U.S. GOVERNMENT PRINTING OFFICE

WASHINGTON : 

For sale by the Superintendent of Documents, U.S. Government Printing Office

Internet: bookstore.gpo.gov Phone: toll free (866) 512–1800; DC area (202) 512–1800

Fax: (202) 512–2250 Mail: Stop SSOP, Washington, DC 20402–0001

91–887PDF 2005

) FOR VA’S NURSING SHORTAGE: IS THERE

MORE THAN ONE ANTIDOTE?

HEARING

BEFORE THE

SUBCOMMITTEE OVERSIGHT AND INVESTIGATIONS

OF THE

COMMITTEE ON VETERANS’ AFFAIRS 

HOUSE OF REPRESENTATIVES

ONE HUNDRED EIGHTH CONGRESS

FIRST SESSION

OCTOBER 2, 2003

Printed for the use of the Committee on Veterans’ Affairs

Serial No. 108–25

(
COMMITTEE ON VETERANS’ AFFAIRS 

CHRISTOPHER H. SMITH, New Jersey, Chairman 

MICHAEL BILIRAKIS, Florida 

TERRY EVERETT, Alabama 

STEPHEN E. BUYER, Indiana 

JACK QUINN, New York 

CLIFF STEARNS, Florida 

JERRY MORAN, Kansas 

RICHARD H. BAKER, Louisiana 

ROB SIMMONS, Connecticut 

HENRY E. BROWN, JR., South Carolina 

JEFF MILLER, Florida 

JOHN BOOZMAN, Arkansas 

JEB BRADLEY, New Hampshire 

BOB BEAUPREZ, Colorado 

GINNY BROWN-WAITE, Florida 

RICK RENZI, Arizona 

TIM MURPHY, Pennsylvania 

LANE EVANS, Illinois 

BOB FILNER, California 

LUIS V. GUTIERREZ, Illinois 

CORRINE BROWN, Florida 

VIC SNYDER, Arkansas 

CIRO D. RODRIGUEZ, Texas 

MICHAEL H. MICHAUD, Maine 

DARLENE HOOLEY, Oregon 

SILVESTRE REYES, Texas 

TED STRICKLAND, Ohio 

SHELLEY BERKLEY, Nevada 

TOM UDALL, New Mexico 

SUSAN A. DAVIS, California 

TIM RYAN, Ohio

PATRICK E. RYAN, Chief Counsel and Staff Director 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS 

STEPHEN E. BUYER, Indiana, Chairman 

MICHAEL BILIRAKIS, Florida 

TERRY EVERETT, Alabama 

JOHN BOOZMAN, Arkansas 

DARLENE HOOLEY, Oregon 

LANE EVANS, Illinois 

BOB FILNER, California 

TOM UDALL, New Mexico

(II) 
(III)

C O N T E N T S 

October 2, 2003

Page

) For VA’s Nursing Shortage: Is There More Than One Antidote? .................... 1

OPENING STATEMENTS 

Chairman Buyer ...................................................................................................... 1

Prepared statement of Chairman Buyer ........................................................ 41

Hon. Darlene Hooley ............................................................................................... 2

Hon. John Boozman ................................................................................................. 12

Hon. Tom Udall ....................................................................................................... 14

WITNESSES 

Blakeney, Barbara A., President, American Nurses Association ........................ 17

Prepared statement of Ms. Blakeney .............................................................. 79

Converso, Ann, Vice President, United American Nurses ................................... 22

Prepared statement of Ms. Converso .............................................................. 113

Foley, Regina, Vice President of Nursing and Chief Nurse Executive, Ocean 

Medical Center, Brick, NJ ................................................................................... 32

Prepared statement of Ms. Foley .................................................................... 123

Janzen, Sandra K. Associate Chief of Staff, Nursing, James A. Haley Veterans’ Hospital, Tampa, FL ................................................................................. 6

Prepared statement of Ms. Janzen ................................................................. 72

Myers, Sarah, Immediate Past President, Nurses Organization of Veterans’

Affairs .................................................................................................................... 20

Prepared statement of Ms. Myers ................................................................... 109

Novak, Julie C., Head, School of Nursing, Purdue University ............................ 29

Prepared statement of Ms. Novak ................................................................... 116

Raymer, Mary C., Nursing Education Program Manager, Health Care Staff 

Development and Retention Office, Department of Veterans Affairs, New 

Orleans, LA ........................................................................................................... 8

Prepared statement of Ms. Raymer ................................................................ 75

Rick, Cathy J., Chief Nursing Officer, Department of Veterans Affairs ............. 4

Prepared statement of Ms. Rick, with attachments ...................................... 43

MATERIAL SUBMITTED FOR THE RECORD 

Kit: 

Handle with Care submitted by American Nurses Association .................... 87

Statements: 

American Association of Nurse Anesthetists (AANA) ................................... 128

National Association of Clinical Nurse Specialists (NACNS) ....................... 133

Sarah Atkins, RN, MS, OCN, American Federation of Government Employees (AFGE) .............................................................................................. 135

American Association of Critical-Care Nurses ............................................... 147

National Association of Orthopaedic Nurses .................................................. 153

Study: 

University of Pennsylvania’s School of Nursing Study, submitted by Ms. 

Cathy Rick ..................................................................................................... 50

Written committee questions and their responses: 

Chairman Buyer to Department of Veterans Affairs .................................... 155

Chairman Buyer to American Nurses Association ........................................ 159

Chairman Buyer to United American Nurses, AFL-CIO .............................. 161
Page

IV

Written committee questions and their responses—Continued

Chairman Buyer to Ocean Medical Center .................................................... 164, 167, 169

Congresswoman Hooley to Ocean Medical Center ......................................... 167, 169, 170

Congressman Boozman to Ocean Medical Center ......................................... 169
(1)

) FOR VA’S NURSING SHORTAGE: IS THERE 

MORE THAN ONE ANTIDOTE? 

THURSDAY, OCTOBER 2, 2003

U.S. HOUSE OF REPRESENTATIVES, SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATIONS, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC 

The subcommittee met, pursuant to notice, at 10:01 a.m., in room 

334, Cannon House Office Building, Hon. Steve Buyer (chairman of 

the subcommittee) presiding. 

Present: Representatives Buyer, Bilirakis, Everett, Boozman, Filner, Hooley, and Udall. 

OPENING STATEMENT OF CHAIRMAN BUYER 

Mr. BUYER. I am going to go ahead and start the hearing, even 

though all members are not here. I will go ahead and read the 

statement. 

The Subcommittee on Oversight and Investigations of the Committee on Veterans’ Affairs will come to order. 

In today’s hearing, we hope to learn how the VA is addressing 

its current nursing shortages and what steps the Department is 

taking to address a potential exodus that could occur over the next 

few years. 

According to the VA, 35 percent of its registered nurses are eligible for retirement by year 2005. If the VA does lose one-third of its 

36,000 RNs, where does that leave the veterans who will be in dire 

need of care? 

Because the VA has an aging population which will require more 

complex care from highly skilled professional nurses, we cannot ignore what is in front of us. 

On Monday, September 29, 2003, the American Health Line reported that ‘‘Historically, high nursing shortages have created a 

game show-like frenzy among hospitals, which are offering sign-on 

incentives, such as vacations, vehicles, massages, concierge services, free tuition for nurses and their children, and bonuses of up 

to $10,000.’’

It is easy to surmise from this that there are indeed too few 

nurses available to fill hospital vacancies, nursing homes and other 

needs at specialty clinics, but also to fill the need at the VA. 

Statistics certainly tell us this is the case, according to the National Conference of State Legislatures’ health policy tracking service, which was last updated on April 1, 2003, that found the number of full time equivalent nurses was 1.89 million in 2000. This 

represents a nursing shortage of 110,000, or 6 percent. It is esti-
2

mated that by year 2015, the demand will increase and the shortage will almost quadruple, to 20 percent. 

What we are looking for here today is not just a discussion about 

the problem, but what are the solutions to these problems facing 

our health care organizations. 

Earlier this year, I visited a VA hospital in Tampa, FL, the 

James A. Haley Hospital. While at that facility, I learned that it 

had achieved Magnet status. When I asked ‘‘What does that 

mean?’’ I was told that receiving such a designation represented 

the highest level of recognition that the American Nurses 

Credentialing Center can grant to a health care organization. 

Harvey Holzberg, President’s staff, Robert Wood Johnson University’s Hospital, said ‘‘We believe the quality of nursing is the key 

to our hospital’s success. Receiving the Magnet award is the highest formal recognition testimonial to that quality . . .the award 

was recognized by the entire hospital family as a formidable accomplishment on the part of our nurses.’’

Please note I did not say there are not enough RNs. What I am 

saying is that individuals with their RNs are leaving the profession 

in search of more lucrative and less demanding work. Major reasons include not only burnout, but the work climate, work satisfaction, patient quality of care, and managerial support. The Magnet 

program addresses many of these concerns. 

To sum it up, the purpose of today’s hearing is to find out two 

things in particular: the extent of the problem, and what is a potential solution that the VA should turn to to attract recent nursing graduates. 

I would also like to thank the American Association of Nurse Anesthetists and the National Association of Clinical Nurse Specialists for submitting statements, and they shall be entered into the 

record. 

(See pp. 128 and 133.) 

Mr. BUYER. I now recognize the ranking member for any comments she may have. 

OPENING STATEMENT OF HON. DARLENE HOOLEY 

Ms. HOOLEY. Thank you, Mr. Chair. 

America faces a critical nursing shortage, and the shortage has 

many causes. There is a shortage in the number of trained and 

qualified nurses actively engaged in their profession. There is a 

shortage of recognition for the dedicated work of our nurses. There 

is a shortage of interest in gaining admission to America’s nursing 

programs. 

HHS determined that graduations for our nursing schools have 

shown a steady rate of decline, 26 percent for the 5 year period 

ending in 2000. Why? A projected shortage of more than 800,000 

registered nurses is forecast by 2020. There is a decline in interest. 

Is it less cool today to be a nurse? Nursing is demanding work. 

Nursing is gratifying work. Nurses are sometimes taken for granted. Nurses are sometimes overlooked as stakeholders contributing 

to the management of both their patients and their organizations. 

Nationally, we must make every effort to assure the health of the 

nurse training pipeline. Are our nurse training facilities modern 
3

and are they staffed with adequate numbers of qualified instructors? 

There are today indications that a shortage in qualified nurse instructors is but one hurdle that must be overcome to assure the 

adequacy of America’s nurses corps. 

As the committee of jurisdiction for the Department of Veterans 

Affairs, this domestic shortage of nurses is of great concern. We 

must not only seek solutions to this crisis on a national level, we 

must make every reasonable effort to authorize and encourage VA 

to compete for quality nurses in a tight market. 

Once we look at the root cause of this decline nationally, we will 

be able to better determine the possible solutions, and what action 

is necessary to generate greater interest in a career in nursing. 

Many ideas and programs have been fielded. We should ask how 

well these are working to rekindle national interest in the nursing 

profession. 

The VA presents unique challenges because dire fiscal constraints limit nurse recruiting actions. Bonus recruitments and cutting edge programs are limited. Word of mouth stories proliferate 

the perception that VA nurses are overworked and under recognized by the VA medical system. Management decisions just occur, 

and there is often one key stakeholder group left out of the decision 

process. Advocates of the Magnet certification program will testify 

today. They will present data regarding the benefits of their program. Major health care facilities pay to undergo the certification 

process. It is a valued symbol. Clearly, certification is a status symbol among health care facilities. It is an indicator that the subject 

facility is nurse friendly from a management perspective. Nurses 

and nursing issues become part of the strategic planning process. 

The certification tends to draw the best nurses to the facility, 

nurses who seek a total employment package that may include 

competitive salaries, but truly values participation and job satisfaction. 

A positive culture is created around this concept. Certification is 

an indicator of good management from a nurse’s perspective. But 

just as you can have intelligence without a college degree, or bravery without the reward of a medal, you can have good nurse management without Magnet certification. 

The Magnet program is getting results today. No question about 

it. When 40, 50, or 60 percent of facilities nationwide are certified, 

will Magnet lose its importance? Will it no longer be a symbol of 

status? 

The fundamental long term value of the Magnet program is that 

it facilitates interest in and use of strategic management processes. 

All stakeholders belong in that process. This is basic management, 

but sometimes it has gone astray. The principles and cultural 

changes that underlie the certification are the true value of the 

effort. 

I yield back my time. 

Mr. BUYER. Thank you. 

I would like to welcome the first panel here today. We have 

Cathy J. Rick, RN, CNAA, FACHE, chief nursing officer, Department of Veterans Affairs. Sandra K. Janzen, MS, RN, CNAA, associate chief of staff, Nursing, James A. Haley Veterans’ Hospital, 
4

Department of Veterans Affairs for Tampa, FL, and Mary Raymer, 

RN, MA, CNAA, nursing education program manager, Health Care 

Staff Development and Retention Office, Department of Veterans 

Affairs, New Orleans, LA. Ms. Rick. 

STATEMENTS OF CATHY J. RICK, CHIEF NURSING OFFICER, 

DEPARTMENT OF VETERANS AFFAIRS; SANDRA K. JANZEN, 

ASSOCIATE CHIEF OF STAFF, NURSING, JAMES A. HALEY 

VETERANS’ HOSPITAL, TAMPA, FL; AND MARY C. RAYMER, 

NURSING EDUCATION PROGRAM MANAGER, HEALTH CARE 

STAFF DEVELOPMENT AND RETENTION OFFICE, DEPARTMENT OF VETERANS AFFAIRS, NEW ORLEANS, LA 

STATEMENT OF CATHY J. RICK 

Ms. RICK. Thank you and good morning. Chairman Buyer and 

Ms. Hooley and members of the subcommittee, I thank you for this 

opportunity to present testimony regarding the impact of the national nursing shortage on the Veterans’ Health Administration, 

the nation’s largest employer of registered nurses. 

As you have mentioned, by the year 2020, the United States RN 

workforce is forecast to be roughly the same size as it is today. Unfortunately, this is estimated to be nearly 20 percent lower than 

national RN workforce requirements. A modest increase in enrollment in generic nursing programs was experienced in 2002. However, far larger increases are needed if the trends are to be 

reversed. 

I would like to highlight three key points with regard to nursing 

workforce issues affecting patient care and staff satisfaction in VA. 

They are, one, VA’s commitment to effective nursing recruitment 

and retention. Two, VA’s direction in terms of making data driven 

management and staffing decisions, and three, the importance of 

our proposed legislation in terms of serving veterans’ nursing care 

needs now and in the future. 

First, the current and projected shortage of nurses is a symptom 

of the ever changing landscape of the health care industry in this 

country. 

VHA is committed to addressing short and long term issues affecting staff satisfaction and clinical practice. This is imperative in 

light of the nursing shortage, to assure a desirable work place that 

attracts the most promising and competent nurses to VA. 

Published findings underscore the need to focus on improving the 

work environment for nurses, as you both mentioned, in order to 

increase staff satisfaction and to ensure the provision of safe, high 

quality patient care. 

Negative work environments are characterized by undesirable 

work schedules, inadequate support staff, lack of respect, and lack 

of nursing involvement in patient care decisions. 

The 2001 report, A Call to Action, VA’s Response to the National 

Nursing Shortage, provided the foundation for VA’s retention, recruitment, and outreach activities to address work environment 

issues. 

I will share a few examples of our current initiatives that improve the nursing environment. 
5

First, the VA’s staffing plan directive. As required by the Department of Veterans Affairs’ Health Care Programs Enhancement Act 

of 2001, Public Law 107–135, this directive outlines national guidance for incorporating staff opinion in defining workload and patient outcome indicators at the point of care as key determinants 

for developing and evaluating staffing plans. 

A second example is the VA nurse qualification standards. These 

standards demonstrate VA’s commitment to maintaining an appropriate mix of qualified registered nurses to respond to health care 

trends, and VA will continue to hire and value the contributions of 

nurses prepared at the associate, baccalaureate, and doctoral level. 

Technological advances in health care treatment and equipment, 

evolving health care trends, modifications in delivery systems, and 

consumer expectations require nurses to constantly adapt to 

change and new roles. 

One of the results of the new qualification standards is that 64 

percent of VA nurses are prepared at baccalaureate and higher degrees. I would note that the importance of this keep in light of Dr. 

Linda Aiken’s recently published research shows that mortality 

and failure to rescue rates were 19 percent lower in hospitals 

where 60 percent of the nurses had BSNs and higher, as compared 

to hospitals where only 20 percent were BSNs. 

Another example of initiatives for VA’s retention and recruitment 

is our nurse/physician collaborative. In response to nurses identifying a need for better communication and stronger collaboration 

between nurses and physicians, VA is implementing a nurse/physician collaboration breakthrough series. This is designed to foster 

greater interdisciplinary understanding between professions. This 

has the effect of simultaneously improving patient care, as well as 

nurses and physicians’ satisfaction with the work environment. 

Ms. Raymer and Ms. Janzen will be highlighting additional VA 

retention and recruitment initiatives. 

For my second point, I would like to highlight VA’s commitment 

to database management and staffing decisions. The VA nursing 

outcomes database project is a 16 month project, creating a database of nursing sensitive quality indicators. These data will enable 

understanding of relationships between nurse staffing and patient 

outcomes, and facilitate benchmarking for identifying best 

practices. 

In addition to the findings from this project, we look forward to 

the findings and recommendations from the VA Commission on 

Nursing. The Department of Veterans Affairs’ Health Care Programs Enhancement Act of 2001, again, Public Law 107–135, established the Commission to among other things consider legislative and organizational policy changes to enhance the recruitment 

and retention of nurses and other personnel. We look forward to 

their recommendations in May of 2004. 

Finally, I would like to thank you for your interest and support 

of VA’s proposed legislation, defining initiatives that will have significant positive impact on our ability to retain and recruit a highly 

qualified workforce. 

These initiatives are designed to correct impediments to retention and recruitment identified by VA administrators and nursing 
6

leadership, and supported by data, and they will provide VA with 

a far greater competitiveness in hiring and retaining nurses. 

These legislative proposals specifically address concerns regarding scheduling flexibilities, and nurse executive pay. 

Retention initiatives and recruitment strategies will continue to 

have my full attention, as we work together to address national 

nursing workforce challenges. We really do appreciate your interest 

in assessing workforce needs and implementing innovative strategies to address them. 

VA’s health care workforce is critical to the success of our mission to care for those who shall have borne the battle. 

Thank you for your attention. 

[The prepared statement of Ms. Rick, with attachments, appears 

on p. 43.] 

Mr. BUYER. Thank you, Ms. Rick. 

Ms. Janzen, I recall having met you at the Tampa facility with 

Mr. Bilirakis. I have come a long way since my initial asking you 

that question, what is Magnet status. I just want you to know that. 

(Laughter.) 

Ms. JANZEN. It was very clear from your comments. 

Mr. BUYER. There are all types of people and all types of politicians, and a lot of them just like to act like they know what they 

are talking about. Right? If I don’t know, I am going to tell you I 

don’t know. That way, I get to learn. That’s why you are here. You 

are going to help us. Please. 

STATEMENT OF SANDRA K. JANZEN 

Ms. JANZEN. Thank you very much. I can make my comments 

shorter because you have become very well educated in the Magnet 

process. 

As you know, I am the Associate Chief of Staff for Nursing responsible for nursing practice at the Tampa VA, the nursing homes 

in Orlando and Tampa, and the large clinics in Orlando, Viera, and 

Port Richey, and community-based outpatient clinics. 

Thank you for holding these hearings on the nursing shortage 

and its implications for the VA. 

My testimony will present Magnet Nursing Services Recognition 

Program and how this credentialing process may improve recruitment in retention associated with the nursing shortage in VA. 

As you know, in March 2001, our VA facility was the first and 

still is the only VA that has successfully achieved Magnet recognition. Four others, however, are in the stages of application and 11 

more are exploring the application process. 

The concept of Magnet recognition emerged with the 1980s nursing shortage, with a study of successful hospitals who did not experience a shortage or difficulty in recruiting and retaining nurses. 

Characteristics of Magnet organizations included a participative 

management style, nursing staff involvement at all programmatic 

levels, collegial nurse/physician relationships, supportive organizations, and highly qualified transformational nursing leaders. 

In the 1990s, these same characteristics continued to be manifested in successful organizations and are now the basis for the 

Magnet Recognition Program. 
7

In 2002, the Joint Commission on the Accreditation of 

Healthcare Organizations publicly acknowledged the importance of 

a supportive work culture such as Magnet in its report, Healthcare 

at the Crossroads. 

Today, Magnet recognition is achieved through a stringent and 

comprehensive process that includes organizational self assessment, based on the Magnet criteria, development of an action plan 

to enhance administrative and clinical programs, and a written application that is appraised and scored to determine the degree of 

excellence. 

If an organization exceeds the excellence score, a rigorous site 

visit focuses on the professional staff providing nursing care, and 

how organizational leaders support nurses in their practice. 

I believe our veterans deserve clinical excellence provided by 

Magnet nurses. 

Patient care requires a team of professionals, and Magnet standards ensure interdisciplinary collaboration, and thus recognizes the 

entire organization. 

How is Magnet recognition helped us? Tampa’s nursing recruitment and retention situation has improved dramatically in the past 

2 years. It is a very competitive environment in Florida. Our RN 

turnover rate has dropped from 14.5 to 10.2, or nearly nine percent 

lower than the Florida average. The vacancy rate in the Tampa VA 

Medical Center fluctuates between seven and eight percent. This is 

half the community average in West Central Florida, despite adding new positions to activate more critical care beds, managing 

double digit growth in outpatient care, and treating the highest 

volume of patients in the VA health care system. 

In 2001, our facility used supplemental agency staff in our intensive care units and acute care areas due to staffing shortages. Although agency use never exceeded two percent of all registered 

nurse hours, today our units are staffed without any additional 

agency nurses, and we successfully recruited highly qualified staff 

to activate a 26 percent increase in our critical care beds. 

Our staffing levels have stabilized, and nurses are spending more 

of their working hours with patients. Tampa nurses perceive staffing levels to be adequate, and they report they have sufficient time 

to meet patient needs. 

Our annual nurse satisfaction survey results have improved in 

all six domains, some areas more than others. We are going in the 

right direction. 

Tampa’s clinical outcomes are also very good. Our patient fall 

rate is below national benchmarks despite aggressive implementation of initiatives to minimize restraint use. Our pressure ulcer 

rate compares favorably to external benchmarks. Patient satisfaction is high. Nurses routinely receive compliments from veterans 

and their families. 

We have an educated staff who are valued as competent key 

members of an interdisciplinary team. Sixty-five percent of our 

nurses have a bachelor’s or master’s degree compared to national 

reports of 38 to 48 percent. This again substantiates the findings 

in Dr. Aiken’s study that Cathy Rick described. 

Again, thank you, Mr. Chairman, for holding this very important 

hearing. An energized, satisfied, well-educated professional nursing 
8

workforce is achievable in VA, using the Magnet model for excellence in patient care. Veterans deserve no less. 

Thank you. 

[The prepared statement of Ms. Janzen appears on p. 72.] 

Mr. BUYER. Thank you. Ms. Raymer. 

STATEMENT OF MARY C. RAYMER 

Ms. RAYMER. I am very glad to be here this morning. I am from 

the Health Care Staff Development and Retention Office, which is 

a field based headquarters office actually located in New Orleans, 

LA, and what I would like to do is give you a summary of the programs that are currently in place that are managed from that office 

that address nursing recruitment and retention. 

First, just a little brief overview about where our office has 

observed—— Mr. BUYER. Mary, if you could also include statistical outcomes 

in your remarks. 

Ms. RAYMER. Yes, I will. 

Mr. BUYER. Thank you. 

Ms. RAYMER. In the last 2 years, we have observed from the office a significant expansion in the recruitment and retention of certain health care professionals. Among these are physicians in certain occupations, like radiology, and pharmacists, as the retail 

pharmacy industry has grown, that has become an increased issue 

for the VA. 

However, the shortage of nursing personnel is present in almost 

every community, differing only in severity and in the type of nursing staff needed. Obviously, many of our efforts have focused on 

nursing recruitment and retention. 

The programs currently in place promote nurse recruitment and 

retention and are broadly grouped into education programs, national placement service, advertising and marketing, and development of the nurse recruitable at each medical center. 

I will begin with the education program. The employee incentive 

scholarship program, the national nursing education initiative, and 

the employee education debt reduction program are all components 

of the health professional education assistance program. 

The scholarships program provides funding support for VA employees to attend nursing programs, to become licensed practical 

nurses or registered nurses. The nursing education initiative provides funding support for VA’s registered nurses to obtain baccalaureate degrees in nursing and advanced degrees. The VA employee may receive up to 3 years of full time education with a funding support at a maximum of $32,043 allowed in 2003. 

Since the programs were implemented in 2000, there has been 30 

employees enrolled in the LPN program, with three of those graduating by 2002. There are 197 VA employees enrolled in the associate degree program, with 20 graduates by 2002. 

The significant point of these programs is that they produce new 

nurses for the Department, and help replace those individuals that 

are planning or have already retired from the system. 

The national nursing education initiative provides funding for 

registered nurses to obtain baccalaureate degrees in nursing and 

advanced degrees. Through fiscal year 2002, there has been 2,639 
9

scholarships awarded to registered nurses, with 427 of those participants graduating by 2002. Approximately 60 percent of those 

awards were for baccalaureate degrees and 81 percent of them are 

awarded to nurses in the staff nurse role. 

The program also supports advanced nursing practice and generates potential faculty as 939 participants are enrolled at the master’s level, 52 at the doctorate level, and 75 in post-graduate study 

for such specialties as wound care management or palliative care. 

The participants’ service obligation with the VA is for 1 to 3 

years following the completion of their academic program. 

The program has been a powerful recruitment and retention in- centive for the VA. Through 2002, the VA had obligated $34.7 million to these programs, with an average award of a little over 

$11,000 per nurse for an average of 2.2 years of study. 

The education debt reduction program provides education debt 

reduction payments to recently appointed nurses. These are people 

that have been with the Department or in their appointed position 

for less than 6 months. The first awards were authorized in 2002, 

with registered nurses receiving 46 percent of the awards, and a 

total of $12 million. The average award per nurse was $14,184. 

The final education program that we administered is called the 

VA learning opportunities residency or VALOR. This is a program 

which has been in place since the 1990s and provides a paid, 

precepted work experience for baccalaureate nursing students who 

have completed their junior year. The goal of this program is to retain these students after they finish their program, and hopefully 

then they will become VA nurses. In fiscal year 2003, our funding was $1.7 million for this program, and it provided experience for 290 students. The funds are 

always fully utilized with 116 facilities out of the 165 having at 

least one VALOR student. 

The national placement program, through the use of the 

vacareers.com web site, the application process on line, and the national advertising programs, do our national programs for video, 

audio and other kinds of media. 

This past year, we implemented a nurse recruiter advisory group 

that will help us keep in touch with the field and provides a valuable conduit for input into all of these programs. 

In planning for 2004, we then developed a comprehensive nursing recruitment and retention proposal that included a variety of 

initiatives. Among them were the continuation of the education 

program, the increase of the number of VALOR positions. We 

asked for an additional 110 positions for VALOR. Then most significantly, the addition of an upward mobility program. 

This last program then will provide funding for VA employees 

who are not nurses to go to school and become either LPNs or RNs. 

This is a significant program as it will add new nurses to the 

Department. 

In summary, those are the major programs that our office manages and the outcomes we have had to date. 

I also thank you very much for having these hearings, and helping us in any way you can to continue our work. 

Thank you. 

[The prepared statement of Ms. Raymer appears on p. 75.] 
10

Mr. BUYER. Thank you. Ms. Rick, are there hospitals that are in 

particular geographic regions that have shortages where others do 

not? Can you tell as you look across the country? 

Ms. RICK. The variation with regard to the impact of the shortage in our facilities across the country really mirrors what is happening in all other communities across the country. Although our 

vacancy rate and our turnover rate on average in all areas of the 

country is lower than national averages, it mirrors that trend. If 

it is high, such as in California and New York in the community, 

those shortage issues are impacting the VA as well. 

Mr. BUYER. When Congress came in and chose the 60 percent 

number of nurses with a baccalaureate degree, was that about 

right? 

Ms. RICK. Health and Human Services data? 

Mr. BUYER. Was that a right thing to do? 

Ms. RICK. Actually, the current research that was just published 

last week does validate that projection, that 60 percent or higher, 

but the statistical difference was when there were at least 60 percent of the RN workforce trained at baccalaureate and higher degrees, yes. It does validate that. That is Dr. Aiken’s study that 

Sandy and I mentioned. We can make copies of that study available to you, if you would like. 

Mr. BUYER. Maybe I should re-ask the question this way. What 

are the increased measurable outcomes that you can elaborate on 

that would reinforce this is the right thing to do or we should even 

trend it higher? We made a huge investment here. That is what 

I would like to know. 

Ms. RICK. What Dr. Aiken’s study demonstrates is that there is 

a 19 percent reduced mortality rate, a reduced rate in what is referred to as failure to rescue. There is a reduced rate of complications with a higher percentage of RNs prepared at that level; reduces the incidence of patients who will die from complications following procedures. 

Her study was based on a surgical patient population, primarily 

elective patients, so those patients who are not expected to have a 

high incidence of complications and mortality. 

Mr. BUYER. Going back to my geographic question, are there VA 

hospitals whereby we would be at 60 percent, if you look at a community based facility, that they might be at 40 percent or 30 percent, or some may be higher, how is the VA rating with regard to 

local community health standards, geographically? 

Ms. RICK. We have not evaluated it to that level of detail at this 

point. We do plan on doing that. I know that our national average 

is 62 percent. 

Mr. BUYER. Could you do that for us? 

Ms. RICK. Sure. 

Mr. BUYER. Everything is based on the local community standards, especially when it comes to liability. I would like to know 

that. 

Ms. RICK. We can provide that information. 

Mr. BUYER. Thanks. Ms. Hooley? 

Ms. HOOLEY, Thank you, Mr. Chair. Just a couple of questions, 

Ms. Rick. 
11

In your comments, you talked about Dr. Aiken’s research relating 

to RNs and patient ratios and that the ratio of one to four in fact 

saves lives. Is the VA supporting the findings on that one to four 

ratio? 

Ms. RICK. What Dr. Aiken’s study demonstrates is that the numbers and types of staff have a direct relationship and our predictors 

for patient outcomes. In her follow up study, the study that you are 

referring to with regard to ratios of licensed staff to patients, the 

follow up study further defined that the level of education of nurses 

is a better predictor than the number. In her article that was published last week, which she emphasizes in her research, is that 

both are significant in determining staffing methodology in patient 

care delivery models. 

The number of licensed staff is important, and even more important is the level of education of that staff. 

Ms. HOOLEY. How many of your nurses have a BS or BA or baccalaureate degree? 

Ms. RICK. Sixty-two percent. 

Ms. HOOLEY. What is your ratio? 

Ms. RICK. We do not prescribe a ratio and actually do not even 

endorse standardized ratios. The staffing plan that I mentioned 

really is meant to give the staff at the point of care the opportunity 

to define legitimate workload indicators from their expert opinion 

and patient outcome indicators, so that they can best determine as 

an interdisciplinary team, what is the best staffing mix and patient 

care delivery model. 

We really do oppose the approach of having a prescriptive nurse 

to patient ratio approach because it looks at patient care in isolation of the whole team, and does not really incorporate all of the 

necessary support staff. 

Ms. HOOLEY. How does the VA compare to most large hospitals 

in the United States? The nursing shortage is happening in the 

VA. It is happening everywhere. How do the VA hospitals compare 

in registered nurses, people with baccalaureate degrees; how do 

they compare with other hospitals? 

Ms. RICK. Comparable or better. If you are looking for something 

more concrete, it is hard to say for each facility, not that we cannot 

do that, but what I presented were some national figures. Our 

turnover rate is significantly less. Our vacancy rate is significantly 

less. We have the ability to attract and retain staff, and with our 

qualifications standards and the emphasis on the value of that education with our education programs, as Mary mentioned, we are 

able to achieve a high percentage of strong education for our staff 

mix. 

Ms. HOOLEY. One of the things that I hear all over, and certainly 

in the Portland VA Hospital, is a nursing shortage, but you hear 

it literally from every hospital. One of the many causes seems to 

be that we do not have enough instructors. In our case, in my 

state, there was an article in the paper the other day about one of 

the community colleges and their nursing program where literally 

they do not have the money to expand their program, and they 

have a waiting list. I think what a shame—they have a waiting list 

of 60 some students that are all qualified, because we do not have 

the instructors. We do not have the money to add new programs. 
12

Does the VA work with our colleges to address this issue? What 

do you do with other institutions in addressing that nursing shortage? 

Ms. RICK. Most definitely, we do. You describe a scenario that is 

replicated across the country with waiting lists for associate degree 

community colleges as well as baccalaureate programs. That is the 

case. The aging workforce in the faculty ranks is in dire straits. 

What we have done is enter into partnerships in the communities more so than with our national initiative at this time, so that 

VAs supplement faculty by having joint appointments, providing 

faculty for clinical experiences, and actually we are looking at a 

proposal to help fund some of those faculty joint appointed positions as well. 

At a national level, I work very closely with the American Association of Colleges of Nursing and the American Association of 

Community Colleges, to look at appropriate partnerships, to design 

the right workforce for the best patient outcomes, and try to break 

down the barriers of those things that we look at that may be individual interests, but really to be patient focused. 

Ms. HOOLEY. I would be really interested to know, if you could 

do that either today or later on, how many of the joint faculty positions there are that you worked with. I am really interested in this 

whole issue. Right now, we are recruiting nurses from all over the 

world, taking away in fact some desperately needed health care in 

some other countries, but needed here. 

I am very interested to know what you are doing with other institutions and what those numbers look like in helping deal with 

this whole issue. 

Ms. RICK. We would be glad to provide additional information. 

We did provide a video tape that describes some of our best practices in that area. The video tape does highlight some of the programs with our academic partners, and that might be of interest 

to you as well. 

Ms. HOOLEY. Thank you. 

Mr. BUYER. Mr. Boozman, you are recognized for 5 minutes. 

Mr. BOOZMAN. Ms. Janzen, tell me about the difference in the 

Magnet situation versus the regular hospital? A ward in a regular 

hospital would be thus versus the other. I guess what I am curious 

about is is it a money thing? Is the Magnet program a lot more expensive to operate, or is it more an organizational thing? Is it little 

things like doctors treating nurses with more respect in those situations? I don’t mean that bad. Again, things like that. Tell me how 

it works a little bit. 

Ms. JANZEN. In many ways, it really is a little bit of all of those 

things. I think cost is a question that is clearly a fair question. The 

cost for Magnet recognition does come with costs, and it is based 

on the number of beds. 

If indeed we were to apply today for our nursing home and our 

acute facility, it would probably cost us in appraiser fees, the application process and everything, maybe about $44,000. That sounds 

like a lot of money. However, when you take a look at the recruitment costs that are out there and retention costs, it really does average out. That is part of the cost. 
13

One of the things that really underlies the physician/nurse relationship issue is the issue of competence. Nursing competence, to 

be able to interact with physicians, and be respected for the unique 

knowledge that nurses know, this is one of the underlying components that comprises the essentials of magnetism in the current research that is out there on Magnet hospitals. 

A very well educated staff that can make good contributions in 

the interdisciplinary team, strengthens teamwork and patient care. 

I believe that we have that at Tampa. I do believe that is one 

of our areas of difference. 

Another area of difference from the community is we are addressing the issues of technology and trying to make our work 

place a safer place to be, and the Chairman mentioned our ceiling 

mounted lifts. We are looking to design a facility that really addresses a much safer work environment for nurses, and we really 

need to look at some technological solutions so that we can keep 

older nurses working longer, and that they don’t become hurt and 

injured and leave the profession early on. 

Another issue that I think is different for our organization, but 

it is also unique to Tampa, is we have worked very closely with the 

University of South Florida. The College of Nursing at the University of South Florida and all affiliating organizations in the Tampa 

Bay area, have almost doubled the number of nurses that they are 

producing through a new innovative model, where our nursing 

staff, staff nurses, serve as preceptors for a core number of nurses 

who go through the bachelor’s program. 

We have just graduated our first couple of classes. I believe this 

will have those nurses come to work for us or Moffit or Shriners, 

because that is our work group. We had one student who wanted 

to live away from us, but within less than a month after having 

graduated, experienced the private sector and came back home to 

the Tampa VA, within one month. 

I do think that is another effective model. We try many things. 

It is a very competitive market in Florida. If you notice, our turnover rate is higher than the national average, and we are a Magnet 

facility. 

Mr. BOOZMAN. Once the consulting fees are done, that aspect, 

your operation, is there more expense at that point, compared to 

a normal facility? Is it more just in the organization, how you do 

it, compared to another facility? 

Ms. JANZEN. I think the expectation is to live to a higher standard for the rest of your life, which is a wonderful thing, I think, 

for an organization. I do believe in time, we will be better able to 

say what the positive outcomes are for patients. We are beginning 

to collect that information in a more systematic way, but I think 

our outcomes will be better. 

Mr. BOOZMAN. I guess your cost of doing business, once you have 

done the consultant stuff and we say that is over, going forward, 

is that the same as any other hospital? 

Is your staffing higher or lower? Are you paying more? Do you 

see what I am saying? 

Ms. JANZEN. Yes. I do not think we are paying any more than 

the community. The VA is not a pay leader. 
14

Mr. BOOZMAN. I am comparing to the other VA hospitals that 

have not gone through this. 

Ms. JANZEN. It has not been measured in the VA. We are looking 

at how we can possibly do that in more concrete ways to build a 

business case. I think it is going to be less. After 4 years, there is 

the cost of redesignation, which is not as high as the initial application. 

I think the costs are going to be less. However, we are going to 

continue to strive to improve care very systematically like a good 

organization will do. I do not think that the cost is going to be any 

more. In fact, I certainly hope in time it will be less. 

Mr. BOOZMAN. Thank you. 

Mr. BUYER. Mr. Udall, you are recognized for 5 minutes. 

OPENING STATEMENT OF HON. TOM UDALL 

Mr. UDALL. Thank you, Chairman Buyer. 

Ms. Rick, thank you for being here today. We very much support 

the idea, at least I do, that you are doing better than the private 

sector in these turnover rates and the vacancy rates, and you are 

showing some real successes there. 

What I wanted to ask you about is to discuss the mortality rate 

as a function of the BSN degree ratio among the nursing staff of 

a facility. You mentioned it in your testimony and you also attached the Penn study. 

Clearly, this not a stand alone issue. Perhaps the economically 

disadvantaged public service style hospitals can afford fewer BSNs, 

and what do you think are the other factors that would explain this 

mortality rate measurement? 

Do you believe these studies are accurate? I know there are some 

that have contested the studies. 

Ms. RICK. I have the utmost confidence in the study, and not just 

because I am educated at that level. It is not a self interest at all. 

It is really focused on patient outcomes. I know that is a challenge 

to those of us who are educated at a higher level than an associate 

degree. 

I want to emphasize my personal and VA’s commitment to associate and diploma degree nurses. It is a significantly valuable contribution by all nursing staff. I do think that mix is appropriate to 

consider long term in the health care industry, and especially in 

the VA. 

The rigors of Dr. Aiken’s study, I cannot speak to as well as others can that are perhaps better versed in research, but anything 

that gets published in JAMA and that goes through the kind of rigorous review from the foundations that supported it, is not something that is treated lightly. It is not something that others may 

call ill prepared, ill designed, ill interpreted. 

I think it is significant and should be taken very seriously, and 

I think what the challenge will be to folks like yourself in legislation is to look at it from the patient’s perspective, and to really look 

at how to understand the science and the evidence that she offers 

us in this study, and follow up studies that will need to be done, 

so that we really focus on what is right for patient care delivery 

and be careful about those of who may have—I do not know that 
15

I want to include myself in that—everybody has some self interest. 

I just caution you to be attentive to that. 

The evidence is sound. The science is well-developed and wellpublished. It is well-analyzed. 

I think there is need for additional science in the same area. The 

impact on patient outcomes, there are many compounding factors. 

Nurses are not the only impact. We know that. It is clear this is 

a significant finding. I think it is a wake up call to all of us to really look at it from the patient’s perspective. 

Being a consumer, I would like to consider that it is taken seriously. 

Did I answer your question? 

Mr. UDALL. Yes. Thank you. 

One of the things you mentioned I think in your testimony is one 

of the factors that is identified as far as nursing shortages is that 

there is a poor image of nursing as a career choice, and you cite 

this 2001 Gallup poll of the public perceptions of professions, where 

nurses ranked number one in terms of honesty and high ethics for 

the second consecutive year, but at the same time, nursing ranks 

137 out of 250 professions in terms of desirability. 

What do you think we can do to help change that image? Is there 

anything that we can do to change the image so that more individuals go into nursing? 

Ms. RICK. I am not sure that legislative leaders—there is not 

something that comes to mind that would have a significant impact. It really is the burden of the practice settings to create the 

right work environments, and to demonstrate that it is not only an 

honorable profession, but a satisfying profession, and to really address those issues with regard to having the right support staff and 

having those who are educated to provide professional care really 

have the opportunity to do that, and to really look at having the 

right people do the right things in increasing the respect and voice 

of nursing, so it is clearly looked at as a full partner in the interdisciplinary team. 

I think it is really our burden to continue down that road. Legislatively, we can always use more money. You know that. I think 

the burden is for us to really work on our work environments and 

hopefully get the support with regard to our proposed legislation on 

flexible schedules and pay equities for our leadership ranks. 

Mr. UDALL. Thank you. Mr. Chairman, I see my time is exhausted here. Thank you. 

Mr. BUYER. Thank you. The University of Pennsylvania in their 

recent release cited that the educational level of hospital nurses 

may be as important as how many RNs are at the bedside in determining whether patients survive common surgeries. According to 

the University of Pennsylvania’s School of Nursing Study released 

today, which was September 24, in the Journal of the American 

Medical Association, ‘‘In a study of 232,342 patients, researchers 

from the Center of Health Outcomes and Policy Research found 

that raising the percentage of bedside RNs with bachelor’s degrees 

from 20 to 60 percent would save four lives for every 1,000 patients 

undergoing just common surgeries. Surprisingly, of 168 hospitals 

studied in Pennsylvania, the percentage of university-trained RNs 

varied from 0 to 77 percent. A conservative estimate suggests the 
16

difference between best and worse staffing in education scenarios 

could translate into 1,700 preventable deaths in Pennsylvania 

alone.’’

I would ask for unanimous consent that this study be incorporated by reference only in the record. Hearing no objection, so 

ordered. 

(See p. 50.) 

Mr. BUYER. I want to congratulate not only you, Ms. Janzen, but 

everyone who worked so hard to achieve such status and to be the 

first in the VA. 

Ms. JANZEN. Thank you. 

Mr. BUYER. Not to be too hard on the VA, but I wish the leadership of the VA had done that. I wish they were the ones who were 

driving this force. I am being tough on you now. I wish you had 

been the driving force, but instead, you know what, sometimes 

those initiatives come from the field, which in turn you can either 

say, great job, atta girl, and continue to set the high standards, 

and inspire others. 

As we look at this across the VA facilities, how wonderful it 

would be if we could have all our VA hospitals achieve the status 

which Tampa has. 

As you go back to Tampa, will you please take with you the 

warm appreciation and congratulations from us. 

Ms. JANZEN. I certainly will. 

Mr. BUYER. I apologize for my ignorance when I showed up, and 

you said hey, we have Magnet status. I said, what is that? 

Ms. JANZEN. The staff will be absolutely delighted. Thank you so 

much. 

Mr. BUYER. I feel so awkward now. Ms. Raymer, when you mentioned your statistical outcomes, we talked about recruiting. My 

question is on retention. These programs have the national nursing 

education initiative and you also have your VALOR program. What 

we would like to know is are they working? In other words, after 

the 3 years, are people then leaving or are you getting the retention benefit that you desired? 

Ms. RAYMER. I cannot give you——

Mr. BUYER. If you cannot answer that, you can answer for the 

record. 

Ms. RAYMER. I do not have the statistics to answer it yet, but 

just in looking at the data, for the people that finish, yes, they do 

stay. 

Mr. BUYER. If you could provide that for the record. 

Ms. RAYMER. We will provide that for the record. 

Mr. BUYER. Are there any other follow-up questions? 

Ms. HOOLEY. Very briefly. 

Mr. BUYER. Very. 

Ms. HOOLEY. I just have a statement I would like to enter into 

the record. It is from an Oregon RN, Sarah Atkins, an oncology 

nurse that works for the Portland VA Medical Center. 

[The statement of Sarah Atkins appears on p. 135.] 

Ms. HOOLEY. Her statement reveals a lack of management/labor 

cooperation during the current Magnet certification process. 
17

You can talk to me afterwards about what is the process the VA 

engages their stakeholders in credentialing, or you can answer me 

in 30 seconds. 

Ms. RICK. It looks like you are directing that question to me. 

Ms. HOOLEY. I am. 

Ms. RICK. It is expected that we include our labor partners in decisions such as this. It really is a partnership, not only in making 

decisions with regard to culture and organizational changes, but 

there are some logistical changes that may evolve over time. The 

best way to approach considering a Magnet recognition process is 

to really do it in partnership. 

Ms. HOOLEY. Thank you. Thank you, Mr. Chairman. 

Mr. BUYER. Ms. Janzen, when you went through the certification 

process in Tampa, you brought the unions to the table from the beginning; correct? 

Ms. JANZEN. In fact, we are very proud of the fact that the recommendation to seek Magnet recognition came from our labor partnership council and then went to the director of the facility. 

Mr. BUYER. What happened in Portland was the opposite. That 

is the impetus of the question. Ms. Rick, as other facilities try to 

do that, it is very important that everybody sits at the table. 

Ms. RICK. I understand. 

Mr. BUYER. Thank you. This panel is dismissed. I appreciate 

your testimony. 

I now recognize the second panel. Would you please come and 

take seats. 

I would like to recognize Barbara Blakeney, president of the 

American Nurses Association. 

Dr. Sarah Myers, immediate past president of Nurses Organization of Veterans’ Affairs, and Ann Converso, United American 

Nurses. Ms. Converso, you are on the third panel. 

Ms. CONVERSO. I am? Okay. 

Mr. BUYER. Unless you have a flight you have to catch, or a 

lunch appointment. 

Please, Ms. Blakeney? 

STATEMENTS OF BARBARA A. BLAKENEY, PRESIDENT, AMERICAN NURSES ASSOCIATION; SARAH MYERS, IMMEDIATE 

PAST PRESIDENT, NURSES ORGANIZATION OF VETERANS’

AFFAIRS; AND ANN CONVERSO, VICE PRESIDENT, UNITED 

AMERICAN NURSES 

STATEMENT OF BARBARA A. BLAKENEY 

Ms. BLAKENEY. Thank you, Mr. Chairman. Good morning. I am 

Barbara Blakeney. I am the president of the American Nurses Association. I would like to thank you for the opportunity today to address the issues regarding nursing in the VA. 

I would like to highlight a couple of key points today, and that 

is I think we all recognize that nursing is a primary foundation of 

health care in this country. It focuses on prevention, long term 

care, acute care, care across the life span, and quality of care for 

our veterans will not improve without nurses being active throughout the VA in important policy and decision making processes within the VA. 
18

America is experiencing a crisis in nurse staffing, and the Department of Veterans Affairs is experiencing a similar crisis to national trends, and if the availability of the supply of nursing personnel remains constant, the ability of the Veterans’ Administration facilities to meet the health care needs of our veterans will be 

severely adversely effected. 

Congress has recognized this problem by establishing a national 

commission on VA nursing. That commission will submit its final 

report to the VA Secretary in May of 2004, with specific legislative 

and organizational recommendations, to ensure the availability of 

a qualified nursing workforce, to meet the needs of America’s veterans. 

The ANA looks forward to the release of this report and to working with the VA to achieve their goals for nursing. 

ANA supports an integrated state and federal legislative campaign to address the current impeding nursing shortage. I would 

just like to say that at a time when we are finally beginning to attract young people into nursing, and a time when there are now 

nursing candidates available, at this exact same time, the opportunity for those students to take advantage of their education is severely affected by one, what has already been talked about here 

today, which is a serious shortage of nursing faculty. 

Secondly, and I think increasingly more importantly, is the fact 

that the percentage of nursing education that happens in the public 

sector is being profoundly impacted by state budgets. 

At a time when we finally have nursing students, we are turning 

them away. In one instance, over 200 nursing students were turned 

away in a state college system, because of the cut backs in that college system, because of the early retirements offered and accepted 

by nursing faculty, and by the lack of ability to attract new people 

into nursing education. 

We recognize that is a huge issue today, and we ask the Committee as they look at the veterans’ issues to also take into account 

the huge number of nursing students who go and get their nursing 

education through the public sector, which is horribly impacted by 

state budgets at this point. 

Many of the solutions that are applicable to the VA are applicable across the health care system. While some issues regarding 

nurse recruitment and retention were addressed by the Nurse Reinvestment Act, many issues remain that relate to the RN work 

environment. 

I would like to highlight some of the key future strategies that 

deal directly with the nursing shortage. 

On issues of health and safety, ANA has conducted an on-line 

health and safety survey in August of 2001, where 88 percent of 

the nurse respondents reported that health and safety concerns influenced their decision to continue working in the field of nursing, 

as well as the kind of nursing they choose to perform. There are 

too many nurses out there who love being acute care nurses in 

acute care hospitals, who can no longer physically do that work. 

That’s a shame, and that’s a travesty. 

ANA has just launched a proactive multi-faceted campaign aimed 

at promoting safe patient handling and preventing musculoskeletal 

disorders among nurses. This campaign, which we call Handle 
19

With Care, will begin with a safe patient handling conference to be 

held at the Tampa Veterans’ Administration Hospital, in their Patient Safety Center of Inquiry and the University of South Florida 

in March of 2004. 

I know you know, Mr. Chairman, that program, that health safety program at the VA Center in Tampa is leading the way in terms 

of addressing many of the issues that are important for us in terms 

of keeping nurses in the workforce. 

That conference will highlight those issues. That conference will 

highlight the fact that we need to look at architecture in hospitals. 

We need to look at engineering in hospitals. We need to create a 

hospital room of the future that takes advantage of the technology 

that is being designed in such places as the VA Medical Center in 

Tampa. 

Technology and innovation is a growing issue and a growing area 

where we need to develop better and future focused areas of inquiry and areas of development. 

I would call your attention, Mr. Chairman, to an issue of the 

Nursing Outlook where a summary of the proceedings of the American Academy of Nursing Conference on using innovative technology to decrease nursing demand and enhance patient care delivery can be found, and I would ask, Mr. Chairman, if this may be 

submitted for the record. 

With regard to overtime, nurses across the country are expressing deep concern about the dramatic increase in the use of mandatory overtime. ANA hears that overtime is a huge issue, and a continuing problem, where nurses can be charged with abandoning of 

patients if they refuse to accept overtime. 

We have had nurses brought before the Boards of Registration 

and Nursing on issues around overtime. 

Staffing is critical. Being able to further develop approaches to 

staffing and to develop safe staffing patterns is critical. 

The VA, like most private health care systems, continues to 

struggle with the development for valid, reliable and 

implementable—excuse me. I was in Norway yesterday, Mr. Chairman. I am still struggling with what time of the day it is, sir. 

Implementable nursing staffing outlines. The ability to improve 

the nurse workforce and the nurse environment, which is a critical 

piece of the Magnet program. It is about being able to create an 

environment where collaborative practice, where respect for each 

other’s knowledge bases, where respect for each other’s perspectives, and what each discipline link can bring to the care of the patient that makes a difference, I believe, in the Magnet program. 

ANA is very proud of the Magnet program, proud of our role in 

helping to create it, and proud of our ANCC program, which is a 

subsidiary of ANA. 

Mr. Chairman, I see my red light is on, so I will stop here, but 

ask that you consider the fact that the environment in which 

nurses practice is critical. The environment in which nurses practice will make a difference in the health care of our veterans. 

As the daughter of a World War II soldier in Europe, as the niece 

of a sailor on board the USS Phoenix moored at Pearl Harbor on 

December 7, and as the cousin of a two tour Vietnam combat engineer, all of whom have received care at the VA system, I recognize 
20

the importance of that system, sir. I do not believe that our veterans deserve any less than the very best. 

Thank you, Mr. Chairman. I will be happy to answer any questions. 

[The prepared statement of Ms. Blakeney appears on p. 79.] 

Mr. BUYER. Thank you. In your testimony, you cited a request 

for an article from a journal be entered into the record. 

Ms. BLAKENEY. Yes, sir. It is Nursing Outlook. It is the May/

June issue of 2002, Volume 51, No. 3. 

Mr. BUYER. Any objections to entering it into the record? 

[No response.] 

[Link to http://www.mosby.com/nursoutlook] 

Mr. BUYER. Hearing no objections, it will be so entered. Will you 

please leave a copy of that with the Clerk? 

Ms. BLAKENEY. Certainly, Mr. Chairman. 

Mr. BUYER. Thank you. 

Mr. BUYER. Dr. Myers, you are now recognized. 

STATEMENT OF SARAH MYERS 

Ms. MYERS. Mr. Chairman and members of the Subcommittee on 

Oversight and Investigations, I am Sarah Myers, a doctorally prepared nurse executive in geriatrics and mental health at the Atlanta Veterans’ Affairs Medical Center. 

I am presenting testimony in this capacity as well as the immediate past president of the Nurses Organization of Veterans’ Affairs, known as NOVA, the professional organization of over 35,000 

registered nurses employed by the Department of Veterans Affairs. 

NOVA is very concerned about the national nursing shortage, as 

well as the ability of the DVA to continue to recruit and retain 

highly qualified nurses to care for our nation’s veterans. 

National nursing leaders in health care organizations are projecting a shortage of registered nurses that is unprecedented, both 

current and future projections of the numbers of professional 

nurses available are such that the nation’s demands for these services will be insufficient at best. 

At the same time, changes in health care delivery systems will 

require larger numbers of more educated nurses, who will be performing increasingly complex functions, both in hospitals and other 

health care settings in the community. 

The DVA is already experiencing challenges in maintaining an 

adequate workforce. If it is to stay adequate, it must remain competitive in both pay and workforce innovations. 

It is no surprise in the interim report to the VA Nursing Commission that the staffing theme was pervasive throughout the 

report. 

Earlier this year, NOVA developed a document entitled Critical 

Need for a Strong Nursing Workforce, which outlines several programs and addresses recruitment efforts to be considered by this 

Subcommittee, the House Veterans’ Affairs, and the DVA for the 

upcoming decade. 

In that report, I have outlined in my testimony a nursing recruitment initiative proposal, which totals $35.45 million per year. The 
21

provision of flexible educational opportunities, academic partnerships to ensure numbers of nursing faculty and outreach programs 

directed at the high school students are positive recruitment efforts 

directed at aggressively addressing the nursing workforce issue. 

No single strategy will be effective in reversing the nursing 

workforce crisis. This proposal presents a coordinated approach of 

a nursing recruitment grant program, a nursing education support 

program, and a marketing strategy designed to meet the current 

and future needs of VA nursing professionals. 

The program provides a variety of resources for generating RNs 

and LPNs, ranging from current nursing students to existing VA 

employees, to future nursing students through outreach in high 

schools and colleges. As is well documented in health care and the 

VA literature, the shortage of nursing personnel currently being experienced will reach its most critical state in 2010 and beyond. 

You have heard already from Mary Raymer about the VA 

VALOR program, which I have discussed in my proposal. Another 

program is the VA nursing education faculty program earmarked 

for $2 million. This program implements the nursing education faculty-sharing program, which combines VA employment with nursing education, academic program faculty assignments and partnerships. 

The VA nursing education faculty program will create partnerships with schools of nursing. The program establishes specific 

positions for nursing faculty for those schools who have students 

participating in the VALOR program, as noted above. The schools 

of nursing establish clinical experiences with their VA partner, 

which would promote student selection of VA employment following 

graduation. 

Another program is the VA nursing education for employees. As 

you can see, this program is earmarked for $17.15 million. It funds 

a tuition assistance or upward mobility program. The initiative 

provides education and salary replacement funding for VA employees enrolled in licensed practical nursing, associate degree nursing 

programs and bachelor degree nursing programs. 

The proposed program would fund 75 licensed practical nurses 

per year beginning in the year 2005, and 200 RNs per year beginning in the year 2006. 

I think the VA cadet nurse program has been referenced already 

in a previous testimony. The VA cadet nurse program combines VA 

volunteer work and the student educational employment program. 

It offers a progressive work experience program which the student 

may enter at varying levels. 

The VA volunteer role enables students under the age of 16 to 

gain initial training and experience in working in the nursing environment. After the age of 16, the student can transition to a paid 

appointment under the student education employment program, as 

a certified nursing assistant, which could be continued through 

graduation from a vocational LPN, associate degree program, or 

bachelor’s degree program in nursing. 

Thus, the graduating baccalaureate degree nursing student who 

begins a VA work experience as a volunteer at age 14 would have 

built 8 years of familiarity and organizational loyalty with the VA. 
22

Also, I have included recommendations for the administrative 

support for four full time employee equivalent personnel, as well as 

supplies. 

The DVA has implemented several positive initiatives to impact 

staffing, including the establishment of the Commission on VA 

Nursing, the establishment of the VA Nursing Workforce Group, as 

well as the adoption of their recommendations, recent enhancements to the locality pay, and changes to the nurse qualifications 

standards. 

I thank the members of the Oversight and Investigations Committee for this opportunity to share with you some ideas of how to 

address the recruitment and retention facing the Department of 

Veterans Affairs. 

Consideration of these proposals will go a long way to enhancing 

a bright future for the dedicated nurses who care for our nation’s 

heroes. 

Thank you. 

[The prepared statement of Ms. Myers appears on p. 109.] 

Mr. BUYER. Thank you. Ms. Converso. 

STATEMENT OF ANN CONVERSO 

Ms. CONVERSO. Good morning. Thank you, committee members, 

for this opportunity to draw attention to the very important issue 

of the nurse staffing shortage in VA medical facilities. 

My name is Ann Converso. I have been a registered nurse in 

acute medical/surgical units and I.V. therapy at the VA Western 

New York Health Care in New York’s VISN 2 for more than 30 

years. I have also been an active member of my union, the New 

York State Nurses Association and its national, the United American Nurses, AFL-CIO, during that time. I now serve as vice president for the 100,000 nurses of the UAN, 6,000 of whom are VA 

nurses. 

In my years as a VA nurse, I have experienced several nursing 

shortages firsthand. I believe I do speak for other VA nurses when 

I say that we love our jobs, and the important work we do in caring 

for our nation’s veterans, but because of deteriorating working conditions and a lack of respect, registered nurses are leaving the bedside in favor of many other job options now available to us, from 

clinic jobs, outpatient jobs, computer jobs, or leaving the profession 

entirely. 

In a 2002 survey by the United American Nurses, three out of 

every ten nurses said it was unlikely that they would be in a hospital staff nurse position in 5 years. The VA health care system has 

by no means been immune to the shortages. 

As nurses leave the VA system, new nurses are not joining the 

VA at comparable rates and patient load is increasing. In its own 

report, A Call to Action, the VA states that it must replace up to 

5.3 percent of its RN workforce per year to keep up with RNs retiring. By all accounts, that is not happening. We are caring for more 

patients who are often sicker with fewer nurses at the bedside. 

Clearly, VA nurses have choices. I believe I and other VA nurses 

can shed some light on why nurses are leaving the bedside and 

what we can do together to make the VA a more attractive place 

for nurses to stay and work. 
23

Through my role in my union and my position on the National 

Commission on VA Nursing, I hear daily from VA nurses about the 

problems they face at their work places. Staff nurses who play a 

pivotal role as care givers at their VA facilities say their experience, knowledge and expertise are not being respected. Nurses are 

functioning at some facilities with staffing levels that are unsafe. 

Many VA facilities do not meet the threshold medical/surgical ratio 

of four patients per nurse that is cited in the Linda Aiken’s 2002 

study on nurse to patient ratios. 

Some VA facilities, like their counterparts outside the government, have responded to this staffing crisis by mandating overtime 

that is unsafe for patients and nurses, forcing nurses to work 

understaffed or floating RNs to different units without proper 

training. Additionally, nurses at the bedside are not being involved 

in decision making processes. 

We must also address the inequities that cause the VA medical 

system to lag behind the civilian facilities as an employer of choice. 

Compensation under the Nurse Pay Act of 1990 has not kept pace 

with the private sector’s ability to provide multiple salary increases 

per year, and an innovative structure of non-salary perks and benefits. Too often, qualified experienced nurses in the VA system are 

being denied promotions solely on the type of nursing education 

received. 

Staff nurses know and are willing to share their solutions. As a 

long time nurse activist, I know there is a place where staff nurses’ knowledge and views are solicited, respected and acted upon—in 

our unions. 

Staff nurses have a seat at the table, a voice in decision making, 

and the respect we deserve because of our union. Nurses who are 

organized on average earn a higher salary, have better staffing levels, and have more of a say in their work place. 

As a VA union nurse, I have input into bar code medication procedures, representation on my health and safety committees, access 

to a fair and equitable disciplinary and grievance process, and valuable guidance through the VA promotions process. 

In the VA system, we must cultivate an environment where 

nurses are respected for the invaluable work we do. Actively involving staff nurses in the decision making processes in their VA facilities must be a priority if we are to keep more staff nurses in the 

VA system. 

VA nurses in my union have made a difference in the quality of 

care in their facilities by advising on the best safety devices to use 

through their health and safety committees, on inadequate staffing 

levels through submissions of assignment despite objection forms, 

through support for legislation like the VA Medical Workforce Enhancement Act. This bill gives the Secretary of the VA the flexibility to empower staff nurses with greater decision making on 

staffing levels, nurse to patient ratios, and patient caseloads. 

Some facilities are exploring ways to involve nurses in decision 

making processes through the Magnet program, which you have 

heard about. In the years since its inception, the Magnet designation has become a sought after credential among hospitals. 

What is equally if not more important to me is the process a facility must demonstrate it has gone through to achieve Magnet sta-
24

tus. A Magnet facility’s administration must talk to and listen to 

its nurses. It must show evidence that staff nurses are involved in 

decision making and care giving processes. 

To me and the nurses I represent, the process, the criteria, and 

the culture that a hospital must develop involving staff nurses in 

its decision making, in its Magnet application, is even more important than the piece of paper that finally grants the hospital Magnet 

status. 

Both Magnet facilities and VA facilities where RNs have a union, 

and Tampa has both, are excellent models for involving nurses, the 

people providing round the clock care for our veterans, in the decision making loop. 

If we are to encourage staff nurses not only to come to the VA 

but to stay in the VA, we must work to give them a voice in the 

challenges and changes faced in our VA facilities. 

VA Secretary Anthony Principi has said that he is making quality patient care a priority. That cannot happen with fewer nurses 

at the bedside. If we truly seek to attract and retain skilled, experienced registered nurses in the VA system, we must respect front 

line RNs who deliver bedside care by giving them greater input 

into their work environments. 

I thank you, once again, for the opportunity. 

[The prepared statement of Ms. Converso appears on p. 113.] 

Mr. BUYER. Thank you. Ms. Hooley, you are recognized for 5 

minutes. 

Ms. HOOLEY. Thank you, Mr. Chair. Just a couple of things. First 

of all, for all of the nurses out there, thank you. You do a terrific 

job. 

Ms. Blakeney, you mentioned the need to increase the number of 

nurse graduates to ameliorate the nursing shortage. We may agree 

that a cultural change is needed in the way potential nurses view 

careers in nursing. There may be other methods for increasing the 

number of nurses, particularly to the benefit of the VA. These are 

just some things I am throwing out. 

Could we, for example, build a VA school of nursing similar to 

DOD’s school on uniform medicines, where students receive free 

training in return for their promise to serve for a period of time? 

Would that kind of a program work? Has this been studied? 

What can we do in Congress to both increase the nurse pipeline 

and assure VA recruits its fair share? 

Ms. BLAKENEY. Thank you for the question. I believe first, anything that we can do to encourage people to come into nursing, we 

should be considering doing. Right now, the Congress has before it 

as part of the appropriations issues, the Nurse Reinvestment Act. 

I urge you to look at fully supporting that Act, because it will put 

money in the pipeline to do exactly what you are talking about. 

There are possibilities to consider, with students who have federal loans, that the loan forgiveness program be extended into the 

VA system, so that any new graduate moving into the VA system 

has a significant loan repayment reduction occurring for as many 

years as they work in the VA. We already have that in place for 

medically under served areas, where for every year you work in an 

under served area, ten percent of your loan repayment is forgiven. 

The idea of being able to offer that in the VA is certainly some-
25

thing that I think could be relatively easily done because the infrastructure already exists. 

The idea of creating a school of nursing to support the VA in line 

with the DOD may well be an opportunity worth exploring. It may 

be possible to even extend the DOD program to include or to create 

available slots for nurses to go into the VA, as opposed to actually 

replicating what might already be there. That might be a possibility. 

The opportunity to increase student placements in VA medical 

centers is critical, because what we know is that students, when 

they are placed for their clinical placements, if they like what they 

see, it’s a good recruitment tool. 

Being able to enhance and support the VA medical centers so 

that they can be more active and being able to serve as clinical 

placements is certainly a concept worth exploring. 

The bottom line is that if we have a nursing shortage, we will 

have a nursing shortage in the VA system. Keeping the VA financially attractive and keeping the clinical environment in the VA 

and building the clinical environment in the VA so that it becomes 

an attractive place to work is part of what the VA can do, and what 

you and the Congress can do in terms of financially supporting the 

development of centers of excellence, and in looking at developing 

centers of excellence within the VA medical centers, not unlike 

what we have right now in Florida, the opportunity to build that. 

The idea that nurses are a critical part of decision making across 

the board, as my colleague, Ann Converso, has just mentioned, the 

ability to make sure that nurses are part of that. 

I can share with you a personal experience in an institution 

where I worked, where we built a new ambulatory care center. The 

nurses were not involved in that. Three days before that center 

opened, the nurse managers were given a tour of that facility, and 

within half an hour, we pointed out $500,000 worth of mistakes, 

because we weren’t part of that process. 

Nurses need to be a part of the processes. This applies across the 

board. It is not just the VA system. When nurses are not part of 

those processes, it speaks to they are not valued. It speaks to the 

fact that what they know and how they practice is not valued as 

part of the system. 

When we don’t build technology into the hospital room, then 

what we are saying is we do not value the nurse’s ability. She is 

expendable. Her back is expendable. Her legs, her knees are expendable. That is what we do when we do not require and we do 

not create opportunities for nurses to participate in that decision 

making from the very beginning. 

Creating those opportunities demonstrates a respect for the profession and the individuals who are in that profession, and that is 

what brings nurses in, and that is what keeps nurses. 

It’s the environment in which we work, the respect with which 

we are treated in those environments, and the recognition that we 

have things that can contribute to the well being of that institution, as well as to our patients; doing those things will address the 

nursing shortage not only in the VA, but across the country. 

Ms. HOOLEY. Thank you. 

Mr. BUYER. Thank you. Mr. Boozman? 
26

Mr. BOOZMAN. I’d like if the other panelists would comment also 

on the nursing shortage, what steps we can take. I appreciate your 

answer. I think that was very good and very useful. Do you all 

have anything you would like to add to that? 

Ms. MYERS. I do not. I think her remarks were very comprehensive. 

Mr. BOOZMAN. I agree. Certainly, this is the primary thing that 

we are dealing with today. Again, you mentioned the problem with 

the states and stuff. If you had an action that you wanted us to 

do, what would you rank at the very top, as far as trying to—the 

states do not have any money. They are in difficult situations. They 

are not only cutting this program. They are cutting all of their programs. They are in a very difficult situation. Most of them have 

balanced budget amendments, unlike the Federal Government. 

If you had to say one action, what would you like for us to take 

away today, as far as your top? I do not know if that is a fair question or not. 

Ms. BLAKENEY. The shortage will not get better until we address 

some of the fundamental flaws that we have in our health care system. For nurses, some of those flaws have to do with having the 

work that we do better valued within the environment that we are 

in. 

It is having nurses participate and being recognized as valued 

partners in the decision making that occurs in health care. 

If I could do one thing for the already existing nurses, it would 

be to try to address that. If I could do one thing to attract young 

people into nursing beyond that, it would be funding nursing education. 

A fact that a huge percentage of our nursing programs are in the 

public sector is very, very good in that it guarantees access. It is 

very, very bad when we have a state budget crisis as we do today. 

The ability for the Federal Government to be able to support those 

programs right now is paramount, and to try to encourage our 

states to do at least no further cutting in health care and the 

health care education areas and our schools of nursing. 

It is not just nursing. We are here today to talk about nursing, 

but we have to recognize it is a problem that is going to hit all of 

our disciplines. We have to think about why that is, and part of 

why that is the health care system that is struggling. We are not 

going to solve the nursing shortage or anybody else’s shortage, 

until we fundamentally address the health care issues. That is a 

huge undertaking, as I think we all recognize. 

Mr. BOOZMAN. Thank you. 

Mr. BUYER. Mr. Udall? 

Mr. UDALL. Thank you, Chairman Buyer. 

Dr. Myers, as I look across the portfolio of incentive programs, 

I see many methods to draw nurses to particular organizations. 

What programs are targeting semi-retired or alternate career 

nurses to get them back into the fold? 

Ms. MYERS. I didn’t identify any of those programs in my testimony, but the one that comes to mind that’s not here is the initiative within the VA to support retired nurses on a fee basis system, 

where they come back and they work X number of days within the 

VA. 
27

As a personal testimony, at the Atlanta VA, we do have some of 

those nurses. One currently is working in the methadone clinic, 

which is one of the areas I am responsible for. There is a program 

that provides injections to methadone patients, approximately 45 to 

50 per day, including a Saturday clinic. It is one of the innovative 

methods that are being used. 

Mr. UDALL. Has that one been successful, the one you are familiar with? 

Ms. MYERS. Yes, it has been. 

Mr. UDALL. Are there any other programs, information programs, 

targeting the very young in America to begin changing the culture 

and to make nursing an attractive profession? 

Ms. MYERS. I think I mentioned the VA cadet program. There 

are also nurse recruiters on every station. They go out to high 

schools. They are invited to high schools, doing recruitment fairs 

during the year, where they target high school and middle school 

students. 

Also, nurses within the profession themselves are invited to high 

schools. Just during this past year, I went to three high schools 

myself as part of their Career Day. There are many other health 

professionals within the VA who also are experiencing that same 

opportunity. 

Mr. UDALL. Do you see a change in attitude at the high schools 

when you are out there personally? 

Ms. MYERS. I do. Students who have no idea what they want to 

do when they grow up, they welcome the idea of people coming. 

Most of them are surprised that I am not in a nurse’s uniform or 

a scrub. It really is an exciting opportunity for professionals to be 

involved in, nursing professionals. 

I also have students from Georgia State University and Emory 

University. These are students in the master’s program who are 

pursuing their higher education as nurse practitioners or clinical 

nurse specialists. 

Mr. UDALL. Thank you very much. I yield back, Mr. Chairman. 

Mr. BUYER. Thank you. Dr. Myers, in your testimony, in reference to the VALOR program, you stated for fiscal year 2003, 

$1.701 million for 290 students. However, in 2002, only 17 percent 

of the VALOR participants were hired by VA facilities. 

My question to you is is this a program that we should decrease 

funding, do away with, or increase funding? 

Ms. MYERS. I do not think we should decrease funding. I think 

we need to go back to the drawing board, meaning the VA, and 

look at why we have this decrease in the number of VALOR students. It may be we have to use more creative strategies to get students into the program as well as ensure that they graduate from 

the program. 

Mr. BUYER. The nice thing about your testimony is hopefully the 

chief nursing officer of the VA takes your testimony and holds it 

tight, goes back to the drawing board on the program. I welcome 

you to do that. Otherwise, we will take actions, and you may not 

like what we do. How is that? 

Ms. RICK. Hear you loud and clear. 

Mr. BUYER. All right. What we try to do here is try to figure out 

the measurable outcomes. That is not good. 
28

Secondly, Ms. Converso, I am to extend a welcome to you from 

Mr. Jack Quinn of Buffalo, New York. Congressman Quinn is a 

member of the full Committee here on Veterans’ Affairs. You are 

smiling. Great. I knew there had to be something I did not know 

about. Mr. Quinn is a valued member of the committee, and he extends his welcome to you. 

Ms. CONVERSO. If you could pass along to him that it is snowing 

in Buffalo today. Just so he knows. (Laughter.) 

Mr. BUYER. You know, ma’am, that is just not newsworthy. 

(Laughter.) 

Ms. CONVERSO. October 2nd, it is. (Laughter.) 

Mr. BUYER. It is like saying it is sunny in San Diego. (Laughter.) 

Mr. BUYER. I’m sorry. 

Ms. CONVERSO. I will remember that. 

Mr. BUYER. I am sorry. I will extend that to him. 

You had mentioned the lack of consultation and lack of respect 

are problems for VA staff nurses. Then I have to weigh that 

against the testimony of Ms. Sandra Janzen with her VA Magnet 

hospital in Tampa, how the Magnet facilities are known for enhancing communication and valuing of nursing services. 

Would you support working toward Magnet status at your facility in Buffalo? 

Ms. CONVERSO. Yes, I would, and actually, we have looked into 

that. I think embodied in my testimony is really the getting there 

versus the piece of paper. 

Mr. BUYER. It is all about getting there. 

Ms. CONVERSO. I think it is the culture and it is the respect, and 

to have people at the decision making table. I think there are facilities out there, whether they are in the VA or outside of the VA, 

that do not ever achieve Magnet. Maybe they do not have the 

$40,000 that Ms. Janzen talked about, but their nurses do not 

leave those facilities because that is the culture of their facility. 

I think the other thing that we talked about at the VA Commission last week is sort of reframing the recruitment and retention 

scenario. I think it is really retention and then recruitment. I think 

we have them sort of in the wrong order, because we can do a lot 

of things to recruit, but I think many people in this room will tell 

you that people come into the profession and after months or a 

year on the job, are very dissatisfied with the positions they are in. 

Mr. BUYER. Sometimes facts create perceptions. Sometimes they 

are real. Sometimes they are not. I have to ask this question. Out 

of the 85 Magnet facilities, only a handful of them are under collective bargaining agreements. Why would that be so? 

Ms. CONVERSO. I do not know that I have the answer to that. 

Mr. BUYER. I do not know, either. I did not know what and why. 

I will just let it sit. I will let the question sit. I do not know why. 

Ms. CONVERSO. I do not know the answer to that question. Sorry. 

Mr. BUYER. That is fine. I was just curious. I do not want to create a perception, either, if it is not real. I thought I had to ask the 

question. 

Does anyone have any further questions? 

[No response.] 

Mr. BUYER. Thank you. I appreciate your testimony. It was of 

value today. I am sorry. 
29

Ms. Blakeney, were you recruiting in Norway? 

(Laughter.) 

Ms. BLAKENEY. No, sir. I was actually attending a meeting of the 

International Council of Nurses, where recruitment was talked 

about. 

Mr. BUYER. Very good. Thank you very much. 

We now welcome panel three. Julie Cowan Novak. She is the 

head of the School of Nursing at Purdue University, West Lafayette, IN. We also have Regina Foley, Vice President and Chief 

Nurse Executive, Ocean Medical Center in Brick, NJ. 

Ms. Foley, Mr. Smith wanted to be here to introduce you. He is 

caught on the floor. 

Please, either of you can begin. Dr. Novak. 

STATEMENTS OF JULIE C. NOVAK, HEAD, SCHOOL OF NURSING, PURDUE UNIVERSITY; AND REGINA FOLEY, VICE PRESIDENT OF NURSING AND CHIEF NURSE EXECUTIVE, OCEAN 

MEDICAL CENTER, BRICK, NJ 

STATEMENT OF JULIE C. NOVAK 

Ms. NOVAK. Good morning. Mr. Chairman and members of the 

subcommittee, thank you for inviting me to speak on this very important issue of Magnet status as a tool for recruiting and retaining nurses. 

Regardless of the health care organization’s size, setting or location, achieving Magnet designation serves to attract and retain 

quality employees. Magnet designation helps consumers locate 

health care organizations that have a proven level of excellence in 

nursing care. ‘‘In an environment rife with controversy about patient safety in 

hospitals, medical error rates, and nursing shortages, consumers 

need to know how good the care is at their local hospitals. Magnet 

is a seal of approval for quality nursing care.’’ The magnet recognition program was developed by the American 

Nurses Credentialing Center, the credentialing arm of the American Nurses Association, to recognize health care organizations that 

provide the very best in nursing case, and uphold the tradition 

within nursing of professional nursing practice. The program also 

provides a vehicle for disseminating successful practices and strategies among nursing systems. 

The Magnet recognition program is based on quality indicators 

and standards of nursing practice as defined in the ANA Scope and 

Standards for Nurse Administrators. The Magnet designation process includes the appraisal of both qualitative, for instance, leadership roles and shared decision making, and quantitative, nurse/patient ratios, factors in nursing. 

Recognizing quality patient care and nursing excellence, the 

Magnet recognition program provides consumers with the ultimate 

benchmark to measure the quality of care that they can expect to 

receive. As a natural outcome of this, the program improves the 

positive work environment and elevates the standards of the nursing profession. 

The objectives of the Magnet recognition program includes recognizing nursing services that use the Scope and Standards for Nurse 
30

Administrators, providing a quality in a milieu that supports professional nursing practice, providing a vehicle for the dissemination 

of successful nursing practice and strategies among health care organizations using the services of registered professional nurses, 

and promoting positive patient outcomes. 

Magnet designation is an important recognition of nurses’ worth. 

I think we have heard several allusions to that issue today. Designation recognizes the quality of a nursing program and demonstrates its importance, and the importance of nurses to the success of the entire organization. ‘‘This is one of the highest achievements a hospital can attain in 

the nursing world. Magnet status recognizes the caliber of the 

nursing staff and what that professionalism translates into in 

terms of patient care and health care services.’’ Dr. Linda Aiken’s independent research shows that Magnet designated facilities consistently out perform their peers in recruiting 

and retaining nurses. ‘‘The label ‘Magnet hospital’ originally was 

given to a group of U.S. hospitals that were able to successfully recruit and retain professional nurses during a national nursing 

shortage in the 1980s. Studies of Magnet hospitals highlight the 

leadership characteristics and professional practice attributes of 

nurses within these organizations. Hospitals selected meet the following criteria: 1. Nurses within the hospitals considered them 

good places to practice nursing. 2. The hospitals had low turnover 

and vacancy rates. 3. The hospitals were located in areas where 

there was significant regional competition for nursing services.’’ Magnet designated health care organizations consistently out 

perform their peers in recruiting and retaining nurses, resulting in 

increased stability in patient care systems across the organization. 

A national survey conducted in March 1999 dramatically illustrates the competitive edge enjoyed by Magnet designated facilities. 

This survey found that 93 percent of the public would have more 

confidence in the overall quality of a hospital if that hospital had 

passed the nursing standards required to be a Magnet program. 

The same survey found that 85 percent of the public would have 

more confidence in a long term care facility that had passed similar 

nursing standards. 

Thus, in addition to the quality of nursing care, the Magnet designation speaks to a facility’s overall quality. 

I would note there is a quote also included from Mayo Hospital. 

We asked a visitor from Mayo how he was able to attract nurses 

in the middle of Minnesota. He said ‘‘We have Magnet status. That 

is the important thing.’’

I then had the great pleasure of showing him our award for Magnet status. I would note that at Purdue University, Mayo comes 

every year to our Career Fair and recruits five to eight of our top 

nursing graduates from each of our Purdue baccalaureate nursing 

graduate classes of approximately 100 students. 

Their Magnet status is one of the criterion that the graduates 

use for choosing their place of employment from among five to ten 

offers per graduate. 

Research documents state that high quality nurses is one of the 

most important attributes in attracting high quality physicians. 

Therefore, achieving this status creates a positive halo effect be-
31

yond the nursing services department that permeates the entire 

health care team. 

A basic premise of the Magnet designation is a climate that reinforces collaborative working relationships. As Dr. Aiken and Donna 

Sullivan Havens reported, ‘‘They foster respect and caring for the 

individual, both patients and staff, and actively bring out the best 

in people.’’

The Magnet culture is holistic in creating dynamic and positive 

milieu for professional nurses. Core values such as empowerment, 

pride, mentoring, nurturing, respect, integrity, and team work are 

demonstrated in Magnet facilities. ‘‘Thus, these hospitals have been 

cited as cultures of excellence, the measure of goodness, and the 

gold standard in nursing.’’

Magnet hospitals are infused with values of quality care, nurse 

autonomy, informal non-rigid verbal communication, innovation, 

bringing out the best in each individual, and striving for excellence. 

‘‘The Magnet process facilitated an intense look at the way we organized and delivered nursing care. It encouraged each of us to 

take responsibility for improving our service.’’

The Magnet recognition program establishes standards of excellent which health care organizations must attain. According to a 

study conducted at the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing, ‘‘Magnet hospitals consistently provide the highest quality of care.’’

Of respondents of are cent survey, 93 percent indicated that 

knowing a hospital had passed rigorous standards would increase 

their confidence in overall care provided by the hospital. 

The Magnet recognition program application and appraisal process has already been highlighted by Sandra Janzen, and is included in detail in my remarks, in terms of the eligibility requirements. Those are presented on the ANCC web site. 

Of note, the Veterans’ Health Administration’s support for the 

bachelor of science in nursing for positions beyond entry level is 

consistent with other progressive health care facilities and Magnet 

designation, that places a high value on learning. 

In Aiken’s work published in JAMA on September 24, and this 

has already been mentioned multiple times, it concluded that in 

hospitals with higher proportions of nurses educated at the baccalaureate level or higher, surgical patients, 232,342 cases were analyzed, and those individuals experienced lower mortality and failure to rescue rates. 

The criteria for the Magnet application process has been presented in terms of the application fees. It is four phases. First, second, third and fourth phase. 

The highlights once Magnet designation is awarded, the health 

care organization is notified immediately if the Commission on 

Magnet recognition votes to extend Magnet designation, and a nationwide press release is issued by ANCC. 

The public notice of Magnet applicant evaluations by ANCC 

Magnet recognition program appraisers is, of course, significant 

input from patients, families, clients, staff and public with who 

health care organizations interact is sought to assist Magnet program appraisers in the evaluation of nursing services that have ap-
32

plied for designation, and the contact information, of course, is 

presented. 

In summary, as the head of the Purdue University School of 

Nursing in West Lafayette, IN and associate dean of the Schools 

of Pharmacy, Nursing and Health Sciences, I know that our undergraduate and graduate nursing students select from among five to 

ten employment opportunities each year. 

If they are not geographically bound to the greater Lafayette 

area, they begin their search with an examination of the ANA web 

site of Magnet designated hospitals. Many of the hospitals with 

whom we partner in the Central Indiana area and throughout the 

State of Indiana are applying for Magnet designation, and those 

are the institutions with which we are expanding our partnerships 

in learning, engagement and discovery. 

Thank you. 

[The prepared statement of Ms. Novak appears on p. 116.] 

Mr. BUYER. Thank you for your testimony. Ms. Foley. 

8STATEMENT OF REGINA FOLEY 

Ms. FOLEY. Good morning. My name is Regina Foley. I am a registered nurse and vice president for nursing, chief nurse executive, 

at Ocean Medical Center. Our hospital is 237 beds, non-profit, nonunionized. It is on the beautiful Jersey shore in New Jersey. 

Mr. BUYER. Is it snowing? 

Ms. FOLEY. It does snow in New Jersey. Not as much as Buffalo, 

but it does snow in New Jersey. 

Ocean Medical Center is a member hospital of the Meridian 

Health family, a health system consisting of three hospitals and a 

number of partner companies, including long term and home care. 

As a nurse executive, I have been directly involved with nursing 

workforce issues and the development of a wide range of short and 

long term nursing recruitment and retention strategies and 

programs. 

A highlight in our organization is that being in Ocean County, 

and I cannot give the statistics, but Ocean County has a huge volume or number of older adults. We choose not to call them the gerontology population. They are a little sensitive about that. Sixtytwo percent of our volume is the older adult. Obviously, my teams 

need to develop different strategies to meet the needs of that group. 

It is a very special population. 

The next issue we have are the baby boomers that are coming 

up right along side of it with huge issues that we will need to deal 

with. 

My responsibilities at Ocean Medical Center include recruiting, 

maintaining and developing a nursing workforce that is appropriately prepared to deliver quality nursing care to our medically 

diverse patient population. 

I will discuss Ocean Medical Center’s commitment to nursing excellence through participation in the Magnet recognition program, 

as well as other strategic initiatives that have enhanced the work 

environment for our nursing staff. 

I believe that these initiatives, such as incorporating continuing 

education, research, collegiality, and collaborative practice are extremely important. 
33

When asked why the new RNs chose to come to Ocean Medical 

Center, many of the staff tell us they wanted to work for a Magnet 

designated facility for these very reasons. 

All of our nurses participated in the preparation of the Magnet 

application and many interacted with Magnet appraisers during 

their site visit. Going through the Magnet application process has 

promoted a greater sense of team work and camaraderie among 

them. In addition, the Magnet process has fostered in our nurses 

a sense of ownership, because they understand that this recognition comes with responsibility, as well as accountability, to uphold 

these standards of excellence. 

I believe our turnover rates and vacancy rates, which happen to 

be only 1.5 percent as of today, quite proud about that, have improved as the nurses have become more involved in decision making and in improving their own practice environment. 

We have a new model of care. Our participation in the Magnet 

recognition program has led to a reassessment of our care delivery 

model to further enhance the work environment and promote staff 

retention. 

Across the system, we have developed a new model. We have 

called it the Magnet Model of Care, which increased staffing, a no 

float policy, which is extremely important, increased technology, 

such as laptop computers, and a dedicated nurse educator and physician champion. 

Nurses on these units are expected to achieve national certification in their area of specialty and to participate in our new 

CARE program, which is a clinical ladder program. The nurse leader also had to go through a selection process, and part of our criteria was that she was baccalaureate prepared and nationally 

certified. 

These outcomes are being measured monthly to evaluate the impact on the enhancements. 

Ocean Medical Center first applied for Magnet recognition in 

1998, and was selected as the 12th hospital to achieve this award. 

Just this past year, I am pleased to report that we are redesignated as a Magnet hospital. All three hospitals in the Meridian 

Health System have achieved this recognition, and we take pride 

in being the first health care system in the country to achieve this 

status. 

Our purpose in seeking this recognition originally was to highlight the quality of our nursing department and the importance of 

our nursing staff to our health care organization. Through the application process, we were able to reflect on our strengths as a 

nursing department. The in-depth self study process provided us 

with focus and direction and helped to facilitate our growth in 

meeting and maintaining the highest standards of excellence. 

The site visit reinforced what we had learned and afforded us the 

opportunity to receive outside validation of the quality of the environment of practice at Ocean Medical Center. During our last site 

visit, the appraisers cited three areas that were particularly noteworthy, nursing research, initiatives for the care of the older adult, 

and I said it was very important to ask, and nursing utilization of 

information technologies. 
34

Other recruitment activities that we have is that we have a boomerang program which reinstates former employees with full benefits and seniority. If they wanted to go to another place, you know, 

the grass is always greener, and we believe we can allow our staff 

to explore those options, they can always come back home and be 

reinstated with their seniority and their benefits. 

We have a summer student externship program with the ability 

to stay on as per diem staff while they are in the program. We offer 

about $250,000 a year in scholarships. Our OFFER program, they 

work two 12 hour shifts on the weekend and they receive full time 

pay and full time benefits through the duration of their academic 

career. We have a clinical recognition program with salary advancement. Staff also receive monetary reward for national certifications and baccalaureate degrees. 

We have a grassroots staff group, and my colleagues have addressed the high school level, thinking about choosing nursing as 

a career, and we also address the elementary level, if you can 

imagine, from K–8. The reward that the nurses see from that environment is really terrific. 

Some other retention initiatives that we have is that we have a 

philosophy that we hire for talent and train for skill. 

In conclusion, at Ocean Medical Center, we recognize the significance of the current and impending shortage, our aging nursing 

workforce, and our aging patient populations, and have taken steps 

to improve our recruitment and retention efforts. Effective recruitment and retention plans, however, must go beyond immediate necessity to fill vacant positions. 

The environment where nurses practice must be enhanced so 

that nursing is seen as an attractive profession that offers professional growth and satisfaction. 

Participating in the Magnet recognition program has helped us 

enhance our efforts in improving the nursing work environment. 

Thanks for inviting me to share on behalf of Ocean Medical Center and the ability to work with such great nurses that I have. 

Thanks. 

[The prepared statement of Ms. Foley appears on p. 123.] 

Mr. BUYER. Thank you for your testimony. 

Ms. Hooley, you are now recognized. 

Ms. HOOLEY. Thank you, Mr. Chair. 

Dr. Novak, how many hospitals nationwide have applied for the 

Magnet certification, and what is the rate of certification based on 

certification requests? How long does it take to get through the 

process? How many apply? How many fail? Just give me some kind 

of idea about that. 

Ms. NOVAK. I know that there are 85 that are approved, and 

there are many more in process. I know it can take several years. 

I am not sure how many have been denied. I might defer to Barbara Blakeney. I am not sure about the denial. I am not on that 

committee or in that group. 

Ms. HOOLEY. Eighty-five are Magnet hospitals. 

Ms. NOVAK. Right, and we have several partners in Indiana currently, Clarion, St. Francis is in process, I think, St. Vincent, and 

our new hospital, the Arnette Hospital is from the beginning in the 

planning stages. 
35

Ms. HOOLEY. Generally, do you know what the average time is 

to get through the process? Are we talking about 6 months, 5 

years? 

Ms. NOVAK. I have heard a range of anywhere from 1 to 2 years. 

I have not heard anything exceeding that. 

Ms. HOOLEY. Once you reach that status, do you have to reapply? How long does that status last? What is the re-application 

process? 

Ms. NOVAK. I think there is a reinstatement about every 4 years. 

Ms. HOOLEY. What do you have to do for that reinstatement? 

Ms. NOVAK. I think there are again site visits and there are documents that are prepared for the process. The students who have 

visited those hospitals have talked with the nurses in those hospitals in their seeking employment. As I mentioned, each of them 

have many opportunities for employment, and this is one of the 

driving forces, when they do those visits and visit with the hospitals and with the nurses in those individual settings, they are 

more likely—we have students going to Methodist Hospital in 

Houston. We have many going to the Mayo system. We have many 

going to Cleveland Clinic, a whole variety of settings, many academic health science centers are attempting to achieve this. The 

University of Colorado has been definitely a very attractive site for 

many of our students, and it is the Magnet status that is one of 

the things that very much appeals to them. 

In terms of one of your other questions related to solutions and 

the recruitment piece, one of the things that we are doing locally, 

and I think many baccalaureate programs are doing, I mentioned 

that we admit 100 students each year. We are now increasing that 

over the next 2 years to 150 students that we are admitting, and 

the partnerships with various hospitals. I think that was also mentioned, with some of their master’s prepared nurses actually taking 

student groups so that they are providing the educators. 

Our master’s and doctoral program, our developing doctoral program, is going to focus on nurse educator, so that we are attempting to also address that shortage. 

Ms. HOOLEY. Good. One of the things I was just going to ask you 

is, you know, we talked about how to retain nurses, how do you 

keep them in the profession, because we know a lot of nurses have 

left the profession, and how do you bring them back. You have 

done a great job with that. 

The other issue was what do you do in a state like mine where 

they literally, because of state budgets, have cut off nursing programs, where you have a lot more people wanting to get into the 

programs and there are no slots, and then the whole issue of nurse 

faculty. 

Ms. NOVAK. As I mentioned, we have enlarged our class. We also 

work closely with the community college program in the area with 

those individuals that do not meet the requirements. When we 

went from 100 to what we are focused on, 150, or our target, we 

were turning away individuals with 1300 SATs, our class was so 

full, and we had three qualified for every one that we were admitting. 
36

Ms. HOOLEY. That is a real shame that we are turning away people and at the same time, we have all the baby boomers ready to 

retire, and at a time that we already have a critical shortage. 

Ms. NOVAK. Right. We have enlarged our classes, and we can 

only accept so many because we have to have clinical sites for the 

education or we compromise the quality. We have gone certainly 

much further out of the greater Lafayette, IN area in developing 

partnerships with Clarion and other hospitals in Indianapolis and 

throughout Central Indiana and the state. 

We also have many of our students going for internships and 

residencies throughout the country. That, again, keeps them 

hooked into the process and excited about what it is they are doing. 

Ms. HOOLEY. Thank you. 

Mr. BUYER. I look at it perhaps from another perspective. If Purdue University is having to turn away students with 1300 SATs, 

she has one great program. 

Ms. HOOLEY. Right. 

Mr. BUYER. You have one great program. Obviously, you have 

made a judgment call here on what it takes. You have your own 

budgets you have to deal with, too, but how you maintain that 

quality and how you participate in changing the culture to set new 

standards of excellence. That is why we invited you here to come 

testify. 

Will you please tell me as an administrator here, the testimony 

that we received here today and articles that have been written 

about the faculty exodus, how are you retaining—if you are getting 

these great students, they are there because you have a great program, but how are you retaining the premium faculty? 

Ms. NOVAK. I think the same sorts of issues in terms of how we 

retain nurses in the hospital, listening to them, valuing them, giving them lots of opportunities for growth and development. I think 

that is always critical at a work site. 

Although we have 37,000 students, the facilities were built for 

probably 30,000, so they have capped many of the undergraduate 

admissions with the exception of nursing and technology. They are 

allowing us to grow, and they will allow us to continue to grow as 

many as we can take in with the faculty, and through these partnerships, we do not have to continually hire an additional faculty 

member at Purdue, but rather develop adjunct partnerships with 

the hospital system, so that the hospital— Clarion is designating 

a Purdue unit of educating—they want our graduates, obviously. 

They are designating a Purdue unit. They will be providing a clinical nursing specialist who will be the partner educator with Purdue, but primarily hired and paid by Clarion. 

We are out developing many of those partnerships, as many as 

we can, because that is the only way we can expand and still maintain the quality of our program. We have 96 percent pass rates on 

boards, and we have had that for many, many years. We do not 

want that to be compromised. As Dr. Aiken’s study states, smarts 

trumps a whole lot of other things. We want to keep these bright 

young people. 

We are also doing a lot with recruitment through our nurse managed clinics. We are identifying middle schoolers, because we believe we need to bring them in younger than high school, and we 
37

have a 22 percent Hispanic population in Delphi, IN, and any of 

the middle schoolers who are interested can do rotations at our 

clinic, but we particularly targeted Hispanic middle schoolers that 

we are bringing into the clinic, getting them interested and excited 

about health care at a very early age. 

We also have a program called Are You Man Enough to be a 

Nurse. This was initiated at Texas Tech. We have a very strong 

focus on trying to bring more males into nursing. That slogan was 

actually developed by a fifth grader who had a father who was a 

nurse, a male nurse. There was a button contest and that was the 

theme, and it is really just a great program. That is another way. 

We are doing a lot in the recruitment end, spending a lot of time 

in middle schools and high schools to try to get kids excited about 

nursing. 

Mr. BUYER. What is the average pay of one of your recent graduates? 

Ms. NOVAK. In the range of $40,000 to $50,000. Of course, as has 

been mentioned, there are many sign-on sorts of bonuses and other 

sorts of things to attract them into the arena. Of course, we want 

to keep our nursing graduates in Indiana. Seventy-five percent do 

stay in Indiana at this point. We do not want to compromise that 

either. We are reaching out and trying to develop those partnerships. 

We are also trying to take as many of our programs into rural 

communities because if an individual comes from a rural community, if you can educate them there and keep them there, particularly our advanced practice nursing students, so they can do their 

clinical rotations in their home communities, they are more likely 

to stay in under served areas. We have a very strong focus in our 

graduate program on that. 

Mr. BUYER. Ms. Foley, in your testimony, you were highlighting 

the positive results of the Magnet program and the nurse vacancy 

rate that you have presently at 1.5 percent. What was it prior to 

achieving Magnet status? 

Ms. FOLEY. It was about 9, 9.5, at that time. We have been a 

member of Magnet recognition since 1998. 

Mr. BUYER. Congratulations. 

Ms. FOLEY. For disclosure purposes, at that time, in New Jersey, 

we did close a hospital that was a sister hospital to this site, a hospital system called Point Pleasant. In the year 2000, we closed that 

hospital. The community was a little upset with us. It is quite emotional, closing a health care facility in your neighborhood, and some 

became disenchanted. 

Mr. BUYER. It is just as emotional as trying to open a new one. 

Ms. FOLEY. I can only imagine. 

Mr. BUYER. Would you concur with that statement? 

Ms. Novak. Yes. 

Mr. BUYER. Let me move to a strategic vision. As we press the 

bounds of excellence, achieve these standards of Magnet facilities, 

trying to then raise the standard, increase cooperation, change a 

culture, does it raise all boats, or do we have an unintended consequence of only increasing the gap in a tiered health system? 

Ms. NOVAK. I think nurses in general have been far under utilized with regard to their expertise. I think a very strong back-
38

ground in health promotion and disease prevention has been significantly under utilized. I think a health care delivery system that 

looks at how nursing can change the system, can move us from a 

public health crisis into a situation that will truly be a significant 

change from the local to the global community, is very important. 

I think we are an untapped resource, basically. I think there is 

much that nurses can do. We have been restrained at every level, 

from full practice, from what we have been educated to be able to 

do. I think that is where the giant disservice is to the American 

people, including the veterans. I think the veterans’ system, with 

their valuing education and attaining excellence has really been at 

the forefront, and I think that the private sector has much to learn 

from that, this adoption of Magnet status would be one more step 

in terms of leading the way for the private sector who have not 

made this move, and are still in a very position dominated sort of 

health care system that does not address that curative care is only 

going to get us so far, and it is extremely expensive, and we need 

to put far more emphasis on health promotion and disease prevention, and nurses are the profession to do that. 

Ms. FOLEY. The skill and the knowledge of a nurse today is not—

I can only speak to the facility that I am in, and I have been there 

for 15 years—to allow the nurse to be autonomous, independent, 

choose relationships with wise leaders, the nurse is not utilized 

today as they should be, to the full scope and breadth that they can 

contribute. 

Believe me, it is not utopia. I do not mean to say best hospital 

on the earth. It is a darned good hospital in New Jersey and the 

best nurses in the country. 

That environment has to be created for them to really feel that 

they are making a difference every day, to be passionate about 

what they are doing, and to know that they are respected and validated, and the validation, I guess, is the Magnet piece, but to be 

respected on an ongoing basis. 

I would not be concerned about the tiered approach. The community will not allow that to happen. Americans will not allow that 

to be. 

I think the Magnet recognition is a foundation that is to be built 

upon, like 80 some odd hospitals throughout the United States 

have achieved the status. The ANCC is going to continue to raise 

the bar. I do not mean to say from a tiered approach, but it is going 

to be a little tougher in 2005, 2006, 2007. I do not know that you 

hear a lot about Magnet, Magnet, Magnet, I think it is more about 

creating that culture in a facility that you want your best care 

givers to practice in, and the nurses are not tapped into to know 

what their opinion is. 

As I spoke in my testimony about a great environment to work 

in. That is why we are doing this pilot. We asked 10 to 15 nurses, 

tell me about your perfect work environment, what do you need. Is 

it cell phones? Is it technology? Is it national certification? Is it a 

specific patient population? All the answers are there. I just do not 

know that we tap into our own resources that we have. 

Does that answer your question? 

Mr. BUYER. Let me rephrase it. 

Ms. FOLEY. I guess I didn’t, then. 
39

Mr. BUYER. No, your testimony was great. America has a tiered 

health system, quasi-governmental, private tiered health system. 

We do. We mask a lot of the problems and never really want to discuss them. We really do not. 

I endorse and love pressing the bounds. I do. Raising standards, 

pressing bounds. 

As we are doing that, are we only making the better better or 

as you press the bounds, are you raising all health systems? That 

is what I am trying to figure out. Are we creating gaps in those 

tiers? I just do not know. If you do not have the answer, say you 

do not have the answer. I am just asking from a business standpoint, because we have something on movement for the country, 

and I just would like to know. 

I believe that for this Committee to press the VA to do this Magnet status, we look at it because it is about the care to the veterans, and we are going to make that demand on the VA because 

this Committee gives our veterans special status. We have a bias 

on this Committee with regard to the veteran. 

Now, I am going to look across the country, because what happens in the country impacts the VA. I am trying to find out as you 

press the bounds, if you are saying your top ten students, Mayo 

Clinic comes down and takes them, they are not going into an 

inner city or a rural hospital. See what I am saying? 

Ms. NOVAK. They come and take ten great students, but we have 

I would say about 100 great students that graduate every year, because of our intense scrutiny on the front end of the process. I am 

just saying that Magnet hospitals are an attraction to them. 

If you are looking at recruiting and retaining and interesting 

new graduates in the VA system, that is something that they look 

at. It is not that they necessarily want to go to a Mayo Clinic. They 

want to go to a Magnet hospital where they are going to be valued, 

and where they are going to be able to function to the full extent 

of their scope of practice, and that is what they are interested in. 

I think more and more hospitals are in the process because of the 

shortage, of trying to attain Magnet status. It is 85 now. I think 

that number is going to increase significantly because other hospitals in the private sector are going to do this, to try to attract 

top graduates and graduates in general. 

I think in terms of the tiering, we are working very closely with 

the community college system, with our loan diploma program locally, and I think it is the only one in the State of Indiana, to try 

to move them sort of through that ladder concept and matriculation, so that they will have baccalaureate degrees. I think this 

study by Aiken—she is very highly regarded across many, many 

disciplines, and is a very meticulous researcher, and I would trust 

her data. 

Because of the acuity in hospitals, the VA system and otherwise, 

the acuity is so significant that we need better educated individuals 

making those decisions, determining when other health care providers need to be involved, and I think that is a hallmark study 

for doing that, and I think people go into nursing, if they have a 

1300 SAT, they can go into anything they want to go into, really, 

and we have very bright young people choosing nursing, and more 

and more of them, I think with the Johnson and Johnson cam-
40

paign, $20 million was put into that campaign, and we saw between a 10 and 20 percent increase in applications to nursing 

programs. 

It was really moving away from a negative way that nursing has 

been portrayed in the media to something very positive, and if you 

look at the nurses, the real nurses, that they have highlighted, 

they have highlighted those sorts of things that every single panelist has been talking about. 

They have tremendous self-respect. They are self-assured. They 

are confident. They are bright. They know what they are doing. 

That is who we need to take care of our veterans and everybody 

else. 

Mr. BUYER. I asked the question not to be a critic of the present 

movement to increase those standards. I only asked the question 

to scrutinize whether or not there are unintended consequences of 

the movement. 

Ms. Hooley, do you have a question? 

Ms. HOOLEY. Just a question and then a statement. 

Do we know how many hospitals we have—I am trying to figure 

out 85, what percentage is that? 

Ms. NOVAK. There are several thousand hospitals, I believe. 

Ms. HOOLEY. I know there are thousands. I just do not have a 

clue as to what percentage that is. One of the things that I appreciate from all of the panelists today is talking about the importance 

of nursing and how valuable they are to our hospitals and care of 

patients. Many times, they are under utilized. I have believed that 

for a long time. 

The comment I have to make is not only do we have a shortage 

of nurses that we have to deal with, and then how to best use our 

nurses, but I think we also need to keep our eye on the longer picture, and that is we have 43 million Americans without any health 

insurance, as you talk about a tiered system. I think you constantly 

have to not only look at all aspects of health care, but you have 

to look at that larger picture that we have a lot of people that do 

not have anything. 

Thank all of you for your testimony. 

Mr. BUYER. I want to thank you for coming to sunny Washington, DC. To Ms. Rick, hopefully, you leave the room with a 

sense that of all your VA hospitals, and I guess now you have four 

in application, 11 are considering, if you could provide the Committee with regard to what your vision is on how to move Magnet 

status to the entire system, whether you agree with it or disagree 

with that. Please have a conversation in paper with us. All right? 

Thank you very much for your testimony. This has been a valuable hearing. Thank you. The hearing is now concluded. 

[Whereupon, at 12:19 p.m., the subcommittee was adjourned.] 
(41)

A P P E N D I X 

STATEMENT OF THE HONORABLE STEVE BUYER 

SUBCOMMITTEE ON OVERSIGHT AND INVESTIGTIONS 

COMMITTEE ON VETERANS’ AFFAIRS 

HEARING ON ) FOR VA’S NURSING SHORTAGE: 

IS THERE MORE THAN ONE ANTIDOTE? 

OCTOBER 2, 2003 

GOOD MORNING. TODAY’S HEARING IS ENTITLED: ‘‘PRESCRIPTION FOR 

VA’S NURSING SHORTAGE: IS THERE MORE THAN ONE ANTIDOTE?’’ I 

DON’T THINK ANY OF THE WITNESSES THAT WE WILL HEAR FROM TODAY 

WILL DISPUTE THE FACT THAT THERE IS A CRITICAL NATIONWIDE NURSING SHORTATGE. 

DURING TODAY’S HEARING WE HOPE TO LEARN THE EXTENT OF THE 

PROBLEM WITHIN THE VA AND, MORE IMPORTANTLY, WHAT IS THE DEPARTMENT PROPOSING TO REMEDY THE MASS EXODUS THAT IS LIKELY 

TO OCCUR OVER THE NEXT FEW YEARS. THIS LOOMING HEALTH CARE 

CRISIS CERTAINLY DEMANDS THAT THE VA TACKLE THE PROBLEM AGGRESSIVELY—SOONER RATHER THAN LATER. 

ACCORDING TO THE VA, THIRTY-FIVE PERCENT OF ITS REGISTERED 

NURSES ARE ELIGIBLE FOR RETIREMENT BY THE YEAR 2005. IF THE VA 

LOSES ONE-THIRD OF ITS THIRTY-SIX THOUSAND RN’S, WHO WILL TEND 

TO THE VETERANS NEEDING CARE IN THE NEXT FEW DECADES. BECAUSE 

THE VA HAS AN AGING POPULATION, WHICH WILL REQUIRE MORE COMPLEX CARE FROM HIGHLY SKILLED PROFESSIONAL NURSES, WE CANNOT 

IGNORE THIS PROBLEM. 

ON MONDAY, SEPTEMBER 29, 2003, AMERICAN HEALTH LINE REPORTED 

THAT: 

HISTORICALLY HIGH NURSING SHORTAGES HAVE CREATED A 

‘GAME SHOW-LIKE FRENZY AMONG HOSPITALS,’ WHICH ARE OFFERING SIGN-ON INCENTIVES SUCH AS VACATIONS, VEHICLES, 

MASSAGES, CONCIERCE SERVICES, FREE TUITION FOR NURSES 

AND THEIR CHILDREN AND BONUSES OF UP TO $10,000. 

ONE COULD SURMISE FROM THIS THAT THERE ARE INDEED TOO FEW 

NURSES AVAILABLE TO FILL HOSPITAL VACANCIES, INCLUDING THOSE 

AT THE VA. STATISTICS CERTAINLY TELL US THIS IS THE CASE. ACCORDING TO THE NATIONAL CONFERENCE OF STATE LEGISLATURES’ HEALTH 

POLICY TRACKING SERVICE, WHICH WAS LAST UPDATED ON APRIL 1, 

2003, FOUND THAT THE NUBMER OF FULL TIME EQUIVALENT NURSES 

WAS 1.89 MILLION IN 2000. THIS REPRESENTS A NURSING SHORTAGE OF 

110,000 OR SIX PERCENT. IT IS ESTIMATED THAT BY THE YEAR 2015 THE 

DEMAND WILL INCREASE AND THE SHORTAGE WILL ALMOST QUADRUPLE TO TWENTY PERCENT. 

WHAT WE WANT TO HEAR FROM OUR WITNESSES TODAY ARE SOLUTIONS TO THE PROBLEMS FACING OUR HEALTH CARE ORGANIZATIONS IF 

THEY CONTINUE TO EXPERIENCE DIFFICULTIES IN RECRUITING AND RETAINING NURSING PERSONNEL. 
42

EARLIER THIS YEAR, I VISITED THE JAMES A. HALEY VETERAN’S HOSPITAL IN TAMPA, FLORIDA. WHILE AT THAT FACILITY, I LEARNED THAT 

IT HAD ACHIEVED ‘‘MAGNET STATUS.’’ WHEN I ASKED, ‘‘WHAT DOES THAT 

MEAN’’? I WAS TOLD THAT RECEIVING SUCH A DESIGNATION REPRESENTS THE HIGHEST LEVEL OF RECOGNITION THAT THE AMERICAN 

NURSES CREDENTIALING CENTER CAN GRANT TO HEALTH CARE ORGANIZATIONS. HARVEY HOLZBERG, PRESIDENT’S STAFF, ROBERT WOOD JOHNSON UNIVERSITY HOSPITAL SAID:

WE BELIEVE THE QUALITY OF NURSING IS THE KEY TO OUR 

HOSPITAL’S SUCCESS. RECEIVING THE ANCC MAGNET AWARD IS 

THE HIGHEST FORMAL RECOGNITION TESTIMONIAL TO THAT 

QUALITY... THE AWARD WAS RECOGNIZED BY THE ENTIRE 

HOSPITAL FAMILY AS A FORMIDABLE ACCOMPLISHMENT ON THE 

PART OF OUR NURSES. 

WE KNOW THAT IN SOME INSTANCES, RNs ARE LEAVING THE PROFESSION IN SEARCH OF MORE LUCRATIVE AND LESS DEMANDING WORK. 

MAJOR REASONS THAT HAVE BEEN CITED INCLUDE BURNOUT, WORK 

CLIMATE, WORK SATISFACTION, PATIENT QUALITY OF CARE AND MANAGERIAL SUPPORT. 

THE MAGNET PROGRAM ADDRESSES MANY OF THESE CONCERNS. WE 

WILL LEARN MORE ABOUT THIS PROGRAM TODAY. WE ALSO WOULD LIKE 

TO HEAR ABOUT OTHER OPTIONS THAT MIGHT BE AVAILABLE TO ASSIST 

THE VA WITH ITS NURSING RECRUITMENT EFFORTS. 

IN AN EFFORT TO BE AS INCLUSIVE AS POSSIBLE, WE CONTACTED 

FOURTEEN NATIONAL NURSING ORGANIZATIONS AS WELL AS ANA ORGANIZATIONAL AFFILIATES TO RECEIVE THEIR INPUT ON HOW THE NURSING SHORTAGES HAVE AFFECTED CARE IN THEIR SPECIALITY FIELDS. 

THESE STATEMENTS WILL BEINCLUDED IN THE OFFICIAL HEARING 

RECORD. 

I WANT TO THANK THE AMERICAN ASSOCATION OF NURSE ANESTHETISTS (AANA) AND THE NATIONAL ASSOCIATION OF CLINICAL NURSE 

SPECIALISTS FOR SUBMITTING THEIR STATEMENTS TODAY.
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155

WRITTEN COMMITTEE QUESTIONS AND THEIR RESPONSES 

CHAIRMAN BUYER TO DEPARTMENT OF VETERANS AFFAIRS
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171

Æ