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 delivery system, and to its largest integrated health care system - the Veterans Health Administration (VHA). Registered nurses comprise the largest health care workforce in the nation, and the VA has the largest nursing workforce in the world. The 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 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, workforce projections show that the current shortages are just a minor indication of the systemic shortages that will soon confront our health care delivery system. 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.

It is important to realize that the causes, and therefore the answers, to the new nursing shortage are complex and interrelated. It is critical to examine issues in the work environment, education, and health delivery systems. 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 nurse satisfaction issues are inexorably tied to changes in nurse employment practices over the last decade. A quick review of nursing workforce data shows that we have been directly impacted by the turmoil that has typified the health care sector for the last decade. Throughout our entire health care system, innovative methods of cost containment were the hallmark of the 1990's. New models of health care delivery were implemented in our health care facilities, and highly-trained, experienced - and therefore higher paid - personnel were often 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, which had previously been growing in the hospital sector, reversed to the negative. In addition to reducing staff nurses, many providers eliminated positions for nursing middle managers and executive level staff.

As you are aware, the VHA has also undergone major restructuring. Since 1995, its has downsized inpatient capacity and while adding 350 additional care sites. Today, the VHA provides health care to more than 500,000 additional veterans with 25,000 fewer employees that it did just six years ago. In addition, the amount spent per patient has been cut by 24 percent. Much like the rest of the private health care system, VA nurse have been directly impacted by these changes. For instance - in the five years between September 1995 and September 2000, the VA cut ten percent of its total RN positions.

The Current Employment Situation

It is increasingly evident that the changes in the RN employment environment over last decade have precipitated a downturn in the number of people choosing to work 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 disturbingly large number of nurses (500,000 nurses - more than 18 percent of the national 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 currently employed 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 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. Nurses in VA medical centers in particular are being confronted by staff downsizing, increased patient acuity, shorter hospital stays, bed closures, and flat-lined budgets. These changes have caused such a deterioration in the work environment that nurses are opting not to accept staff nurse positions. Hence the increasing staff vacancy rate being reported by the VHA as well as private health care providers. 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 supports an integrated state and federal legislative campaign to address the current and impending nursing shortage. Many of these solutions are directly applicable to the VHA. Following are key federal initiatives we hope this Committee will consider.

Overtime
Nurses across the nation are expressing deep concerns about the dramatic increase in the use of mandatory overtime as a staffing tool. ANA hears that overtime is the most common method facilities are using to cover staffing insufficiencies. Employers may mandate 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. 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, 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 an error that a nurse who is not being required to work a 16 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. ANA is seeking relief from the use of mandatory overtime in the private sector through Medicare provider contracts.

Currently, the VHA does not have a nationwide policy on mandatory overtime, nor does the VA collect nationwide statistics on the use of mandatory overtime. Recent increases in overtime costs, however, do substantiate what ANA and the UAN have been hearing - that mandatory overtime is being used regularly and routinely. Reports show that the VA nearly doubled its annual overtime costs in the three years between 1997 and 2000. These reports are disturbing and they highlight the need to address the abuse of mandatory overtime in our VA medical cneters. The practice could be halted by an executive order, through regulatory action within the VHA, or through federal legislation.

Adequate Staffing
Of course the use of mandatory overtime is a symptom of a larger problem, inappropriately low nurse staffing. ANA has long held that 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 where 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 (Nurse Staffing and Patient Outcomes in Hospitals, released on April 20, 2001) found strong and consistent evidence that increased RN staffing is directly related to the decreased incidence of urinary tract infections, pneumonia, shock, upper gastrointestinal bleeding, and shorter 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. 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. The VHA, much like private health systems, continues to struggle with the development of valid, reliable and implementable nurse staffing guidelines. In 1985, the VA developed nurse staffing guidelines. These were then suspended in the mid-90's and a new methodology was developed. This new expert-panel based methodology for nurse staffing and resource management has been implemented to varying degrees of success across the 173 medical centers. In the best cases, expert panels consisting of shift supervisors, nurse administrators, staff nurses and union representatives meet on a regular basis to make recommendations on nurse staffing needs. These panels investigate variables ranging from nurse experience levels, patient acuity trends, census data, use of overtime, and changes in administrative workloads to determine nurse staffing needs. Recommendations are then made through the nurse executive.

ANA supports this model, and we urge this committee and the VHA to urge all of the medical centers to implement the expert-panel methodology or a comparable system. As my colleague from Florida will attest, one of the main components of the magnet hospital designation, and one of the chief indicators of nurse satisfaction, is the ability of the staff nurse - the individual who provides direct patient care - to have meaningful input into staffing and other patient care determinations. When implemented properly, the expert panel methodology provides an excellent opportunity for this communication.

Education Support
ANA applauds the VHA for its recent change in the nurse qualification standard. This new standard makes a BSN (bachelors of science in nursing) a criteria for promotion. The ANA supports efforts designed to make the BSN the standard for entry into nursing practice. The increasing acuity of today's patients, combined with shortened lengths of stay and decreased staffing requires all nurses to be as clinically prepared as possible. ANA is particularly pleased by the National Nursing Education Initiative (NNEI) which provides scholarships for RNs in the VHA who return to school to attain baccalaureate and advanced degrees. Nurses in the NNEI are eligible for a maximum of $20,000 in scholarship funds. In return, nurses in this program must meet a service obligation. For instance, a full-time student must agree to serve as a full-time VHA employee for a period of one calendar year for each year of school or part thereof for which a scholarship has been granted.

To date, more than $50 million has been obligated under NNEI. There are a total of 1427 participants in the program; 67 percent are enrolled in baccalaureate programs and 30 percent are in advance degree programs. Six nurses in the Martinsburg facility have enrolled in RN to BSN program. In addition, our first application for enrollment in a Masters Program has just been approved. I am thrilled that these nurses are able to take this opportunity to further their education, and I urge this Committee to be vigilant in ensuring that the promise of continuing education is maintained.

With that said, I would be remiss if I did not point out the few bugs in this new education initiative that need to be addressed. As current staff nurses are being evaluated and promoted on basis of their educational preparation, it is important that they be able to take the time needed to further their education. I am disturbed by reports that staff nurses who would like to continue their education are being told that their facility can not schedule the time off that they need to attend school. Certainly it was not the intent of this program to base nurse promotions on educational attainment, while at the same time placing barriers to their education.

The NNEI does contain a provision that allows a medical center to pay a "replacement salary" to hire a new (typically temporary) staff nurse to carry out the duties of an employee who is unavailable while pursing full-time education or training. However, funding for these replacement salaries is conspicuously absent from the NNEI, and the responsibility to find funding has been left to the Facility Director. Nurses in facilities where the Director can not or does not locate funds needed for replacement workers will continue to be disadvantaged until this problem is remedied.

Locality Pay
As this Committee is very well aware, the Veterans Benefits and Health Care Improvement Act (P.L. 106-419) was signed into law last year. ANA strongly supports this law which makes a number of significant changes to the old nurse locality pay system. The new system requires Facility Directors to use third-party industry wage surveys in making such adjustments and authorized the Department's Under Secretary for Health to modify any adjustment determination made by an individual Facility Director. It also requires the Secretary to report annually to this Committee on the staffing of covered positions and on pay adjustments.

ANA urges this Committee to remain vigilant in your oversight of these programs. It is too early to evaluate the effectiveness of this new system, but a few potential problem areas have already emerged. For instance, it may be difficult to obtain accurate wage surveys because most private facilities deem this information proprietary. Additionally, the B.S.N. requirement discussed above makes the VA staff nurse population significantly different than those found in many private facilities.

ANA is concerned that there may not be an appropriate mechanism for gathering the information needed to update VA nurse executive compensation. In addition, ANA maintains that nurse practitioners should qualify for the enhanced program of specialty pay that the VHA offers physicians and dentists (as authorized under Subchapter III of Chapter 74, 38 U.S.C.). We look forward to working with you on these important issues.

Conclusion

In closing, I would like to reiterate the point that the problems that the Veterans Health Administration is experiencing with nursing recruitment and retention will remain and likely worsen if changes in the workplace are not addressed. In fact, the profession of nursing as a whole will be unable to compete with the myriad of other career opportunities available in today's economy unless we improve working conditions across the board. We must strive to make direct care an attractive vocation for our high-caliber RNs. Nurses, 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 will have to begin by improving the environment for nursing.

ANA looks forward to working with you, and our health care provider and union 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 your continuing efforts to address the health care needs of America's veterans.

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