As this Committee is aware, 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. 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 reporting problems filling nursing positions. Employers are having difficulty finding experienced nurses, especially in emergency departments, critical care, labor and delivery, and long term care who are willing to work in their facilities. Press reports about emergency department diversions and the cancellation of elective surgeries due to short staffing are becoming commonplace. 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, and therefore the answers, for the emerging nursing shortage are complex and interrelated. It is critical to examine issues in education, health delivery systems and the work environment. ANA maintains that the reasons for the current nurse vacancy rates to the impending shortage are multifaceted. Therefore, we must approach this shortage from many fronts.

Recent Changes in Nurse Employment

Current staffing problems are inexorably tied to changes in nurse employment practices over the last decade. Just ten years ago we were emerging from the nursing shortage of the late 1980's. Nursing workforce issues had caught the attention of the highest reaches of the Reagan and Bush Administrations and the HHS Secretary's Commission on Nursing had recently released recommendations on methods to improve the work environment for nurses. Very few of these workplace initiatives were actually implemented, but health care facilities across the nation did institute aggressive recruitment campaigns and wages were increased. In fact, the Health Resources and Services Administration's (HRSA's) National Sample Survey of Registered Nurses shows that the average real annual salary of all RNs employed full-time rose 33 percent between 1980 and 1992 (in constant 1984 dollars). 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, managed care began to exert downward pressure on provider margins. In addition, the impact of the change in Medicare reimbursement to prospective payment was taking hold. 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. Lesser-skilled, lower-salaried assistive staff were hired as replacements, and RN salaries decreased in both actual and real terms.

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, dropping most precipitously in areas of the country that experienced high managed care saturation. Many providers eliminated positions for nursing middle managers and executive level staff. Hospital employment for unlicenced 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 unlicenced 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 changes in the RN employment environment in the last decade have 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, low starting 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 (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).

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. I know as a nurse educator, nurses often ask my students, "Why on earth do you want to become a nurse and get into this mess? It's not worth it. You can't give patients the care they need--there's just not enough staff to do it right."

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 with their jobs, 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. ANA statistics show that nurses typically burn out and leave hospital bedside nursing after just four years of employment.

Years of discontent have led us to a situation in which an alarming number of our experienced RNs have chosen to leave the profession. The 2000 National Sample Survey of Registered Nurses shows that a large number of nurses (500,000 nurses - more than 18 percent of the nurse workforce) who have active licenses are not working in nursing. In Illinois alone, the numbers of licensed RNs who are no longer working in nursing increased by 8% in the years between 1996 and 2000. Clearly, something in the practice setting is driving these nurses away from their chosen profession.

The Environment of Care

In an effort to ascertain the cause of nurse discontent, ANA recently conducted an on-line survey of nurses across the nation. Nearly 7,300 nurses took the opportunity to express their opinions about their working conditions. These nurses report that over the last two years they have experienced increased patient loads, increased floating between departments, decreased support services and increasing demands for mandatory overtime. These studies reveal that the recent changes in RN employment have negatively impacted patient care, the work environment for nurses, the perception of nursing as a career, and the staffing flexibility needed to address temporary staffing shortages.

The American Hospital Association reports that there are 126,000 openings for RNs in hospitals across the nation. We have all been hearing about the difficulties that they are having finding nurses to take these positions. I often hear from staff nurses in Illinois who tell me that the reason for these vacancies is dissatisfaction with the work environment. The numbers of nurses with active licenses who are no longer working in nursing bolsters my belief that there is not a current shortfall in the number of nurses, per se. Rather, there is a shortage of positions that these RNs find attractive. Nurses are, understandably, reluctant to accept positions in which they will face inappropriate staffing, be confronted by mandatory overtime, inappropriately rushed through patient care activities, and face retaliation if they report unsafe practices.

Solutions

ANA is supporting an integrated state and federal legislative campaign to address the many components of the current and impending nursing shortage. Following are key federal initiatives we hope this Committee will consider.

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. Studies show that when there are more nurses, there are lower mortality rates, shorter lengths of stay, better care plans, lower costs, and fewer complications. 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.

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. ANA's recent survey states that 75 percent of nurses surveyed 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 were a great concern. The public at large should be alarmed that more than 40 percent of the nurses who responded to the ANA survey stated that they would not feel comfortable having a family member cared for in the facility in which they work.

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 these 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 as a condition of participation in the Medicare and Medicaid programs. In addition, we support your efforts to enact upwardly adjustable, minimum nurse to patient staff ratios in skilled nursing facilities. In addition, we support the active implementation of the expert-panel based methodology for nurse staffing and resource management in our Veteran's Affairs Medical Centers.

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. 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 and Medicaid conditions of participation.

I applaud you, Chairman Durbin, for your efforts to develop legislation to ban the use of mandatory overtime through the Medicare Program. ANA endorses this effort because problems arising from mandatory overtime harm patients, nurses and the nursing profession. We also encourage you to work with the Bush Administration to assure that similar overtime protections are enacted for nurses who work in government facilities that are not covered by Medicare law (e.g., VA Medical Centers, the Department of Defense, the Indian Health Service, and prisons).

Whistleblower Protections
In addition, nurses must be able to speak out about quality-of-care problems without fear of retaliation or loss of their jobs. Patient advocacy is the heart of nurse's professional commitment. In turn, patients depend on nurses to ensure that they receive proper care. Patients must be assured that nurses and other health care professionals, acting within the scope of their expertise, will be able to speak for them without fear of retaliation.

Whistleblowing by nurses usually results from concern about issues that jeopardize the health or safety of patients, or occupational safety and health violations that place the employee at risk. Although they are responsible for patient care and well-being, nurses often are powerless when another health care provider performs unethical or life-threatening practices. There have been a number of legal cases involving nurses who have "blown the whistle" on their employers.

Current whistleblowing laws remain a patchwork of incomplete coverage. For example, the False Claims Act contains a whistleblower provision that applies only in cases of fraud of Federal funds. The Emergency Treatment and Labor Act (EMTALA) includes protection for patient advocacy, but only for personnel working in the emergency department of a hospital. The Whistleblower Protection Act of 1989 only applies to federal employees (e.g., VA nurses). This confusing, incomplete coverage leaves many nurses in fear of reprisal. This lack of protection prevents many nurses from taking the risk of trying to protect public health and safety. Reprisal has included dismissal, harassment, and blacklisting. This patient advocacy issue is addressed by a provision in the Bipartisan Patient Protection Act (S. 283, H.R. 526), which ANA strongly supports.

The Emerging Nurse Shortage

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 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 both the Nurse Reinvestment Act (S. 706, H.R. 1436) and the Nursing Employment and Education Development Act (S. 721) as both take important steps in alleviating the growing shortage of nurses. Chairman Durbin, I understand that you are working on legislation that contains many similar education initiatives. The ANA and I support you in these efforts because these programs will help boost nursing school enrollments and will encourage existing nurses to go back to school to increase their levels of education. The combination of scholarships, loan repayments and innovative recruitment techniques contained in these bills are much needed. ANA wholeheartedly agrees with you that the solution to the nursing shortage lies in the further development of our nation's existing nurse population and the cultivation of our youth into this very worthwhile profession.

Immigration
The ANA and I have deep concerns about the use of immigration as a means to address the emerging nursing shortage. As you are well aware, Chairman Durbin, immigration is the standard "answer" proposed 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 and 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.

• 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. In fact, several cases came from Illinois. 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 support better health care for all Americans.

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