One of my rural hospital contacts recently identified “recruitment of qualified nursing staff” as a major issue in his/her hospital.  You may share this concern —a study from 2008 by Deana Molinari and Maria Monserud states CAHs identify “filling nurse vacancies as their number one concern” (  The study went on to identify attributes to CAH nurse recruitment.  If you are running a CAH, this study is worth reading.

The major issue was “recruitment of qualified nursing staff.”  I think the key word is “qualified.”  To me this entails more than licensed.  In Lean Six Sigma, all good projects start with good data and facts.  The study referenced above identified a variety of facts we can use to confirm qualifications and hiring limitations.

Fact #1:  Rural hospitals need to hire ‘generalist’ nurses able to cover multiple nursing disciplines

Fact #2:  Rural hospitals generally have fewer dollars available for compensation and therefore often pursue new graduates (who often have student loans to repay)

Fact #3:  Someone with rural roots is more likely to enjoy working in a rural setting

Fact #4:  Nursing students exposed to rural training/care during school have greater incidence of rural practice; some schools of nursing eagerly embrace rural instruction.

Fact #5:  Rural communities have difficulty satisfying cultural, family, or other needs of new graduate nurses

Fact #6: Not from this study, but CAHs are often the largest employer in their community

I like to link some of the facts together to get a feel for how they fill out the entire picture.

– Fact #1 and #2 – Broader range of skills/knowledge, but potentially less pay.

– Fact #1 and #4 – Broader range of skills/knowledge and some schools cater to those requirements.

– Fact #3 and #5 – Rural children tend to enjoy working in rural settings as adults more so than urban counterparts do.

– Fact #5 and #6 – what can communities do to become better at satisfying their largest employers’ recruitment needs?

– Fact #2 is Narrow Framing.  See my blog article “Corporate Decisions – Bad for Business!”  Narrow Framing is limiting the options willing to consider

Did any of the combinations spark an idea of where you can improve?  Did you get ideas on how can you take advantage of your positives while minimizing your negatives?  Did you get ideas for which school of nursing to recruit from, or interview questions to ask?  Now, you need to benchmark why your nursing staff came to you, and why they do not stay.


For more data, survey every nurse employed in your facility over the last couple of years.  For nurses dismissed for cause, your DON/SNE should review the file to determine relevancy.  Keep the survey simple; you are looking for general headings and topics.  You should be able to keep this survey to fewer than 30 questions with comment opportunities.  Understand what attributes contributed to why every nurse began and left your employment.  Please note; this is not a staff satisfaction survey!  For information concerning attributes in rural nurse recruitment, see “Development of the Nursing Community Apgar Questionnaire (NCAQ): a rural nurse recruitment and retention tool” at .

Attributes that attracted your current nurses to you are what works for you, and you want to build on it.  You may not want to start with all 50 attributes identified in the NCAQ study above, but you will want to get a solid idea from your employees…you might really be shocked!

For those leaving/left, you want to know if their move was motivated by:

– Finances

– Professional development

– Personal circumstances

If not one of these three things, then, perhaps something more in your control chased them away.  If you control it, you can fix it.  Read their comments and find the common issues for themes.  Document and graph your findings.  You just established critical factors for recruitment at your facility.  Critical factors are the pieces of a process that hold the secrets of success at your specific location at a specific time.

At this juncture, you have some facts and data to work with.  Start with the two or three critical factors most often listed as motivation to leave.  Assign teams (recruit community leaders to participate on some teams – remember Facts #5 and 6) to work through Lean Six Sigma tools.  Note that improvement here should not drastically change or discontinue the attributes to begin employment.

How can Lean Six Sigma address a huge issue like nurse recruitment:  One-step at a time, one facility at a time!  Projects of this complexity take considerable time, focus, and energy.  A reasonable person who runs regularly does not wake up one day and decide to run a marathon tomorrow.  A reasonable person practices on shorter distances and builds endurance before attempting a marathon.  A reasonable person may even hire a coach to achieve better results faster.  Like the reasonable runner, you may want to work on some shorter projects and build your skills before you try running this marathon.  If you feel you have to tackle a large, complex project immediately, consider hiring a coach.

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Or reach out directly to Jamie Martin, SigmaMed CEO and Black Belt.