Members of the Subcommittee:

Good morning Mr. Chairman and Members of the Subcommittee, I am Mary Foley, MS, RN President of the American Nurses Association. ANA is the only full-service association representing the nation's registered nurses (RNs) through its 54 constituent nurse member associations. Our members include RNs working and teaching in every health care sector across the entire United States. I myself have more than 25 years experience as a staff nurse, a nurse executive and a clinical instructor in nursing.

Today, health care institutions across the nation are experiencing a crisis in nurse staffing, and we are standing on the precipice of an unprecedented nursing shortage. Let there be no doubt about it, the current and emerging shortage of RNs poses a real threat to the nation's health care system. RNs are the largest single group of health care professionals in the United States; we underpin the entire health care delivery system. Concerns that we have all been hearing about the current nursing shortage underscore the fact that having a sufficient number of qualified nurses is critical to the nation's health.

The emerging nursing shortage is very real and very different from any experienced in the past. Hospitals, long term care facilities and other health care providers across the nation are having difficulty finding experienced nurses who are willing to work in their facilities. Press reports about emergency department diversions and the cancellation of elective surgeries are becoming commonplace. Nurses are reporting that understaffing is jeopardizing patient care. In addition, projections show that these current shortages are just a minor indication of the systemic shortages that will soon confront our health care delivery system.

It is important to realize that the causes for, and therefore the answers to, this emerging nursing shortage are complex and interrelated. A comprehensive approach to this problem must contain programs designed to improve nurse education, health delivery systems, and the environment in which nurses work. To this end, leaders of national nursing organizations are currently attending a four-day summit in the DC area. This Call to the Nursing Profession, has been convened to enable nursing organizations to develop a comprehensive plan to ensure that patients continue to receive safe, high-quality nursing care; to retain experienced nurses in the profession, and; to recruit more people into the profession. No answer will be complete unless it addresses all of these components.

Recent Changes in Nurse Employment

Current staffing problems are inexorably tied to changes in nurse employment practices. Therefore, I will provide brief overview of changes in nursing employment over the last decade. Just ten years ago we were emerging from the nursing shortage of the late 1980's. At that time, nursing workforce issues had caught the attention of the highest reaches of the Reagan and Bush Administrations. The HHS Secretary's Commission on Nursing developed a list of 16 recommendations on methods to address the shortage. Very few of the workplace initiatives contained in this report were actually implemented. However, health care facilities across the nation did institute aggressive nurse recruitment campaigns, federal funding for nursing education was increased, and nurse wages were raised. At the same time, RN employment in hospitals grew by a steady rate of 2-3 percent annually through the 1980's and early 90's. By the early 1990's reports of nurses shortages had significantly diminished.

However, in the mid-1990's, the picture changed. At this time, the new Medicare prospective payment system and increased cost savings measures instituted by managed care began to exert downward pressure on reimbursement. Faced with decreasing margins, providers eagerly sought out and implemented programs designed to reduce expenditures. New models of health care delivery were implemented, and highly-trained, experienced - and therefore higher paid - personnel were eliminated or redeployed. As RNs typically represent the largest single expenditure for hospitals (averaging 20 percent of the budget), we were some of the first to feel the pinch.

Analysis of census data shows that between 1994 and 1997 RN wages across all employment settings dropped by an average of 1.5 percent per year (in constant 1997 dollars). Between 1993 and 1997, the average wage of an RN employed in a hospital dropped by roughly a dollar an hour (in real terms). RN employment in the hospital sector reversed to the negative, and reports of lay-offs became common as lesser-skilled, lower-salaried assistive staff were hired as our replacements. Many providers eliminated positions for nursing middle managers and executive level staff. Hospital employment for unlicensed aides, however, increased by an average of 4.5 percent a year between 1994 and 1997.

The overall impact of the changes in the 1990s was to increase pressure on staff nurses who were required to oversee unlicensed aides while caring for a larger number of sicker patients. The elimination of management positions shortened the career ladder and decreased the support, advocacy and resources necessary to ensure that nurses could provide optimum care. At the same time employment security was uncertain and wages were being cut.

The Current Employment Situation

Not surprisingly, the rapid deterioration in the RN employment environment precipitated a downturn in the number of people working in the nursing profession and growing discontent among those who remain. As the image of professional nursing has changed from a field that offered many opportunities and high job security to one that holds great uncertainty, relatively low wages and difficult working conditions, students have shied away from nursing programs. The number of students entering nursing school has dropped consistently and dramatically through the mid-to-late 1990's. Nursing schools responded by reducing the number students they accept and the number of faculty that they employ.

A recent ANA survey of nurses revealed that nearly 55 percent of the nurses surveyed would not recommend the nursing profession as a career for their children or friends. In fact, 23 percent of the respondents indicated that they would actively discourage someone close to them from entering the nursing profession. In fact, it is common for nursing students to be approached by experienced nurses who advise them to find another occupation - one that is less stressful and more highly esteemed.

A large multi-national survey recently conducted by the University of Pennsylvania's Center for Health Outcomes and Policy Research shows that America's nurses are particularly dissatisfied with their jobs. More than 40 percent of nurses in American hospitals reported being dissatisfied, as compared to 15 percent of all workers. In addition, this report shows that 43 percent of American nurses score higher than expected on measures of job burnout.

This job burnout leads the average American nurse to leave hospital employment after only four years. Unfortunately, many of these nurses are choosing to leave the profession altogether. The 2000 National Sample Survey of Registered Nurses shows that an unusually large number of nurses (500,000 nurses - more than 18 percent of the nurse workforce) who have active licenses are not working in nursing.

Recent reports by the General Accounting Office, the Congressional Research Service, academia and private market research indicated that job dissatisfaction is a major factor contributing to the current nursing shortage. Nurses are, understandably, reluctant to accept positions in which we will face inappropriate staffing, be confronted by mandatory overtime, be inappropriately rushed through patient care activities, and be unable to provide the high quality care that we were trained to give.

Solutions

ANA is working to address current nurse staffing shortfalls, to improve the work of nursing and to encourage more young people to enter the profession of nursing.

Adequate Staffing
The safety and quality of care provided in the nation's health care facilities is directly related to the number and mix of direct care nursing staff. More than a decade of research shows that nurse staffing levels and skill mix make a difference in the outcomes of patients. In fact, four HHS agencies - the Health Resources and Services Administration, Health Care Financing Administration, Agency for Healthcare Research and Quality, and the National Institute of Nursing Research of the National Institutes of Health - recently sponsored a study on this very topic. The resulting report, released on April 20, 2001, found strong and consistent evidence that increased RN staffing is directly related to decreases in the incidence of urinary tract infections, pneumonia, shock, upper gastrointestinal bleeding, and decreased hospital length of stay.

A recent ANA survey reveals that 75 percent of nurses feel that the quality of nursing care at the facility in which they work has declined over the past two years. Out of nearly 7,300 respondents, over 5,000 nurses cited inadequate staffing as a major contributing factor to the decline in quality of care. More than half of the respondents believed that the time they have available for patient care has decreased.

The University of Pennsylvania research shows that 70-80% of more than 43,000 registered nurses surveyed in five countries reported that there are not enough RNs in hospitals to provide high quality care. Only 33 percent of the American nurses surveyed believed that hospital staffing is sufficient to "get work done." This survey reflects similar findings from a national survey taken by the Henry J. Kaiser Family Foundation (1999) that found that 69 percent of nurses reported that inadequate nurse staffing levels caused great concern for patient care. We should all be concerned that more than 40% of the responding nurses in the ANA survey stated that they feel that the quality of care has suffered so severely that they would not feel comfortable having a family member or loved one receive care in the facility in which they work.

In addition to the important relationship between nurse staffing and patient care, several studies have shown that one of the primary factors for the increasing nurse turnover rate is dissatisfaction with workload/staffing. Adequate staffing levels allow nurses the time that they need to make patient assessments, complete nursing tasks, respond to health care emergencies, and provide the level of care that their patients deserve. It also increases nurse satisfaction and reduces turnover. For these reasons, ANA supports efforts to require acute care facilities to implement and use a valid and reliable staffing plan based on patient acuity. In addition we support efforts to enact upwardly adjustable, minimum nurse to patient staff ratios in skilled nursing facilities.

Mandatory Overtime
Nurses across the nation are also expressing concerns about the dramatic increase in the use of mandatory overtime as a staffing tool. We hear that overtime is the most common method facilities are using to cover staffing insufficiencies. Employers may insist that a nurse work an extra shift (or more) or face dismissal for insubordination, as well as being reported to the state board of nursing for patient abandonment.

The use of mandatory overtime is not as uncommon or isolated as some would have you believe. In fact, the term ‘mandation' has been coined by the health care industry to describe this staffing tool. A recent ANA survey (sample size of 4,826) revealed that two-thirds of nurses are being required to work some mandatory or unplanned overtime every month.

Our concerns about the use of mandatory overtime are directly related to patient safety. We know that sleep loss influences several aspects of performance, leading to slowed reaction time, failure to respond when appropriate, false responses, slowed thinking, and diminished memory. In fact, 1997 research by Dawson and Reid at the University of Australia showed that work performance is more likely to be impaired by moderate fatigue than by alcohol consumption. Their research shows that significant safety risks are posed by workers staying awake for long periods. It only stands to reason that an exhausted nurse is more likely to commit a medical error than a nurse who is not being required to work a 16 to 20 hour shift.

Nurses are placed in a unique situation when confronted by demands for overtime. Ethical nursing practice prohibits nurses from engaging in behavior that they know could harm patients. At the same time, RNs face the loss of their license - their careers and livelihoods - when charged with patient abandonment. Absent legislation, nurses will continue to confront this dilemma. For this reason, ANA supports legislative initiatives to ban the use of mandatory overtime through Medicare conditions of participation.

We are working through the Medicare system because we believe that the abusive use of overtime promotes poor patient care and therefore is a matter of public health safety. Just as limits on work hours for airline pilots and truck drivers are enacted through transportation law, we believe that this matter should be handled through health law. On a more practical level, we also believe that Medicare provider contracts cover more nurses in more facilities than an amendment to the Fair Labor Standard Act would.

Health and Safety:
As this Committee is aware, nurses are also leaving the profession due to avoidable injuries sustained on the job. This Committee took the lead last year in addressing one of the most devastating threats facing nurses and other health care workers - the threat of infection from contaminated needles and sharps. Your support and hard work on behalf of the Needlestick Safety and Prevention Act will save the lives of countless nurses and health care workers. An ANA survey of nearly 5,000 nurses that was released last week reveals that 80 percent of facilities are now providing safe needle devices for injections, IV insertions, and taking blood. This represents an incredible accomplishment for such a short period of time. ANA is confident that we will reach full compliance in the near future. On behalf of the 2.6 million registered nurses in America - thank you.

I wish I could report that our concerns about workplace health and safety are now solved. Unfortunately, the new ANA survey shows that health and safety concerns continue to play a major role in nurse's employment decisions. In fact, 88 percent of the nurse respondents reported that these concerns influence decisions about what type of nursing work they will perform. The top-ranking concerns are focused on the acute and chronic effects caused by overwork and fatigue, the risk of a disabling back injury, and the threat of sustaining an on-the-job assault. Government statistics show that nurses are more likely to sustain back injuries than heavy construction workers. In fact, studies of back-related workers compensation claims reveal that nursing personnel have one of the highest claim rates of any occupation or industry. Three of the top seven occupations at greatest risk for musculoskeletal disorders are health care occupations where the workers perform repetitive patient handling tasks.

The threat of on-the job violence is just as real. More than half of the respondents to the ANA survey reported being threatened or verbally assaulted in the last year, 17 percent reported being physically assaulted. Unfortunately, emergency department nurses are subjected to the same violence that brings patients into their care, and nurses in psychiatric facilities may be left unprotected from the most unstable and violent patients.

The public at large should be alarmed that the nurses who took part in the ANA poll responded overwhelmingly (75.8%) that unsafe working conditions interfere with their ability to deliver high quality care. We can do better than this. Our nurses and their patients deserve more. ANA is committed to continuing our work with this Committee, employers, and other health workers to find effective, common-sense, cost-effective solutions to these concerns.

National Labor Relations verses Kentucky River Community Care
In this time of deteriorating working conditions and increased stress, it is important that nurses maintain their ability to use collective bargaining to improve their working environment. Nurses are using this tool to curb the use of mandatory overtime, stem the inappropriate use of unlicenced assistive personnel, and to improve on-the-job safety.

ANA was disappointed when the U.S. Supreme court ruled this spring that six registered nurses at a Kentucky facility met the definition of ‘supervisor' and are therefore ineligible to join a union or participate in collective bargaining. A split court upheld an the Sixth Court of Appeal's decision that these nurses met the definition of supervisor because they use independent judgment to direct the work of others. ANA concurs with the National Labor Relations Board in our belief that the court applied an unreasonably broad definition of supervisor in this case.

RNs regularly delegate certain patient care tasks to lesser-skilled assistants (e.g. assistance with bathing) in order to focus on other tasks that require more advanced skills (e.g., administering IV medication). Such delegation is governed by state laws and regulations, federal regulations, and the facility's own policies. The mere fact that a nurse directs these tasks does not mean that he or she has the ability to hire, fire, promote or discipline these employees. Therefore, the ability of staff RNs to direct the work of others should not be confused with the management-sanctioned authority that true supervisors exercise over the professional lives of employees.

ANA believes that the broad definition of supervisor contained in the National Labor Relations Act will continue to prompt unnecessary litigation and will interfere with the ability of many staff RNs to organize. We look forward to working with this Committee to craft a definition that contains a more appropriate definition of supervisor.

The Emerging Nurse Shortage

Traditionally, nursing shortages have been successfully addressed by changes in the market for nursing care. Health care facilities have normally responded to such shortages by instituting recruitment campaigns and increasing compensation. These actions served to attract more people into the profession, and to bring back those who had left. Unfortunately, the answer is not going to be so easy this time.

Today's staffing shortage is compounded by the lack of young people entering the nursing profession, the rapid aging of the RN workforce, and the impending health care needs of the baby boom generation. As new opportunities have opened up for young women and new stresses have been added to the profession of nursing, fewer people have opted to choose nursing as a career. New admissions into nursing schools have dropped dramatically and consistently for the past six years (the General Accounting Office reports a 20 percent decline in baccalaureate enrollments, a 11 percent decline in associate degree programs, and a 42 percent decline in diploma programs).

The lack of young people entering nursing has resulted in a steady increase in the average age of the working nurse. Today, the average working RN is over 43 years old. The national average is projected to continue to increase before peaking at age 45.5 in 2010. At that time, large numbers of nurses are expected to retire and the total number of nurses in America will begin a steady decline. At the same time, the need for complex nursing services will only increase. America's demand for nursing care is expected to balloon over the next 20 years due to the aging of the population, advances in technology and various economic and policy factors. In fact, the Bureau of Labor Statistics ranks the occupation of nursing as having the seventh highest projected job growth in the United States.

The increasing demand for nursing services, coupled with the imminent retirement of today's aging nurse, will soon create a systemic nursing shortage. A recent study published in the Journal of the American Medical Association estimates that the overall number of nurses per capita will begin to decline in 2007, and that by 2020 the number of nurses will fall nearly 20 percent below requirements.

Now is the time to address this impending public health crisis. ANA strongly supports the Nurse Reinvestment Act (H.R. 1436, S. 706) and the Nursing Education and Employment Development Act (S. 721). These comprehensive bills addresses many issues in nurse education and will greatly aide recruitment into the profession. The combination of innovative recruitment techniques, curriculum support, scholarships, and loan repayments contained in these bills will enhance all aspects of nurse education. ANA urges this Committee to support the further development of our nation's existing nurse population and the cultivation of our youth into this very worthwhile profession.

Immigration
ANA has deep concerns about the use of immigration as a means to address the emerging nursing shortage. Throughout a number of nurse shortages, immigration has been promoted as the standard "answer" by employers who have difficulty attracting American nurses to work in their facilities. We have been down this road many times before without success. There are a number of problems with increasing the immigration of foreign-trained nurses, following are just a few issues:

• The influx of foreign-trained nurses only serves to further delay debate any action on the serious workplace issues that continue to drive American nurses away from the profession. As I mentioned earlier, a Presidential task force called to investigate the last major nursing shortage developed a list of recommendations. These 16 recommendations, released in December, 1988, are still very relevant today - they include issues such as the need to adopt innovative nurse staffing patterns, the need to collect better data about the economic contribution that nurses make to employing organizations, the need for nurse participation in the governance and administration of health care facilities, and the need for increased scholarships and loan repayment programs for nursing students. Perhaps if these recommendations were implemented we would not be here today. Certainly, we will be here in the future if they are ignored. ANA strongly believes that we should not recruit foreign nurses when the real problem is the fact that the domestic health care industry has failed to maintain a work environment that is conducive to safe, quality nursing practice and that retains experienced American nurses in patient care.

• There are serious ethical questions about recruiting nurses from other countries when there is a world-wide shortage of nurses. The removal of foreign-trained nurses from areas such as South Africa, India, and the Caribbean deprives their home countries of highly trained health care practitioners upon whose skills and talents their countries heavily rely.

• In addition, immigrant nurses are too often exploited because employers know that fears of retaliation will keep them from speaking up. There are numerous, disturbing examples from our experience with the expired H-1A nurse visa. The INS Chicago District issued a $1.29 million fine against FHC Enterprises, Inc. for 645 immigration document violations. FHC, Inc. fraudulently obtained 225 H-1A visas which were used to employ Filipino nurses as lower-paid nurse aides ($6.50 per hour) instead of as registered nurses ($12.50 per hour). The Catholic Archdiocese of Chicago agreed to pay $50,000 in fines and $384,700 in back wages to 99 Filipino nurses who were underpaid. In Kansas, 66 Filipino nurses were awarded $2.1 million to settle a discrimination case in which the Filipino nurses were not paid the same wage rate as U.S.-born registered nurses at the same facility. These are just a few of the cases that have come to light over the last decade.

Conclusion

ANA maintains the current nursing shortage will remain and likely worsen if changes in the workplace are not immediately addressed. The profession of nursing will be unable to compete with the myriad of other career opportunities available in today's economy unless we improve working conditions. Registered nurses, hospital administrators, other health care providers, health system planners, and consumers must come together in a meaningful way to create a system that supports quality patient care and all health care providers. We must begin by improving the environment for nursing.

ANA looks forward to working with you and our industry partners to make the current health care environment conducive to high quality nursing care. Improvements in the environment of nursing care, combined with aggressive and innovative recruitment efforts will help avert the impending nursing shortage. The resulting stable nursing workforce will improve health care for all Americans.

Read Addendum to Statement (9/25/01)

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