Older workers in the nursing and care sector
Engelsk sammendrag av Fafo-rapport 2021:20
This report deals with older personnel who work as registered nurses, nursing associates and healthcare assistants in care homes and in home care services. We examine the proportion of over 50s in the relevant job categories and survey the retirement patterns and exit or mobility rates. We also investigate what it feels like to be an older worker in these occupations, what challenges they meet, how they perceive their working environment and management. In addition, we examine whether they feel recognised and valued, what their prospects for development are, and not least whether they consider their occupation and their sector to be a good choice for their late careers, and what might be needed for them to keep on working in these jobs.
The report summarises a sample of recent research and statistics relating to employment, retirement and working conditions in the industry, supplemented by some own analyses of register data from Statistics Norway. Furthermore, qualitative interviews were conducted in the winter/spring of 2021 with fifteen older workers in the sector, from three different municipalities.
Employment in the nursing and care sector
The number of employees in the nursing and care sector has increased from approximately 170 000 in 2010 to more than 197 000 in 2019. During the same period, the number of older workers has increased from 60 000 to 67 000. However, the overall growth of the sector’s workforce has been so substantial that the proportion of older workers was lower in 2019 than in 2010. The proportion of women has remained high throughout, but has seen a small drop from 89 to 85 per cent. The oldest age groups are somewhat under-represented in the private sector and among male workers.
Among the ‘youngest’ over 50s, the retirement rate remained stable from 2010 to 2015, whereas it fell among older age groups. The greatest drop in retirement rate was found among the very oldest age groups, from 69–70 years and older.
As more the oldest workers stay on in the nursing and care sector, there has been a corresponding drop in the sector’s exit rates. Simultaneously, there has been a drop in the proportion of older workers who transfer to other parts of the labour market. Thus, there is an increasing share who stay on in the nursing and care sector until they leave the labour market.
If an employee decides to leave the nursing and care sector, they normally transfer to other parts of the health and social services industry, for instance to work in a hospital. Home helps and healthcare assistants have the highest retirement rates among older workers, yet these also tend to keep working for the longest.
Working conditions, sick leave and retirement
The expected retirement age for a 50-year-old registered nurse in 2019 was 60 years and 5 months. For home helps and care workers, the corresponding age was close to 62 years and for auxiliary nurses and nursing associates it was close to 60 years. Almost 25 per cent of 50-year-old registered nurses were expected to retire before they turned 62, compared to 20 per cent of home helps/care workers. Nevertheless, compared to 2002 there has been a substantial decline in early retirements, particularly among home helps/care workers, and to some extent among auxiliary nurses. This means that fewer older workers than before retire due to ill health. Furthermore, 100 per cent incapacity for work is now an infrequent occurrence.
The proportion of workers who stay in the job until they have turned 67 nevertheless remains unchanged, except from among home helps/care workers. This is because more people are now retiring at 62 and 63 years of age. Most of retirees between the ages of 62 and 67 leave under the contractual early retirement scheme (AFP scheme). However, there are differences between the job categories: more registered nurses than auxiliary nurses and home helps/care workers retire under job-specific retirement age schemes (særalderspensjon), while home helps/care workers are more often disabled.
Among nursing associates, auxiliary nurses and care workers, health problems were reported to be one of the most important reasons for leaving under the contractual early retirement scheme (from 62 years). Excessive physical strain was also an important factor. Nevertheless, only 7 per cent reported that inadequate workplace adaptations influenced their decision to retire. More than half reported that they wanted more leisure time. However, this did not equate to a wish for a never-ending holiday. Many wanted to retire due to poor health combined with heavy workloads, as these are challenges experienced by many.
Among those who continue to work, the most important reasons stated for doing so were that the job continued to be interesting and rewarding, they felt that the employer needed them, and they continued to be in good health and were not particularly tired. Compared to the municipal workforce in general, considerably fewer said they continued to work because they were still in good health, and asubstantial share had chosen to work in spite of health problems. One in five stressed the importance of workplace adaptations.
The listed reasons were given in 2012, as more recent data are not available. However, it is unlikely that the situation has changed considerably since then, since the rate of retirement for these groups remains high. As the number of observations is quite small and the margins of error are large, all figures must nevertheless be interpreted with caution.
According to the National Institute of Occupational Health in Norway (STAMI, 2018), health and social services are among the most risk-exposed industries in the Norwegian economy. Staff report high levels of exposure to a number of potentially harmful psychosocial and organisational factors, such as night-time working, onerous job demands in combination with low job decision latitude, emotionally demanding tasks, imbalance between effort and reward, as well as violence, threats and undesirable sexual attention. They are also more at risk of being exposed to passive smoking, detergents/disinfectants and biological substances. Work in a squatting/kneeling position and awkward lifts are also far more widespread than in most occupations. In addition, a higher share report that they experience significant role conflicts. However, in terms of motivation, engagement, job satisfaction and a sense of belonging, they are no different from the national average.
Registered nurses and other nursing and care staff work in occupations with the highest recorded rate of sick leave due to work-related problems, whether with a doctor’s sick note or self-certified. Organisational factors like shifts and rosters are also specific to the sector. Both are factors that have been shown to increase the risk of absenteeism. Some mechanical (ergonomic) risk factors that may cause musculoskeletal problems, like heavy lifting and lifting in awkward positions, are also common in several of the occupations.
At the same time, the shortage of registered nurses and nursing associates has a significant adverse effect on the quality of home-based and care home services. This impacts professional standards: the perceived quality of treatment, opportunities for prevention and engagement in activities, the prevalence of infections and pressure wounds, the safeguarding of residents with mental health problems and the incidence of weight loss among service users. It also has an impact on how the local authority’s primary care services manage to follow up on elderly patients when they have been discharged from hospital. According to the service providers themselves, they are increasingly having to make difficult and taxing prioritisations by deciding who to help, how much time to spend on individual patients and service users, and what type of care and treatment should be provided.
The stories of the older workers
In order to gain insight into the working day of older workers in the nursing and care sector, we interviewed fifteen such workers in the winter of 2021. The interviewees were nursing assistants, auxiliary nurses, nursing associates and registered nurses who provide home-based care services or work in a residential care setting. The age range was from 60 to 70. Twelve were women, and three were men. Some of them had full-time jobs, others worked part-time, some worked only night shifts, others worked mornings, evenings, nights and weekends, while yet others swapped between day and night shifts.
All of the auxiliary nurses, nursing associates and healthcare assistants had broad and varied work experience from different sectors. Their range of earlier employment included retail and bakery work, lorry driving, work in the hospitality sector, in schools and in after-school activity programmes. The registered nurses however, had been working in the sector throughout their working life, including longer periods in hospitals.
The interviews gave us an overall impression of a highly dedicated group of workers. They expressed a love for their work, and got on well with residents and colleagues. They had chosen their job because they like people, and because they enjoy providing care and assistance. Their older age and many years of experience gave them reassurance because they knew the routines and mastered their job well. They also pointed out that their ‘maturity’ made them calmer and more tolerant than they used to be, and they felt that they were better than younger staff at recognising and communicating with residents. They are also loyal and are willing to lend a hand, even if their health is faltering and the tasks sometimes feel overwhelming. They did however report a number of work-related challenges.
What they consider to be a particular strain is not the physical nature of the work – as they have aids to help them – but the fact that their working day has become so busy. They have to jump from task to task and do not have enough time to spend with the residents/service users. They seldom have time to catch their breath and meal breaks sometimes have to be skipped. The strain on their conscience and psyche is perhaps greater than the physical wear and tear on their body.
According to the interviewees, their busy working day is a result of low staffing levels, the constant addition of new tasks, systems and routines, the growing reporting and documentation requirements and the fact that residents and service users are ‘sicker’ and need more help than previously. The latter is partly linked to the Coordination Reform, but also what they perceive to be stretched finances and labour shortages in the sector.
The older employees describe the access to continuing and further education and competence enhancement as good, but that there are few opportunities for adapting the work. Very few reported that the workplace have an active age policy (seniorpolitikk). What they miss is not special measures aimed at this group but more tailored adaptations of the work, such as a slightly slower pace and more opportunities to take a break when needed – either more 5–10-minute breaks per day or a few extra days off a year – or the introduction of a job rotation system to ensure that the most stressful tasks are more evenly distributed among staff. Some reported that if their shifts and/or work tasks were changed they would stay in the job longer. Many would also like to see better and more suitably tailored computer training, so that they can also master this part of the job.
It also seems that the behaviour of some managers is the main problem and chief reason for some staff wanting to leave. This may be an indication that employees will stay in the sector longer if relatively simple and inexpensive measures are implemented, such as being more selective when recruiting managers.
What can be done?
The shortage of personnel in the nursing and care sector has been known for a long time. The demand for labour is also expected to see a sharp increase in the years ahead as a result of the growing share of older people in the population. The proportion of older workers in the sector is also high. There were almost 88 000 employees over the age of 50 in 2019, and the proportion in this age group working full time is also higher than in other age groups. Older employees therefore make up a disproportionately large share of the total full-time equivalents in the sector
The fact that many of the employees are in their 50s and 60s means that a high proportion will leave the sector every year through disability and normal retirement. As STAMI’s working environment analyses show, several occupational groups in health and social care services have a generally high exposure to a number of risk factors in the working environment and an accumulation of health problems, sickness absence and incapacity for work. Many are therefore disabled in their 50s, and a good number take contractual early retirement, even though early retirement has fallen in recent years. Leaving the sector to work in other occupations is less common. Only a third of over 50s who leave the sector continue in another job.
Home helps and healthcare assistants, as well as staff who work short part-time hours, are most likely to leave. The higher exit rate among part-time workers may be an indication that providing full-time positions is important for retaining staff. However, part-time work can also be an adaptation for workers with health problems. If this is the case, providing more full-time positions alone will not be a sufficient or suitable tool for reducing the exit rate among older workers.
Leaving the sector before retirement age is strongly associated with health problems and workloads. This does not only apply to those who retire due to ill health but also those who leave under the contractual early retirement scheme (AFP) as well as workers for whom job-specific retirement ages apply. However, some continue until well into their 60s because they are in good health, enjoy their work and feel that they are needed. This was also reflected in the responses from the older employees interviewed. They like their job. Many are also aware that there is a demand for their labour in the sector, and their conscience has made them push themselves in their daily work even when their health has not always been the best. They also believed, rightly or wrongly, that this way of thinking was the preserve of older employees.
If more nursing and care staff are to be retained as older employees, there needs to be a focus on health and workloads
With regard to specific measures and what can be done to prevent workers leaving the sector early, there is no doubt that increasing staffing levels is important. However, this is expensive, and the question is whether the problem can be solved in the short term when there is a general shortage of suitably qualified labour. It is nevertheless a paradox that increasing staffing levels is likely to lead to more people working longer, thus providing a labour supply that will be far greater than the increased number of new employees alone would indicate.
Increasing the number of staff can perhaps slow the pace of work to a degree and enable staff to take a few more short breaks and spend time with the residents/service users. There would also be more opportunities to adapt the work for people with health problems and for older employees with chronic musculoskeletal issues. The current practice seems to entail work tasks primarily being adapted for brief periods in connection with long-term sick leave.
The nature of the adaptations will, however, vary in line with the different needs and wishes of the individual workers. Some staff finds night shifts to be the most stressful, while others prefer night work. Some enjoy having many different tasks, while others want a slower pace with more opportunities to sit down and chat and spend time with residents and service users etc. Adaptation therefore often requires individually tailored solutions. This takes time because the needs of the employees and the potential of the workplace to accommodate any adaptations must be examined, and measures need to be devised. Managers currently appear to have little time to spend on this. The number of employees per manager is also far higher in the nursing and care sector than in other industries.
Some workers also want greater rotation between departments and tasks to ensure that they do not always have responsibility for the heaviest and most labour-intensive residents/service users. This indicates that the organisation is not always appropriate from a prevention perspective. Some of the sick leave could probably be reduced if workloads were more evenly distributed between departments and employees.
It is also apparent that not everyone finds it easy to use computers and new technological aids for reporting and documentation, and this can reduce workers’ self-efficacy. Training in this area could therefore be improved. A review of reporting routines may also be beneficial at some workplaces with an aim to reducing the reporting burden when possible. Either way, employees should be given sufficient time to perform these tasks in addition to their other work.
It is also worth noting that some of the physical strains that occur, despite various technical aids, are due to the fact that the aids are often provided too late for users to benefit, as reported by some of the home care services staff. It is unclear how widespread this problem is, but where it does occur, routines should probably be reviewed and practices changed.
And finally: why is it so important to retain older employees? The older employees themselves point out that they are experienced, they are familiar with the routines and know what to do, even when crises arise. They believe that their many years of experience makes them better at ‘reading’ the patients and can therefore more easily recognise when the service users and residents need closer follow-up and help, when they should be checked by a doctor, when they are in the final stages of life, and so on. This knowledge is important for doing a good job. They also believe that with age they have become more self-assured and more independent in the execution of their work tasks; qualities they consider to be an advantage for service users and their families as well as younger colleagues, as it also makes them feel more self-assured. They also point out that age in itself can be an advantage in the direct interaction and communication with older residents and service users as they have various common frames of reference. Their age also means they have a better understanding of what aging entails. Together with the specialist know-how they have acquired through education and continued learning, this means they are far more skilled in the job than when they were younger.