic records such as the regional health information exchange for further clues/information about the patient.

The plan moving forward would have been one borne of collaboration: to strictly follow isolation precautions until the test results came back later that day, acknowledging that the pretest probability was low.

It is an inconvenient truth that younger generations are less likely to wear masks, as demonstrated by Haischer(27) and colleagues; however, the safety of staff and other patients is paramount, and examining without PPE is unacceptable. Open discussion is a central tenet of conflict resolution and would validate the position that each physician was placed in before the perceived confrontation.

Conclusion

Physician leaders can play a vital role in setting the tone and creating the infrastructure necessary to bridge generational differences. The cost of programs such as Grey Guidance and GAT are not insignificant, but can be well worth the investment from a strategic, financial, and patient care perspective. Traditionalists and Boomers have a lot to offer the younger generations and vice-versa, if they are open and informed in their approach.

In closing, consider the cautionary words of John Priestly, novelist and social commentator, who cautioned, “There was no respect for youth when I was young, and now that I am old, there is no respect for age — I missed it coming and going.”

References

1. Farrell C. Retired Doctors Return to Work for COVID. Forbes. March 27, 2020. www.forbes.com/sites/nextavenue/2020/03/27/retired-doctors-return-to-work-for-covid-19/#6c6437da1ae7 . Accessed March 31, 2020.

2. Boysen PG, Daste L, Northern T. Multigenerational Challenges and the Future of Graduate Medical Education. Ochsner J. 2016;16:101–107.

3. Frey WH. The Millennial Generation: A Demographic Bridge to America’s Diverse Future. Brookings. January 2018. www.brookings.edu/research/millennials . Accessed May 31, 2020

4. Wiltz T. Racial Generations Gap Looms Large for States. The Pew Charitable Trusts. January 16, 2015. www.pewtrusts.org/en/research-and-analysis/blogs/stateline/2015/1/16/racial-generation-gap-looms-large-for-states . Accessed May 31, 2020.

5. Johnson M. The Healthcare Future Is Female. Athena Health. February 14, 2018. www.athenahealth.com/knowledge-hub/practice-management/healthcare-future-female . Accessed May 31, 2020.

6. Wood S. Leading Five Generations in the Workplace. Steve On Leadership. http://steveonleadership.com/teams-culture/hiring/leading-five-generations-in-the-workplace . Accessed May 31, 2020.

7. Association for Talent Development. The Great Generational Divide. Association for Talent Development. February 5, 2014. www.td.org/insights/the-great-generational-divide . Accessed June 1, 2020.

8. U.S. Bureau of Labor Statistics. Healthcare Occupations. Occupational Outlook Handbook. Washington, DC: US Bureau of Labor Statistics. https://www.bls.gov/ooh/healthcare/home.htm . Accessed March 1, 2021.

9. AHA Committee on Performance Improvement. Managing an Intergenerational Workforce: Strategies for Health Care Transformation. American Hospital Association; 2013. www.aha.org/system/files/2018-01/managing-intergenerational-workforce-strategies-health-care-transformation-2014.pdf . Accessed June 1, 2020.

10. Hoffower H. There Are 5 Distinct Generations of Employees in the Workplace for the First Time — And It’s Created the Need for Companies to Hire ‘Generational Consultants’ to Keep Them All Happy. Business Insider. May 3, 2020. www.businessinsider.com/generational-consultants-help-companies-work-with-millennials-gen-z-2020-3 . Accessed June 1, 2020.

11. Shaw H. Sticking Points. Carol Stream, IL: Tyndale House Publishers Inc; 2013: 5-6, 43, 218–24.

12. Carter D. Bridging the Workplace Generation Gap Through Tech, Design and Leadership. Forbes. December 18, 2018. www.forbes.com/sites/forbeshumanresourcescouncil/2018/12/18/bridging-the-workplace-generation-gap-through-tech-design-and-leadership/#21c9251b39ab . Accessed June 1, 2020.

13. Bakker A. Generation Gap: How To Connect Boomers & Millennials. Blankslate. www.blankslate.partners/boomers-millennials-generation-gap . Accessed June 4, 2020.

14. Deloitte. The 2016 Deloitte Millennial Survey. https://www2.deloitte.com/content/dam/Deloitte/global/Documents/About-Deloitte/gx-millenial-survey-2016-exec-summary.pdf . Accessed June 3, 2020.

15. Everwise. Bridging the Generational Gap in Your Workplace. Everwise. May 23, 2018. www.geteverwise.com./leadership/bridging-the-generational-gap-in-your-workplace . Accessed June 4, 2020.

16. Hewlett SA, Sherbin L, Sumberg K. How Gen Y and Boomers Will Reshape Your Agenda. Harv Bus Rev Jul-Aug 2009;87(7-8):71–6, 153.

17. Multigenerational Workforce Training – Boomers, Xers, and Millennials. OperationsInc. https://operationsinc.com/human-resources/multigenerational-workforce-consulting-training-services . Accessed June 4, 2020

18. Health Research & Educational Trust. Diversity in Health Care: Examples from the Field. Chicago, IL: Health Research & Educational Trust. www.aha.org/system/files/2018-01/eoc_case_studies.pdf . Accessed June 4, 2020.

19. Becker’s Hospital Review. The Google Approach: How Hospitals Can Create Cultures That Drive Employee Engagement, Satisfaction. Becker’s Hospital Review. February 28, 2014. www.beckershospitalreview.com/human-resources/the-google-approach-how-hospitals-can-create-cultures-that-drive-employee-engagement-satisfaction.html . Accessed June 4, 2020.

20. Gluckselig K, Milne R. The Effectiveness of Collaborative Spaces in Healthcare. Perkins Eastman. October 26, 2017. https://www.perkinseastman.com/white-papers/ . Accessed June 4, 2020

21. Gupta S, Mak S, Detsky A. The Other Generation. JAMA. 2015; 313(13):1319–20.

22. Yoo, J, Matos, M, Bota, M, Schrewe, B, Armstrong, L. Bye to Burnout: Intergenerational Narratives Break Barriers. Med Educ. 2019; 53:518.

23. Hollander JE, Carr BG. Virtually Perfect? Telemedicine for Covid-19. N Engl J Med 2020; 382:1679–81.

24. Revenue Cycle Advisor. Slack Adds HIPAA Certification, May Be Eyeing Healthcare Sector. HealthLeaders. February 8, 2019. www.healthleadersmedia.com/innovation/slack-adds-hipaa-certification-may-be-eyeing-healthcare-sector . Accessed June 14, 2020.

25. Gonzalez C. Welcoming Slack to the Healthcare Industry. Onpage. February 14, 2019. www.onpage.com/welcoming-slack-to-the-healthcare-industry . Accessed March 7, 2021.

26. Nightfall. 4 Best Practices for Healthcare teams using Slack. Nightfall blog. May 1, 2020. https://nightfall.ai/resources/best-practices-healthcare-teams-using-slack . Accessed March 7, 2021.

27. Haischer MH, Beilfuss R, Hart MR, Opielinski L, Wrucke D, Zirgaiis G, Uhrich TD, Hunter SK. Who Is Wearing a Mask? Gender-, Age-, and Location-related Differences During the COVID-19 Pandemic. medRxiv 2020.07.13.20152736