1. Spring 2002 Advanced Nursing Administration III

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With the increasing shortage of nurses, and no quick fix in sight, recruitment has become more difficult. One emerging approach, often driven by non-nurse administrators, is to differentiate pay based on nursing specialty and offer significant sign-on bonus programs. The rationale for this is that qualified high-demand nurses, such as those in critical care, are in short supply; to motivate them to leave their present position requires higher compensation. Another emerging scheme is variable shift bidding, an "ebay" approach where in-house nurses enter online wage bids to fill vacancies in existing schedules. This scheme views a nurse as a commodity, not as a professional.


As a group of graduate students in a combined nursing administration and business management program, we believe that differentiating compensation packages based on specialized practice areas and shift bidding undermines the profession as a whole. These desperate short-term strategies are myopic and will not produce the desired results. Furthermore, higher paying tertiary care centers will have a competitive financial edge in recruitment. This will result in a backlash effect if other venues across the care continuum are unable to accept patients for continuing community-based care due to the lack of adequate nursing staff.


Transformational leadership, long-term recruitment and retention strategies, and increasing the supply of nurses are the answers. Nursing leaders must constantly use their organizational power to implement and sustain a professional vision of patient care services. Nurse leaders who model the way and provide inspiration for a shared vision will be successful in creating work environments that retain staff. At the highest level, environments and systems need to be established where emotional intelligence inspires change. Chief Nurse Executives (CNEs) need to believe in transformational leadership and create visions for their organization, including direction and plans to achieve goals. Send a message that supports the staff already in the organization.


Nurse leaders who are strong role models for followers can be counted on to do the right thing. 1 Leaders need to unite the profession, not succumb to apparent quick fixes. Imagine what CNEs would do if they were offered the unrestricted choice of using $100,000 to recruit and retain staff. How many would choose to pay 10 new employees a bonus over rewarding and rebuilding the existing loyal, but tired, workforce? The American Nurses Association (ANA) surveyed 7300 nurses. 2 Half of them stated they had stress-related illnesses, and felt exhausted, discouraged, or saddened by what they could not provide their patients. Three quarters reported that the quality of care had decreased over the past 2 years.


The international Hospital Outcomes Research Consortium studied 711 hospitals in five countries. 3 The sample consisted of 43,329 nurses from the United States, Canada, England, Scotland, and Germany. In short, the U.S. nurses reported more than 40% of present working nurses were dissatisfied with their jobs and were burned out. One-third of the nurses, age 30 or younger, were planning to leave their jobs in the next year, and 15% of the current nursing workforce will be retired by 2008. Other countries' data differed slightly, but the trends are the same, suggesting we cannot import our way out of this shortage. We need more staff, but the nurse workforce needs respect as a profession, and appreciation for its contribution to healthcare and wellness programs. Solid leadership vision and retention programs aimed at addressing these issues would add institutional value and create recruitment solutions.


Tough times require leaders who can take the heat. In the name of patient safety and advocacy, nurse leaders need to unite and be ready to close beds if staffing allocations are at risk. Nurse leaders are charged with protecting their fellow professionals from working unsafe mandatory overtime and with unreasonable patient ratios. There is a reason why 54% of working nurses would not recommend their own profession to their children or friends. 4


We all witnessed the power of police and firefighters' unity during and after September 11, 2001. Even after those disasters, the New York police and firefighter applications to replace the fallen heroes created a long waiting list. What we need to do within our daily collegial practice is to model their relational power. If we can learn anything from them, it is that a respected image of our profession would create professional unity and power. Let's address the horizontal violence nurses have inflicted toward themselves. Eventually, recruitment and retention issues could take up less of our energy.


The Nursing Employment and Education Development Act (Senate Bill 721) is under consideration by the U.S. Congress. This bill will amend the Public Service Act to establish a nurse corps and provide a multifaceted approach to nursing retention and recruitment. Interventions would be implemented to support nursing education and a competitive, safe work environment. Funding to support more student nurses is an excellent approach to addressing the near term problem. We must create environments where nurses will want to stay and practice. Earlier this year, Johnson & Johnson launched a multimillion dollar advertising campaign designed to address the nursing shortage and the image of nursing. This represents an extremely valuable link between nursing and corporate America. Nursing leadership must promote partnerships with industry. Now is the time to develop support from other corporate institutions.


Leadership and retention strategies are contextual. What works in one area of the country may not transfer to another. However, some themes are clear. More nurses are needed. Remedies to improve the work environment must be addressed. Promoting education through clinical ladders, certification rewards, and increased compensation based on earned academic degrees will create an environment for life-long learning, a characteristic of professional practice. Education elevates an individual's knowledge base, and increases self-esteem and confidence. A nurse who is respected and valued by the organization will be less likely to resign. These recommendations will serve the individual nurse and the organization, and ultimately help to elevate the profession.


Differentiating pay and sign-on bonuses are logical, quick solutions to a severe workforce problem, but these directives will erode our professional nursing practice. A combination of strategies focusing on professional image, unity, and leadership will result in improved recruitment and retention rates. Four national nursing leadership organizations-the American Association of Colleges of Nursing (AACN), the American Nurses Association (ANA), the American Organization of Nurse Executives (AONE), and the National League for Nursing (NLN)-assert that the "profession must engage in ongoing long-term workforce planning regardless of the perceived or real pressures related to the short-term demand for nursing services."5




1. Northouse P. Leadership Theory and Practice. 2nd ed. Thousand Oaks, CA: Sage; 2001. [Context Link]


2. Cornerstone Communications Group. Analysis of American Nurses Association Staffing Survey. Washington DC: American Nurses Association; 2001. [Context Link]


3. Aiken L. Nurses' reports on hospital care in five countries. Health Affairs. 2001; 20( 3):1-11. [Context Link]


4. Hopkins M. Critical condition. Nurse Week. 2001; 2( 3):15-18. [Context Link]


5. American Organization of Nurse Executives. Talking Points on the Joint Commission White Paper on Nurse Staffing and the Quality of Care in Hospitals. Available at: Accessed January 31, 2001. [Context Link]