Creating a High Retention Workforce in Eye Care

Jeyachandran Sowmia
HR co-ordinator
Aravind Eye care system

Retention of employees is a major challenge for health care. Success at retaining employees requires an organizational culture that inspires loyalty and commitment.

Recruitment and Retention is one of the biggest challenges in healthcare. Wide spread labor shortages exist in many healthcare professions, including laboratory technicians, radiology technicians, certified nursing assistants, pharmacists, medical technicians and most alarming of all, registered nurses .On a broader scale all business and professions are competing for the same pool of talented people, especially those who are technically or scientifically adept .No matter what the state of the economy, the best and the brightest are always in demand.

Shortages of workers throughout the industry are expected to continue into the foreseeable future. An attempt is made to study the human resource crisis in different parts of the world, encompassing both the developing and developed countries and present a solution to the crisis. The regions and the countries covered are:

Retention in Developing Countries

Africa Asia Retention in Developed countries The source material for the study are various web sites, journal ,study materials and research article .

The important websites are Attrition in Developing countries

There is a severe lack of human resources due to the recruitment by northern countries of medical professionals and staff attrition due to poor motivation or remuneration.

It is estimated that developing countries invest about 500 million in training health professionals who are then recruited by developed countries, equivalent to roughly 25 per cent of the total overseas development aid to these countries .


The African continent is characterized by an extreme lack of health care personnel and facilities. The state of health care in Africa provides an alarming contrast to the rest of the world. Poor practitioner-to patient ratios, total absence of eye care personnel, inadequate facilities, poor state funding and a paucity of educational programs are the hallmarks of eyecare in Africa. The prevalence of blindness in Africa is 0.8 to 1.4% compared to 0.2% in America and Europe.1 The tragedy of the African statistics is that much of the blindness is preventable. A significant feature of the eyecare crisis is the lack of programs to adequately train optometrists in Africa. The entire continent has only nine optometric programs which are based in four countries: South Africa, Ghana, Nigeria and Tanzania. These programs vary in their scope and produce far too few optometrists to meet the needs of their own countries, let alone the needs of other countries. Penisten2 found that Ghana, for example, had 10 optometrists and 14 ophthalmologists who served the needs of 15 million people.
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Retention Issues in Ghana

Ghana, a low income developing country, is undergoing health sector reforms aimed at achieving greater equity of access to services, improved efficiencies in resource utilization, development of wider linkages with communities and other partners, as well as improved quality of health services.

Unpublished preliminary studies indicate a high level of migration of Ghanaian physicians and nurses soon after graduation. The rates are expected to be as high as 50% - 70% outside the country within 5 years of graduation. This is a serious issue that threatens the MOHs capacity to implement its health reform and decentralization programme.

These reforms have strong influences on, and are influenced by, issues of human resources development, deployment and motivation. Some of the human resources issues debated under the reforms include issues of distribution of personnel, re profiling of staff types and skill mixes including delegation of some essential skills. Issues of gender influence on staff distribution, as well as social and geographical factors, affect human resources deployment to meet the health sector reform goals.
  1. Development of new staffing guides

    The MOH has undertaken various studies to help link staff placement more closely with workload. Criteria utilized, help ensure that the staffing levels are guided by the availability nationally of particular staff types and includes the kinds of services offered within each facility. Staffing Norms have been determined and categorised for various types of facilities and institutions in the health sector. For the first time specific work has been done towards creating norms to guide the level of staffing for the two teaching hospitals (which contribute significantly to the staff loss from other levels).

  2. Determination and creation of staff posts for each unit

    The approved norms have now been applied extensively:
    1. to determine more clearly, vacancies in each work location, and
    2. as basis for new staff posting transfers.
    This exercise has helped to reveal the location of surpluses and shortfalls in staffing and to gradually begin the delicate process of reversing imbalances through retirement and transfers to needy locations.

  3. Decentralization of Personnel Administration and Salary Management

    To be effective, it is proposed that together with the increasing decentralization of recurrent expenditure to district managers, personnel emoluments would be administered alongside. This will provide opportunities for local managers to use savings made on salary budgets to motivate staff, especially those in deprived areas. It is realised though, that such a system, in the absence of central rationalization, may worsen existing staff distribution whereby richer urban locations will pay higher salaries and continue to attract the best qualified staff.

  4. Motivation & Incentives to Encourage Effective Deployment of Human Resources.

    To reinforce these institutional changes and ensure motivation in a more visible way, a new scheme and new conditions of service are being designed to implement the Ghana Health Services and Teaching Hospitals Act (Act 525, 1996), i.e.,
    1. Removes management responsibility from technical and professional staff and places it into the hands of full time managers.
    2. Recognises more clearly the need to compensate staff working in rural and unpopular areas. This will be effected through pay based on workload and also by providing compensation for the lack of social utilities and amenities. It is proposed that rural service of four or more years duration should shorten promotion time and also give early opportunity for specialisation and further training.
    3. Common grades and titles and career pathways are proposed which shall allow for all cadres to reach the highest levels of remuneration and to encourage other cadres aside from those in the more recognised and vocal professions.
    Other systems being developed are aimed at improving staff morale by decentralising the award of promotions and other benefits making the process less time consuming and more efficient. It is also proposed that savings made from salary budgets in areas where staff are reluctant to accept postings to are used to provide incentives to staff.

    De-linking from the Civil Service is expected to improve pay conditions and benefits beyond what was possible under the Civil Service.

  5. Redistribution of staff.

    Despite overall shortages of staff, clearly there are severe misdistributions and the creation of the new service and its decentralised nature is an opportunity to achieve greater distribution of staff according to need. The service can sustain this through decentralised recruitment systems that will advertise vacancies according to the locations where staff are needed and not as part of an ongoing global staff recruitment as previously occurred in the civil service.

  6. Re-profiling:

    The multi-purpose community health worker, combining clinical and preventive skills should become an essential and cost effective cadre for service delivery in Ghana. Relaxation of the gender rules that prevent males from belonging to certain cadres also need to be reviewed and action initiated in changing the statutes. Skill delegation and equipping staff based in rural areas to handle a wider spectrum of emergencies should increase the confidence of clients in the services. Multi-skilling can be expected to reduce the number of staff required to provide basic services and encourage efficiency in utilising staff.

  7. Incentives and Motivation:

    These factors remain major influences on the management and retention of human resources. The salary differentials between attractive foreign countries, such as the USA and South Africa, and Ghana cannot be easily bridged because of the current economic performance. However substantial non-monetary influences exist. These include increasing local opportunities for specialist and postgraduate training, rewarding staff according to differential workloads, especially for those working in locations that are considered unpopular, and also improving the efficiency with which personnel actions are handled.

    Resolving human resources issues will be essential to implementing Ghanas health sector reforms. This will involve strong management capacity as well as complementary service delivery staff. These are non-negotiable factors in meeting the challenge of developing and sustaining a new image for the Ghana Health Services.

    (source :
High Attrition Rate in South Africa

The prevalence of blindness in South Africa is 0.75%, which amounts to some 240,000 people who are blind. There are also nearly 350,000 people who have low vision.
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There are 275 ophthalmologists in the whole of South Africa: 250 of them work in the private sector catering for the needs of 8 million people, whilst only 25 work in the government practice that services 32 million people. The CSR for the indigent population is 850 per million of the general population per year. In order to eliminate blindness due to cataract, it should be 3000 for South Africa

Another matter of concern is the high attrition rate of staff. It regularly happens that experienced members of staff leave and are replaced by inexperienced more youthful members without the same experience. It has been identified that the high attrition rate of staff as a major problem and developed the following strategies which are contained in their strategic plan:
  • accommodation for staff in rural areas
  • To develop a strategy for marketing health facilities
  • To upgrade critical posts
  • To create recreational facilities in all rural health facilities
  • To motivate for a clinic/ward clerk per facility
  • To motivate for a non-taxable rural package allowance for all staff
  • To ensure timeous availability of resources.
Emigration of Health Care Workers In Malawi

Ministry of Health reports indicate that the prevalence of blindness in Malawi is 1%, in other words about 100,000 people. We estimate that there are around 20,000 incurably blind adults and nearly 4,000 children. Some 150,000 people suffer from low vision.

In the not too distant past, discussions involving "health" and "migration" would likely have focused on the physical and mental condition of immigrants,. Today, however, the connection between health and migration can just as readily be illustrated by a hospital Malawi, which has only 30 nurses, 26 of whom have plans to leave the country.

Controversy surrounds the proper role of policy interventions in the global labor market of health care professionals. Emigration of health care workers weakens already failing health systems in the developing world. Yet this movement may more accurately be described as a symptom or an aggravating factor, and not the root cause of health care system failures in the developing world.

It is still unclear what the new rules of engagement will be to retain and train health care workers where they are most needed and to mitigate the grave imbalance between the rich and the poor with regard to health care. In light of these factors, experts are weighing a series of policy options that have important implications for the migration of the world's health care workers.

Ethical considerations that pit the right of individuals to move against a greater public good are at stake as well. Policymakers find themselves struggling with two complex sets of issues: how can health care workers with needed skills maintain their freedom of movement and the opportunity to respond to more favorable employment offers outside their country or region of origin without damaging the fundamental right of others in a population to a basic standard of health care?
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Attrition in Zimbabwe

Zimbabwe has approximately 11,000 healthcare professionals, many of whom are infected with HIV/AIDS. While some health workers are able to pay for antiretroviral therapy, the majority cannot afford the cost which ultimately leads to a significant mortality rate. In addition, in their search for access to healthcare, many healthcare providers migrate from Zimbabwe, leaving an ever-larger gap in local healthcare services. As a result, healthcare services are becoming increasingly scarce in Zimbabwe.

In an effort to reduce attrition, Healthcare Provider Antiretroviral Drug Access Initiative provides antiretroviral treatment to healthcare workers who are unable to pay for medication. The programs premise is that if treatment is provided locally, retention of healthcare workers will improve, which will be beneficial for the health of the entire community. The Initiative is an international collaboration between the University of Harare in Zimbabwe, Brown University Medical School, The Miriam Hospital of Rhode Island and ICEHA.
(source : )


The demand for eye and vision care services and personnel in Asia will, most likely, continue to increase with the technological demand for visual skills and vision-related performance in the workplace.

Retention issues in Cambodia

Cambodia, with a largely rural population (80%) of over 10 million, is still emerging from a long period of civil conflict and instability.

The health workforce still remains in transition from the period of destruction of physical and social infrastructure during the Khmer Rouge period between 1975 and 1979. "Massive numbers" of Cambodian health professionals were killed in this period, with only 50 doctors remaining by 1980. This contrasts with the figure of 431 medical doctors who graduated from the Faculty of Medicine in Phnom Penh's six-year program in 1975.

The rural medical workforce in Cambodia faces challenging recruitment, retention and professional support issues. Currently in Cambodia there are over 17,000 health staff, of which 1,998 are doctors (11% of the workforce). Of these, 948 are centrally based in Phnom Penh. There are 1,050 at Provincial and District level, but no public doctors based in communes or villages. Numbers of women doctors remain low.

Rural doctors in developed countries such as Australia have recruitment and retention deficits and high occupational risks (especially stress-related), professional isolation, high workloads, reduced access to professional development, and special practice needs. Substantial progress has been made by the College to gain formal recognition of the distinct professional standards for Rural and Remote Medicine. ACRRM(The Australian College of Rural and Remote Medicine) recognizes and accepts its responsibility to support and represent the rural and remote medical profession and improve the health services of rural communities. ACRRM is committed to providing sound training and continuing medical education models based on appropriate standards, innovative methods of service delivery, and partnerships that improve practice.

The partnership concept arose at the 4th World Rural Health Conference in Calgary, Canada. ACRRM had discussions with a number of Asian Doctors' Associations and offered support for capacity strengthening activities. Agreement has now been made with the President of the Cambodia Medical Association. The project has been established as collaboration between ACRRM and CMA, as opposed to an imposed "aid" activity.

Retention issues in developed Countries

Data from developed countries tend to indicate that recruitment and retention are serious issues in health care An alternative indicator to vacancy is job turnover, which is often used to evaluate retention difficulties. In countries such as the United Kingdom (UK) and the United States of America (USA), turnover rates are quite significant, as they are estimated to be around 20%.

Various consequences are associated with the inability to recruit and retain nursing staff. Closure of, or reduced access to, clinics and wards, as well as lower quality of care and productivity, are common examples of nursing shortages. In addition, high turnover is likely to lead to higher provider costs, such as in recruitment and training of new staff and increased overtime and use of temporary agency staff to fill gaps. Turnover costs also include the initial reduction in the efficiency of new staff and decreased staff morale and group productivity. The literature shows that the costs associated with recruitment and retention problems are substantial.

The challenge for each health system is to identify and implement a package of different types of incentives that will meet its needs; it is unlikely that one package of incentives will be right for all organizations or contexts. Most of the research on increasing motivation and job satisfaction in health workers has been undertaken in developed countries, where the resources for such activities are available.

Factors influencing Retention and Attrition of Alaska Community Health Aides / Practitioners :

A Qualitative Study :

Alaska Community Health Aide Programme (CHAP) Directors association served as the advisory committee for the project.
The purpose of this study was to identify the factors that contribute to Community Health/Practioner (CHA/P) retention and attrition, with an emphasis on the influence of CHA/P support structures within the community and from family, colleagues and employers.

The data were initially collected and sorted by an number of factors to identify those most pertinent to CHA/P retention and attrition. The primary factors responsible for retention or attrition of CHA/P include the following.

Co-worker support Good communication and team work with co- workers helps provide CHA/Ps with empathetic emotional support and improves their ability to share workload and support one another.

Access to basic training Newly hired CHA/P s need to feel adequately prepared and trained for their duties. A fully trained clinic staff helps relieve the workload burden of other CHA/P in the clinic as well.

Fully staffed clinic - A fully staffed fully trained clinic enables the sharing of the daily workload and on-call duties.

Community support : Individual community members and tribal councils can do much to make CHA/p feel valued and appreciated for their efforts .

Family support : CHA/Ps need family to help with child care and eldercare responsibilities , as well as basic household and subsistence activites.

Analysis and findings:

The analysis and findings is organized according to major findings based on specific questions from CHA/P interview guide.

  1. Recruitment / Expectation/ Resignations
    1. How CHA/P are Recruited :

      The two ways in which the CHA/Ps were recruited were through word of mouth or in response to an open job posting. Newer CHA/P and those from high attrition communities were more likely to have responded to a posting. Health aides with experience and those from low attrition communities were more commonly invited to become a health aide by someone in a respected position.
    2. What attracts CHA/P to the job
      • good/job career opportunities
      • interest in medicine
      • just wanting to try it out
    3. Expectations of the job
      • they do not know what to expect
      • CHA/Ps reporting their job matched their expectations were expectations were split evenly among high and low turnover community health aides.
    4. Reasons for quitting
      • Personal issues
      • Stress/trauma / burnout caused by the job.
    5. Reasons for returning after quitting
      • For a variety of reasons
      • Encouragement from community members
      • Need for a job/or benefits are the commonly cited reasons.
    6. Rewards of being a CHA/P
      • Passionate mission
      • Rewards like
        • Clinical aspect of their work
        • Positive contribution to the community
        • challenge and learning opportunities
      • the excitement and unpredictability of the work
      • simply having a good job in the community
      • Challenges of being a CHA/P
        • Long hours and being on-call
  2. Call/Patient Load
  3. Clinical Support
    • CHA/Ps with more experience or located in low attrition communities , had more confidence in their own abilities and felt they had gained the of other providers in the medical field, relative to newer health aides in high attrition sites.
    • Clinic with high attrition appeared to have less staff cohesion ,contributing to the feeling of not being supported clinically.
  4. Community Support
    • CHA/Ps in low attrition sites had more positive things to say about community support.
    • More experienced CHA/P and those from low attrition sites felt more support from village in emergencies and also felt more community provided more financial or material support to the clinic.
    • Helath aides from high attrition felt that they were not as supported by their village compared to the low attrition community counterparts.
  5. Family Support
    • Independent of years of experience , health aides cited the need for understanding and encouragement from family as a major requirement for job success , with childcare the second most cited need.
    • More experienced health aides were more likely to cite the challenges of being away from home and were more vocal about the supportiveness of their families.
    • CHA/Ps from low attrition communities seemed more comfortable talking about the time away from home mentioning both positive and negative aspects.
  6. Emotional support
    • More experienced health aides and health aides from low attrition communities relied on support from coworkers.
    • Health aides from high attrition communities and more experienced health aides mentioned emotional support from god, as well as support from family.
    • It should also be mentioned that without the coworker support many health aides were left with no way to vent.
    • Some health aides mentioned patient privacy issues keep them from reaching out to other people other than coworkers.
    • Finally, there was a sentiment that only another health aide would understand their situation
  7. Cohesiveness of staff

    Cohesiveness of staff is an important retention factor in clinics.

    Characteristics of cohesive staff
    • Regular scheduled staff meetings
    • Supportiveness in Time Off
    • Experienced health aides teaching the less experienced.
    • Cooperation to share the burden of the work.

The major theoretical model used to organize our research findings is Maslows Hirearchy of needs. Using this model less experienced CHA/P s cam be understood separately from their more experienced counterparts , facilitating a better understanding of each groups unique needs.

Maslows Hierarchy of Needs:

Maslows Hierarchy of Needs provides one way of classifying human needs, and also has been one of the most influential psychological models of the 20th century. It has also emerged as a fairly popular model for explaining job satisfaction factors ,partly because it provides a classification system for human needs, but also because it provides concrete implications for managing these needs within complex organizations.This model is shown in fig.1

Fig.1 Maslows Hierarchy of Needs:

According to Maslow , people are motivated to fulfill their unsatisfied needs, and there are certain lower needs which must be satisfied before higher needs can be fulfilled . Maslow classified needs into general types , including physiological, safety, love , and esteem- arguing that these needs must be met before a person can meet higher needs and be self actualized . Maslow calls all these basic needs Deficiency needs because humans cannot move towards the higher level of self actualization, where they can maximize their potential . until these lower cravings have been assuaged.

There are considerable implications with this theory for employer organizations . It can be argued that unless employers provide with a mean to placate their basic deficiency needs, employees will not be able to reach for the higher levels of job satisfaction and self-actualization in the workplace.

Maslows Theory and CHA/P Profession:

This research would indicate that CHA/P have a hierarchy of needs within their profession , as well , this model is shown in the figure.2

This model uses the Maslow concept that there are basic needs that must be met before CHA/Ps can move towards Self- actualization or complete satisfaction with their career. The research would support the notion that the items on the lowest level of the pyramid( the most basic CHA/P needs) are most likely to be associated with attrition. Items higher on the pyramid are probably not as likely to have a causal relationship with attrition , but the fulfillment of these needs can help improve job satisfaction for CHA/P .Based on the data, CHA/Ps from high attrition communities , or who have less experience , with more than ten years of experience , appear to function more toward the top of the triangle , while CHA/:Ps from high attrition communities , or who have less experience ,are more likely to be working to fulfill the five basic needs demonstrated at the bottom of the pyramid . These basic needs include positive co-worker support , timely access to basic training ,access to a fully staffed-clinic , support from the community served, and family support

Fig.2. Health Aide Hierarchy of needs

Fatigue and stress in the Attrition Cycle

In summary, the following five major areas were found to form the basis of CHA/P retention needs: co-worker support , adequate and timely basic training , a fully staffed clinic , positive community support, and family support. Although the other factors (such as fair wages , good benefits , generous leave policies , adequate clinical support and access to additional training opportunities ) were also important to CHA/Ps , focusing on them alone without addressing the five basic CHA/P needs is unlikely to positively impact retention.

Each of the five primary factors contributing to attrition affects CHA/P fatigue, stress , and burnout , thus fostering the cycle of attrition in many communities . this feeling of burnout was exemplified by one CHA/P interviewee who told the research team , They cant pay me enough to do this job . This cycle of attrition is summarized in the fig.3

Fig.3 Cycle Of Burnout

In this cycle , the decision by a CHA/P to quit leads to either a short-staffed clinic and /or a clinic that is staffed with new ,inexperienced and untrained staff members. Both of these situations lead to inadequate staffing to share job duties , especially complex cases and on call hours. Therefore remaining clinic staff members are saddled with an unreasonable burden of patient care, leading to long hours, fatigue, and strife both within their families and amongst the remaining clinic staff.. These in turn may lead to perceptions of poor quality of care ,both amongst community members and by CHA/P themselves , if they feel that they must provide services that are beyond their comfort level of training they have completed. Consequently, more CHA/P may quit, which then exacerbates and compounds this cycle.

Breaking this cycle is not easy, but developing interventions that solve different aspects of this cycle are what will ultimately bring staffing to a community.

Conclusion and Recommendations

CHA/Ps practicing in remote locations are an integral part of Alaskas rural tribal health care infrastructure. However, some advances in patient access that CHA/Ps has made could be made threatened by high attrition rates within the profession. This research suggests that a number of improvements could be made to the program so that CHA/Ps feels more satisfied in their jobs and acknowledged as an important component.


The research suggests a number of potential solutions for decreasing the CHA/P attrition. The recommendations include

  1. Improving on-call
    • Additional pay for on-call hours
    • Paid time off after hard on-call nights
    • No make-up of on-call after taking annual leave.
  2. Improving community Support
    • Advocate for health aides within their communities
    • Provide means for communication with village council
  3. Emotional Support
    • By having supportive co-workers to share and vent which can be integral to employee retention.
  4. Access to Training:
    • It is crucial to get the employees trained because having a fully staffed ,fully trained clinic team not only helps decrease the stress level of the individual of CHA/P , but also decrease the burnout of the CHA/Ps in the clinic by providing more people with which to share on-call ,trauma and complex cases.
Summing-up :

The studys main focus is the global health workforce, which it identifies as being in crisis. In turn, this is contributing to crumbing health systems in many countries. Recent international attention to health systems is welcomed; however it is remarkable how little attention has been focused upon health workers, who are central to the functioning of any health system. Noting that neglect of human resources is an old problem, the study identifies new forces that are buffeting health workers.
  • The first threat in African countries is a large numbers of health workers themselves falling ill and dying of AIDS. In many cases, the losses of workers due to AIDS is exceeding the new staff graduating from training colleges as it is in Zimbabwe.
  • The second threat to the workforce of a poor country is emigration to richer countries, pulled by better wages and working conditions. There is a global market for health professionals, which responds to the demand of the wealthy at the expense of the basic needs of the poor. The dense concentration of health professionals in the richest countries indicates that there is in principle no ceiling on the capacity of a society to absorb health care. But this insatiable demand is stripping the poorest nations of their most essential staff. In the middle are countries like South Africa, which export physicians and nurses to developed countries, and in turn import them from poor sub-Saharan African countries such as Zimbabwe and Ethiopia.

    For Example

    • In Ghana, 604 of 871 medical officers trained between 1993-2002 have left the country. Ghana has lost about 2,500 nurses to Europe between 1999-2002. For its population of 20 million, currently Ghana has 1,842 physicians and 17,196 nurses and midwives.
    • Same is the case in Malawi which has only 30 nurses, 26 of whom have plans to leave the country.

  • These problems come on top of enduring, structural obstacles to the proper development of human resources for health. Human resources is considered low priority and a backwater field . Two decades of health sector mis-reforms' have treated health workers as a cost burden, not an asset, imposing ceilings on staff numbers and salaries, while reducing spending on education. The price of this starving of the health sector pipeline is now becoming apparent: Africa simply does not have the people it needs to run its health systems.
The study presents empirical evidence from across the world, demonstrating the close correlation between the presence of qualified health workers and key health outcomes.

Moreover, unlike other inputs, a health workforce cannot simply be bought on demand. It takes decades to build up a dedicated, professional and effective health workforce: it is an investment.


1. The first of these is that initiatives to strengthen the health workforce must focus on the national and community levels, with global reinforcement.' This cannot be achieved with a one size fits all' approach: policies and programmes must be specifically tailored for each country.

2. A second key action is to bring together relevant national and regional stakeholders and actors into a global Action-Learning Network,' to provide a valuable hub for accelerating exchange and learning on human resources for health.

3. Addressing the issue of international labor migration of health workers, the emphasize is on the principle of essential national human resources' in the health sector. Thus, rich countries should no longer rely on importing health professionals from poor countries, but should seek domestic self-sufficiency.

4. Noting the critical shortage of human resources for health in Africa, the report calls for an urgent programme of training an additional one million health professionals for Africa.

5. In the case of the developed countries where there is a sizeable percentage of attrition of health care workers , focus should be on to make the health care workers feel important ,indispensable and integral part of the system.

  1. Peg C. Neubauser , Building a High-retention Culture in Health care , HBR,JONA ,Volume 32 ,Number 9, September 2002.
  2. AHA commission in workforce for Hospitals and Health Systems, In Our Hands, April 2002.