If you are having trouble hiring nursing staff, don't be surprised. We are facing a serious nursing shortage that unfortunately is destined to grow much worse before it gets better. In this article, I'll explore some of the reasons why it's so difficult to find qualified, experienced nurses and show you how to hire and retain nurses for your facility.

Why the shortage? The nursing shortage is a product of simple supply and demand. Remember, close to 90 percent of the nurses in the U.S. are over 30, and the average practicing nurse is in his or her mid-40s (at least many of us can say we are "above average!"). The baby-boomer nurses will begin to reach retirement age (65) around 2010, leading the RN retirement wave, and half of our nurse workforce will be eligible to retire over the next 23 years. Couple those data with the fact that nursing school enrollments have been dropping, and it's easy to see why the supply of nurses is dwindling.

Meanwhile, demand is increasing. The U.S. population continues to grow at about one percent per year, which means that the demand for health care, and surgical interventions, will also continue to grow. When managed care first penetrated the health care market, many experts predicted that gatekeeper strategies would keep patients out of outpatient surgery centers, but the number of patients going to surgery centers, and the number of centers themselves, has in fact increased. Nurses now have a variety of options open to them, and they have the leverage to get what they want.

So how do we cope? We need to figure out what our nurses want and find creative ways to make them feel rewarded, needed, and satisfied in their positions. We also need to convince novice nurses that ambulatory surgery is a great niche, where they can really make a difference to their patients and maintain control over their personal lives. With those goals in mind, here are my strategies for finding and keeping your nurses.

Strategy #1: Give Your Nurses Reasons to Stay The most effective strategy for beating the nursing shortage is keeping your current nurses happy. That means giving them as many reasons as possible to stay and as few reasons as possible to leave.

According to a small study in the May issue of Nursing Management, the top five reasons nurses stay in their positions are:

-- co-worker communication and support;

-- job satisfaction;

-- schedule and shift satisfaction;

-- opportunities for diverse clinical experiences and challenges; and

-- salary.

The reasons nurses leave include:

-- low salary;

-- poor benefits;

-- inadequate recognition, respect, or input into practice;

-- schedule and shift dissatisfaction; and

-- other career opportunities.

Two nursing societies, the American Organization of Nurse Executives and the American Society for Healthcare Human Resources Administration, recommend five strategies for keeping experienced nurses:

1. Know the competition's initiatives and create new programs to match or exceed theirs. To find the best examples of what others are doing to retain nurses, you may want to contact some of the institutions recognized by the Magnet Nursing Services Recognition Program, which is administered by the American Nurses Credentialing Center (ANCC). The ANCC established this program to recognize health care facilities that do an outstanding job of promoting and nurturing nurses and serve as "magnets" to attract and retain them. So far, the Magnet Program has recognized 15 magnet hospitals and one long-term care facility, but perhaps your ambulatory care facility can be the first to receive this honor. The staff nurses within the magnet facilities may be available to share their ideas and help you improve your nursing program. You can find the facility names, telephone numbers and contact information on the American Nurses Association web site at www.nursingworld.org/ancc/magnet.htm (you can also call (202) 651-7264 for more information).

2. Assess the culture in your institution - does it seriously value nursing's contribution? I often hear nurses lament that no one asks them for their ideas, and they get no feedback if they offer suggestions. I am heartened, however, when I see nurses attain positions where they can influence and improve their institutions. Recently, one of my students, an RN First Assistant intern, was asked to be a representative on her local community advisory board. In this position, she will join forces with the CEO and trustees of her small community hospital to perform needs assessments and develop new programs for the community. Take every opportunity you can to expose your nurses to these opportunities - the practical perspective that they bring to the group, and the confidence and experience that they gain from these positions, are invaluable.

3. Know the demographics and career patterns of your nursing staff and design programs to enhance them. Sit down with your nurses one-on-one and find out what is important to them; you may find, for example, that a nurse who has children values a flexible schedule more than a pay raise, while another may need financial help for furthering her education. Make sure that your workplace is family-friendly and offers a balanced life.

4. Update and create clinical management systems that reflect the work of nursing and accurately measure patient demand for care. A good place to start is the Perioperative Nursing Data Set, published by the Association of Perioperative Registered Nurses. This document contains various nursing diagnoses, nursing interventions and patient outcomes to help nurses quantify, code and document the care they provide in the perioperative setting. By basing your nursing protocols on this document, you'll be able to track what kind of care your nurses are providing and compare your center with other institutions. Go to www.aorn.org/research/ pnds.htm or call (800) 755-2676 for more information.

5. Make professional and career development opportunities available. Send your nurses to conferences and offer them relevant and meaningful in-service education (and not the kind that is just scheduled to meet a schedule). Consider offering incentives for certification (and even monetary grants for certification preparation or exam fees) and a mentoring program for those who wish to publish, do research, or make a presentation at a professional meeting. Have one of your nurses develop a continuing education resource center to collect information on seminars, classes, and scholarships that may be interesting to your staff.

Use the Internet to bring educational opportunities to your nurses. The Duquesne University School of Nursing, for example, offers RN/BSN and RN/BSN/MSN degrees that allow nurses to complete undergraduate courses online (go to www.duq.edu/nursing/onlinebsn.html for more information).

Don't stop at these suggestions; survey your nurses on what constitutes meaningful professional growth and a quality working environment, and find ways to provide both. Just a few additional thoughts: Retention efforts must transcend "just money." Keep in mind that at some point, one of your competitors will likely up the ante and "show them the money." However, if your workplace provides high job satisfaction, if you encourage and value your nurses' suggestions and implement them whenever possible, if your culture is warm and if you encourage employees to grow, you will lose very few nurses.

Strategy #2: Recruit the best When you do experience employee turnover, don't fall into the trap of hiring a "warm body" to fill the position. It's critical to hire the most talented, most qualified person possible. Remember, competition for surgical cases is intense in most areas, and patients and surgeons have definite ideas about what they want to see in nursing staffs. If they don't get it at your facility, they won't return.

When interviewing candidates, keep in mind the results of the following study of what patients want from nurses:

-- professional knowledge;

-- rapport, or a "human connection" with the patient;

-- partnership and shared decision-making between the nurse and the patient;

-- individualized treatment;

-- caring and nurturing attention;

-- promptness in meeting the patient's needs;

-- continuity; (having the same nurse as often as possible); and

-- coordinated care (making sure nurses communicate with other providers).

The American Nurses Association recommends looking for these skill sets:

-- knowledge of resources available to the patient;

-- the ability to connect with, calm, and soothe patients;

-- ability to assess the patient's family and social situation and involve the family in the patient's care;

--ability to assess the patient's risk for complications;

-- commitment to patient advocacy (making sure the patient¹s needs always come first);

-- accurate problem solving and clinical decision making;

--ability to safely delegate to others; team building skills; and

--ability to collaborate with other health care providers.

To find nurses with these capabilities, it may be necessary to "think outside the box." Here are a few suggestions:

--Do not insist on one or two years of med-surg experience. Instead, focus on recruiting the best and brightest person you can find, regardless of his or her experience level. Even a new graduate who has completed a perioperative nursing course is appropriate. Design an orientation program or an internship that supports novice nurses. You will need to invest in someone to oversee the program, and you will need to teach your staff to help out with the educational process. Don't expect the nurse to understand what to do right away. You need to be patient and foster skill acquisition and competency development over time.

--Invite nursing students for a clinical rotation.

--Offer growth opportunities by developing a clinical career ladder.

Strategy #3: Design an RN First Assistant Program One way to develop a clinical career ladder is to offer all your new hires the opportunity to grow into RN First Assistants. Now, you may be wondering who will take care of the patients if all the OR nurses go on to become RNFAs, and it's a reasonable question. But, remember, our goal is to recruit bright, talented nurses into the OR, and there's no better way to do that than to offer a career ladder. Also, remember that to accumulate the basic perioperative competence required to pass the CNOR exam takes a few years. Only then does the nurse have the opportunity to apply for an educational grant to enter a formal RNFA program. During that time, your bright, ambitious nurse will be doing a great job for you in perioperative nursing.

When setting up your RNFA program, I recommend instituting standards that the RNFA candidate must meet in order to be considered for promotion. These might include AORN membership, holding seats on institutional committees, and presenting in-service programs to the rest of the staff. All these activities contribute to professional growth, increase job satisfaction, recognition and respect, and engender employee commitment.

One final note. Offering an RNFA pathway is an excellent way to attract male nurses to your facility. Men are often more interested than women in gaining entry into the OR; they characteristically enjoy positions where there is some autonomy and true collaboration. It is very common for my college to have male RNs in both our entry-level perioperative nursing courses and in our RNFA courses.

Over the next decade, your institution's ability to find and keep excellent nursing staff may literally make the difference between success and failure. Implement the above strategies, and you'll be the early bird that harvests the best worm, leaving the "leftovers" for other facilities.