Good morning, Mr. Chairman and Members of the Committee. My name is Kathryn Hall, I am a certified cardiac care nurse. I currently serve as the Executive Director of the Maryland Nurses Association and Project Director for the Maryland Colleagues in Caring Project. I am here today representing all of the members of the American Nurses Association (ANA) and Maryland Colleagues in Caring to offer support for your efforts to improve the recruitment and retention of America's registered nurses (RNs). ANA is the only full-service association representing the nation's registered nurses through its 53 state and territorial member nurse associations.

Health care providers across the nation are experiencing a crisis in nurse staffing, and we are standing on the precipice of an unprecedented nursing shortage. I am pleased to see that this Subcommittee has acted so quickly to gather information on nursing workforce issues. 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.

Today, hospitals, long term care facilities and other health care providers across the nation are experiencing a nurse staffing shortage. Employers are having difficulty finding experienced nurses, especially in emergency room, critical care, Labor and Delivery, and long term care who are willing to work in their facilities.

The examples from the current staffing shortage are indeed striking:

• In November, 2000, 10 percent of the surgical beds at Johns Hopkins Hospital went idle as a direct result of the nurse staffing shortage - causing delays and cancellations of surgeries.
• In August, 2000, the Maryland Hospital Association reported that nearly 15 percent of the nursing jobs in that state were vacant - up 33 percent from January of the same year.
• The Water View Health Care Facility is a long term care facility in Salisbury, Maryland that is licensed for 150 beds. Due to staffing shortages, Water View is currently only filling 50 of these beds.
• At a recent meeting of the Maryland Commission on the Crisis in Nursing the Director of Nursing at one of the states largest long term care facilities indicated that she spends one to two hours out of each day dealing with the issue of staffing and "holds her breath" when the phone rings.
• Recently, 54 of the 102 members of the Arkansas Hospital Association responded to a nurse staffing survey. These hospitals reported 752 budgeted, vacant RN positions. Projections from the Arkansas Nurses Association show that there will be no more than 657 students graduating from Arkansas nursing schools in 2001.

Many providers are particularly hard-hit by today's staffing shortage because they had already cut their RN staff to the bare minimum. During the past decade, many acute care providers have implemented aggressive measures to reduce the costs of health care. As nurses salaries typically represent 20 percent of the average hospital budget, they have been targeted for aggressive cuts. In fact, as recently as the mid-90's many RNs were being laid off from hospitals in order to be replaced by lower-salaried assistive personnel. These changes have occurred at the same time that the patient acuity has increased, the use of sophisticated technology has increased, and the length of stay has decreased. Therefore, fewer nurses are being asked to care for an increased number of sicker patients with greater health care needs.

The reductions in the RN workforce have, in turn, 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. As a professional who has worked as a staff nurse as well as a nurse administrator, I know that the current staffing problems are directly related to the reluctance of nurses to accept positions where they will not be supported by appropriate staff, confronted by mandatory overtime, inappropriately rushed through patient care activities, and unable to report unsafe staffing practices. These problem are compounded by an increasing number of nurses who are retiring and a shrinking pool of new nurses. 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 produced, or the ability to change our work environment?

Preliminary information from the national sample survey of RNs that will be released tomorrow shows that there are nearly 2.7 million registered nurses in America, but more than 18 percent are not working in nursing. We must ask ourselves why these people have left their chosen profession? How can we attract them back?

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. One recent multi-state study documented that five adverse outcomes measures (hospital length of stay, pneumonia contracted while in the hospital, postoperative infection, bed sores and urinary tract infections) are significantly decreased with higher RN staffing levels.

Maryland and ANA national have heard strongly, repeatedly, and unequivocally that nurses are concerned that hospital nurse staffing is inadequate to provide quality care. Several studies have shown that one of the primary factors for the increasing nurse turnover rate is workload/staffing.

An ANA survey released just last week 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.

Nurses across the nation are also expressing concerns about the dramatic increase in the use of mandatory overtime as a staffing tool. Today, overtime is the most common method facilities are using to cover staffing insufficiencies. Many nurses contend employers insist they 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 and subsequently to staff 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.

Nurses are placed in a unique situation when confronted by demands for overtime. We are ethically bound to refuse to engage in behavior that we know could harm our patients. At the same time, we face the loss of our license - our careers and our 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.

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.

Whistle-blowing 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 particular, nurses have been instrumental in identifying violations of research standards and refusal of care to newborns.

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 corporation employees. However, current whistle-blowing 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.

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. In Maryland, the average practicing RN is 46 years of age, and the average nursing faculty member is 48. 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 an even more critical 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. There are good programs in place at the Health Resources and Services Administration within the Department of Health and Human Services that can help advert these dire predictions and infuse RNs into the areas of the country hardest hit by the nurse staffing shortage. For instance, the Nursing Education Loan Repayment Program provides up to 85 percent loan repayment for undergraduate RN education as well as advanced practice nurses (masters and above) who agree to work for at least 2 years in an eligible health facility identified by HHS as having a critical shortage of nurses (e.g., community health centers, migrant health centers, rural health clinics, certain public hospitals, Indian health service centers). This essential student support enables individuals who might not have otherwise entered nursing to make major contributions to health care. Recent reports show that roughly fifty percent of all applications made for loan repayments are denied due to a lack of funds. ANA and a number of other nursing organizations support increasing funding for the nurse education loan repayment program to $10 million in FY 2002.

The Colleagues in Caring nursing workforce project in Maryland just completed a survey of students in the first and last year of their nursing programs. These students reported that the number one barrier entering school and continuing their education was the ability to secure funds for school while balancing their home and work requirements. Many senior students were deeply concerned about the large loans they would be facing upon graduation.

We also support the expansion of programs operated under the Nurse Education Act (NEA). The NEA programs provide competitive grants to schools of nursing, academic health centers, nursing centers, state and local governments and other public or private nonprofit entities to strengthen programs that provide nurse education. Unfortunately, lack of funding and constraints within the current NEA funding methodology have kept HRSA from funding programs such as scholarships for disadvantaged nursing students. The HRSA Division of Nursing reports that it will not even hold a competitive grant cycle for nurse stipend and pre-entry programs this year due to a lack of funds. ANA and a number of other nursing organizations support efforts to increase funding for the activities of the NEA by $25 million.

We also encourage you to support us in granting the Division of Nursing the operational flexibility needed to target these funds to areas where the nursing shortage is most acute. Currently, the NEA funding methodology requires approximately 75 percent of all appropriated funds to be used for advanced practice nursing programs. While the ANA certainly supports training opportunities for nurse midwives, nurse practitioners and clinical nurse specialists, we understand that the most pressing need will be for entry-level, direct-care nurses. We also understand that most advanced practice nurses are drawn from this very same population.

Thank you for the opportunity to testify before your Subcommittee. Now is the time to address the myriad of issues causing the current staffing shortage and the impending nurse shortage. We must begin by improving the environment for nursing. Until we address issues such as inappropriate staffing, mandatory overtime and whistle blower protections, facilities will continue to experience staffing shortages. Conversely, efforts to recruit young people into nursing will be fruitless if new RNs choose not to work in areas that are experiencing staffing shortages.

The ANA and I look 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 advert the impending nursing shortage. The resulting stable supply of high quality nursing care will make great strides in your continuing efforts to address the needs of our aging population.

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