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Authorizing Safety Net Public Health Programs
Subcommittee on Health
Ms. Diana Baker RN, BS
Good morning Mr. Chairman and Members of the Subcommittee. I am Diana Baker, RN, an assistant nurse manager on the urology/gynecology unit at the Cleveland Clinic in Cleveland, Ohio. I am pleased to be here today representing the American Nurses Association (ANA) in support of 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 RNs. I am a member of the Ohio Nurses Association, one of the 54 constituent member nurse associations of the ANA. 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. The Nurse Education Act programs administered through the Division of Nursing at the Health Resources and Services Administration are designed to ensure an adequate supply of nurses in under served areas throughout the nation. These programs have greatly impacted the nurse workforce and have enjoyed substantial Congressional support. Building on these programs is the best way to address the concerns that we have all been hearing about the growing nursing shortage. The extent of the concern about this emerging shortage underscores the fact that having a sufficient number of qualified nurses is critical to the health of our nation. ANA can assure you that 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 and the impending shortage are multifaceted. Therefore, we must approach this shortage from many fronts. The Emerging Nurse Shortage The current nursing 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 until 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 is expected to 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 (S. 706, H.R. 1436), which was drafted by a member of this Subcommittee - Representative Lois Capps, a fellow nurse. This comprehensive bill addresses many issues in nurse education and will greatly aide recruitment into the profession. It enjoys the broad support of practicing nurses throughout the nation as well as institutional providers and educators. The Nurse Reinvestment Act contains funding for public service announcements to educate the public about the many rewards of a nursing career. It supports grants for health career academies to create partnerships between health care facilities, nursing schools, and high schools to introduce high school students to nursing curriculum. The bill provides nursing recruitment grants to support outreach programs in primary, junior, and secondary schools and to support nursing students. It establishes a new nurse corps to provide educational scholarships in exchange for commitment to serve in a health facility determined to have a critical shortage of nurses. It supports career ladder grant program to assist individuals, health care providers and schools of nursing to enable the nursing workforce to obtain continuing education - and, importantly, fosters the development of nursing faculty needed to teach these students. It directs the Secretary of HHS to establish rules for making payments to non-hospital-based, federally certified hospice programs and home health agencies for the reasonable costs of providing nurse training, and reauthorizes and modifies the federal Medicaid match for nursing home clinical education of nurses. The comprehensive combination of innovative recruitment techniques, curriculum support, scholarships, and loan repayments will enhance all aspects of nurse education. ANA wholeheartedly agrees 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. Recent Changes in Nurse Employment In addition to enhanced nurse education programs, ANA urges this Subcommittee to take a deeper look into nurse workforce issues. It is important to realize that demographics are not the only cause for the emerging nursing shortage. 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. By the early 1990's reports of nurses shortages had significantly diminished. Unfortunately, the picture changed abruptly in the mid-1990's. At this time, managed care began to exert downward pressure on provider margins. In addition, the impact of Medicare prospective payment was taking hold. In response to financial pressures, 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. 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 Current Employment Situation These recent changes in nurse employment served to increase the 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. Numerous studies reveal that these 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. Not surprisingly, these changes have precipitated the current downturn in the number of people choosing the nursing profession, and growing discontent among those who remain. A recent ANA survey 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 that when I was a nursing student, working nurses would approach me and advise me to find another career - a clear sign of dissatisfaction. 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. 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. It is a sad fact that staff nurses typically burn out and leave hospital bedside nursing after just four years of employment. This discontent is prompting an alarming number of our experienced RNs to abandon nursing. The 2000 National Sample Survey of Registered Nurses shows that a large number of nurses (500,000 nurses - more than 18 percent of the total nurse workforce) who have active licenses are not working in nursing. Clearly, something in the practice setting is driving these nurses away from their chosen profession. 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, inappropriately rushed through patient care activities, and unable to provide the high quality care that we were trained to give. Solutions ANA is supporting an integrated state and federal legislative campaign to address the many components of the current and impending nursing shortage. Key among these is strong support for recruitment and education initiatives such as the Nurse Reinvestment Act. In addition, we are also supporting improvements to organization of the work of nursing. ANA understands that in addition to attracting more young people to the profession, we must also create a environment that fosters the retention of our experienced nurses. Following are two workplace 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 the 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 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 efforts to enhance the current minimum nurse-to-patient staff ratios in skilled nursing facilities. Mandatory Overtime ANA is concerned that nurses across the nation are expressing concerns about the dramatic increase in the use of mandatory overtime as a staffing tool. ANA understands 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. Concerns about the use of mandatory overtime are directly related to patient safety. It is well established 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 highlights the fact 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 we know could harm patients. At the same time, RNs face the loss of their license - our 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 provider agreements. I can tell you that I have made the personal decision not to use mandatory overtime to meet staffing needs in my unit because I believe that it fosters an environment rich for medical error and contributes to nurse turnover. My experience as a staff nurse and an assistant nurse manager has taught me that mandatory overtime is not a safe or viable staffing option. Conclusion ANA and I encourage this Committee to act now to support the Nurse Reinvestment Act. The very fabric of our safety net programs rely on an adequate supply of well-trained nurses. We can not stop there, however. The fact is that the current nursing shortage will remain and likely worsen if changes to 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. 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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