I was very impressed and touched by the "Tough Times In Healthcare" Letter to the Editor in the March 2002 issue of JONA (Volume 32, Number 3, page 122). There is, however, something I would like to add to that author's focus.

To borrow an idea from continuous quality improvement, we need to have a long-term nursing shortage solution that includes solving the problem "upstream." Attracting new people into the profession is, while clearly necessary and appropriate, a short-term and "downstream" response.

It seems imperative, especially for acute care hospitals, to solve the problems that helped to create the shortage in the first place, namely, understaffing (prior to a shortage) and lack of support systems. Nurses, working in an environment in which they had to care for too many patients, lacked available supplies, accessed medications with outmoded pharmacy systems-those nurses are the ones who have told others (children, relatives, friends, and acquaintances) not to seek nursing as a profession. In essence, acute care hospitals (financial burdens very well understood) have, in many instances, reaped what they have sowed.

The shortage will not be solved if the only approach is recruitment. The problems "upstream" of inadequate budgeted care hours and lack of support systems need to be addressed simultaneously or the "recruits" will not be "retained." Hopefully, organizations see that nurses are their best marketers, can increase patient satisfaction, can spread by word-of-mouth what a great place "their hospital" is to work. Not only do nurses keep patients coming back to hospitals (which helps the bottom line), but also they are the best recruiters for the profession. There is something to be said and hoped for in solving the problem "upstream."

Judith A. Rizzo, PhD, RN, CNAA