DOI: 10.31038/AWHC.2019235

Introduction

In most industrialized countries, the nursing workforce, an overwhelmingly numerically female dominant profession, is aging [1]. Analysis of data suggests that this is due to interrelated social and economic factors pushing nurses towards later retirement. Nurses are choosing to remain in the workforce longer, delaying retirement for reasons that include economic and financial necessity, continued desire to care for others and meet professional goals [2], and positive life-span development that is attributable to increased life expectancy and longevity [1–2]. Apart from intrinsic motivators, there is also a growing drive to increase the labour market participation of older individuals in response to shifting population structures secondary to population aging [2, 3–5]. In occupations such as nursing where skills shortages are already being experienced, population aging threatens to deepen this existing problem [6].

Older nurses represent a pool of untapped human capital. Through their accumulated experience and resulting expertise, older working nurses present a number of benefits for economic growth and social welfare. However, if these benefits are to be derived from the continued participation of older nurses in the labour market, the intersecting challenges that they experience in the workplace must be recognized and addressed. The intersectionality of the physicality of nursing work, its embeddedness in gender-based power relations, the health care consequences of population aging, and the increased risk of disability and other outcomes associated with working when older must be taken into consideration in designing healthy, age-friendly work environments where a diversity of nurses can thrive.

Intersectional Issues of Concern

Older nurses working in the labour market are impacted by multiple and gendered axes of influence that must be understood. Equally importantly, they must be considered as part of employers’ and policy makers’ responses both to the struggles of older nurses in the workforce and to the broader challenges of population aging for health care. Key influences and issues of concern are explored briefly below.

Consequences of Aging on Working

While our bodies change with age (e.g., decreased strength, flexibility, and bone mass) [7] disability and illness are not an inevitable part of aging [8]. This notwithstanding, the probability of work-induced disability and injury increases as workers age [5, 9]. Data support that older workers are less apt to acquire injuries on the job than younger workers; however, aging-related physiological and cognitive changes make older workers susceptible to more severe and permanent injuries [5]. Older workers are more likely to experience soft tissue injuries affecting the back, neck, and feet [5, 9–10]. The probability of older nurses sustaining such injuries and acquiring disability is made even more likely because of the physically strenuous nature of nursing work [9] and the concurrent risk for violence [11]. Recent data reveals a significant positive correlation between age and incidence of nurses working with some form of physical or mental impairment [12]. This finding was consistent with other data indicating that the likelihood of individuals experiencing disability increases with age [12].

Given this context, it is surprising that disability among nurses is a topic rarely discussed within the literature and equally absent from policy and administrative perspectives [9, 13]. Available literature reveals that nurses with disabilities, particularly those who acquire a disability while working, receive very little support to persist within the profession [13–14]. Unsupported nurses with disabilities are left in a difficult situation with very little choice, often leaving direct practice or the profession altogether [13–14].

Gender-based Power Relations and Labour Market Discrimination

The influence of age on working does not happen in a vacuum and is not exclusive of other factors impacting individuals’ lives and their work. Gendered experiences of women in labour markets have a compounding effect on working women who are aging. With a few exceptions, women account for approximately 90–95% of the nursing workforce the world over. As a female dominated profession, deeply embedded within nursing are the gender-based power relations of society. As such, the nursing profession is reflective of the value placed on women and their standing in society [15]. In particular, the erroneous feminization of nursing and gender-based discrimination have resulted in occupational segregation and consequently, the forcing down of wages in the profession. Unfortunately, dominance of females within the profession is not effective against the gender-pay gap. Across practice settings, positions, and specialities, male nurses typically out earn female nurses [16–17]. This gender pay gap is also unaffected by education, a common means by which an individual can increase their earnings [17].

Although not all of the factors contributing to the gender pay gap within nursing are known, workplace discrimination and gender discrimination have been identified as factors limiting women from advancing in the workplace and gaining positions of authority [17]. Additionally, gender expectations of women within society have been identified as contributing factors. Like other working women, female nurses often must balance work and care for children, other dependent family members, or both, often at the expense of career progression and their health [18, 19]. While performing this juggling act can and does fall to men in some circumstances, the societal expectation that women should take care of their loved ones, even when they are working, persists. Many women have reported experiencing the weight of these often-unspoken expectations [18, 20].

Population Aging, Health and Health care

Trends in the health of populations and health care are yet another axis of influence on older nurses’ participation in the workforce. These trends include a diminished and slow-growing nursing supply resulting in inadequate staffing; [1, 21] increasing patient volumes and the requirement for more health services due to increased life expectancy and longevity; [1, 22, 23] and increasing patient acuity and the growing complexity of treatment modalities [1, 22]. The sum total of these pressures is that there are ever-rising professional demands and excessive workloads on nurses. Nurses are faced with increasing psychosocial, physical, and cognitive demands. In some cases, they must also deal with unsafe and unhealthy conditions such as workplace violence. Consequently, there is greater likelihood of fatigue, injury, and disability among today’s nurses, which have been linked to overall measures of the quality of nursing work life and patient safety [1, 20, 24]. Older nurses may be doubly impacted by these pressures associated with aging that are situated within the context of gendered labour market experiences.

Intersectional Considerations for Ways Forward

By and large, efforts to address the challenges faced by older working individuals have focused on the consequences of aging, often in isolation of other factors. Nursing-specific interventions that have been championed include flexible scheduling, shorter work shifts, comprehensive disability management programs with an emphasis on accommodation, and redesign of the work environment to meet ergonomic needs and reduce injuries [9, 25]. While there is no doubt that these initiatives are needed and would be of benefit to all nurses, they do not go far enough to address the multiple axes of influence and oppression structuring the experiences of not only older working nurses, but younger nurses as well.

An intersectional approach is needed whereby aging in the nursing workforce is understood in the context of the other interconnected factors that in some cases may have a far more significant impact on working nurses than the consequences of aging. An intersectional understanding of working, aging women exposes the multiple forces that impact upon the experiences of older nurses. These experiences should be understood in ways in which age, gender, issues of power and domination, and socioeconomics intersect with the work experience. Moreover, an intersectional approach to aging in the workplace provides the opportunity to reflect on and apply a social justice discourse in dealing with the challenges faced by nurses.

Ultimately, the problem of a skills shortage in nursing and the multitude of challenges accompanying an aging nursing workforce cannot be addressed through a sum-of-the-parts approach. An intersectional approach calls upon stakeholders to focus on the complexities of the situation and employ a broader frame to understand these problems. Using a well-informed frame in evaluating aging in the nursing workforce will enable changemakers to accurately recognize the issue of skills shortage and retention of nurses as being layered by structural inequalities along axes of age, gender, ableness, and social status. In this context, solutions should be pursued which are emancipatory and aim to empower the nursing workforce while also interrogating and seeking to remedy structural discrimination and injustices, such as the gender pay gap and visible and invisible barriers to career advancement and fulfillment. Estimates predict that upwards of 7 million skilled health professionals (the majority nurses) are currently needed globally [26]. In this context, failure to recognize the context and experience of work for aging nurses, compounded by the profound lack of incentives for younger nurses to remain in the profession [26] will undoubtedly negatively impact not only nurses, but likely the health of individuals, families, groups, and communities around the world who rely on nurses to provide compassionate, high quality care.

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