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. Certainly, the current and emerging shortage of registered nurses (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. 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 care system.

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 currently experiencing a nurse staffing shortage. 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 the 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 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 shortage, and the answers to the impending shortage are multifaceted. Unfortunately, there is no single cure to what ails nursing.

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 1980s. 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 the issue. Health care institutions across the nation instituted aggressive recruitment campaigns and wages were increased. In fact, average RN wages increased by $4 an hour in the decade between 1983 and 1993 (in constant 1997 dollars). The Division of Nursing's national sample survey shows that the real average annual salary of all RNs employed full-time rose from $17,398 in 1980 to $23,166 in 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. Employment in home health also showed impressive growth.

However, in the mid-1990's the picture changed. During 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 experience 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 decimated 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. Enrollments in four-year nursing schools have dropped by approximately 5 percent per year over the last 6 consecutive years. 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.

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.

At the same time, an alarming number of existing RNs are choosing not to work in nursing. The 2000 National Sample Survey of Registered Nurses shows that a record number of nurses (500,000 nurses - more than 18 percent of the nurse workforce) who have active licenses are not working in nursing. Another national survey commissioned by the Federation of Nurses and Health Professionals reports that 50 percent of all nurses have recently considered leaving direct care positions for reasons other than retirement. Clearly, something in the practice setting is driving these people away.

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. The majority (70 percent) of the respondents work in hospitals or acute care facilities, 50 percent were staff nurses. 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.

This survey reveals that the recent reductions in the RN staffing has 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 current staffing problems are directly related to the reluctance of nurses 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. After all, how many of us would want to work in an environment where we have little to no control over the number of hours that we work, the quality of the work we produce, or the ability to change our work environment?

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 RN staffing is directly related to the incidence of urinary tract infections, pneumonia, shock, upper gastrointestinal bleeding, and increased 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 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. 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 respondents 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, and respond to health care emergencies. It also increases nurse satisfaction and reduces turnover. For these reasons, ANA supports efforts to require facilities to implement and use a valid and reliable staffing plan as a condition of participation in the Medicare and Medicaid programs.

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, delayed responses, failure to respond when appropriate, false responses, slowed thinking, diminished memory and others. 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 that 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. Problems arising from mandatory overtime harm nurses, their patients, and the nursing profession. For this reason, ANA supports legislative initiatives to ban the use of mandatory overtime through Medicare and Medicaid conditions of participation.

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.

In 1989, Congress enacted the Whistle-Blower Protection Act to protect Federal workers. This law was expanded in 1994 to cover workers in veterans' facilities hired under Title 38, as well as government employees. However, current whistleblowing laws remain a patchwork of incomplete coverage. Fear of reprisal and lack of protection prevent many employees 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 S. 283, the Bipartisan Patient Protection Act, 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 nurses. Nationally, 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. The programs included in these bills will help to 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 agrees with the underlying premise of the legislation, which asserts 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.

Conclusion

However, ANA maintains that no matter how many resources are placed into increasing educational opportunities for nurses, the nursing shortage will remain and likely worsen if changes in the workplace are not also 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 supply of high quality nursing care will make great strides in continuing efforts to address the health care needs of all Americans.

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