HOUSTON--Layne Behrmann faced a critical career decision about a year and a half ago. The father of three sat down with his wife and painstakingly deliberated the pros and cons of the offer being made to him: to join Methodist Hospital in Houston as a full-time staff nurse, but with a 20 percent pay cut from the agency nursing he had been doing for several years.

The pros: becoming a member of the coronary care staff he'd come to trust while working on assignment at the hospital for several months, having a manager he respected, and using cutting-edge technology--plus regular hours and good benefits.

The cons: the reduction in pay (which was mostly offset by the benefits) and the loss of freedom. "When you're an agency nurse, you can work real hard and then take some time off," says Behrmann, 38, a registered nurse. "I missed that the other week. I could've had cheap round-trip tickets to Europe, and I couldn't do it."

Behrmann took the plunge, choosing a staff job at the 1,000-bed facility. And the gamble paid off--for administrators of the Methodist Health Care System. They had forced Behrmann's hand, telling him and dozens of other talented agency and temp nurses that if they wanted to keep doing the same work at Methodist, it could be only as full-time staff. Had the hospital system not been able to recruit Behrmann and others to full-time status, its nursing vacancy rate would have risen.

And that was just the problem Methodist was hoping to solve, in one of the most ambitious efforts in the nation to deal with the chronic nursing shortage. Before Methodist shifted to staff nurses, an average of 20 percent of its nursing positions were vacant at any one time. Nationally, some hospitals have a nursing vacancy rate of as high as 40 percent.

High vacancy rates are expensive. The staffing gaps were forcing Methodist to spend up to $1.5 million a month on outside nurses, often at a much higher cost per person than for staff nurses. So in late 2001, the system vowed that by the end of 2002 it would spend no money on outside nurses. It met that goal by aggressive recruiting, setting up a pool of staff nurses it could rely on when there was extra demand, and asking temp and agency nurses like Behrmann to commit to staff jobs. It has also focused on less tangible factors--the working conditions that can make a staff position more appealing than better-paying temp jobs.

Methodist's bid to get and keep an adequate nursing staff may be the boldest such effort, but other hospitals are also trying to wean themselves from temp and agency nurses. The payoff, they believe, goes beyond lower nursing costs to improved care and patient safety--and not just because of better staffing levels. At Methodist, nursing supervisors say that familiarity with hospital routines and procedures is also critical in ensuring high standards of care. Satisfaction surveys of patients and nearly 5,000 employees in Houston, they say, prove this point. "Patient satisfaction has gone up 20 percent since the period we were using a lot of agency nurses," says Judy Spinella, vice president of operations at Methodist. "When our agency use was at its highest, our patient satisfaction was at its lowest."

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