Recruiting the 21st Century Nurse

Getting to the Heart of the Matter

by Susan McCabe, EdD, RN, CS

The signs seem to be everywhere. Pages of want ads. Sign-on bonuses. Recruitment fairs everywhere. All heralding the return of yet another nursing shortage. Nursing shortages are not new, and the last few decades of nursing have been characterized by an almost perennial cycle of nursing shortages. Yet an increasing chorus of voices is calling attention to this shortage as different, as more critical, more worrisome than past shortages (Buerhaus, 2000a; Buerhaus & McCue, 2000; Nevidjon & Erickson, 2001; Peterson, 2001). Some see the current nursing shortage as an indication of a looming crisis threatening the very future of the profession. Lately, it is beginning to feel in many ways as if the sky may be falling.  

The Nature of the Shortage: Facts and Fiction

            Amid the background of worry and fear, a picture of the present nature of our profession is emerging. It is a picture most of  us feel on a visceral level every working day. Many sources of data exist measuring and documenting the current nursing shortage. Table 1 identifies Internet sites useful in quantifying the shortage. Even a brief snapshot of the facts, as shown in Table 2, is compelling. Nurses, when asked, report the quality of nursing care is declining, that they would not feel comfortable having a family member cared for where they work (Health Resources and Services Administration [HRSA], 2000). We have acute shortages of RNs in certain geographic areas as identified in Table 3.

            We have acute shortages of nurses with certain specific, technical skills (Buerhaus, 2000b; Purnell, Horner, Gonzalez & Westman, 2001; Stapleton, 2001). The average national salary for nurses, when factored for inflation, has declined annually since 1994 (Buerhaus, 1998; Buerhaus, 2000a). Working RNs are leaving the profession well before retirement age. In 2000, 494,000 working-age RNs failed to renew their nursing licenses, compared with 443,000 in 1998 and 387,000 in 1992 (HRSA, 2000; Fagin, 2001; Stapleton, 2001). On the surface, the picture that emerges does indeed seem bleak.  

Factors Fueling the Nursing Shortage

            The underlying causes of our current nursing shortage are complex. Many of the factors fueling this shortage, such as enhanced career choices for females, poor working conditions, and cost containment strategies that have eliminated positions and capped salaries, have been at the core of past shortages (Nevidjon & Erikson, 2001). The current shortage, however, is considered unique and alarming because of new, complex, and convergent factors. This shortage is occurring at the same time as a general workforce shortage (Buerhaus, 2000a).  While nurses are in short supply, so are secretaries, maintenance workers, lab techs, pharmacists, and all sorts of service personnel. This is further exacerbated by a global workforce shortage, limiting our ability to use a traditional strategy to past shortage, such as importing foreign nurses from overseas.

            Perhaps the single most critical factor raising the alarm and separating this shortage from others we have faced is the aging of America’s nursing workforce. We will lose more nurses to retirement in the next decade than we will have entering our profession. Only 10 percent of us are under age 30. Most of us, 65 percent of RNs, are age 30 to 45, and 20 percent are age 50 to 64 (Fagin, 2001; Jacobs, 2001; Moses, 1997). Not only do we face a current shortage, we face an ongoing wave of losses, through retirement, of our experience base. With the retirement of these nurses will go a depth of knowledge, experience, and talent that will ripple through the profession. Even as our experience base is eroding, nursing school enrollments have decreased nationally each of the last four years (HRSA, 2001; Stapleton, 2001).   

What is the Good News?

            While pieces of the picture look bleak, it is important to examine the whole picture and realize that there is good news amid the bleak facts that represent the nursing shortage. We represent the largest group of health care professionals in this country (Nevidjon & Erikson, 2001). We are valued within our society and trusted by our consumers. For example, a recent poll conducted by the Gallup Center to rank the public’s perception of the honesty and integrity of members of different professions found that nurses were ranked second, immediately behind firefighters (Moore, 2001). Physicians, in contrast, were rated sixth in the same poll.

            Past shortages have led to responses such as the increased use of unlicensed personnel. The good news is that these models have, for the most part, proven to be ineffective (Buerhaus, 2000a; Buerhaus, 2000b; Nevidjon & Erikson, 2001). Interestingly, just as with nurses, shortages of unlicensed personnel have contributed substantially to the failure of these models. Other more significant issues, such as high patient acuity levels, concerns over medical errors, and concern over legal issues, have also worked together to defeat these models of care. And failure of these models has highlighted the value of nursing care.

            Nursing in the past few years has gained more roles, garnered more responsibility and opportunities, than we have lost (Peterson, 2001; Prescott, 2000; Ventura, 1999; Williams, 2000). Advanced practice nurses have begun to document the economic viability of their role, and insurance reimbursement for those services has improved. Interest in health care outcomes has shifted focus back to relational components of care that have historically been a strength of nursing, providing us with a ripe environment to prove our worth within the context of the totality of health care. We are in demand, and are likely to stay so for the next few decades. Factors such as increasing population growth, increasing longevity for our consumers, and a focus on chronic rather than acute care, are all fueling the demand for professional nursing. America values nurses, trusts nurses, needs nurses. 

Addressing the Shortage: Recruiting Nurses for the 21st Century

            It is easy in the face of the data on the nursing shortage to become like Chicken Little and feel as if the sky is falling. But buried within our current crisis is possibility. Recruiting new nurses will be a challenge, but one that may allow us to grow, expand, and extend the profession in ways we otherwise might not have done. The word “recruit,” “crescere” in Latin, means to grow (Barnhart, 1995). The urgent and pressing  question for all of us is, “How will we grow?”

             Our professional organizations have been and are continuing to strategize solutions. Many significant expert consensus reports, such as ones from ANA, NLN, and other groups have been issued to provide guidance in addressing the shortage. As an example, Table 4 provides highlights of one such prominent report, the Milbank Memorial Fund Report. This and other similar reports, while providing valuable information, continue traditional approaches to our cyclic shortages using strategies directed toward education, work environment alteration, regulatory, and legislative changes. While successful in the past, these strategies may be less effective and less appropriate in reversing the current shortage. Perhaps it is time for more creative, inclusive solutions that speak to the heart of the shortage. 

            New strategies for recruiting the 21st century nurse require us to be clear about whom we are recruiting and the nature of the profession for which we are recruiting. Second career recruits who have only a short time to contribute to nursing will not solve the nursing shortage fueled by the aging ranks of RNs. Shifting practicing nurses from one place to another will not solve it. Recruitment strategies should focus on recruiting young students into nursing and retaining nurses in active practice within the profession. We are recruiting students who will not practice nursing for at least two to four years. What will health care be like then? What will nursing be like? Unless we can be fairly clear and accurate in our prediction, we may fail to recruit the type of person who will be interested, motivated, and successful in a nursing career.

            As we age, we need to recruit individuals who will grow and contribute and build nursing into the future. But recruiting young people requires altering some of our most basic professional processes. Our young recruits are from “Generation X,” individuals with distinct and specific characteristics that do not always mesh well with our traditional academic and administration procedures. Ripples of this are already noticeable. Spend a few moments with a nurse educator and you will hear concerns over today’s less prepared, lazy, and unmotivated student. The students we need to recruit are different and have different needs and learning styles. The individuals we need to recruit value personal time over work time, do not choose school or work over leisure, but rather demand both. They seek greater autonomy, less bureaucracy, inclusive decision-making. They desire freelance or temporary employment over long term, and are loyal to the work, not the employer (Kupperschmidt, 2000; Smith, 2000). Generation X’ers are the future of nursing. They are a generation raised on technology, comfortable with change, flexible in problem solving, accepting of diversity, and seek autonomous functioning (Santos & Cox, 2002; Smith, 2000). That seems a strong base on which to build the future of nursing if we can successfully alter our educational and administrative approaches based on older personnel characteristics, reduce our negative impressions, and build on positive characteristics. While envisioning the future practice world our nursing recruits will face matters, and while developing pedagogical strategies to match our students’ characteristics matters, there are even more compelling recruitment strategies we all must be part of  if nursing is to continue as a visible and viable profession. 

Getting to the Heart of the Matter 

            So at its heart, what are the recruitment strategies we need most to consider? There seem to be three strategies, frequently overlooked, that are at the heart of the matter. Strategies that are more illusive, less concrete than those identified in Table 4, that get to the heart of us, the heart of nursing. Strategies that require us to examine our individual contribution and our collective participation in solving the nursing shortage. 

            The first strategy concerns using our size. We are the largest health care profession. That is not an insignificant fact. Our numbers, while declining, remain large. Our societal value is high. Yet we continue to fail to speak with one cogent voice. We fail to marshal our numbers into a power base of meaningful political clout. Until this changes, we experience frustration and anger at our inability to advance professional agendas that make our profession more attractive to autonomous, independent students who have abundant career opportunities. Because we are needed, because we are valued, because we are the largest, the opportunity exists to recruit from a position of strength, and to collectively wield our power in meaningful ways to alter our profession to be more competitive and attractive. Nurses, every one of us, need to critically examine our responsibility for and contribution to building professional cohesion if recruitment of future nurses is to be successful. 

            The second strategy at the heart of the matter concerns altering our roles and the empirical measures of quality. We are empowered during this shortage by virtue of being a rare commodity. This offers us the possibility of  altering roles that, while traditional to nursing, may no longer serve our interest. The image of nursing remains one of hard work, long hours, reams of paper work, low pay, and subservient roles. This image makes it difficult to attract to our ranks the best and the brightest. This image is fueled by current realities that nurses have multiple non-direct care role functions such as paperwork, management of supplies and inventory, and so on that may not serve us well in the 21st century.

            The shortage affords us an opportunity to critically examine current roles and to use the power of our rarity to implement new roles. We all need to be part of identifying new roles and being willing to relinquish older, outdated roles that continue negative images of nursing.  We need an image that will entice and excite recruits. As an element of new roles, we all must take seriously our responsibility to empirically measure and establish the quality of our care through more rigorous attention to outcomes.

            The third strategy at the heart of the matter concerns caring. We are, at our heart, a caring profession. Yet we need to critically examine how we care for the students we do recruit. How we care for our peers and colleagues. As the shortage stretches us thinner and thinner, as our students are perceived as lazy and unmotivated, the tendency is to become angered, to voice our frustration, to take that frustration out on one another. It makes us criticize our peers, our students, the very profession, and to bemoan the day we chose nursing as a career. While an understandable response, it is one with unintended consequences  Students in the clinical setting see role models of frustrated, angry, burned out nurses who often tell students to drop out of nursing and find another career. Students, criticized for being lazy, often feel equally unsupported and uncared for in educational settings.

            The bemoaning nurse, the unsupported student, these are the public faces of our profession, the living recruitment poster for nursing. Would you be easily recruited after contact with these poster children?  As practicing nurses talk to friends and neighbors, as nurses grab students in the clinical setting and ask why they possibly want to be a nurse, we worsen the problem of recruitment. Recruitment strategies must be linked with caring to talk positively about our profession, caring about each other and supporting our ranks. Recruitment strategies must be linked with not only recruiting individuals to enter nursing in the first place, but to careful caring and mentoring them into the culture of nursing.  To recruit successfully, we must care successfully.  

            We are a caring profession. A critically important profession faced with trying and turbulent times. But it is in the heart of this challenge that we can find possibility and growth. Recruitment is a responsibility of every nurse in every setting. Until we are all part of the recruitment, we are part of the problem.  We can do better than that. We must do better than that for the future of nursing. What will you do to recruit a nurse today?    

Susan McCabe, EdD, RN, CS, is an Associate Professor in the Professional Roles Mental Health Nursing Department at East Tennessee State University in Johnson City, Tenn. She received the 2001 President’s Award from the International Society of Psychiatric Mental Health Nurses and the 2000 Teacher of the Year Award from ETSU.  

This article supported, in part,  by an educational grant from Eli Lilly & Company.  

Table 1                                                                                                                  Available Internet Resource Sites for Information on the Current Nursing Shortage

Table 2                                                                                                                                Health care, working conditions, and the nursing shortage:  What are the facts?

*Developed from data from: (Fagin, 2001; Jacobs, 2001a; Stapleton, 2001; Peterson, 2001; Purnell, et.al., 2001;  Health Resources and Services Administration, 2000).

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