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Authorizing Safety Net Public Health Programs
Subcommittee on Health
Ms. Linda O'Leary
Good morning Mr.
Chairman and members of the Committee, my name is Linda O'Leary and I am Vice
President and Chief Nursing Officer at Regional Medical Center Bayonet Point in
Hudson Florida. I am pleased to
testify this morning on behalf of the Federation of American Hospitals (FAH) on
the critical issue of the growing healthcare workforce shortage. The Federation is
the national trade association representing some 1,700 privately-owned and
managed community hospitals and health systems providing health care across the
acute and post-acute spectrum. Our
member hospitals provide care for patients in both urban and rural America. At Bayonet Point,
we have a 290 bed acute care facility that is part of a larger hospital system
owned by HCA, Inc. We have adopted a range of activities in my hospital, and at
the corporate level to recruit and retain an adequate supply of RNs and other
caregivers. As the Chief Nursing
Officer I would like to convey my personal experiences in maintaining an
adequate workforce at Bayonet Point, as well as a snapshot of the shortage as a
whole. THE
PROBLEM
The issue of
shortages of nurses and other health care providers, and retention of them
within healthcare facilities, is a growing problem across the country.
In some areas, the crisis is imminent, in others - it has arrived.
Nurses in specialty areas such as operating room nurses, emergency room nurses
and intensive care nurses are in particularly short supply.
The Federation
recently convened an ad hoc task force to assist in gathering information
regarding the depth and breath of the shortage and to solicit its members'
ideas and action plans to address the shortage.
The task force has members from all Federation companies and is composed
of professionals representing a range of specialties within their corporations. Essentially our
member hospitals have told us that:
A new report by
Fitch, IBCA, Duff & Phelps entitled "Health Care Staffing Shortage"
states "The fundamental problem is the decreasing relative supply of nurses in
this country. As of March 2001,
there were 2.7 million licensed registered nurses (RNs) in the U.S., with 2.2
million employed in nursing. .Currently,
80%-85% of hospitals have reported a nurse shortage, and nationwide there is a
10%-12% vacancy rate of nurses in health care facilities." The
American Hospital Association recently completed a survey of more than 700
hospitals across the country. Their
study revealed that "Hospitals have up to 168,000 open positions - 126,000
of those are for registered nurses." Also, according to the survey, 21% of
hospitals have openings for pharmacists, while 18% had unfilled positions for
radiological technologists. The problem will
grow worse as the nursing population ages.
According to the Health Resources & Services Administration (HRSA)
and the American Organization of Nurse Executives (AONE), the average age of
nurses in the year 2000 was 48. (See attached chart #1). According
to the American Nurses Association (ANA) "Approximately 50% of nurses are
entering their 50s, and many will leave the workforce within the next 10 years.
As of 1996, only 9% of nurses were under the age of 30."
The shortage has attracted attention across the country as hospitals
report growing vacancies and their advocates in Washington call for action. The
Federation is certainly not alone in calling for federal assistance in this
area, the American Hospital Association, the American Nurses Association and the
American Medical Association have all issued statements recognizing the extent
of the problem. The job of an RN
has changed over the last twenty years. With
a higher proportion of patients with complex care needs and greater acuity,
there has been an increased demand for nurses with specialized training. Many
nurses entered the profession because of its nurturing nature, patient stays are
now shorter and more care is delivered on an outpatient basis, thus limiting the
nurse-patient relationship. Also,
the increased use of technology demands a different and more advanced skill set.
As you in Congress are well aware hospitals and their staff spend countless
hours dealing with burdensome regulatory requirements and filling out paperwork.
This takes nurses away from the bedside where they belong. There has also
been an expansion of care delivery settings in which nurses can work, thereby
spreading the existing workforce more thinly.
Hospitals are now competing with home health agencies, health maintenance
organizations, pharmaceutical companies, and recruitment firms to hire nurses
and other providers. Of course, while
the job of a nurse has evolved, so too has the field of opportunity for women
who traditionally filled these jobs. Fewer
and fewer young women are entering the nursing profession, and to date there has
been little success in reaching out to men and minorities to join the
profession. According to a study by
Peter Buerhaus, "Policy Responses to an Aging Registered Nurse Workforce,"
women graduating from high school in the 1990s were 35 % less likely to become
RNs than women who graduated in the 1970's. The decline in new
nurse graduates in combination with the rapid aging of the existing pool of
nurses and the aging population paint a picture of health care delivery in
significant stress. The existing workforce shortage is projected to get much
worse. Predictions for workforce employee vacancies are difficult to
nail down, however, the Bureau of Labor Statistics states that 450,000
additional registered nurses will be needed to fill the present demand through
the year 2008. According the
General Accounting Office congressional testimony before the Senate Government
Affairs Committee on June 27, 2001, ".Enrollments in registered nursing
programs have declined over the last 5 years, shrinking the pool of new workers
to replace those who are leaving or retiring.
The problem is expected to be more serious in the future as the aging of
the population substantially increases the demand for nurses."
The
State of Florida I
would like to draw your attention to some specific examples within the state of
Florida in order to illustrate the depth and breadth of the shortage. The
Florida Hospital Association recently released their annual nurse staffing
report which details the extent of the shortage in my state.
Because of the shortage - the survey found that the use of temporary
agencies was reported by 83% of the hospitals surveyed, and that 74% of those
surveyed utilized nurse travelers and 73% used on-call staff.
This is a growing phenomenon. The
survey found that many hospitals used financial incentives including sign-on
bonuses and seasonal bonuses. During
the survey week of February 18th- 24th of this year, the
survey found that 3,087 RN positions were vacant within the
hospitals surveyed. This
represents a 15.6% RN vacancy rate in the hospitals responding. (See
attached chart #2.) The
problem is further detailed by studying the vacancy rates by RN Specialty. (See
attached chart #3) Not
only are we experiencing RN shortages in Florida at a rate of 15.6%, but
hospitals are experiencing a shortage of Pediatric Critical Care nurses at a
rate of 17.1%, Adult Critical Care nurses at 16.8%, and a shortage of
Medical-Surgical nurses at a rate of 17.2%.
These vacancy rates reflect a dramatic increase from rates just a year
ago. The Pediatric Critical Care vacancy rate increased by an alarming 10%. Experts
agree that hospitals are competing with other health care providers for their
workforce. In the state of Florida,
the vast majority of nurses are still employed in the hospital setting - over
59% in the year 2000. The other
practice settings are: 18% in the community/home health arena, 10% in ambulatory
care, 7% in nursing homes, 2% in nursing education and 4% in some other
category. (See
attached chart #4) Bayonet
Point At my hospital, our current vacancy rate for
RN's is between 25 and 27%, which translates into roughly 80 open RN
positions. Currently, I have 14
RN's in specific training courses for specialties such as operating room and
critical care nurses - that number would be double if I could find more nurses
to undergo this training. We have a number
of recruitment efforts underway. HCA
offers tuition reimbursement for all employees who pursue health care careers.
Bayonet Point and seven other hospitals in our area have a new
partnership with Pasco-Hernando Community College.
We have agreed to fund additional teachers in the nursing school and have
purchased the school a full-size mannequin as a teaching tool.
In return, each hospital has the opportunity to provide scholarship money
for up to 25 students at a time. Each
student agrees to work for us for 2 to 3 years in return for the scholarship
money - we have 16 students joining us in August. Another outreach
effort we have underway is educating career counselors at the junior high and
high schools about the field of nursing and opportunities and careers within the
health care field generally. We
have found that many career counselors have little information about the career
paths available. Beyond
recruitment, we must also focus on nurse retention.
Bayonet Point has instituted bonus programs for staff to increase their
working hours and we often modify work schedules to meet personal needs. We offer a variety of pay and incentive practices to meet the
specific individual needs of our workers. One
very important component of retaining nurses is asking their opinion.
We seek out ways to involve nurses in care and treatment options and look
for devices to reduce the difficult physical demands of the profession. The issue we all
face as nurses is that it is a physically demanding profession that requires
night and weekend work. Our nurses
are dealing with an increased acuity level, demanding patients and families and
limited resources. My job as a CNO
is to promote nursing as a rewarding career, listen to my staff, understand
their concerns and work in partnership with them to resolve issues as quickly as
possible. SHORT
TERM SOLUTIONS Nurse
Travelers and Staffing Companies A
side effect of workforce shortages is the development and growth of two staffing
innovations: nurse travelers and nurse staffing agencies across the country.
Although both entities have been in existence for a number of years, new
companies are now recruiting thousands of traveler nurses who work at a facility
for a period of months, weeks or days and then move on.
These nurses travel the country to locations based on pay, specialty,
weather, and whim. According to an
article in The New York Times entitled "Nurse Shortage Puts a Premium
on Staff Agencies", July 17, 2001, "Hospitals paid $7.2 billion last year
for temporary employees, mainly nurses, according to The
Staffing Industry Report, an industry news letter.
And, spending on medical staffing is likely to increase more than 20% a
year, it says, to $8.7 billion in 2001 and $10.6 billion next year." A
number of these traveler companies have begun initial public offerings of their
stock and are doing quite well financially despite the downturn in the stock
market. The industry report states
that traveling nurse companies charge the hospitals between $40 - $50 an hour,
with higher hourly rates in high cost settings.
As an added incentive to become a traveler, these companies frequently
offer other benefits such as paid apartments, liability insurance, and health
benefits for nurses who work a minimum period of time.
An executive from one of the traveling companies based in Boca Raton, FL,
Cross-Country TravCorps, estimated the ranks of traveling nurses have doubled in
the past five years, with 15,000 nurses now crisscrossing the country.
(Washington Post "Ranks of Traveling Nurses Grow" June 7,
2001) Immigration In addition to the
growing utilization of nurse travelers and staffing agencies, a greater number
of hospitals are recruiting their workforce abroad. I wanted to provide the
subcommittee with some background information on the limited opportunities that
we have to recruit and hire foreign nurses.
The main
recruitment vehicle currently is the Labor Department's H1-C visa program.
Regular green card applicant nurses are still coming into the United States, but
at an extremely slow rate. The
Department of Immigration is notorious for lengthy delays and time consuming
processes that significantly slow any sort of regular influx of foreign nurses
into the U.S. During the nursing
shortage in the late 1980s, Congress created a special visa for nurses called
the H-1A visa. Under the government
program, the industry was able to recruit 6,000-7,000 nurses a year; the program
expired in 1995. Since 1995,
Congress has not approved a comparable program.
In fact, in late 2000, it expanded the number of visas that could be
issued to recruit high-tech workers, but it overlooked healthcare.
Congress passed the "Nursing Relief for Disadvantaged Areas Act" in
1999; however, it limits the number of foreign RNs to 500 per year. This
legislation amended the Immigration and Nationality Act to establish a four-year
nonimmigrant classification (H-1C) for nonimmigrant registered nurses in health
professional shortage areas. The
program was created as a temporary, limited solution and will expire in 2003.
The "Nursing
Relief for Disadvantaged Areas Act" permits up to 500 foreign nurses to work
in the U.S. per aggregate fiscal year. To
qualify, hospitals must have at least 190 acute care beds, be located in
federally designated areas with health care worker shortages, and meet
thresholds on Medicare (35%) and Medicaid patient mix (28%.)
Hospitals are also limited in how many nurses they can hire under this
program based on the size of the state. According
to the Department of Labor, only 14 hospitals benefited from this program. The
law directs the Secretary of Health and Human Services to recommend 1) and
alternative to the H-1C program as a permanent remedy to the registered nurse
shortage; and 2) a more effective program enforcement system. As mentioned
above, there is some confusion regarding the H-1B Visa which was created to
permit skilled foreign professionals to work in the U.S. for a period of up to
six years. The H-1B Visa is also
employer specific and is for "professional positions."
Such positions are defined as specialty occupations that require critical
and practical application of a body of highly specialized knowledge.
Many medical and health occupations meet this definition, but foreign
nurses are only eligible for H-1B status if the position would typically be
filled by a nurse in a supervisory or research position.
Due to the nursing shortages HCA hospitals are facing, Dr. Frank M.
Houser, M.D., HCA's Senior Vice President, Quality, and Corporate Medical
Director, just returned from travel to India in an effort to recruit nurses to
work in our hospitals. However, as
illustrated above, the opportunities for international recruitment are extremely
limited because of existing immigration laws.
The United States is also increasingly competing for nurses with other
countries. For example, British hospitals, with the aid of their government,
have already gotten a competitive advantage. Their recruitment offers include no
visa requirements for degreed critical care Indian nurses willing to relocate to
British hospitals. LEGISLATIVE
POSSIBILITIES FOR THE LONG TERM Federation
members have undertaken a wide range of innovative activities in order to
recruit qualified nurses. But the
problems of the shortage are so vast and complex that we are looking to Congress
and the Administration to foster current activities, as well as provide support
for further development and funding of nursing recruitment, education and
retention. As
you know Mr. Chairman, a number of pieces of legislation have been introduced
that attempt to increase the numbers of individuals entering the nursing field,
by assisting with education and training, and also with retention of trained
health care staff. Broadly, the
Federation supports legislation that seeks to improve the following areas: ·
Recruitment - We believe that federal leadership to
promote and enhance the image of nursing would be very helpful.
Many Federation members are already reaching out within their local
communities to advance the public image of the profession, but increased federal
attention to the critical role nurses play in our health care delivery system is
key. ·
Faculty - We recognize that in order to ensure a steady
supply of the most qualified nurses we need to ensure the development and
support of nursing faculty. Greater
financial support of nursing programs is also important to ensure an adequately
trained workforce. ·
Community Outreach - We support federal grants that
would foster innovative community/private partnerships in shortage areas.
Examples of activities already undertaken by Federation members include
outreach to vocational programs, partnering with nursing programs and providing
sites for clinical rotations. ·
Nurse Service Corps - The Federation supports the
development of a nurse service corps that would allow loan repayment for nurses
that serve in shortage areas/facilities. Recruits
for this program should be able to provide patient care in a wide range of
settings irrespective of tax status. ·
Immigration - Federal leadership to increase
recruitment of nurses is critical, but just as critical is modifying immigration
laws to allow more nurses to come to the United States from abroad.
Current immigration laws severely limit the number of nurses who can be
recruited internationally. Further
slowing down the process is the Department of Immigration and Naturalization
Services which delays legal immigration for months at a time.
We ask Congress to review the current visa programs for nurses and
consider expanding the existing H-1C visa program and/or reauthorizing the H-1A
program. Immigration reform could
help alleviate some of our staffing shortages in short order. Specifically,
members of this Committee have introduced legislation that would attempt to
increase the numbers of workers entering the nursing workforce and provide
opportunities and incentives to alleviate the shortage.
The "Nurse Reinvestment Act" -- H.R. 1436 was introduced by
Representatives Lois Capps (D-CA) and Susan Kelly (R-NY).
This legislation would foster community partnerships and innovative
programs for recruitment. The bill
would also develop a national nurse service corps.
We believe that this legislation has many valuable ideas and could serve
as a starting point, however it falls short because it does not ensure that
nurses could work in the facility of their choice. Specifically, all Federation
member facilities would be excluded from using the Nurse Service Corps, as well
as the other sections of the bill. We would like to work with Representative
Capps and Kelly to amend the legislation to ensure that their creative solutions
to the workforce crisis are helpful to all hospitals. The other promising piece of legislation introduced by members of this Committee is the "Nurse of Tomorrow Act of 2001" H.R. 1897 introduced by Representatives Eliot Engel (D-NY) and Mary Bono (R-CA). HR 1897 would authorize the Secretary of HHS to make grants to health care facilities for nurse recruitment and retention activities, as well as encourage facilities to assist in nurse education and training. The bill also establishes refundable tax credits for nurses. The Federation supports the ideas embodied in HR 1897, and applauds the bill's sponsors for including all facilities in their legislation. CONCLUSION CNO's
are a passionate lot who firmly believe in the profession of nursing.
They work continuously to support their staff and to provide them with
the tools they need to deliver care. I
have been a nurse for over 30 years and, frankly, cannot imagine doing anything
else. Federation members and all healthcare facilities are facing a workforce
crisis. Our hospitals are on the front lines of delivering patient
care, but our most precious resource, our workers are in very short supply.
We look forward to working with Congress and the Administration to
attempt to solve this complex and growing problem.
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