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CHALLENGES FACING THE HEALTHCARE INDUSTRY WORKFORCE: A LITERATURE REVIEW
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ABSTRACT
A challenge facing the healthcare industry today and in the coming years is increasing workforce shortages. There is a growing demand and a great shortage of healthcare workforce across healthcare organizations, and it is predicted to continually increase in the near future. Three key areas pose challenges to the healthcare workforce that has the job of caring for the growing aging population. These areas are workforce shortage, training/development, and retention. The purpose of this paper is to examine the serious challenges facing the healthcare industry workforce that is caring for America’s aging population. The literature review identified several factors influencing the quality of care provided, including an insufficient workforce, lack of training and continued development, and inability to retain quality employees. These factors and others directly affect the quality of healthcare provided to seniors. Addressing and identifying these challenges are critical for both healthcare industry and its workforce for developing and implementing solutions. Healthcare has been changing and will continue to change; however, the quality of care should never be sacrificed for seniors due to any deficiencies on the part of leadership in meeting these challenges. Quality of care is uncompromising, and that is why it is necessary to begin immediately to implement viable solutions to address these issues at once; otherwise, care will continue to diminish over time.Therefore, the paper provides an explanation and recommendations of possible solutions to help alleviate these challenges that continue to plague this workforce and assist the healthcare industry in providing better quality of care to seniors.

Keywords: healthcare, aging population, caregivers, workforce shortage, care

CHALLENGES FACING THE HEALTHCARE WORKFORCE AND THE AGING POPULATION
INTRODUCTION

Today’s world is moving faster than ever before with new technology, an increased population, and more immediate access to information than was available even twenty years ago. However, with these changes come new challenges and the remains of some of the older challenges facing the healthcare workforce, specifically the sector that provides care and services to the aging population. A challenge facing the healthcare industry today and in the coming years is increasing workforce shortages. There is a growing demand and a great shortage of healthcare workforce across healthcare organizations, and it is predicted to continually increase in the near future (King, 2009). Based on the U.S. Department of Labor (2012-2013), industries and occupations related to healthcare are predicted to be among the fastest job growth between 2010 and 2020. According to Lofgren (1999) and Hartsfield (2001), the collective issues of shortage of healthcare workforce, an aging population, reduced budgets, and growing demand have resulted in a sever workforce shortage at the nation’s healthcare facilities. Hofmann (2012) believes that “The health care systems in many high income countries will face substantial challenges in the near future: An increasing population of old people, a boost in the need for health care services, and fewer people to provide and finance the services” (p. 2). Therefore, new approaches and strategies are necessary to manage and solve these new substantial changes and tackle these challenges.

PURPOSE OF THE STUDY

The purpose of this paper is to examine the serious challenges facing the healthcare industry workforce that is caring for America’s aging population. The literature review identified several factors that influence the quality of care provided, including an insufficient workforce, reduced budgets, lack of training and continued development, and inability to retain quality employees. These factors and others directly affect the quality of healthcare provided to seniors. Addressing and identifying these challenges are critical for both healthcare industry and its workforce for developing and implementing solutions, as well as a better understanding of the challenges. Therefore, the paper provides an explanation and recommendations of possible solutions to help alleviate these challenges that continue to plague this workforce and assist the healthcare industry in providing better quality of care to seniors.
LITERATURE REVIEW

Workforce Shortage
The American Hospital Association’s Board of Trustees has acknowledged the immediate and long-term shortage of healthcare workforce (Hartsfield, 2001). Sloane (2003) stated that “Demographic changes, new technologies, burnout, poor working conditions and compensation, the lack of a career ladder and a failure to prepare a new generation all have contributed to the worker shortage.” (p. 20). The biggest challenge facing today’s workforce is limited supply. As baby boomers age and retire from the healthcare field, there is not enough supply to fill their roles. So, as demand for care increases as they age, the workforce to care for them may be inadequate. This dramatic changes in the demographic structure of the U.S. population will have a major affect in the future of the workforce. An estimated 20 percent of the population will be over the age of 65 by 2030 (Zywiak, 2010). These demographic changes of the healthcare workforce can have profound short and long-term affect on access to healthcare (The demographic challenges facing Colorado’s health care workforce, 2010). Williams (1992) stated that “The character of the American workforce is changing dramatically, even as demands on individual employees at every level are becoming far more complex” (p. 15). Delp, Wallace, Geiger-Brown, and Muntaner (2010) have mentioned that “Aging of the baby boom generation and high rates of women’s employment portend an increased demand for, but diminished supply of, traditional caregivers, making recruitment and retention of workers a critical long-term care issue” (p. 922) Understanding these changes help to determine the size of the workforce and the demand for goods and services (Henderson, 2012).

Currently, there are fewer healthcare professionals than needed but the gap between the supply and demand is expected to grow rapidly and substantially when the baby boomers start to retire. Older population will be requiring that care and assistance they once provided, as well as the many other baby boomers who will be in need of the same. Supply of these highly qualified professionals will be low and the demand will be high, higher than today or in the past due to the substantial difference in baby boomers compared to other waves of generations of the past (Henderson, 2012). Czaja and Sharit (2009) stated that “The aging of the population presents vast societal challenges to ensuring that our infrastructures can support the needs of older people enabling them to live healthy, independent, and productive lives” (p. 34)
The U.S economy is projected to add more than 20 million new jobs by 2020 and healthcare is expected to be among the fastest growth occupations (Henderson, 2012). According to Zywiak (2010), the increasing demand for care is driven by aging population which is growing and requiring more health care and services. The rate of baby boomers who are turning to age 50 is 11,000 per day, while the generation following them is much smaller, and less number joining the workforce compared to the past years (Lofgren, 1999). Hilborne (2008) has mentioned that “The Bureau of Labor Statistics projects that by 2014, the US would need 81,000 additional medical technologists and technicians to replace retiring staff and another 68,000 to fill newly created positions.” (p. 23). By 2020, more than 800,000 staff nurse is estimated to be vacant (Kleinman, 2004). Therefore, it is critical to create work environments that attract, retain, and train workers in the healthcare field.
Training and Development

There is a critical need to provide training and support for the healthcare workforce in Continued Care and Long Term Care facilities in order to provide quality care services (MacDonald, Stodel,& Casimiro, 2006). King (2009) believes that “Some health care workers in hospitals and nursing homes may not be well educated, receive little training regarding patient care and needs, and become marginalized by the more professional specialized medical staff” (p. 55). The Training and Development of the healthcare workforce is at the forefront because once recruitment takes place, the training begins, as does continued development of each individual employee. Whether initial training prior to being hired or continued training after employment, both are extremely important to ensure the individual has grasped the fundamentals of the profession. It’s also critical to maintain these skills by providing training throughout their careers. This is vital to their development and to the quality of care they will provide. One of the primary challenges is ensuring this workforce has adequate training to care for those diseases plaguing this aging population, such as Dementia and Alzheimer’s.

In addition, the U.S. workforce is becoming increasingly diverse, which means that training has to be relevant to the needs, learning styles, and perspectives of adults of varied races, cultures, languages, and other characteristics (Salsberg, 2003; Winchester, 2003). Such a confluence of situations creates a great demand for training to improve the work skills and effectiveness of existing workers while training the large numbers of new staff members who are needed. Nevertheless, it takes several years to develop and implement new training programs and more years before a significant number of qualified individuals begin joining the industries. The challenge of preparing the right number of health professionals with the adequate skills for the future has become more difficult due to the constant changes in the organization and financing of the healthcare delivery system (King, 2009).
Retention

Public and private sector businesses are competing to recruit and retain nurses and the existing minimum staffing requirements that manage nursing homes have not been able to provide quality of care (Kash, Castle, Naufal, & Hawes, 2006; Kleinman, 2004). Quality care and its delivery can be compromised greatly with a high turnover rate among these healthcare professionals. This fact combined with a potential deficiency in experience can be detrimental to all involved, especially those seniors who are receiving their services. Generally speaking, many people, not just the elderly, prefer a level of consistency and routine; however, this is even more so with seniors. Continuity, consistency, and stability are all important to the wellbeing of a person, especially when it comes to the healthcare services provided to the elderly.

Sloane (2003) sees that retention is more important than recruitment and training of new workers. Employees leave their job for many different reasons such as job dissatisfaction, job stress, lack of autonomy, and inadequate salary and benefits (Kleinman, 2004). The high rate of turnover is costly to hospitals and patients for number of reasons such as it “affects the quality of patient care, increases patients waiting time for series, and reduces the number of services ..the hospital can offer” (Kleinman, 2004, p. 128).
Studies have determined some factors that linked with turnover rates. “These include staff benefits, in-house [certified nursing assistant] CNA training, and management continuity, and these are potentially important organizational factors that are useful in the development of retention strategies” (Kash et al., 2006, p. 611). In order to afford the opportunity to this workforce to be successful and fulfilled, leaders must understand that investing in them is non-negotiable. Consistency is just as important for the employees themselves as it is for those they care for. Quality and integrity matter to everyone; both should be the fabric in which healthcare leaders wrap their employees and consumers.
The best way to keep employees is to help them to see how much they are valued by the organization and to create a workplace that employees want to stay in (Sloane, 2003). Because the senior often cannot express that appreciation, the organization must make up for that gap. Involving the staff in creating their work and care-giving environment is also important. Being appreciated and having input that matters typically rank higher than salary as job satisfiers. The staff are often dealing with patients who have difficulty helping themselves physically or mentally and can sometimes be very difficult; the environment can feel depressing, especially when patients die, and that’s the unfortunate reality of the nursing home setting. With that said, there are opportunities to make this job more appealing, connecting with the calling of the individual to add dignity to an older person’s “golden” years; the flexibility to work with a more consistent patient population, as well as the opportunity to bring their special talents to make a difference to those for whom they care.
Recruitment
The senior market is a difficult market because the pay is often not as high as what hospitals can pay, and the work is often more difficult because of the more complex patient care needs. For example, the senior population often needs more assistance due to physical limitations as well as mental infirmities. Those working in the senior market do so largely because they have a calling to care for the elderly. So, in order to recruit, it is important to connect the organization’s mission and purpose in such a way that you attract those whose personal calling matches what you do. What you may not be able to make up in pay, make up for in amenities and flexibility to the workforce that often cannot be found in the acute hospital world. Also, focus on the opportunity to build relationships with patients over time that is a differentiating dynamic from the acute hospital environment.
Recruitment has been an ongoing struggle for healthcare industry; however, the fact is with many baby boomers nearing retirement and entering into a stage of their life where they will be the ones requiring care, the challenges facing this workforce are even greater. Rambur, Palumbo, Mclntosh, and Thomas (2008) advised:
Nursing is the largest group of health professionals, and shortages in this group have received substantial attention over the past several years. Moreover, recent studies have linked the shortage of nurses to serious patient safety issues, further underscoring the need for ongoing and accurate measurements of supply, demand, and skill mix. (p. 106)
It can be difficult to recruit highly qualified and experienced workers because there is a collection of undesirable attributes that one can find unappealing in this type of career. A study was conducted in 2003 with the objective of identifying factors that influence job satisfaction among home care workers in a consumer directed model. The study involved interviewing 1,614 home care workers in Los Angeles, Ca., Delp et al., (2010) discovered the following findings and conclusions:
Principle findings: Abuse from consumers, unpaid overtime hours, and caring for more than one consumer as well as work-health demands predict less satisfaction. Some physical and emotional demands of the dyadic care relationship are unexpectedly associated with greater job satisfaction. Social support and control, indicated by job security and union involvement, have a direct positive effect on job satisfaction. Conclusions: policies that enhance the relational component of care may improve workers’ ability to transform the demands of their jobs into dignified and satisfying labor. Adequate benefits and sufficient authorized hours of care can minimize the stress of unpaid overtime work, caring for multiple consumers, job insecurity, and the financial constraints to seeking health care. Results have implications for the structure of consumer-directed models of care and efforts to retain long-term care workers. (p. 922)
It is without question that if the healthcare workforce does not level out to meet the demand, care will continue to be in jeopardy. The solution to this problem begins with proper recruitment techniques and knowing the workforce one is attempting to bring on board.
Job Satisfaction
Once recruited and trained, employees require continued development. They need to feel appreciated and valued. They need to feel as though they are a part of a team, and working together to be successful can contribute to overall job satisfaction, which can lead to a higher rate of retention. In a career field such as healthcare, it can be physically, emotionally, and mentally exhausting. For most, knowing that they are a part of a group of people who care about them and want to work together to get the job done can make all the difference in the world, in addition to working for leaders who support them. Teamwork is believed to produce efficient and effective patient care, lower healthcare staff turnover rates, raise job satisfaction, improve communication among healthcare professionals, and enhance management of care services (MaCdonald et al., 2006). This type of environment and shared values amongst employees begins with their leadership. Leadership from the top clear down to first line supervisors must be on the same page, both are equally important in creating and sustaining an environment that is positive for their employees, who in turn create the best living conditions possible for those seniors they are caring for. It should be based on teamwork and always keeping in mind why they are all there in the first place: to provide the best quality care to the elderly. It begins with leadership, shared by first line supervisors, and carried out by everyone within the organization. If this is a core value that is instilled within the organization and is fully shared by the leadership then such a challenge can be met with great success.

Leadership
Once recruited, trained, and after a long-term investment is made in the development of these workers, the health care industry must then focus attention on retention of these professionals. Many factors will influence how this will be done, and there is still much research needed to determine the best methods to accomplish this in the future. It is clear that continued training and development are important throughout a healthcare professional’s career; however, a collection of other factors exist in retaining the most highly qualified in their positions.
Outdated leadership practices play a major role in the healthcare system, increasing the cost and poor quality outcomes (Weberg, 2012). Strong leadership within an organization is equally important and has a serious impact on retention. There are several studies that found clear association between leadership style and retention. According to Kleinman (2004), “As is evident from the preceding review of literature, effective leadership has been demonstrated to be an integral component of retention and should be an important part of any multidimensional recruitment and retention strategy.” This is even more crucial within these healthcare career fields because of the shortages; employers are aware of this and understand that in order to keep the best people employed with them, they must offer competitive compensation packages; otherwise, they risk losing their investment (Delp et al., 2010). Moreover, studies show that “leadership behaviors that include support and consideration of staff, high visibility, and willingness to share leadership responsibilities positively influence staff nurse retention” (Kleinman, 2004, P. 128)
CONCLUSION AND RECOMMENDATIONS

This literature review gave an overview of challenges of new and emerging changes facing the healthcare industry workforce. There were several ideas brought to the forefront on ways to bring improvement to those areas in need of attention. All three areas discussed are of high priority and are all interconnected to some extent. Workforce shortage, training/development, and retention each contribute significant value to the quality of the healthcare workforce. They also have a great overall impact on the quality of care seniors receive from this workforce. The primary goal of any leadership within this field is to provide the best and highest quality of care to its consumer, which in this case is seniors. This happens by ensuring the staffing shortages are filled with highly trained and genuinely compassionate individuals who understand the needs of the elderly.
Moreover, employers must look at their workforce as the most important and most valuable resource they have. It means leadership has the responsibility to foster teamwork and encourage camaraderie among their employees. It means providing quality training consistently to their employees so that they can provide the best quality care to the elderly. These types of initiatives should be genuine and practiced on a daily basis to ensure team cohesiveness and healthy work environment.
Leadership is crucial, and sometimes this call for a change in leadership because what once worked is either not working anymore or the current leadership cannot adapt to the times or the new changes in strategy (Rothwell & Sredl, 2000). Leadership must be willing to be committed to the investment both financially and professionally when hiring, maintaining, and retaining the best employees.
In addition, demographic changes impose new training requirements that need to be relevant to the needs, learning styles, cultures, and languages (King, 2006). Employers are looking at several factors affecting their training models and have a significant amount of responsibility to their employees, as well as their consumers. An investment requires time, patience, money, and continued development. An investment in recruitment, training/development, and a long-term commitment to retaining this investment is required to ensure long-term health; in this case, sustaining a highly trained, competent, and professionally healthy workforce. Some employers are looking to technology to help lessen the burden of training costs and find a more efficient way to accomplish necessary training to their staff. Employers have a desire to ensure their workers are receiving the training they need but with the disappearing budgets is becoming an ever-growing challenge to meet. However, with new technological advances, educational programs are becoming available and are being used by leadership.
One of its benefits for leadership is that it allows them to provide required training to their employees but at a fraction of the cost compared to more traditional ways of training. Macdonald et al. (2006, p. 375) goes on to say, “…online learning might be a suitable means for providing education to healthcare workers and professionals as it would allow them to learn anytime and any place they can access the technology.” There is not only a cost benefit to leadership but a time consideration to employees. There is still much research to be done in the future as to online training compared to more traditional styles of learning; however, in the meantime, many employers utilize this type of technology to their advantage by providing much needed training to their employees at a fraction of the cost.
Finally, potential resolutions and future ways of approaching these challenges more effectively were discussed. Healthcare has been changing and will continue to change; however, the quality of care should never be sacrificed for seniors due to any deficiencies on the part of leadership in meeting these challenges. Quality of care is uncompromising, and that is why it is necessary to begin immediately to implement viable solutions to address these issues at once; otherwise, care will continue to diminish over time. Therefore these discussed factors should be taken into account when developing and implementing solutions to close the gap between the supply and demand on healthcare services.