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

75–471 PDF 2002

S. Hrg. 107–150

FINDING A CURE TO KEEP NURSES ON THE

JOB: THE FEDERAL GOVERNMENT’S ROLE IN

RETAINING NURSES FOR DELIVERY OF FEDERALLY-FUNDED HEALTH CARE SERVICES

HEARING

BEFORE THE

OVERSIGHT OF GOVERNMENT MANAGEMENT,

RESTRUCTURING, AND THE DISTRICT OF COLUMBIA

SUBCOMMITTEE

OF THE

COMMITTEE ON

GOVERNMENTAL AFFAIRS

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

FIRST SESSION

JUNE 27, 2001

Printed for the use of the Committee on Governmental Affairs

(

(II)

COMMITTEE ON GOVERNMENTAL AFFAIRS

JOSEPH I. LIEBERMAN, Connecticut, Chairman

CARL LEVIN, Michigan

DANIEL K. AKAKA, Hawaii

RICHARD J. DURBIN, Illinois

ROBERT G. TORRICELLI, New Jersey

MAX CLELAND, Georgia

THOMAS R. CARPER, Delaware

JEAN CARNAHAN, Missouri

MARK DAYTON, Minnesota

FRED THOMPSON, Tennessee

TED STEVENS, Alaska

SUSAN M. COLLINS, Maine

GEORGE V. VOINOVICH, Ohio

PETE V. DOMENICI, New Mexico

THAD COCHRAN, Mississippi

ROBERT F. BENNETT, Utah

JIM BUNNING, Kentucky

JOYCE A. RECHTSCHAFFEN, Staff Director and Counsel

HANNAH S. SISTARE, Minority Staff Director and Counsel

DARLA D. CASSELL, Chief Clerk

SUBCOMMITTEE ON OVERSIGHT OF GOVERNMENT MANAGEMENT,

RESTRUCTURING, AND THE DISTRICT OF COLUMBIA

RICHARD J. DURBIN, Illinois, Chairman

DANIEL K. AKAKA, Hawaii

ROBERT G. TORRICELLI, New Jersey

THOMAS R. CARPER, Delaware

JEAN CARNAHAN, Missouri

MARK DAYTON, Minnesota

GEORGE V. VOINOVICH, Ohio

TED STEVENS, Alaska

SUSAN M. COLLINS, Maine

PETE V. DOMENICI, New Mexico

THAD COCHRAN, Mississippi

MARIANNE CLIFFORD UPTON, Staff Director and Chief Counsel

ANDREW RICHARDSON, Minority Staff Director

JULIE L. VINCENT, Chief Clerk

(III)

C O N T E N T S

Opening statements: Page

Senator Durbin ................................................................................................. 1

Senator Cleland ................................................................................................ 4

Senator Voinovich ............................................................................................. 4

WITNESSES

WEDNESDAY, JUNE 27, 2001

Rachael Weinstein, RN, Director, Clinical Standards Group, Office of Clinical

Standards and Quality, Centers for Medicare and Medicaid Services, U.S.

Department of Health and Human Services, accompanied by Thomas

Hoyer, Director, Chronic Care Purchasing Policy Group .................................. 7

Denise H. Geolot, Ph.D., RN, FAAN, Director, Division of Nursing, Bureau

of Health Professions, Health Resources and Services Administration, U.S.

Department of Health and Human Services ...................................................... 8

Rear Admiral Kathleen Martin, Nurse Corps, Director, Navy Nurse Corps,

U.S. Navy .............................................................................................................. 11

Janet Heinrich, Director, Health Care—Public Health Issues, U.S. General

Accounting Office ................................................................................................. 13

Ann O’Sullivan, MSN, RN, President, Illinois Nurses Association, on behalf

of the American Nurses Association ................................................................... 26

Gary A. Mecklenburg, President and Chief Executive Officer, Northwestern

Memorial Hospital, Chicago, Illinois, on behalf of the American Hospital

Association ............................................................................................................ 29

Carol Anne Bragg, RN, President, Professional Staff Nurses Association SEIU

Local 998, on behalf of the Service Employees International Union ............... 31

Hon. Lynn Martin, Chair, Panel on ‘‘Future of the Health Care Labor Force

in a Graying Society,’’ accompanied by Mary Jo Snyder, Director, The

Nursing Institute, University of Illinois at Chicago, College of Nursing ........ 35

J. David Cox, RN, Vice President, National Veterans Affairs Council, American Federation of Government Employees, AFL–CIO ..................................... 37

ALPHABETICAL LIST OF WITNESSES

Bragg, Carol Ann, RN:

Testimony .......................................................................................................... 31

Prepared statement with an attachment ....................................................... 129

Cox, J. David, RN:

Testimony .......................................................................................................... 37

Prepared statement .......................................................................................... 152

Geolot, Denise H., Ph.D., RN, FAAN:

Testimony .......................................................................................................... 8

Prepared statement .......................................................................................... 58

Heinrich, Janet:

Testimony .......................................................................................................... 13

Prepared statement .......................................................................................... 94

Martin, Hon. Lynn:

Testimony .......................................................................................................... 35

Prepared statement .......................................................................................... 142

Martin, Rear Admiral Kathleen:

Testimony .......................................................................................................... 11

Prepared statement with attachments ........................................................... 64

Mecklenburg, Gary A.:

Testimony .......................................................................................................... 29

Prepared statement .......................................................................................... 115

Page

IV

O’Sullivan, Ann, MSN, RN:

Testimony .......................................................................................................... 26

Prepared statement .......................................................................................... 107

Weinstein, Rachael, RN:

Testimony .......................................................................................................... 7

Prepared statement .......................................................................................... 49

APPENDIX

Prepared statements submitted for the record:

Brigadier General Barbara Brannon .............................................................. 73

Brigadier General William T. Bester .............................................................. 85

Diane Sosne, Service Employees International Union, AFL–CIO ................ 136

(1)

FINDING A CURE TO KEEP NURSES ON THE

JOB: THE FEDERAL GOVERNMENT’S ROLE

IN RETAINING NURSES FOR DELIVERY OF

FEDERALLY-FUNDED HEALTH CARE SERVICES

WEDNESDAY, JUNE 27, 2001

U.S. SENATE,

SUBCOMMITTEE ON OVERSIGHT OF GOVERNMENT

MANAGEMENT,

RESTRUCTURING, AND THE DISTRICT OF COLUMBIA,

OF THE COMMITTEE ON GOVERNMENTAL AFFAIRS,

Washington, DC.

The Subcommittee met, pursuant to notice, at 10:02 a.m., in

room SD–342, Dirksen Senate Office Building, Hon. Richard J.

Durbin, Chairman of the Subcommittee, presiding.

Present: Senators Durbin, Cleland (ex officio), and Voinovich.

OPENING STATEMENT OF SENATOR DURBIN

Senator DURBIN. Welcome to this hearing of the Oversight Subcommittee of the Committee on Governmental Affairs and my first

hearing as Chairman, so please forgive me as I learn how to do

this. I have usually been listening to gavels, and now I am banging

one, so it is a little different role for me to play. I know that some

of my colleagues are on their way to join us for this hearing this

morning, and I thank all of you for joining us this morning.

This is a hearing that we have decided to kick off our Oversight

Subcommittee with on the subject of the nursing shortage which

faces our country. The Federal Government has an important role

in retaining nurses for the delivery of federally-funded health care

services and other services.

We have to face the possibility that America may ring for a nurse

some day, and no one will respond. As our population gets older

and fewer nurses are graduated and fewer stay in the profession,

that is a very real possibility.

The issue and challenge for us is what we can do today to address this problem, and you will hear from witnesses on both panels that there are things that need to be done.

This issue defies any easy solutions. There is no magic switch

that we can flip or handy button that we can push that will solve

it. We have nearly half a million trained nurses in America who

are no longer practicing their profession. In my home State of Illinois, over 19 percent of nurses are no longer working as nurses.

2

When I talk to nurses, including relatives of mine who are

nurses, they tell me they are burned out, exhausted because of inadequate staffing levels; they are being asked to do double shifts

and are unable to balance their nursing responsibilities with their

personal and family commitments. I know that many nurses feel

that all of the problems of our current health care system, including its finances, are being forced upon them, and it is really just

too much to ask.

If their daughters or sons were to contemplate a career in nursing, many say they would advise against it—not because they do

not love caring for patients, but because of all the stresses that are

brought to bear on them today with inadequate compensation.

Since 1992, wages for nurses after inflation have risen by less

than 1 percent. But managed care has pushed the finances of our

hospitals to a near breaking point. This leaner face of health care

is described by many nurses as both leaner and sometimes meaner.

A recent survey by the Federation of Nurses and Health Professionals found that half of the current employed nurses surveyed

had considered leaving the patient care field for reasons other than

retirement over the past 2 years. Of those thinking about leaving,

56 percent indicated that they wanted a less stressful and physically demanding job; 22 percent said they were concerned about

the schedules and hours; and 18 percent sought higher pay. Annual

turnover rates among hospital staff nurses have increased to 15

percent, up from 12 percent in 1996. A recent survey of nursing

home chains found turnover among RN’s and LPN’s to be over 50

percent.

The situation is even more drastic in some of our Nation’s poorest rural and inner city communities. They may soon have inadequate or no hospital health care because finding nurses who are

willing to work in their neighborhoods is almost impossible. Some

of these hospitals operate amid the harshest poverty and crime in

our country. The employees of these hospitals often treat the worst

and most troubling cases.

I recently supported the effort of a hospital in Chicago that was

desperate for nurses to try to find some way to change the immigration law to deal with the issue. But generally, immigration is

not a long-term solution to the underlying problem of poor workplace conditions and in some instances actually threatens patient

safety, and at the very least drives more and more professionals

away from the caring profession of nursing.

Last year, The Chicago Tribune ran a three-part series on medical errors caused by nurses. It was an eye-opener. And the Institute of Medicine released a sentinel report on medical errors

throughout the health care system, reporting that annually, we

might have almost 98,000 deaths due to medical errors. This can

only be described as alarming and really points to the need to overhaul our health care system.

We will be hearing from several nurses today about the conditions under which they work which contribute in many cases to a

less than safe environment for patients. I was shocked to learn recently that most nurses now work shifts of 10 to 12 hours and that

some are forced to work double shifts even when they are exhausted. How could a 20-hour day be safe for patients, let alone

3

good for a nurse or his or her family? I will be very interested to

hear from some of the nurses who are here today to testify as to

how they deal with the care of their children and other family

members if their schedule can be forced to change without notice.

If you think the situation is bad now, wait until we get to 2010.

The nursing work force is aging just like the overall U.S. population is aging. Fewer and fewer young people are going into the

career of nursing just as we move to a time when we need nurses

more and more.

I had a recent visit from a head nurse in a nursing home in the

Chicago area, and she told me a story which was incredible. She

said, ‘‘I have been at this all my life’’—she is about 60 years old— ‘‘I love nursing, and I love working with nurses. I recently had a

surgery scheduled at a major hospital in Chicago, and before I

went in for that surgery, I hired a private nurse to come with me.’’ It almost takes your breath away to think that that is a possibility. It really suggests that if we do not address this, we may

reach a stage where we are dealing with graduated health care

even within our hospitals. Who can afford to bring their own nurse

or their own doctor to make sure they get the care they think they

need? And certainly, when it comes to nursing, if this nurse, who

has dedicated her life to it, thought she needed a private nurse to

be by her bedside in a major hospital in Chicago, that is worrisome

for all of us.

I have a chart here which shows the distribution of nurses in

1980 and then in the year 2000. If you took your statistics course,

you can probably follow this a little more carefully. What it shows

us is that the average age of nurses is 45 today; it was 37 in 1983.

A comprehensive approach is needed not only to attract more

young people but also to improve the work environment. Retention

is just as important as recruitment. I will be introducing a comprehensive bill to address the nursing shortage. It will focus on

outreach to young people to encourage them to think about careers

in nursing and other caregiving professions; scholarships and loans

for those who serve in underserved areas, be they urban or rural;

and financial incentives to address inadequate staffing levels that

put the public in danger. The bill will also provide additional educational opportunities to those who are in the process of

transitioning to the work force as the welfare reform bill is fully

implemented.

But beyond recruitment and training, we really cannot solve this

problem without looking at workplace conditions. Spending money

on recruitment and training is wasted if health professionals quit

early because they cannot live with the excessive hours, work load,

and stress. We have rules in many other public safety-oriented professions. For instance, the Federal Government does not allow pilots to work continually. We have limits on truck drivers and train

engineers. Shouldn’t we also give protections to nurses so they are

not forced to work hours that put them and their patients in danger due to fatigue?

Many other countries are experiencing similar demographic

changes and are challenged to meet their own health and long-term

caregiving needs. It is not at all clear that immigration can solve

this problem given the global need for more caregivers.

4

As I said earlier, the issue defies easy solutions. However, what

is clear is that we need to invest more significantly in recruitment,

education, and retention if we are to address this long-term need.

At this point, I would like to recognize the ranking member of

the Subcommittee, Senator Voinovich.

OPENING STATEMENT OF SENATOR VOINOVICH

Senator VOINOVICH. Thank you, Mr. Chairman.

I am pleased that the Subcommittee is holding this hearing

today to examine the nursing shortage in the United States and

how it is impacting federally-funded health care programs.

I would like to welcome our two panels of witnesses and thank

them for being here today.

As you know, Mr. Chairman, over the past 21⁄2 years, the Subcommittee has conducted a thorough examination of the human

capital crisis confronting the Federal Government’s work force. In

profession after profession, the story is the same: A lack of skilled

people, an aging work force, or both.

It would seem that this is a similar problem in the nurse work

force—and not just those who work for the Federal Government or

through federally-funded programs. Just as the average age of Federal employees has risen over the years, today’s average registered

nurse is 45 years old, up from 37 in 1983. This increase has taken

place at the same time that the average age of Americans has

risen.

With people living longer, the need for quality health care professionals will only increase with time. Exacerbating the problem is

the fact that hundreds of thousands of nurses are no longer working in the field of nursing, and the number has increased 11 percent in the last 4 years. It will be interesting to discuss why that

is and if there is a correlation with the fact that during the same

period of time, nursing wages have remained stagnant, rising approximately 1 percent.

Mr. Chairman, we have two excellent panels of witnesses with us

today. I am especially pleased to welcome Rear Admiral Kathleen

Martin. As you know, Mr. Chairman, last year, Congress passed

legislation that I sponsored to provide work force reshaping authorities in the Department of Defense. I will be interested in hearing Admiral Martin’s testimony on what is being done to address

the nursing shortage in the Armed Forces.

Thank you again, Mr. Chairman, for holding this hearing, and I

look forward to the witnesses’ testimony.

Senator DURBIN. Thank you, Senator Voinovich.

Senator Cleland.

OPENING STATEMENT OF SENATOR CLELAND

Senator CLELAND. Thank you very much, Mr. Chairman, and

Senator Voinovich. It is nice to be with you, my dear colleagues,

today, focusing on the nursing shortage and the challenge of being

a nurse in America today.

I might say first off that nurses helped save my life. I would not

be here were it not for nurses. The second person to me on the battlefield, Admiral Martin, was a Navy corpsman, and one of the first

hospitals I was evacuated to was the Navy hospital in Danang. So

5

I have a special appreciation for nurses, especially Army dust-off

pilots, Army medics, Navy medics, and Air Force medivac teams.

So I want you to know that I am here today because of nurses and

a whole complement of people who go out there and do an incredible job.

I again commend my colleague Senator Durbin and other Subcommittee Members for today’s hearing on the critical role of

nurses, particularly in the Federal health care system. I am a

former head of the Veterans Administration, and I know the critical role that nurses play there.

In the Federal health care system, we have military and Veterans Affairs nurses. They are not only life-sustaining givers of

care but also givers of hope. As someone who was in the military

and VA health care system for more than a year and a half, I can

certainly attest to that.

When I meet with health care groups from Georgia and across

the Nation, the increasing need for nurses is always part of the discussion. At the June 14 Senate Veterans Affairs Committee hearing on the looming nursing shortage, I emphasized an alarming

statistic—that the Federal health care sector, employing approximately 45,000 nurses, may be the hardest hit in the near future,

with an estimated 50 percent of its nursing work force eligible for

retirement by the year 2004—almost 50 percent of the nursing

work force in the Federal Government and in the military eligible

for retirement in 2004.

Current and anticipated nursing vacancies in all health care settings are attributed to a variety of factors, including more career

choices for women and worsening workplace conditions with mandatory overtime and increasing patient care work loads. It sounds

a little bit like what they said when I was in the Army, that ‘‘Good

duty is rewarded with more duty.’’ I think our nurses in America

are in that position.

I believe that today we are really facing more widespread and

complex challenge with the nursing shortage. There are no quick

fixes, but I do think that part of the key to developing legislative

initiatives and understanding this complex issue is the testimony

we are going to hear today from our panelists. I think it is crucial

that we have nurses recommend to us how they can take safe and

effective care of their patients and for us to assist health care facilities in recruitment and retention of qualified nurses.

One answer that I have is some legislation that I have introduced, S. 937, which is a bill to amend Title 38 of the U.S. Code

to prevent members of the armed services to transfer their Montgomery GI bill educational benefits to spouses and children, and

that assistance could be used for undergraduate or graduate nursing education. It is an effort to retain service men and women, but

it is also an effort to keep spouses and children in the military with

their spouses and to give them an educational opportunity as well,

and give them hope.

I have also introduced S. 1080, the Federal Nurse Retirement

Adjustment Act, which will allow Federal nurses in the Federal

Employee Retirement System to retain unused sick leave and retirement calculations comparable to nurses currently in the civil retirement system.

6

1The prepared statement of Brigadier General Barbara Brannon appears in the Appendix on

page 73. 1The prepared statement of Brigadier General William T. Bester appears in the Appendix on

page 85.

I urge my colleagues to carefully consider the testimony of today’s witnesses as they develop initiatives to help recruit and retain qualified nurses.

Thank you all very much for being with us.

Thank you, Mr. Chairman.

Senator DURBIN. Thank you, Senator Cleland.

I would first like to introduce two people who will not be testifying on the first panel, but I want to acknowledge their presence

and thank them for joining us.

Brigadier General Barbara Brannon 1 is commander of the 89th

Medical Group at Andrews Air Force Base. Thank you for being

with us today. She is the Assistant Air Force Surgeon General for

Nursing.

And Brigadier General William T. Bester 1——

Colonel GUSTKE. He is not here today, Mr. Chairman.

Senator DURBIN. Could you introduce yourself, please?

Colonel GUSTKE. I am Colonel Deborah Gustke. I am the Deputy

Chief of the Army Nurse Corps, sir, representing General Bester.

Senator DURBIN. Thank you very much for joining us today.

I will now introduce the panel that will testify first.

Rachael Weinstein is a registered nurse and Director of the Clinical Standards Group at the U.S. Department of Health and

Human Services.

Dr. Denise Geolot is a registered nurse and Director of the Division of Nursing at the U.S. Department of Health and Human

Services. She administers the Federal program that enables national nursing work force development.

Admiral Kathleen Martin joins us from the United States Navy.

She will deliver testimony on behalf of the Tri-Service Nurse Corps.

She is a Rear Admiral and Director of the Nurse Corps.

Janet Heinrich is Associate Director of the Health, Education,

and Human Services Division at the U.S. General Accounting Office.

Thank you all for coming. We are looking forward to your testimony.

It is the custom of this Subcommittee to swear in all witnesses;

therefore, I will ask all of you to stand and raise your right hand

as I give an oath for the first time in my life.

Do you swear that the testimony you are about to give before

this Subcommittee is the truth, the whole truth, and nothing but

the truth?

Ms. WEINSTEIN. I do.

Dr. GEOLOT. I do.

Admiral MARTIN. I do.

Ms. HEINRICH. I do.

Senator DURBIN. Thank you.

Let it be noted for the record that all witnesses answered in the

affirmative.

7

1The prepared statement of Ms. Weinstein appears in the Appendix on page 49.

I would like to ask you to limit your oral statements to no longer

than 10 minutes and remind you that your entire statement will

be made part of the record.

Ms. Weinstein, please proceed.

TESTIMONY OF RACHAEL WEINSTEIN, RN,1 DIRECTOR, CLINICAL STANDARDS GROUP, OFFICE OF CLINICAL STANDARDS

AND QUALITY, CENTERS FOR MEDICARE AND MEDICAID

SERVICES, U.S. DEPARTMENT OF HEALTH AND HUMAN

SERVICES, ACCOMPANIED BY THOMAS HOYER, DIRECTOR,

CHRONIC CARE PURCHASING POLICY GROUP

Ms. WEINSTEIN. Chairman Durbin, Senator Voinovich, and distinguished Subcommittee Members, thank you for inviting me to

discuss the need for adequate nurse staffing levels. Accompany me

today is Tom Hoyer, Director of our Chronic Care Purchasing Policy Group, who is an expert in Medicare payment policy, who is

with me to respond to your technical payment questions.

As a registered nurse, the issue of nurse staffing is important to

me personally. It is a priority for Administrator Scully and Secretary Thompson, and we look forward to working with you to address this growing concern.

Nurses and nurse aides play a critical role in caring for Medicare

and Medicaid beneficiaries, sometimes working more than the

equivalent of two 8-hour shifts in 1 day. Their work can be exhausting, emotionally as well as physically, and too often they perform their duties without receiving the credit that they deserve.

Nursing requires great dedication, and research has shown that

it is becoming more and more difficult to recruit and retain professionals to perform this difficult work. Moreover, studies continue to

demonstrate that higher nurse staffing levels, especially registered

nurse staffing levels, directly influence positive outcomes in patient

care.

We recognize the important role that nurses play in our health

care system, and we value their dedication and hard work. In our

role as the largest health insurer in America, we need to ensure

that we pay health care providers adequately and appropriately,

and my written statement goes into the details of how we fulfill

this responsibility.

Numerous objective observers including the General Accounting

Office, the Health and Human Services Inspector General, and the

Medicare Payment Advisory Commission have found that Medicare

payment levels in the last few years are more than adequate to

cover the costs of providing high-quality fare in hospitals, skilled

nursing facilities, and home health agencies.

Despite the appropriateness of Medicare reimbursement levels,

our country faces an emerging shortage. We are hearing that a

higher proportion of patients with more complex care needs has expanded the need for nurses with specialized training. We also hear

that the increased use of technology has driven up the demand for

a higher skill level of registered nurses. And the expansion of care

delivery settings has increased the demand for nurses in general.

8

1The prepared statement of Dr. Geolot appears in the Appendix in page 58.

Job dissatisfaction, difficult working conditions, and low compensation may also contribute to the emerging nurse shortage. In

fact, studies indicate that dissatisfaction with working conditions is

a major source of frustration for nurses, both domestically and in

foreign countries. This frustration has led to a decline in enrollment in nursing schools and an increase in the number of nurses

leaving the profession. Additionally, the majority of actively employed nurses is aging.

We are analyzing the situation to determine the best way to ensure that our beneficiaries continue to receive the high-quality care

they need, and we are committed to reducing unnecessary burdens

and complexities in Medicare. We are sponsoring research into

nurse staffing levels in nursing homes, and we are considering

ways to guarantee that nursing homes provide the appropriate

staffing levels based on the results of our research.

In addition, our current conditions of participation for home

health agencies, skilled nursing facilities, and hospitals which

these facilities must meet in order to receive Medicare reimbursement requires that they maintain adequate nurse staffing levels.

And we propose a new hospital condition of participation that

would ensure staffing levels reflect the volume of patients, patient

acuity, and the intensity of the services provided to achieve desirable patient outcomes.

Additionally, we have been working with our partners, including

the Health Resources and Services Administration, to sponsor

nurse staffing studies. A study that we cosponsored with HRSA,

‘‘Nurse Staffing and Patient Outcomes in Hospitals,’’ was just released a few months ago. The results of this study and other efforts

will help inform the public and private sectors as we work collaboratively to find solutions to the emerging nurse shortage problem.

Nurses play a crucial role in caring for our beneficiaries, and we

are concerned that the nurse staffing shortage could have a profound impact on the care that our beneficiaries receive. We must

continue to be vigilant and ensure that we are paying health care

providers appropriately so they can hire and retain adequate levels

of nursing staff. We must continue to make the issue of the emerging nurse shortage a priority. We are working closely with our

HHS partners, and we want to continue to work with you and others to find ways to address this growing concern.

Thank you for this opportunity to speak with you today about

this important issue. I am happy to answer your questions.

Senator DURBIN. Thank you, Ms. Weinstein. Dr. Geolot.

TESTIMONY OF DENISE H. GEOLOT,1 Ph.D., RN, FAAN, DIRECTOR, DIVISION OF NURSING, BUREAU OF HEALTH PROFESSIONS, HEALTH RESOURCES AND SERVICES ADMINISTRATION, U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Dr. GEOLOT. Good morning, Mr. Chairman and distinguished

Members of the Subcommittee.

I am pleased to appear before you today to discuss issues related

to the nurse work force. In my brief statement this morning, I will

provide an overview of the characteristics of the nursing work

9

force, speak about the extent of current and projected nurse staffing levels, and review what the Health Resources and Services Administration is doing to plan for future nursing staff needs.

In March 2000, the Division of Nursing, Bureau of Health Professions, conducted the National Sample Survey of Registered Nurses,

the seventh in a series of surveys on the characteristics of the

nursing work force. The previous survey was completed in 1996.

This survey provides the latest and most comprehensive data on

the characteristics of the registered nurse work force. The full report of this survey is to be released this summer. I will just mention a couple of points in terms of the data. The rest are in my testimony.

There are estimated to be 2.7 million registered nurses in the

United States. This reflects a 5.4 percent increase between 1996

and 2000. Over 2.2 million of the 2.7 million nurses are employed

in nursing. Nearly 72 percent of those nurses work full-time. Sixtyeight percent of the staff nurses working in hospital settings indicated that they were satisfied with their jobs.

When we looked at the educational preparation of registered

nurses, we found that 23 percent had a nursing diploma as their

highest level of preparation, 34 percent an associate degree, and 43

percent had a baccalaureate or higher degree.

The RN population is aging. Nine percent of nurses are under

the age of 30, and 51 percent are over the age of 45.

Nursing students are also older. The average age for a basic

nursing graduate is 30.5.

An estimated 12.3 percent of the RN population reported being

from one of the racial and ethnic minority groups, up from 10.3

percent in 1996.

An estimated 5.4 percent of the RN population are men, up from

4.9 percent in 1996.

There are pockets of nursing shortages throughout the country,

especially for registered nurses with clinical expertise and specialty

preparation. Some hospitals are reporting that they must close

beds and divert patients to other hospitals because of nursing

shortages.

The aging of the nursing population, declining student enrollments in nursing schools, and the current working conditions may

have an effect on future nurse staffing needs. Enrollment in all

nursing programs has declined. Enrollment data from the American Association of Colleges of Nursing reveals that baccalaureate

nursing program enrollments fell 4.6 percent in fall 1999—the fifth

straight year of declining enrollments. Figures for 2000 revealed a

slowing decline to 2.1 percent.

Graduation data from the National League for Nursing indicated

that there was a 13.6 percent decrease in registered nurse graduates between 1995 and 1999.

The answer to whether there is a national nursing shortage is

complex. No single direct measure exists for indicating a shortage

of nurses at the national level. The Division of Nursing has historically used a comparison of the projected supply of nurses and the

projected demand or requirements for nurses to assess imbalances.

Ideally, the number of nurses available to provide services in a

given setting should be in balance with the requirements for nursVerDate 11-MAY-2000 14:40 May 10, 2002 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6633 75471.TXT SAFFAIRS PsN: SAFFAIRS
10

ing services in that setting. Based on outputs from the supply projection model and the demand projection model published in the

mid-1990’s, the supply of and requirements for full-time equivalent

RN’s is expected to be roughly in balance until the year 2010 at

the national level. A projected leveling off of the supply and steep

increases in demand over the years between 2010 and 2020 will result in a widening gap between the number of nurses expected to

be required and the number of nurses expected to be available.

By the year 2020, the model indicates a shortfall in the number

of nurses and the number of needed registered nurses. However,

because of the recent rapid changes in the health care system, it

is difficult to make precise predictions about what the demand for

nursing services will be in the future.

Preliminary estimates from the revised demand forecasting

model and supply projections indicate that at the national level,

there is roughly a balance at this time. However, this does not negate reports from other sources of current shortages in specific

areas, health care sectors, or types of registered nurses.

The demand forecasting model identifies a systemic problem that

will continue to increase through 2020. If these current trends continue, all health care settings, all geographical areas, and all needed specialty nurses may experience nursing supply challenges. But

there may also be advances in technology that may reduce future

demands. HRSA will continue to monitor nursing data to chart future nurse staffing needs.

When we look at the RN-to-population ratio for the Nation as a

whole, our data show that the overall ratio of employed RN’s per

100,000 population has varied from 688 in 1988 during the previous shortage to 798 in 1996 and 782 in 2000. After more than a

decade of increases, the rates appear to be dropping.

In addition, data show that the variation among States is considerable. The numbers range from a low of 520 employed RN’s per

100,000 population in Nevada to a high of 1,675 in Washington,

DC.

HRSA administers programs authorized under Title VIII of the

Public Health Service, often referred to as The Nurse Education

Act. Title VIII was instituted by the Nurse Training Act of 1964

in response to a qualitative and quantitative shortage of nurses as

a key vehicle for Federal support for nursing work force development. Title VIII programs are primarily administered by the Bureau of Health Professions, Division of Nursing.

Specific activities helping to mitigate the shortage of nurses include: Support for basic and advanced nursing education programs;

diversity programs targeting minority and disadvantaged students;

scholarship, traineeships, and loans; and nursing work force analysis.

In fiscal year 2001, the budget for the Division of Nursing Programs is $76.5 million. The administration’s fiscal year 2002 budget would increase the funding for HRSA’s nursing programs by $5

million.

The Bureau’s Division of Student Assistance provides $12.7 million in support to 3,600 nursing students through the Scholarships

for Disadvantaged Students Program and $22 million in support

11

1The prepared statement of Admiral Martin appears in the Appendix in page 64.

for 10,000 nursing students through the revolving Nursing Student

Loan Program.

Within the Bureau of Primary Health Care, the Nursing Education Loan Repayment Program provides $2.3 million to assist 200

registered nurses by repaying up to 80 percent of their qualified

educational loans in return for their commitment to work at health

facilities in shortage areas. In addition, the National Health Service Corps Scholarship and Loan Repayment Program provides $6.3

million to support 94 nurse practitioners and 29 nurse-midwives

providing services to people in underserved areas.

HRSA has been working with the Centers for Medicare and Medicaid Services to examine work force issues, and my colleague has

mentioned them.

So in summary, Mr. Chairman, I appreciate the opportunity to

share with you the latest information on the characteristics of the

nursing work force, the status of what our data show from a national perspective, and the types of activities being undertaken in

HRSA to address the needs of the nursing work force.

Senator DURBIN. Thank you very much, Dr. Geolot. Admiral

Martin.

TESTIMONY OF REAR ADMIRAL KATHLEEN L. MARTIN,1

NURSE CORPS, DIRECTOR, NAVY NURSE CORPS, U.S. NAVY

Admiral MARTIN. Good morning, Mr. Chairman and Senator

Voinovich. It is my pleasure to testify today as the Director of the

Navy Nurse Corps and the Commander of the National Naval Medical Center in Bethesda.

I am also here to speak on behalf of the Chief of the Army Nurse

Corps and the Director of the Air Force Nursing Services.

My colleagues are here to answer specific questions.

Today I would like to discuss one of our principal concerns—the

nationwide nursing shortage and its impact on the military health

care system. I will address this in terms related to both military

nursing and civil service nursing.

As you are well aware, the demand for professional nurses in

America is increasing while the supply continues to decline. The

impact of this diminishing pool affects health care delivery nationwide. Along with the civilian and Federal sectors, the military now

finds itself in a critical struggle to attract and retain nurses for active duty, reserves, civil service, and contract positions.

Our nursing issues, such as compensation, job stress, quality of

life and workplace, are similar to those in the civilian sector. However, due to the distinctive mission of the military, we are not

equally affected by the same challenges.

I would first like to discuss factors having a positive effect on

military nursing. Unlike our civilian and Federal counterparts,

military nurses have long relied upon the medical enlisted forces

to assist in the delivery of health care. These technicians, medics,

and hospital corpsmen possess higher skill levels than their unlicensed civilian colleagues and are considered an integral part of

the nursing team.

12

Additionally, staffing levels in military hospitals have a tendency

to remain more stable. This can be attributed to the turnover rate

for new military nurses and enlisted being controlled by obligated

service contracts and predictable timing of change of duty assignments.

Additionally, on average, military nurses experience a higher

nurse-to-patient ratio, greater collaborative nurse-physician relationships, additional leadership opportunities, diverse practice environments, and broadened career paths.

However, despite the unique military advantages, the effects of

a dwindling supply of best qualified nurses have a detrimental effect on military nursing. Currently, our greatest challenges lie not

only in recruiting new nurses but also in retaining junior to midgrade level experienced nurses.

An adequate force structure is critical to maintaining a high

quality of peacetime health care while ensuring that our fighting

forces and operational commitments are fully supported.

Success with recruiting nurses into the military has varied

among the services, but filling the Reserve Officer Training Command, or ROTC, billets has been difficult for all services. One reason for this could be that fewer high school graduates are choosing

nursing as a career or seeking a military experience while in college. Additionally, nurses with 1 to 5 years of experience are becoming more difficult to attract to the military. This has a direct

impact on health care delivery system and operational readiness

because of the nursing shortfalls in critical specialties such as operating room, critical care, mental health and obstetrics, to name a

few. In addition, the nurses who we are able to recruit are often

40 years and older, leading to an older, limited-term, non-careertrack force.

A fundamental part of the recruiting strategy for all services is

the current nurse accession bonus. Active-duty accession bonuses

may attract individuals, but without additional incentives, it may

be difficult to retain nurses after their initial commitment. Currently, only nurse anesthetists, nurse practitioners, and nurse-midwives are authorized to receive incentive special pay or a board certification pay. These programs have been successful retention tools

thus far, but the civilian-military pay gap is rapidly widening for

advanced practice nurses. Further, retention bonuses may be needed to retain all types of nurses as compensation for increasing the

ever demanding supply.

Because up to half of the nursing force in the Navy and Army

military treatment facilities is comprised of civilian nurses, it is

also necessary to comment on the civil service or government service and contract nurse work force. Current vacancy and turnover

rates vary between the services but are at levels that have a significant impact on mission capabilities. Because of considerable differences in compensation and hiring practices between the government and private sector, we cannot maintain an adequate level of

civil service nurses to meet our needs.

Our civilian competitors are able to provide timely hiring actions

in some instances in less than 1 week from application to first day

in facility. Conversely, the average length of time to bring a new

13

1The prepared statement of Ms. Heinrich appears in the Appendix in page 94.

civil service RN into a military treatment facility is as long as 93

days.

Government-civil service hiring practices and bureaucracy constraints entangle what must be an expeditious process.

To fill the needed vacancies in a timely manner, many military

treatment facilities are forced to hire contract nurses, often at

much higher salaries. Military and civil service nurses work sideby-side these higher-compensated peers, creating additional dissatisfaction for our military and civil service nurses.

Compensation is a powerful driver in the decision to remain with

a military health care organization or to leave. Each of the services

has established open communication and interviews with nurses to

ascertain all reasons for departing military or government service.

All services are instituting proactive initiatives within given constraints to enhance recruiting and retention.

Our military and civil service nurses are extremely dedicated to

the success of the military health care system and our operational

missions. They have been the backbone of our health care facilities

and have served proudly for over 100 years. I truly believe that

they are the finest professional nurses in the world.

Therefore, we must take action to ensure that our patients of the

future will benefit from the services provided by these professional

nurses.

In summary, I believe the main obstacles to first recruiting and

then retaining quality nurse corps officers and civil service nurses

are pay, benefits, and antiquated civil service hiring processes.

Mr. Chairman, on behalf of my colleagues, I thank you for allowing me to share this information and for your support in keeping

military and Federal nursing strong for the future.

Senator DURBIN. Thank you, Admiral Martin.

I might add that there is a vote on, and Senator Voinovich has

gone over to vote, and he will return, and then I will take off, and

we will try to keep things moving.

Ms. Heinrich.

TESTIMONY OF JANET HEINRICH,1 DIRECTOR, HEALTH

CARE—PUBLIC HEALTH ISSUES, U.S. GENERAL ACCOUNTING

OFFICE

Ms. HEINRICH. Thank you.

May I ask that we put the chart up, please?

Mr. Chairman, I also am pleased to be here today as you discuss

issues related to the current difficulties in the recruitment and retention of nurses and concerns about the future supply.

My remarks will focus on what is known about the current supply of nurses, factors contributing to current recruitment and retention difficulties, and factors that will affect the supply of and demand for nurses in the future.

Yes, the U.S. health care system has changed dramatically in the

last 2 decades, affecting the environment in which nurses provide

patient care. Advances in technology and greater emphasis on costeffectiveness have led to changes in the structure, organization,

and delivery of health care services.

14

We now see more patient care shifting to the ambulatory and

community care settings, home care, and nursing homes. This has

increased the demand for nurses outside the hospital. This change

in service settings has also resulted in decreased lengths of patient

stay in hospitals and a decline in the number of beds staffed.

At the same time, the acuity of patients increased as those patients remaining in hospitals were those too medically complex to

be cared for in other settings.

National data are not adequate, as we have heard, to describe

the extent of nurse work force shortages, nor are data sufficiently

sensitive or current to allow a comparison of the adequacy of the

work force across States, specialties, or provider types. Evidence

suggests emerging shortages of nurses available or willing to fill

some vacant positions in hospitals, nursing homes, and home care

agencies.

The nationwide unemployment rate for RN’s declined to 1 percent in 2000, the lowest level in more than a decade. Vacancy rates

as reported by providers, often used as an indicator of possible excess demand, vary for all providers across all States, urban/rural

areas.

For example, California reported a RN vacancy rate of 20 percent

for hospitals in 2000, up from 9.6 percent in 1997. On the other

hand, Vermont in a 2000 survey reported a RN vacancy rate of 4.8

percent in hospitals. It is difficult to understand what those vacancy rates really mean, because they are figured out in different

ways in different facilities.

Job dissatisfaction may play a significant role in both current

and future recruitment and retention problems. In all of the recent

surveys we have reviewed, RN’s reported themselves as ‘‘somewhat’’ or ‘‘very’’ dissatisfied with their jobs in a very high proportion. Inadequate staffing, heavy work loads, and the use of overtime to address staffing requirements were frequently listed as reasons. Nurses have also cited the lack of respect and recognition

given them, along with their perceived lack of autonomy and ability

to participate in decisionmaking, as areas of concern.

Overall compensation is also expressed as an area of concern. As

we show in this chart, earnings have been relatively flat throughout the decade, with only a slight increase in recent years. While

surveys indicate that increased compensation might encourage

nurses to stay at their jobs, money is not always cited as the primary reason for job dissatisfaction. Often, it is the third or fourth

issue that is reported.

Nurses also have expressed dissatisfaction with the decrease in

the amount of support staff available to them. As reported by the

American Hospital Association, current nurse work force issues are

part of a larger concern for shortages of pharmacists, lab technicians, and others.

There is also a shortage of nurse aides who support nurses and

assist patients with personal care. In the studies that we reviewed,

we found that many of the factors that are concerns for nurses are

also concerns for nurse aides and explain the problems that people

experience with retention of nurse aides in all settings.

Growth in the number of new RN’s has slowed, as we have

heard. It is also interesting to hear that there has been a reduction

15

in the number of RN’s taking and passing the licensing exam. This

declined by 23 percent from 1997 to 2000—it was 96,679 in 1996,

and it dropped to 74,787 in 2000.

Even with the relatively large increasing in the nursing work

force over the 1990’s—I think that 2.7 million figure is rather astounding—we can expect a serious shortage in the future as pressures are exerted on both demand and supply. The future demand

for nurses is expected to increase dramatically when the baby

boomers reach their 60’s, 70’s and beyond. During that same period, the number of women in the age groups who have traditionally formed the core of the nursing work force is expected to remain

relatively unchanged. This mismatch between future supply and

the demand for caregivers is illustrated in the change in the ratio

of women age 20 to 54 to the population age 85 and older. That

ratio will change from 16.1 in 2000 to 8.5 in 2030, and 5.7 in 2040.

In conclusion, providers’ current difficulties recruiting and retaining nurses may worsen as the demand for nurses increases

with the aging of the population. Certain changes in the current

labor market are similar to those that occurred in past shortages.

However, the impending demographic changes are widening the

gap between the numbers of people needing care and those available as caregivers. Moreover, the current high levels of job dissatisfaction among nurses due to management decisions to restructure health care delivery and staffing may play a crucial role in determining the extent of future nurse shortages.

Efforts undertaken to improve the areas of workplace environment that contribute to job dissatisfaction may reduce the likelihood of nurses leaving the profession and increase the number considering it.

More data that can describe the scope and nature of the current

problem is needed to assist in planning and targeting corrective actions.

Mr. Chairman, that concludes my statement. I would be happy

to answer questions.

Senator DURBIN. Thank you.

I have a number of questions for the panel. First, for the record,

Ms. Weinstein, CMS used to be HCFA.

Ms. WEINSTEIN. Yes. We have to get used to that as well.

Senator DURBIN. Right. For years, we have had hospital administrators coming to us from across the Nation saying that because of

the cutbacks in Medicare reimbursement, many of them are facing

some very serious budgetary problems. And many of my colleagues,

including myself, did everything we could to increase hospital reimbursement from the Medicare program to deal with what we

thought was an overreaction by Congress of cutbacks in Medicare.

What I would like to ask you is whether the money that we have

been sending back to the hospitals has been reaching the nurses.

Have they seen increases in their salaries and their wages as a result of this increased Medicare reimbursement?

Ms. WEINSTEIN. I would like to answer your question by saying

that we do not earmark any of the dollars for any specific services

provided by the providers. The providers are paid prospectively,

and they are then charged with determining how they are going to

allocate those resources.

16

I would like to defer to my colleague, Mr. Hoyer, to elaborate on

the response.

Senator DURBIN. Mr. Hoyer.

Mr. HOYER. That gets to the response that we do not know. We

do know the payment levels are adequate in all of the settings, but

we do not know the extent to which the hospitals, SNFs, and home

health agencies have used the money to hire nurses or raise salaries.

Senator DURBIN. My understanding is, and I think the testimony

shows, that over the last decade, nurses really have not seen any

substantial increase in their wages—I think it is less than 1 percent—but there has been in the last year, I think, an increase

slightly higher. Are you aware of those statistics?

Mr. HOYER. I am not aware of the nurse salary statistics, Senator.

Senator DURBIN. Well, maybe we can get some of that information from the next panel.

Can you comment on what you are finding as to the profit margins in hospitals after the Medicare increases went into effect?

Mr. HOYER. Well, I can say that hospitals have done reasonably

well. There was some concern after the Balanced Budget Act of

1997, but MedPAC’s latest recommendations, with which we agree,

are that hospital payments are on track, and there is no compelling

reason to change the update.

Senator DURBIN. You have also testified, Ms. Weinstein, as to a

study involving staffing ratios. Are you going to be publishing these

recommended ratios for nurse-patient, doctor-patient treatment?

Ms. WEINSTEIN. Mr. Chairman, are you speaking of the study related to nursing home staffing or the study related to hospital

nurse staffing?

Senator DURBIN. Nursing homes.

Ms. WEINSTEIN. Last summer, we completed the first phase of

our nursing home staffing study, and that study did show that

there was a link between nurse staffing levels and quality of care

for nursing home residents. We are in the process of completing the

second phase of that study. We expect it to be completed by the end

of this calendar year. At that time, we will review the results, and

it will inform us as to what direction we should take for policy in

the long-term care setting.

Senator DURBIN. Will you also be addressing the issue of medical

errors in relation to ratios?

Ms. WEINSTEIN. We have been looking at the issue of medical errors across the board. We have been working collaboratively with

other HHS partners, looking at medical errors in all settings, and

it is something that we will consider as we look at all the evidence.

Senator DURBIN. Good.

I am going to ask that the Subcommittee be in a short recess

now, as I race over to try to make this vote. Senator Voinovich, if

he returns, will ask his questions, and then I will resume.

Thank you.

[Recess.]

Senator VOINOVICH [presiding]. I will call the meeting to order.

Senator Durbin will be back as soon as he casts his vote.

17

I would like to ask a few questions now. The first question that

I have is for Ms. Weinstein and Dr. Geolot. How does the Bush Administration believe that we need to address the problem that the

two of you have made mention of today? Is there anything that you

have heard thus far from the administration in terms of what they

think we ought to be doing about it?

Ms. WEINSTEIN. Senator Voinovich, I would like to address that

question by saying that we believe that we have to continue to

monitor the situation and to ensure that we are paying the providers adequately so that they can appropriately care for our beneficiaries.

We have to continue to collaborate with our colleagues in the Department, including HRSA, the National Institute for Nursing Research, the Agency for Healthcare Quality Research. We have to

look at the studies that they are doing and try to convene partnerships, private and public together, where possible.

Senator VOINOVICH. One of the things that interested me in your

testimony was that you indicated you really believe that Medicare

adequately reimburses providers for nurses; is that correct?

Ms. WEINSTEIN. We had support for that in the recent MedPAC

report, which showed that we are paying hospitals appropriately.

We are in agreement with that report. Also, the Inspector General

and the General Accounting Office have studied the nursing home

issue and reimbursement in nursing homes and have concluded

that we are paying adequately in nursing homes as well.

I would add that the payments we give to providers are not earmarked specifically for nursing services. It is up to the providers

to determine how to use the dollars that they receive and provide

services to beneficiaries, patients, and residents.

Senator VOINOVICH. Dr. Geolot, would you like to comment on

that?

Dr. GEOLOT. Senator, we also think it is extremely important to

continue to monitor the work force and intend to carry out the

sample surveys which give us the national perspective.

In terms of specific programs to support the work force, the Title

VIII programs address basic and advanced nursing education programs, diversity programs targeting minorities and underrepresented individuals, and we have scholarships, traineeships, and

loans, and the administration has proposed an increase for funding

of the programs under this authority in Title VIII.

Senator VOINOVICH. Do you think that is going to be adequate to

deal with the current situation?

Dr. GEOLOT. Well, we realize that there are many competing priorities, and the administration did suggest increases for the Title

VIII programs.

Senator VOINOVICH. So, if I heard you right, you are saying that

on the national level, you think that the number of nurses is in

balance with the demand for care and that should continue for the

next several years but that you see a real problem from 2010 to

2020; is that correct?

Dr. GEOLOT. That is correct.

Senator VOINOVICH. So you would not say that on the national

level you have a real problem right now; things seem to be in balance?

18

Dr. GEOLOT. Well, from a national perspective, our projections indicate that the supply and requirements from a national perspective look like they are in balance. However, I would also mention

that does not negate the shortages that have been identified, and

the national sample survey cannot necessarily get at what is happening at the local level.

Senator VOINOVICH. So that nationally, it looks like it is OK, but

then, when you go back and look at regions, you find there is a

problem. Is that what you are saying?

Dr. GEOLOT. What I am saying is that the national sample survey cannot necessarily capture that information, but we are certainly hearing that there are shortages in geographic areas, there

are shortages for specialty nurses—there are shortages in certain

types of settings, yes.

Senator VOINOVICH. The next question, then, you have just answered. You said you thought that what was being done by the government at the current time is adequately dealing with the problem. If the shortages are there, do you think we should be doing

more?

Dr. GEOLOT. Well, I realize that there are really competing priorities in terms of dollars, and the administration has increased

funding for nursing work force development, or has proposed to increase funding.

Senator VOINOVICH. So what you are saying is that they recognize that there is a problem, and they have increased the funding,

but that it is not enough to deal with what some would say is a

shortage around the country, and that more needs to be done?

Dr. GEOLOT. I am saying that the administration has proposed

an increase in the nursing programs and recognized that there was

a need to increase those programs.

Senator VOINOVICH. Would anyone else like to comment on my

question?

Ms. WEINSTEIN. Yes, I would like to comment. We have heard

through the testimony today that this problem is really multifaceted and that the solution to an emerging shortage is certainly

going to require different types of interventions.

We believe that the Federal Government needs to continue to

monitor the situation, sponsor research where we can, look at the

results of that research, and then go ahead and make Federal policy with adequate data to address the concerns.

Senator VOINOVICH. Do you think, then, that we need to get more

data in order to properly address the problem?

Ms. WEINSTEIN. More data will definitely help us address the

problem, and then we can determine exactly what types of interventions are appropriate.

Most recently, the Centers for Medicare and Medicaid Services

worked very closely with HRSA to sponsor a nurse staffing study

in hospitals. That study was just released in February of this year,

and the results of that study showed that there are strong links between adequate levels of nurse staffing and good patient outcomes.

In fact, the higher numbers of RN’s led to better outcomes for patients. We need to continue to sponsor such research in order to

use the information to guide Federal policy, but I think we also

19

1The information provided by Dr. Geolot appears in the Appendix on page 00.

need to collaborate with our partners in the private sector, look at

what they are doing, and work together to solve the problems.

Senator VOINOVICH. Senator Durbin has mentioned the fact that

he is looking at some legislation, and I am sure he is going to be

looking for cosponsors of that legislation. We should make sure

that we have the information we need to make good decisions so

that what we are doing on the national level is going to be responsive to the real problems and that if we are going to allocate resources, we are allocating them in areas where they will make the

most difference.

You just alluded to the correlation between more nurses and

fewer medical errors. Has there been any authoritative study done

where people admit to medical error? Each year, I attend the John

F. Kennedy School of Government’s 2-day seminar for Members of

Congress. I found it interesting that participants said that in the

government-operated hospitals, there was more being done about

the issue of medical error than in private hospitals because they

were less vulnerable to potential lawsuits. This provides greater

freedom to deal with some of the problems. But lawsuits are another issue. Do you know of any studies where they have identified

medical error and have directly attributed it to the lack of nurses?

Ms. WEINSTEIN. Not specifically, but I can tell you that the Agency for Healthcare Research and Quality is funding numerous studies to look into the issue of medical errors as well as nurse staffing

issues, and I believe that research will inform us on this issue.

Ms. HEINRICH. I could add something to that, Senator.

Senator VOINOVICH. Yes, Ms. Heinrich.

Ms. HEINRICH. Linda Aiken, from the University of Pennsylvania, has a team that has been doing work on hospital structure,

organization, and staffing and linked it with patient outcomes, and

part of that is error. That study is due to come out this summer.

The other thing you allude to is the program that is currently in

place and being developed within the VA system in terms of identifying medical errors and then moving to the root cause, which I

think is going to be interesting and could possibly be a model for

the country.

The other information that I think is very interesting is from

JCAHO, and their sentinel events. As they go in and do root cause

analysis of those sentinel events, serious problems in patient care,

they are finding that 24 percent of those are related and linked directly to nursing issues.

Senator VOINOVICH. Thank you. Senator Durbin.

Senator DURBIN. Thank you very much, Senator Voinovich.

May I ask Ms. Geolot to address the issue of scholarships and

loans for nursing students? I noticed in your testimony that there

are some 3,600 scholarships that we are making available and

some 10,000 loans for nursing students. What is the population of

nursing students in our country—the numbers—if you know.

Dr. GEOLOT. I do not know offhand, but I can provide that information to you.1

20

Senator DURBIN. Fine. Can you tell me if there has been a trend

in this area as in other Federal reimbursement for education to

provide more loans and fewer scholarships?

Dr. GEOLOT. I can provide that for the record as well.

Senator DURBIN. OK. I will just tell you that it has been a general trend over the last 10 or so years to provide more loans to the

students, which of course means more indebtedness and affects

their choice of jobs and where they are going to work. I think that

when you consider nursing, it appears to be more difficult to attract students to nursing school. The ability to graduate them and

attract them to rural areas or inner city areas or areas of special

needs may be a decision that is often dictated by the level of their

indebtedness and how quickly they can be making significant salaries in other places.

I know that nurses are in national demand. I met one at Georgetown University Hospital who has a very interesting life. She flies

from one interesting part of the country to another interesting part

of the country and works for 10 or 12 hospitals at a time. She is

single, and she just got back from California, and wanted to see

what Washington was like, so she ended up at Georgetown Hospital for several weeks, and then off again, always a pretty good

contract waiting for her. But of course, she is single and is not raising a family and is in a different situation.

Let me ask you if you think the current nursing shortage is really driven more by a lack of retention than by a shortfall in the

number of nurses who are being trained. Could you make that call

as to what is the more dominant reason?

Dr. GEOLOT. I think we are seeing a combination of factors. We

are seeing decreased enrollments in schools, and we are now seeing

decreased graduations. So that has to do with the pipeline.

But I think that we are also very concerned about the working

conditions and the need to focus on the retention of the nurses that

we have. So it is essentially a three-prong approach—one that

looks at improving the pipeline or focusing attention on the pipeline; another that focuses on the working environment; and the

third is the retention of the nurses that we have.

Senator DURBIN. Let me ask you this, Ms. Heinrich, following up

on that. If we are dealing with a national nursing shortage, and

we have stagnant wages and deteriorating working conditions,

should we be surprised?

Ms. HEINRICH. I think you have answered the question.

Senator DURBIN. I am afraid I have.

I would ask you, based on what you have seen, if you have any

data on nurses’ wages that we referred to earlier, as to what has

happened to them in the last decade?

Ms. HEINRICH. It is actually very interesting to map that out,

and at your request, we did develop this chart that actually shows

what has happened. It appears that after the last shortage, there

was an upswing in wages, and after that——

Senator DURBIN. And what happened in nursing schools?

Ms. HEINRICH. There was a dramatic increase in enrollments,

yes.

Senator DURBIN. Cause and effect.

21

Ms. HEINRICH. Well, you know GAO; we are a little hesitant

to——

Senator DURBIN. It is as close as I can pin you down.

Ms. HEINRICH. Right. Then, in the mid-90’s, there was a leveling

out and even a dip in adjusted earnings. And then, just in the last

couple of years, there has now been an increase in average earnings.

Senator DURBIN. And were you able to pinpoint the current situation with managed care, where fewer people are being hospitalized, but when they are hospitalized, they have more acute and

critical conditions and need more attention?

Ms. HEINRICH. We did not necessarily link it with managed care.

Other researchers—Peter Buerhaus, for example, did do a very interesting paper that showed a link of nurse employment and wages

with geographic areas that had more concentrated managed care.

I think what is interesting now is that we are seeing so much

play in the industry, and I sometimes wonder if people know what

to pay attention to in the market because there is such disequilibrium.

Senator DURBIN. I noted in your testimony that State legislatures have, in at least 10 States, entertained legislation to limit

mandatory overtime to protect nurses. Is this one of the complaints

that you have heard from the nurses in terms of their work conditions, the mandatory overtime requirement?

Ms. HEINRICH. In all of the surveys that we reviewed, that certainly is one of the top issues that the nurses in these surveys are

concerned about.

Senator DURBIN. Let me ask you this. We will hear testimony

later from the hospital association about paperwork burden that

nurses face. Has this been a complaint that you have heard?

Ms. HEINRICH. That certainly is reported in the surveys, not to

the same extent as some of the other issues around working conditions. Certainly, you hear a lot about the burden of paperwork, and

some people say that IT, information systems, in the future will do

a great deal to alleviate that. On the other hand, GAO, of course,

feels very strongly about the fact that we have to be able to document and be accountable for the care that is being provided. So, of

course, we always want better information on the patient care, the

minimum data sets in nursing homes, for example, than we feel we

have.

Senator DURBIN. Ms. Weinstein, have you looked at that issue in

terms of the paperwork requirements coming out of the Federal

Government imposed on hospitals and transferred ultimately to

nurses and other medical professionals?

Ms. WEINSTEIN. I can tell you that this new administration is

committed to reviewing paperwork requirements, to reviewing regulations and requirements for excessive red tape and burden. It is

a top priority for Administrator Scully, and we are looking at that.

Senator DURBIN. Thank you.

Admiral Martin, let me close my questions by asking you this.

You said that you have a higher nurse-patient ratio in the military.

What is the ratio? Is there an established, published ratio?

22

Admiral MARTIN. No, sir. I cannot give you that. But generally,

overall, it is felt that we have a higher nurse-patient ratio. Our

staffing tends to be a little bit more predictable and stable.

Senator DURBIN. How does military nurse pay compare to civilian nurse pay?

Admiral MARTIN. We have a study going on right now by the

Center for Naval Analysis to compare military and civilian nursing

pay, and they are fairly close to publishing it.

Senator DURBIN. If you saw these figures here that have been given, the $41,000 as an average annual salary for nurses, by your

experience—and I will not hold you to this as to an exact dollar

amount—what is the average annual pay for nurses serving in the

military?

Admiral MARTIN. That is about an average pay for our government civil service nurses that we hire. However, for military

nurses, because we continue if we stay in to go up in rank, our average pay is probably either equal to or a little higher. However,

it is the retention that we really have to work on.

Senator DURBIN. Do you have any rules in the military regarding

the number of hours a nurse may work without rest?

Admiral MARTIN. No, sir.

Senator DURBIN. So a nurse in the military could be working

more than one shift at a time and be asked to take overtime?

Admiral MARTIN. Well, active-duty military are obligated 24/7,

and we all come in knowing that. However, I believe that you will

find that in our military hospitals—I do not know of any Navy hospital that has mandatory overtime. Many of our military nurses

are on call, so if they work one shift and go home and have the

next day off, we might ask them to come in for several hours to

relieve somebody. That is not mandatory or mandatory overtime.

Senator DURBIN. But they are expected to be there.

Admiral MARTIN. I would say we are very flexible now. As the

Commander of Bethesda, if I called a nurse who said, ‘‘I have a

child at home,’’ we would call somebody else.

Senator DURBIN. OK. My last question is this. The civil service

problems that you have talked about caught my attention, and I

called them to the attention of Senator Voinovich, and this is something that we are both looking at. Ninety-three days to hire a

nurse—is that what you are suggesting?

Admiral MARTIN. Yes, sir. Right now, at Bethesda, we have

taken a considerable amount of action, and I have gotten it down

to 45 days. But overall, it had been running 90 to 93 days, yes, sir.

Senator DURBIN. And in the private sector, it is a week or two;

is that my understanding?

Admiral MARTIN. For many of the contract nurses, we can hire

them in about a week or two.

Senator DURBIN. Thank you. Senator Voinovich, any other questions?

Senator VOINOVICH. Yes. In terms of hiring, you were able to

bring it down from 93 to 45 days?

Admiral MARTIN. Yes, sir.

Senator VOINOVICH. So you had the discretion to do that—in

other words, from a management point of view, you were able to

do that. You did not need any legislation or regulatory changes;

23

you were able to just look at the system and streamline it and improve on it.

Admiral MARTIN. Sir, I believe that I screamed loud enough that

individuals heard me and realized that it had not just an effect on

the patients and patient care, but it had an effect on graduate medical education programs as well. A tiger team came to my rescue

at Bethesda to the detriment of several other places.

Senator VOINOVICH. Who is in charge of that? Where do you have

to go to deal with that kind of problem? Who handles that?

Admiral MARTIN. Our HRO, Human Resources Office.

Senator VOINOVICH. In the Navy?

Admiral MARTIN. Yes, sir. Each service has its own single HR

branch.

Senator VOINOVICH. So you had the problem, you went to them

and said this has to be taken care of, you screamed loud enough

so that they got involved and looked at the situation, and they

were able to, just by moving some things around, streamline the

process.

Admiral MARTIN. Yes, sir. They put a small team together to

come over to Bethesda to work. I established a small office space

for them. However, there are other Navy commands, and therefore,

their length of time to hire civil service, maybe not nurses but

other employees, only lengthened because individuals came to Bethesda to assist me.

Senator VOINOVICH. So would you say they need more people in

human resources?

Admiral MARTIN. I would say they are looking at the entire HR

system in the Navy and trying to really put some corrective actions

in place. It is truly a system problem.

Senator VOINOVICH. In terms of hiring civilians, do you think you

have enough flexibility to do that? Does the private sector have

more flexibility in hiring people?

Admiral MARTIN. I do not have as much flexibility as a civilian

hospital because of some of our constraints. I am constrained in

what level I can bring a civil nurse in at because of our classification system and then even retaining a nurse. We do not have a

good career progression ladder for civil service nurses; they often

get stuck at the level they come in at.

Senator VOINOVICH. So that has to be reviewed in terms of being

competitive.

Admiral MARTIN. Yes, sir.

Senator VOINOVICH. I think I recently told Senator Durbin that

one of our nurses here just got her graduate degree and wants to

get a better job, and she applied for an opening at a Federal facility. She is a GS–12 and the job is a GS–14. She sent her application off on the internet to this place, and they sent her back a form

letter saying, ‘‘I am sorry, we are not interested in you. In order

to be hired, you have to be a GS–13.’’

Admiral MARTIN. It is an antiquated system. The same system

has been in place every since I have come into the military. I understand that there is a whole task force looking to change the

classification and hiring system. I have not heard any recent reports or read any recent reports on it, though.

24

Senator VOINOVICH. I would like to personally have you share

with me in the next 2 or 3 months just how things are going in

that regard, because this is kind of a cause ce ́le`bre for Senator

Durbin and me. We just think the Federal Government’s hiring

process and human capital is in crisis, and we need to move very

quickly if we are going to deal with these problems.

I have just a couple of other questions. One is getting back to the

issue of paperwork. The kinds of complaints I get from nursing

home staff and others who deal with the Federal Government are

that the paperwork requirements are just crushing them, and in so

many instances, the people who have to fill out the paperwork are

the nurses. I hear from nurses who work in some of these facilities

who say, ‘‘One of the things I do not like about my job anymore

is that I spend all my time at a desk, filling out pieces of paper,

and I do not really get a chance to get out and spend very much

time with patients. One of the reasons I got into this business was

to have a relationship with people and get that satisfaction. I did

not come to work to be a secretary; I came to work to deal with

patients.’’ I would like you to comment on that.

Ms. WEINSTEIN. I will reiterate my earlier response, which is

that we are looking at paperwork requirements for Medicare and

Medicaid, and Administrator Scully is committed to trying to reduce the paperwork burden where possible. We are looking at

things like the minimum data set for nursing homes, the OASIS

document for home health agencies, and we are looking to see

where we can reduce burden where possible.

Senator VOINOVICH. That is terrific. It would be unbelievable the

burden that would remove in terms of hospital staff right across

the board, because they are just bitter about it. I hear our hospital

folks complain about Medicare and their reimbursement, by the

way; they do not feel that it is adequate. Of course, when I talked

to Donna Shalala, she said it was more than adequate. But then

it is compounded by all the paperwork.

I do not know how it is in Chicago, but what I am hearing from

our administrators in the Cleveland area is that nursing wages

have gone up in the last couple of years pretty rapidly because of

the lack of nurses. In order to attract people and keep people, they

have had to increase wages.

Does anyone want to comment about where wages have been,

say, in the last year or 2 years? The testimony I hear is that the

wages have stagnated, and that is a longitudinal study, I think,

over a period of time. Where are we right now on that issue?

Ms. HEINRICH. You are correct that in the last couple of years,

the reports do show that on average, wages have gone up for

nurses. I think it is hard to say, however, in terms of have they

been adequate or are they enough to attract nurses into particular

facilities, because it is very interesting to see that—wages are only

one factor for nurses. There are other factors about the work environment that they are looking at and deciding whether they want

to work in those environments, and those have to do with work

load, work stress, and the other organizational factors that affect

how nurses can provide patient care.

25

Senator VOINOVICH. So when you are talking about ‘‘environment,’’ you are talking about the hours, the number of patients,

physical facilities—could you elaborate on that a little bit more?

Ms. HEINRICH. Yes. And it also goes to other people who are

there to support nurses in providing the patient care. Certainly we

have heard testimonial evidence, but it was also shown in the AHA

survey that they recently released, that there are shortages not

only in nursing but across the board.

How that plays out is that if you are short a pharmacist, and a

nurse on a medical/surgical floor needs a particular medication and

is not getting it from the pharmacy, what often happens is that the

nurse is filling in the gap there, and she is running to the pharmacy to pick it up. That should not be happening. Or, you have reports by nurses that they are passing out food trays and emptying

the garbage, and they are also expected to be your hands-on, 24/

7 surveillance system for these very complex patients.

Senator VOINOVICH. My sister-in-law had cardiac arrest during

the Inauguration, and she went over to George Washington University Hospital, so I had the chance to talk with some of the nurses

over there. The impression I got was that many of them were independent contractors; they are there, but they are not really on the

hospital payroll.

Ms. HEINRICH. I think that is a very interesting phenomenon,

and we have not done a study on it, but again, certainly testimonial evidence suggests that many of the young nurses have

found it more beneficial to be in a temporary agency or a temporary pool. They are paid more, their benefits go with them wherever they go, they have a great deal of flexibility in terms of when

they work and when they do not work. I think it would be very interesting to study that further.

Senator VOINOVICH. Getting back to what you mentioned, Senator Durbin, about the nurse that you ran into who can go wherever she wants to in the country and always find a job. It would

be interesting to know if she works for an independent third-party

organization that handles that.

Senator DURBIN. I think Mr. Mecklenburg can tell us about those

nurses. I think that when hospitals face severe shortages, they

sometimes hire contract nurses at considerably higher salaries to

fill in, and we can learn about that.

Thank you all very much. I want to thank the panel for your testimony. We may be sending you some follow-up questions, and I

hope that you will be able to respond to us in a few days.

Senator DURBIN. I would now like to introduce our second panel

of witnesses and ask them to come forward.

Ann O’Sullivan, welcome. Ms. O’Sullivan is a registered nurse

and President of the Illinois Nursing Association.

Gary Mecklenburg is President and Chief Executive Officer of

Northwestern Memorial Hospital in Chicago. He is also Chairman

of the American Hospital Association Board of Trustees. Gary,

thank you for being here.

Carol Anne Bragg is a registered nurse and a member of the

Service Employees International Union’s Nurse Alliance, with the

Professional Staff Nurses Association, and is President of SEIU

Local 1998, from Maryland. Thank you for coming.

26

1The prepared statement of Ms. O’Sullivan appears in the Appendix in page 107.

My former colleague from the U.S. House of Representative, the

Congresswoman from the State of Illinois and City of Rockford,

Hon. Lynn Martin joins us on behalf of the Labor Panel and the

Nursing Institute at the University of Illinois. She is the chairman

of the Panel on the Future of the Health Care Labor Force in a

Graying Society. She is accompanied by Mary Jo Snyder, Director

of the Nursing Institute at the University of Illinois-Chicago College of Nursing.

And J. David Cox is a registered nurse and Vice President of the

National Veterans Affairs Council for the American Federation of

Government Employees, AFL–CIO.

Thank you all for coming. We look forward to hearing from you,

and now I am going to administer the oath. Prepare, if you will,

by standing.

Do you swear that the testimony you are about to give before

this Subcommittee will be the truth, the whole truth, and nothing

but the truth?

Ms. O’SULLIVAN. I do.

Mr. MECKLENBURG. I do.

Ms. BRAGG. I do.

Ms. MARTIN. I do.

Ms. SNYDER. I do.

Mr. COX. I do.

Senator DURBIN. Thank you.

Let the record reflect the witnesses answered in the affirmative

and therefore will be allowed to continue.

I would ask you to limit your oral statements to no more than

10 minutes and remind you that your entire statement will be

made a part of the record.

Ms. O’Sullivan, please proceed.

TESTIMONY OF ANN O’SULLIVAN, RN,1 PRESIDENT, ILLINOIS

NURSES ASSOCIATION, ON BEHALF OF THE AMERICAN

NURSES ASSOCIATION

Ms. O’SULLIVAN. Good morning, Mr. Chairman and Members of

the Subcommittee.

I am Ann O’Sullivan, a registered nurse and President of the Illinois Nurses Association. I am pleased to be here today representing the American Nurses Association, or ANA, in support of

your efforts to improve the recruitment and retention of America’s

registered nurses. ANA is the only full-service association representing the Nation’s RN’s through its 54 constituent member

nurse associations.

As the Subcommittee is aware, health care institutions across

the Nation are experiencing a health care crisis in nurse staffing,

and we are facing an unprecedented nursing shortage. As RN’s are

the largest single group of health care professionals in the United

States, the current and emerging nursing shortage poses a real

threat to the Nation’s health care system.

As you may remember, the last nursing shortage was just over

10 years ago. At that time, health care providers did respond by

instituting aggressive recruitment campaigns and by increasing RN

27

wages. In fact, the average real annual salary of all RN’s employed

full-time rose 33 percent between 1980 and 1992. At the same time,

RN employment in hospitals grew by a steady rate of 2 to 5 percent

annually. By the early 1990’s, reports of nurse shortages had significantly diminished.

However, in the mid-1990’s, the picture changed. During this

time, the influx of managed care and changes to Medicare reimbursement began to exert downward pressure on provider margins.

Providers responded by implementing cost containment programs.

As RN’s typically represent the largest single budget item for a

hospital, we were some of the first to feel the pinch. Between 1993

and 1997, the average wage of RN’s employed in hospitals dropped by roughly $1 an hour in real terms. RN employment in the hospital sector significantly decreased, and lesser skilled, assistive

staff were hired as our replacements. In addition, many providers

eliminated positions for nursing middle managers and executivelevel staff.

These staff reductions occurred at the same time that patient

acuity increased, the use of sophisticated technology increased, and

the length of stay deceased.

In the end, these changes increased the pressure on staff nurses

who were required to oversee unlicensed aides while caring for a

larger number of sicker patients. The elimination of management

positions shortened the career ladder and decreased the support,

advocacy, and resources necessary to ensure that staff nurses could

provide adequate care.

Not surprisingly, these changes caused a downturn in the number of people working in the nursing profession and growing discontent among those who remain.

A recent ANA survey of 7,300 nurses across the Nation revealed

that nearly 55 percent of today’s nurses would not recommend the

nursing profession to their children or friends. In fact, 23 percent

of the nurses surveyed indicated they would actively discourage

someone from entering the profession.

In fact, an alarming number of experienced RN’s are opting to

leave the profession. The 2000 National Sample Survey of Registered Nurses showed that half a million nurses who have active

licenses, more than 18 percent of the nurse work force, are no

longer working in nursing. In Illinois alone, the number of licensed

RN’s who are not working in nursing increased by 8 percent in the

years between 1996 and 2000.

As you will hear today, the American Hospital Association reports that there are 126,000 current openings for RN’s in hospitals

across the Nation and that these positions are increasingly hard to

fill. We maintain that the reason for these vacancies and for the

recent exodus from nursing is dissatisfaction with the work environment.

The large number of nurses with active licenses who are no

longer working in nursing indicates that there is not a current

shortfall in the number of RN’s per se. Rather, there is a shortage

of positions that these nurses find attractive.

With that said, I would like to look forward to solutions to these

problems. There are a number of initiatives that the ANA and I

support to improve the environment of care for nursing.

28

The first of these is the need for adequate nurse staffing. More

than a decade of research shows that nurse staffing levels and skill

mix make a different in patient outcomes. In fact, four HHS agencies recently sponsored a joint study on this very topic. The resulting report found consistent and strong evidence that increased RN

staffing is directly related to the decreased incidence of urinary

tract infections, pneumonia, shock, upper gastrointestinal bleeding,

and decreased hospital length of stay.

In addition to the important relationship between nurse staffing

and patient care, several studies have shown that one of the primary factors for increasing nurse turnover is dissatisfaction with

work load and staffing. Understandably, nurses do not want to

work in environments with poor outcomes.

For these reasons, we support your efforts to require health care

facilities to develop and use valid and reliable staffing plans.

Another problem that must be addressed is the use of mandatory

overtime as a staffing tool. I have heard over and over again that

mandatory overtime is being used regularly to cover staffing shortages. Many nurses report that employers insist they work an extra

shift regardless of their level of fatigue. In these situations, nurses

who refuse to work past their regular shift could face dismissal for

insubordination as well as the threat of being reported to the State

board of nursing for patient abandonment.

Certainly it only stands to reason that an exhausted nurse is

more likely to commit a medical error than a nurse who is not required to work a 16- to 20-hour shift.

Unfortunately, nurses are placed in a unique situation when confronted by demands for overtime. We are ethically bound to refuse

to engage in behavior that we know could harm our patients. At

the same time, we face the loss of our license, our careers and our

livelihoods when charged with patient abandonment. Without legislation, nurses will continue to confront this dilemma.

I applaud you, Chairman Durbin, for your efforts to develop legislation to ban the use of mandatory overtime.

In addition, we support legislative initiatives that provide nurses

the ability to speak out about quality of care problems without fear

of retaliation. This issue is addressed by a provision in the bipartisan patient protection act which we strongly support.

Looking even further into the future, one thing is certain. The

current nursing shortage is nothing in comparison to the projected

systemic shortage that will become a reality in the next 10 to 20

years. Current vacancies are compounded by an increased number

of retirement-age nurses, a shrinking pool of new nurses, and the

impending health care needs of the baby boom generation. These

demographic forces will soon produce an unprecedented nursing

shortage. In fact, current projections estimate that the overall number of nurses per capita will fall nearly 20 percent below requirements by the year 2020.

Now is the time to address this impending public health crisis.

Chairman Durbin, I understand that you are developing legislation

that contains enhanced loan repayments, scholarships, career ladder programs, and public service announcements designed to attract more people into the nursing profession. The ANA and I supVerDate 11-MAY-2000 14:40 May 10, 2002 Jkt 000000 PO 00000 Frm 00032 Fmt 6633 Sfmt 6633 75471.TXT SAFFAIRS PsN: SAFFAIRS
29

1The prepared statement of Mr. Mecklenburg appears in the Appendix in page 115.

port you in these efforts. We believe that America must take steps

now to develop its internal nurse work force.

We agree with you, Chairman Durbin. We do not believe that immigration is the answer to the emerging nursing shortage. We have

been down this road many times before without success.

Experience shows that the influx of foreign-trained nurses only

serves to further delay debate and action on the serious workplace

issues that continue to drive American nurses away from the profession. In addition, there are serious ethical questions about recruiting nurses from other countries when there is a worldwide

shortage of nurses. And sadly, there are numerous disturbing examples of the exploitation of foreign-trained nurses. Let us not

make this mistake again. We should not look overseas when the

real problem is the fact that the United States health care system

has failed to maintain a work environment that is conducive to

safe, quality nursing practice and that retains experienced American nurses in patient care.

I also want to comment on the issue of too much paperwork and

nurse dissatisfaction. While we are open to discussing streamlining

paperwork, this is not the primary reason why nurses are leaving

the bedside.

In summary, it is critical that this Subcommittee understand

that no effort to address the nursing shortage will be a success unless we first fix the serious problems in the work environment.

Until we address issues such as inappropriate staffing and mandatory overtime, health care providers across the Nation will continue

to experience worsening staffing shortages. Conversely, efforts to

attract young people into nursing will be fruitless unless we first

fix the problems that are driving experienced nurses away from the

profession.

We look forward to working with you and our partners in the

health care community to develop an environment that is conducive

to high-quality nursing care. Efforts in this direction will have a

positive impact on health care services for all Americans.

Thank you for the opportunity to provide this testimony, and I

would be happy to answer any questions that you might have.

Senator DURBIN. Thank you very much.

Gary Mecklenburg, from Northwestern in Chicago and the American Hospital Association.

TESTIMONY OF GARY A. MECKLENBURG,1 PRESIDENT AND

CHIEF EXECUTIVE OFFICER, NORTHWESTERN MEMORIAL

HOSPITAL, CHICAGO, ILLINOIS, ON BEHALF OF THE AMERICAN HOSPITAL ASSOCIATION

Mr. MECKLENBURG. Thank you, Mr. Chairman.

I am Gary Mecklenburg, CEO of Northwestern Memorial Hospital in Chicago. I am here today as Chairman of the American

Hospital Association, representing the AHA’s nearly 5,000 hospital

and health system members. We appreciate this opportunity to testify on both the immediate and long-term shortage of nurses.

Northwestern Memorial is a nationally-known teaching hospital

affiliated with Northwestern University’s Medical School. We emVerDate 11-MAY-2000 14:40 May 10, 2002 Jkt 000000 PO 00000 Frm 00033 Fmt 6633 Sfmt 6633 75471.TXT SAFFAIRS PsN: SAFFAIRS
30

ploy more than 5,000 caregivers, including 1,100 registered nurses,

and we have 1,200 physicians on our medical staff.

Northwestern Memorial is growing rapidly, and that growth presents many challenges. However, the single greatest challenge

today and in the future is the recruitment and retention of highquality staff to serve our growing number of patients. A recent survey of AHA members revealed that hospitals have close to 168,000

open positions; 126,000 of those positions, or 75 percent, are for

registered nurses.

Several factors contribute to this shortage. First, sicker patients

have resulted in an increasing demand for nurses. Second, there is

a shrinking supply of experienced nurses due to an aging workforce. And finally, a diminishing enrollment in nursing schools has

resulted in a dearth of younger nurses to replace retirees.

At the same time, the number of patients in need of hospital care

is increasing. Seventy-eight million baby boomers are approaching

retirement age and Medicare, but they already are experiencing a

need for more health care. Due to medical advances, we are diagnosing and treating cancer, heart disease, orthopedic conditions at

an earlier age. The resulting demand for health care may soon exceed our capacity to provide it. In fact, some hospitals are being

forced to reduce the number of inpatient beds available, postpone

or cancel elective surgeries, or tell ambulances to bypass their overflowing emergency departments.

But these are not acceptable solutions; they are merely shortterm responses. Hospitals are taking actions to cope with caregiver

shortages. Northwestern Memorial, like other health care facilities

around the country, employs a variety of strategies to attract and

retain nurses, including flexible hours, enhanced compensation and

benefit strategies, onsite child care, and programs to attract youth

to health careers.

Innovative programs aimed at ensuring a current and future

supply of staff come at a significant cost. Many of these expenses

are not recognized as costs by the Medicare program or other payers, making it difficult to be creative in finding solutions.

The AHA recently convened a Commission on Workforce for Hospitals and Health Systems. This diverse group of stakeholders includes hospital administrators, nurses, academics, as well as business and organized labor leaders. The Commission will develop

joint solutions to address worker shortages and release its final recommendations next spring.

While the hospitals of the AHA are taking steps to tackle the

shortage of caregivers, there are actions that Congress can take to

help alleviate this problem.

The American Hospital Association supports the following bipartisan legislation:

The Nurse Reinvestment Act, introduced by Senators Kerry, Jeffords, and Hutchison establishes a national nursing services corps

and supports individuals wishing to advance in or enter nursing careers.

The American Hospital Preservation Act, introduced by Senators

Bayh and Hutchison, provides a full inflationary payment update

for fiscal years 2002 and 2003. This would help hospitals provide

fair and reasonable wage increases and to pay for the work incenVerDate 11-MAY-2000 14:40 May 10, 2002 Jkt 000000 PO 00000 Frm 00034 Fmt 6633 Sfmt 6633 75471.TXT SAFFAIRS PsN: SAFFAIRS
31

1The prepared statement of Ms. Bragg with an attachment appears in the Appendix in page

129.

tives hospitals must use to attract and retain qualified staff. I

would note that in the past 17 years of the Medicare Program, it

has provided a full inflationary update only three times.

The Area Wage and Base Payment Improvement Act, introduced

by Senators Hutchinson and Cleland, recognizes the increased competition for caregivers by providing a floor on the Medicare wage

index to help improve workforce compensation.

Mr. Chairman, this Nation faces a critical shortage of women

and men in health care careers. Collectively, we must take action

before the crisis worsens, and the first steps toward a solution are

for all stakeholders to enter into a discourse and for the Federal

Government to restore remaining Medicare and Medicaid reductions, provide greater support to rural hospitals, and establish new

nursing education initiatives. Together, we can develop solutions

that protect the future of health care for the Nation.

Thank you very much.

Senator DURBIN. Thank you.

I now call on Carol Anne Bragg for her testimony.

TESTIMONY OF CAROL ANNE BRAGG, RN,1 PRESIDENT, PROFESSIONAL STAFF NURSES ASSOCIATION, ON BEHALF OF

SERVICE EMPLOYEES INTERNATIONAL UNION, AFL–CIO

Ms. BRAGG. Thank you, Senator Durbin, for allowing me this opportunity to speak on behalf of the Service Employees International

Union on the current nursing crisis in this country.

I am a full-time registered nurse working in a cardiac unit, a

member of SEIU’s Nurse Alliance, and President of my Local 1998,

Professional Staff Nurses Association, in Maryland. Today I am

speaking on behalf of the 1.4 million members of SEIU, more than

710,000 of whom work in the home health industry and more than

110,000 of whom are nurses. I speak also as someone who is engaged in addressing the nursing crisis on a Statewide level. Last

fall, I was appointed by the Governor to serve on the Commission

on Crisis in Nursing created by the Maryland General Assembly to

investigate and find ways to deal with this urgent issue.

Today, nurses in hospitals and related facilities are caring for

more and sicker patients than we did a decade ago. The result is

that hospitals are truly having increased difficulties filling vacancies for RN’s. The hospital industry cites difficulty in filling vacancies to point to a nationwide nursing shortage, but a closer look at

the data suggests that the real problem is that there is a shortage

of nurses who are willing to work in hospitals under the current

working conditions.

We view this situation as a staffing crisis rather than nursing

shortage. It is systemic understaffing brought on by the restructuring of the industry under managed care that has led to dramatically deteriorating working conditions and increased concern about

the quality of care which causes nurses to leave hospitals. Inadequate, unsafe assignments has given rise to increased numbers of

medical errors. As you said in your opening statement, the Institute of Medicine found that 44,000 to 98,000 Americans die every

32

year in hospitals due to medical errors. While the IOM report exposed a national crisis, it did not explore one of the primary causes

for the crisis, which is understaffing.

SEIU recently completed a national survey reported in this document on the shortage of care. We find that the majority of nurses

identified understaffing as one of the leading causes of medical errors.

In my State of Maryland, the nursing crisis and the deteriorating

conditions has compromised quality of care for the people in our

communities. According to the Maryland Hospital Association,

‘‘over half the hospitals throughout Maryland report that they have

had to close beds, delay or cancel surgeries, disrupt scheduled procedures, and reroute ambulances to other facilities for emergency

patient care.’’ The MHA says that it is increasingly common for patients arriving in an emergency department ‘‘to be held there until

adequate staffing becomes available on a patient unit.’’ Your loved

ones deserve better, and so do mine.

A particularly devastating side effect of the understaffing crisis

is the abuse of mandatory overtime by many health care employers. Nurses are often mandated to work extra hours, which can

mean back-to-back 8-hour shifts, or more hours on top of a 12-hour

shift, to fill the gaps in staffing. Of course, this threatens patient

safety. There is no way an exhausted and overworked nurse is as

alert and accurate as a well-rested nurse coming on fresh for her

shift.

Mandatory overtime also places an incredible stress on family

life, particularly when last-minute changes have to be made to find

child care or care for elderly parents.

According to our survey, nurses in acute care hospitals work an

average of an additional 81⁄2 weeks of overtime in a year. Nurses

are not only being increasingly required to work excessive amounts

of mandatory overtime, but are also required to routinely ‘‘float’’ or

be reassigned to units where they lack expertise and training.

Nurses are being stretched to the limit, experiencing high levels of

stress, chronic fatigue, and work-related injuries.

These intolerable work practices lead to further burnout and undermine a nurse’s sense of professionalism and are driving nurses

from our hospitals, because we were never trained to provide inadequate or poor care.

According to the SEIU survey, only 55 percent of acute care

nurses plan to stay in hospitals until they retire, and only 43 percent of nurses under age 35 plan to stay at the hospital until they

retire. But 68 percent of nurses say they would be more likely to

stay at their facilities if staffing levels in their facilities were adequate.

These statistics show a little discussed fact about the ‘‘shortage.’’ In reality, the current supply of nurses far exceeds the demand. According to the Health Resources and Services Administration survey, there are approximately 500,000 nurses who have licenses but

are not practicing in the field, and the proportion of nurses employed in hospitals has decreased substantially and consistently,

from 68 percent in 1988 to 59 percent in the year 2000.

There is a brief window of opportunity and a fine line between

the staffing crisis and the nursing shortage. Deteriorating staffing

33

and working conditions have led many nurses to leave the profession altogether, and fewer young people are entering it. The nursing school enrollment has declined in each of the last 6 years, and

as a result, the average age of RN’s working has increased to the

age of 45. As these trends continue, there will likely be a severe

nursing shortage in the future.

I have focused my remarks principally on the hospital, since that

is where the nursing crisis is most severe. There is, however, a related and equally serious problem in nursing homes. While RN’s

make up a small proportion of the nursing home work force and

are largely in managerial positions, most of the staff in nursing

homes are certified nursing assistants, L.V.N.s or LPN’s. SEIU

members include more than 120,000 nursing home employees, a

vast majority of whom are C.N.A.s and a large number of whom

are LPN’s.

Similar to administrators in the hospital industry, nursing home

owners have argued that they are facing a shortage of nurses and

nursing aides. For this reason, they have asked for increased Medicare and Medicaid reimbursement and have resisted setting the

minimum staffing standards. But like most hospitals, the real problem is not finding people to work in nursing homes; it is keeping

them there.

The turnover rate for direct care workers in nursing homes is

nearly 100 percent, causing a revolving door of caregivers which

renders continuity of care impossible. Workers are leading due to

heavy work load; they simply do not have enough time to care for

the number of residents they are assigned to, which leads to stress,

guilt, and burnout. Moreover, low wages, lack of health care insurance, and high injury rates make nursing home work

unsustainable for many workers.

Nurses across the country are sounding the alarm because staffing levels are too low to provide the quality of care for the needs

of their patients. In many States where we have unions, we have

turned to the bargaining table to change our working conditions in

order to ensure safe staffing and better patient care.

Eliminating mandatory overtime, establishing safe staffing

standards, and improving recruitment and retention by increasing

pay have been primary issues of contract negotiations from coast

to coast.

At my hospital, we have worked very hard to ensure that the

past practice of not requiring mandatory overtime is followed, and

I can tell you that is very much an incentive for nurses to stay.

Earlier this year, SEIU nurses at Aliquippa Community Hospital

became the first in their State to win an agreement in their contract eliminating mandatory overtime, and their CEO, Fred Hyde,

recently joined the nurses in pressing for a State law in Pennsylvania to protect patients and nurses from mandatory overtime,

calling it ‘‘involuntary servitude.’’

Increasingly, SEIU, along with other unions and the American

Nurses Association, have introduced legislation at the State level

to establish staffing standards, ban mandatory overtime, provide

whistleblower protection for nurses when they speak out on understaffing that jeopardizes good care, and provide for involvement of

direct care nurses in the development of staffing policies.

34

On the Federal level, legislation has been introduced that is designed to attract new people into the nursing profession by making

it easier to access education and training resources. While we applaud these efforts, this will not address the fundamental problems

facing our profession and our patients. Forcing more overtime, or

simply relying on nurse recruitment programs will not solve the

problem, either. Likewise, easing immigration rules to attract more

foreign nurses or expanding the number of visas allowed for nurses

and nursing home workers will only push more caregivers through

the revolving door of our Nation’s hospitals and nursing homes.

All these measures will only treat the symptoms, but will not

cure the disease. Unless and until we address the understaffing

and poor working and patient care conditions that plague our

nurses, we will never resolve this shortage.

Fundamentally, the solution to the nursing crisis lies in the establishment of safe staffing standards in our hospitals. Specifically,

we must set enforceable minimum staffing standards linked to the

acuity of patients, quality of care, skill of the staff, and the skill

mix to ensure that in our hospitals, emergency rooms and outpatient facilities, patients receive the care they deserve.

We must make sure that the minimum levels do not become the

ceilings. We must make safe staffing a requirement for all hospitals

receiving Federal taxpayer dollars. We must make sure the Federal

Government provides adequate oversight of our hospitals and that

the industry’s self-monitoring system under the Joint Commission

on Accreditation of Healthcare Organizations be reformed. We

must also protect the rights of patients and the rights of health

care workers who blow the whistle on staffing problems that jeopardize quality of care without fear of losing their jobs.

This problem did not happen overnight, and it is not going to go

away overnight. The first step we can take today to stop the hemorrhaging by starting a concerted effort to ban mandatory overtime.

Limiting forced overtime will ease the impact of the shrinking supply of nurses by encouraging more nurses to stay in the profession.

It will protect countless patients in the same way that limits on

mandatory overtime is there for train engineers, air traffic controllers, truck drivers, and other occupations where public safety is at

risk.

At the same time, we cannot lose sight of the fact that the system needs help. We must find a way to set meaningful standards

for staffing in the health care industry. Understaffing in our hospitals is a serious problem. It is a problem that will only be solved

through the joint efforts of public officials like you, nurses, and hospital administrators.

Mr. Chairman, we look forward to working with you on this critical issue, and I am certainly happy to answer any of your questions.

Senator DURBIN. Thank you very much for your testimony.

In introducing my former colleague, Congresswoman Lynn Martin, I forgot a very important part of her resume. She served as

Secretary of Labor under President Bush, and she certainly has the

background to address this issue.

Welcome, Lynn.

35

1The prepared statement of Ms. Martin appears in the Appendix in page 142.

TESTIMONY OF HON. LYNN MARTIN,1 CHAIR, PANEL ON THE

FUTURE OF THE HEALTH CARE LABOR FORCE IN A

GRAYING SOCIETY, ACCOMPANIED BY MARY JO SNYDER, DIRECTOR, THE NURSING INSTITUTE, UNIVERSITY OF ILLINOIS AT CHICAGO, COLLEGE OF NURSING

Ms. MARTIN. Thank you very much, Mr. Chairman, and representatives of the other Members of your Subcommittee.

The name of the panel that I chaired—not necessarily with

knowledge at the beginning, that is for sure—was ‘‘The Future of

the Health Care Labor Force’’—in all of its permutations—‘‘in a

Graying Society.’’ You will hear also from Mary Jo Snyder, who is

Director of The Nursing Institute and was also a member of this

panel.

Panel members represented public institutions, academia, think

tanks, private businesses, organized labor, and professional groups.

It crossed racial, gender, and political lines. We have released our

report and recommendations, so this is a serendipitous time, I

think, to come before this Subcommittee for what is an extraordinarily necessary look at the problem across the health care continuum.

I think it is a wake-up call. That crisis will strike with full force

by 2010, and it will continue for many years thereafter. America

will not have enough health care workers, particularly nursing care

workers, to care for the people who will need it most—every senior

citizen.

The health care labor shortage is not a short-term, temporary decline in the supply of nursing care providers. Instead, America, like

the rest of the world, is facing a systemic change in the population

of those being served and in the population of caregiving professionals.

How concerned should we be? Well, consider this. Between 2000

and 2030, the ratio of potential caregivers to people most likely to

need care will decrease by 40 percent.

The usual American solutions of money and technology will not

be enough; although they are part of the answer, they do not provide the living human beings who are needed to care for other real

human beings.

In the past, we have had caregiving shortages. Today, we use

some of the same solutions—flextime, higher wages, bonuses, immigration—all to increase in the short term the number of health

care workers.

But for the future, we are not just facing a temporary shortage.

We are facing a systemic change, not just in the population of those

being served, but in the professions themselves.

The underlying problem has two dimensions—demographic

change and an insufficient supply of professional nurses, nurse

aides, and other health care workers in the work force. The forces

of demographic change are inescapable. We face a future in which

there will be many more older people in the population, some of

whom are sitting here right now; and at the same time, relatively

fewer younger people, both family members and professionals, to

care for them.

36

Between the years 2010 and 2030, the proportion of the United

States population aged 65 or older will increase from approximately

13 percent to 20 percent. That means 30 million people. And the

number of people aged 85 or older will increase by over 4 million.

At the same time, the United States will experience a more than

6 percent decline in the proportion of people aged 18 to 64—the

work force and the family members who have traditionally cared

for elderly members of our society.

These demographic changes will occur, moreover, within a labor

market in which the pool of potential health care employees will be

in high demand by other service sector employers. You have heard

talk about hospitals. This is a concentrated look at specifically the

full range of services that people over the age of 65 will need.

Worse yet, many of the nursing care occupations today are neither attractive nor financially competitive. You have seen the report issued by the University of Pennsylvania School of Nursing.

They surveyed 44,000 nursing professionals, and a shocking 40 percent said they intend to leave the nursing profession for a different

career within 1 year.

Let me turn to the implications and the effects of these trends.

Approximately 20 percent of all informal caregivers employed while

giving such care gave work, either temporarily or permanently.

These are people who work outside the health care setting, this informal network of people who care, temporarily or full-time, for

aunts, mothers, and fathers.

Seven percent of informal caregivers went from full-time to parttime work.

Thirty-three percent of full-time employees and 37 percent of

part-time employees have lost time from work due to these informal caregiving responsibilities.

In other words, the effect on the rest of the economy as these

numbers increase is going to be real and negative. If our country

fails to build the required professional caregiver infrastructure, the

costs will come home to roost in other ways. One way or another,

we will have to care for our growing elderly population. And because it is women who provide most of the informal care, it will be

women who will have to scale back or even quit their jobs to take

care of aging parents and relatives.

We have a list of recommendations from the panel, some for the

private sector, some for the public sector, and some a combination.

It is a reform agenda.

It notes that more money by itself will not totally solve the problem, but that no labor shortage has ever been solved without a

market-based set of economic reasons. In other words, money still

counts.

We recommend for the private sector that they have more attractive wage and benefit packages; that they make the work environment more desirable; and that they use best management practices

across a spectrum of health care facilities. We believe there has to

be ongoing training and continuing education for all nursing care

providers, with a focus on team-oriented education.

For the public sector, we think there should be a Federal commission established to investigate economic incentives targeted to

workers in geriatric nursing occupations. I can only say that with

37

1The prepared statement of Mr. Cox appears in the Appendix in page 152.

all the difficulties, there is still a TV show called ‘‘Emergency

Room’’ where we can see doctors and nurses and nursing care professionals in an exciting work environment. There is never going to

be that successful a show titled, ‘‘Nursing Home.’’ And yet more of

us are going to need those services.

We want to see a public-private panel established to examine

education and training requirements for all nursing care professions that would assist the State and employers in professionalizing all nursing care occupations.

We want to see changes in Medicare rules and regulations so

that all entry-level nursing education and training programs include training in geriatrics. We are finding that so few of them do,

it is actually shocking.

We want appropriate Federal agencies to require guidelines of

the States so that standardized entry criteria may be developed for

training.

And, as you have found out today, there is still not enough data.

We want Federal data collection agencies to be required to provide

more recent data so that you and your colleagues can make appropriate decisions.

We want to see partnerships that can identify the most successful recruitment and retention strategies. We want to focus more on

independent and informal caregivers and the economic consequences of such caregiving.

In conclusion, Mr. Chairman, we have a challenge before us. We

need to start now, because change will take time, and we cannot

afford delay. In the end, I believe that America will respond to this

crisis. The profession of nursing can be enhanced and respected.

America today cares for its elderly. I am confident that we will

find the solutions to make sure we do it for the future.

Thank you very much for having us and for beginning the dialogue.

Senator DURBIN. Thank you very much. Ms. Snyder.

Ms. SNYDER. Actually, Senator, I will defer my comments at this

time. Secretary Martin did a wonderful job, and our written testimony is part of it.

Senator DURBIN. Thank you very much. Mr. Cox.

TESTIMONY OF J. DAVID COX, RN,1 VICE PRESIDENT, NATIONAL VETERANS AFFAIRS COUNCIL, AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL–CIO

Mr. COX. Chairman Durbin, Ranking Member Voinovich, and

Members of the Subcommittee, I am J. David Cox. I have worked

as a registered nurse at the Salisbury, North Carolina W.G. Bill

Hefner VA Medical Center for 17 years.

Being a nurse at the VA and being an American Federation of

Government Employees union activist are my life’s work. On behalf

of the 135,000 caregivers our union represents in the VA, I applaud

you for holding this hearing on the issue of nursing shortages.

Thank you for giving AFGE the opportunity to tell you about the

causes and harmful effects of understaffing at VA medical centers.

38

How bad is the nursing shortage at the VA? Since 1995, the VA

has cut RN staff by 10 percent, its LPN’s by 13 percent, and its

nursing assistants by a whopping 30 percent.

The combination punch of these staffing cuts means one in six

nurses is no longer taking care of America’s veterans.

These staffing cuts hurt patient safety and quality of care. The

constant stresses to the system created by understaffing are creating serious fractures in the health care system. For example,

nursing assistants at the VA help patients with activities of daily

living. They help veterans eat, bathe, take a walk, and, yes, go to

the toilet.

The shortage of nursing assistants at the VA condemns patients

to the indignity, frustration, and anger associated with waiting and

waiting and waiting for someone to come and help them.

Because the VA does not have enough nursing assistants, by necessity LPN’s and RN’s must take on increased work loads and

help veterans with these basic nursing activities. Nurses on wards

are already understaffed, must juggle their extra duties.

While RN’s and LPN’s are spread so thin and must perform more

basic nursing functions, they are not able to keep an eye on their

patients who need adequate monitoring.

Research shows that registered nurse staffing levels were the

most important factor in predicting the success rates of saving patients who have cardiac arrest or go into shock while in the hospital. Unfortunately, this dire situation is in large part due to the

VA’s reorganization and budget. It is not wholly due to a tight

labor market.

VA’s response to its unsafe staffing levels has been to force mandatory overtime on already overwhelmed nurses to work the next

shift day after day.

AFGE locals in Danville, Illinois and Cleveland, Ohio and across

the country have told me alarming stories about nurses working

16-hour days with impossible patient work loads, trying to care for

too many acutely ill patients with too few staff.

To top it off, nurse pay has been stagnant.

These deteriorating conditions are driving more nurses to leave

the VA and the nursing profession. These difficult working conditions are not just symptoms of staff shortages. Forcing nurses to

work two shifts in a row is a prescription for medical errors and

nurse burnout. Mandatory overtime aggravates the problem and is

driving more nurses to leave the VA and the nursing profession.

The overall increase in the VA’s overtime costs suggests that the

VA is using mandatory overtime to fill shifts on a routine basis. In

the past 3 years, VA’s cost for overtime for nurses has nearly doubled.

Stopping mandatory overtime is an immediate step that would

both improve working conditions for nurses and improve patient

safety.

Like other Federal employees, VA nursing staff are paid less

than their counterparts in the private sector. Private hospitals

typically pay staff premium pay to work on weekends. This premium is not for overtime but for a regular shift. Current law on

Federal employee pay prohibits the VA from paying its nursing assistants Saturday premium pay.

39

If VA is to compete for and retain high-quality nursing staff, it

must pay Saturday premium pay for nursing assistants.

Mr. Chairman, I need to tell you that many people who enter the

nursing profession nowadays enter it through the door of a nursing

assistant. I, myself, started as a food service worker and went to

nursing assistant to an LPN to an RN, because somebody reached

out a hand and encouraged me to go to school because there were

loans, because there was an employer who stepped forward and

cared, and I have been able every 2 weeks to contribute back on

a regular basis to the Federal and State Governments that reached

out that helping hand to me.

I encourage you to continue looking at how we can encourage

people to enter whatever door is necessary to become part of the

nursing profession and to be able to care for yourself and many of

our other friends in this room as we continue to grow older each

day, and we need nursing care.

Thank you for caring about the nursing shortage at the VA and

about America’s veterans. I would be happy to answer any questions, sir.

Senator DURBIN. Thank you very much, and thanks to the entire

panel.

Mr. Mecklenburg, it seems like all roads lead back to us—first,

the Federal Government and its level of reimbursement to the institutions that provide health care; our antiquated civil service

rules; perhaps our insensitivity to funding at the Veterans Administration; and loans and scholarships—things that we can do here

on Capitol Hill.

And certainly, a lot of roads lead back to the administrators of

hospitals in terms of how their hospitals are managed and how

they treat the people who work there. I think we have heard in the

course of these two panels a lot of questions raised about mandatory overtime, and I would like to visit that first if I might.

Can you give me an indication—are there hospitals that just categorically do not have mandatory overtime, that just do not impose

that as a policy on their employees?

Mr. MECKLENBURG. Well, let me say that what we have heard

today is that the issue of nurse staffing and mandatory overtime

is a complicated issue, and the mandatory overtime issue specifically is symptomatic of the larger issue that you are exploring of

nurse staffing and critical shortage of health care workers.

You heard a lot from the first panel in terms of data. We could

use more data to understand this problem. So in the absence of either a uniform definition of mandatory overtime or collecting data

on this, I have to tell you what I do know, and let me tell you about

my own organization.

Nurse staffing is a big issue. It has always been an issue. We are

a 24-hour-a-day, 7-day-a-week, 365-day-a-year organization, and

staffing is an issue on every shift. And you use a lot of different

techniques to get the appropriate staffing for the number and acuity of patients that one has to take care of.

We do not know every day what our needs are going to be. We

do not know how many patients are going to show up in the emergency room. We do not know the acuity of patients post-operatively.

So it is a very complicated process.

40

Our clear preference is to use full-time staff, staff who are employed, who are our employees, or permanent part-time staff. I

would point out to you that that is the most economical way for us

to run our organizations as well, and when we are concerned about

cost, moving to overtime, moving to people on call, using very expensive private agencies that cost us double the cost of an RN, and

finally, mandatory overtime as a last resort, are very expensive

ways. But nevertheless, all of those techniques are ones that we

have to have available to us.

In my institution, we do not use mandatory overtime very often

at all; it is a rare occurrence. In my role as chairman of the American Hospital Association, part of what I am doing this year is

going around the country, meeting with colleagues, and talking

about current issues. And one of the hot topics for us, in part because of the light that is being shone on this issue, is to ask about

their mandatory overtime practices. And quite honestly, what I

hear is very similar to what we do at Northwestern Memorial, and

that is that it is a technique to be used as a last resort, for all of

the reasons that I just mentioned.

I think what we have to be careful of in addressing mandatory

overtime—and it is not our preferred way to solve the nursing

shortage; there are too many other techniques that have to be used

for both the short-term and the long-term—is to recognize that we

cannot not deal with the patients in the hospital at any point in

time.

Consider if you will for a moment a small rural hospital in this

country where a nursing unit perhaps has six or seven patients on

the evening or night shift. There is only one nurse required plus

support staff on the evening and night shift. The evening shift

ends. The night shift nurse who is supposed to come in calls in and

has a sick child or is sick himself or herself. What do you do?

The institution as well as the professional nurse are responsible

for taking care of those patients. So as we look at the dimensions

of this and caring for our nurses and providing a positive work environment, we need to recognize that our patients come first, and

we have to assure that there is adequate and continuous staffing

to deliver the quality that we also talk about in this issue.

Senator DURBIN. Have you linked any studies on medical errors

with mandatory overtime?

Mr. MECKLENBURG. I am not aware of those. I have asked that

question. I think your staff asked a question in advance about the

Institute of Medicine report. We have had two reports, as you

know, in the last 18 months. I do not know of any direct correlation

in those two reports dealing with safety, dealing with medical errors and nurse staffing.

I believe there was an Institute of Medicine report in 1996 that

said the evidence did not support a linkage with staffing ratios at

that time.

As you heard from this morning’s panel, these are things that

are——

Senator DURBIN. Medical errors and staffing ratios.

Mr. MECKLENBURG. There was no evidence for mandatory staffing ratios at that time. I do not know of any link in that study on

41

medical errors. Maybe there is some research out there that I am

not familiar with.

But you heard this morning that those studies are occurring because all of us are concerned about medical errors; all of us are

concerned about nurse staffing, and we have to find the evidence

to know if much of that is true or not.

Senator DURBIN. Ms. O’Sullivan, how do we balance this? Put

yourself in Mr. Mecklenburg’s position for a moment. You are the

administrator of a hospital, and the Federal Government and your

conscience tell you that you do not turn people away from the

emergency room. But you are in the midst of a complicated surgery, and you complete the surgery even if it went 14 hours instead

of 4 hours, and the nurse who is supposed to show up for the next

shift just called in and said her car broke down 50 miles away, and

she does not know if she is going to make it.

How do you deal with the overtime issue in that circumstance?

Ms. O’SULLIVAN. First of all, nurses agree that taking care of the

patients is the number one priority. We agree on that.

The issue to solve that particular problem, though, does not start

when the nurse called in sick or when the nurse’s car broke down.

I have been in nursing for almost 30 years, and I have worked numerous overtime shifts when things exactly like that have happened. In an environment where I was respected and valued for my

contributions, where I was being paid adequately for my work, and

where I had not been doing it day after day after day after week

after week——

Senator DURBIN. I see a lot of heads nodding out there.

Ms. O’SULLIVAN [CONTINUING.] And saw very little attempt on

the part of my employer to do something more about it besides require mandatory overtime.

So the solution does not start when the nurse calls in sick. The

solution starts—and it is multifaceted, absolutely. Nurses are there

to take care of the patients. That is the number one priority. But

the best way to take care of patients also revolves around taking

care of yourself and knowing that you are there and capable of taking care of those patients.

Senator Durbin, I would like to comment a moment on the medical error and staffing issue. You referred earlier to The Chicago

Tribune headlines, which we all so enjoyed. You know that after

that, Governor Ryan appointed a task force in the State, and I

have been privileged to serve on that task force representing nursing. It has been an interdisciplinary task force.

The first recommendation we made to the Governor in terms of

dealing with medical errors and patient safety had to do with staffing, interdisciplinary staffing, as has been referred to here by several of the speakers—pharmacists, respiratory therapists, and

nurses. If we do not have that kind of staffing, it only stands to

reason that errors will occur.

In all the reading I did—and believe me, there was a lot of reading for that task force work of specific studies that show medical

errors related to staffing—but they do show, as many panel members today have reported, improved outcomes, less negative outcomes, with RN staffing and appropriate skill mix, staff mix.

42

Senator DURBIN. Let me ask you about another thing. You talked

about basic respect for nurses at the institution. If I heard you correctly, if that is present, when you are asked to fill in in an emergency situation, you have a much different attitude toward that request, rather than being asked repeatedly and not respecting your

own life and your own professional need.

Let me ask you about the issue of nurse injuries. This is something that I was surprised to find out as we prepared for this hearing. Nurses and nurse aides have some of the highest workplace injuries. Nurse aids suffer 13 injuries per 100 employees annually

compared to the construction industry rate of 8 per 100 employees

annually.

Is this a factor——

Ms. O’SULLIVAN. Yes, this is a huge factor. The nursing profession is as dangerous as the coal mining profession in terms of injuries sustained—back injuries and infections are huge issues in

terms of being able to care for patients and having a profession

that attracts people to it.

In my institution and among nurses that I talk with around the

State, that is only aggravating the nursing shortage. We have so

many nurses off work and nurse aides off work because of back injuries. When there is less staff there, whether it be nurses or assistive personnel, you try to lift a patient or move a patient or get

a patient into a chair by yourself. If you do that once, you might

get away with it; if you do it day after day after day, with large

numbers of patients, you are going to sustain a back injury.

When you are tired, when you are overworked, you are going to

sustain injuries. So nursing is a very dangerous profession.

Senator DURBIN. Ms. Bragg, did you run into that as well?

Ms. BRAGG. Senator Durbin, I had the unfortunate experience of

having a patient fall on me as I attempted to get him out of a

chair. He convinced me and another nurse that he could stand on

his own, and we were going to transfer him out of the bed into the

chair, and he fell on me. It did not bother me at that moment, but

about 2 hours later, I was walking down the hall and found myself

lying on the floor, because my disc had come totally out-of-joint,

and I could hardly move.

It is very serious in terms that we have hospitals still using unsafe needles; we suffer recurrence of needle-stick injuries; we have

equipment that is antiquated and old and heavy. When I transfer

one of my CCU patients to a test downstairs, the heart monitor

that I have to carry weighs 40 pounds. Well, I get to carry that in

one hand while I am pushing the stretcher with a 200- to 300-

pound gentleman on it with the other hand.

You go home at night, and the heating pad becomes your best

friend. We should not have to do that. The answer to the question

is that there is no ancillary support to help us in hospitals’ attempts to cut corners and to put people on the line who can do the

job. A nursing assistant cannot do my job, so we cut them and their

roles, and that leaves me in a CCU with no ancillary support to

even help me move these patients.

Senator DURBIN. Mr. Cox, what about the Veterans Administration?

43

Mr. COX. Twenty percent of the VA’s workers’ comp claims are

for back injuries, most of which occur when trying to lift, move, and

transport patients by themselves when there is not another person

to call.

Mr. Chairman, if I could also comment on the overtime issue. A

nurse calling in sick this afternoon and making that coverage because coverage has to be made is one issue. But the VA puts out

a time sheet every other Friday, and on that time sheet, we know

3 weeks ahead of time—there are maybe 10 shifts—that there is

no nurse available, that there is not enough coverage, and then

they say, ‘‘Nurse 1, you will work 16 hours this day; Nurse 2, you

will work 16 hours that day—and by the way, you do not get a day

off this week because you have to work overtime to make basic coverage.’’ It is not the unplanned; it is planned to run on overtime.

Senator DURBIN. That is an important distinction.

Let me stay with the injury issue for a moment. Mr. Mecklenburg, it is clear that this is a big problem for nurses and a big

problem in hospitals, and yet the American Hospital Association

came out against the ergonomics rule. Can you explain that to me?

Mr. MECKLENBURG. The American Hospital Association does support a workable ergonomics proposal. We did oppose the proposal

that was before us last year that was based on manufacturing

standards. The hospital environment has unique aspects to it, and

we are working right now with OSHA on ergonomic standards for

health care.

Hospital work is hard work. Nursing work is very hard work. If

you go across hospitals in the country, regardless of an ergonomics

proposal, there are lots of activities going on to improve safety in

hospitals. But when we get to a regulatory piece, I think we have

to be cognizant that different workplaces need some different interpretations from time to time, and that was the basis for our objections.

Senator DURBIN. I do not disagree with that at all. It clearly has

to be tailormade to the workplace, but we have really reached an

impasse.

Madam Secretary, if I am not mistaken, your predecessor as Secretary of Labor, Elizabeth Dole, was the first to announce the

ergonomics standard or at least identify it as a problem that needed to be addressed. So as Secretary of Labor, you must have gone

through your own experience with the ergonomics. Can you address

the whole question of injuries and health professionals and

ergonomics? It is not the real focus of the hearing, but we should

address it since we have visited the injury question.

Ms. MARTIN. To concentrate if I might on the area that this particular panel looked at, you are quite correct. Although we did not

concentrate on injuries—and Mary Jo may wish to comment since

she directs the Nursing Institute—one of the things that is quite

clear is that the physical labor required in a nursing home is stupendous. And let us again stay with the obvious. Most nurses and

nurse aides are women. Many people in nursing homes cannot help

at all with movement. There is almost no thanks. Some of these

people never have visitors, so their only contact is this health care

professionals. And when she or he does not have adequate support,

44

the answer is that the person receives no help, or you can have the

increase in injuries.

Some of the changes that can occur are technological here. We

can make some differences. But the other part of the reality is that

these are human beings, and I would hope that the impasse in this

area could eventually be worked out in an appropriate way, because you will not have people deliberately choosing careers where

their chance of being hurt is increased; and as they get older, their

ability to do some of these things does become a factor. This is one

of those things that keeps going around.

Nurses and nurse aides are getting older. The requirement, physically, is getting tougher in nursing homes because people go at a

later age, and they are more seriously ill. That is not generally the

place of choice, so the narrowing of the talent pool is something,

and the injury issue is real.

I would ask Mary Jo to comment.

Ms. SNYDER. Thank you.

One of the things that we think is significant in relation to injury

but with this labor issue is that remember we are speaking of the

entire nursing care continuum, not just to the RN The RN’s dissatisfaction from our studies and issues of working conditions and

reasons for leaving the field has a lot to do with their level of support, that support being at all caregiver levels.

We would ask that as we look at solutions, we look at solutions

across the entire care continuum, specifically at the nurse aide and

the other caregiver levels.

We did look at the issue of technology, some of that being ergonomic type of support, to support the nurses’ role in this hard

labor—this is a difficult piece of labor—and we do not believe that

technology is really the solution here.

Senator DURBIN. Well, I think technology can play a role in making life a little easier. The Neon plant in Belvedere, which you visited and I have visited, changed the workplace and saw a dramatic

decline in the number of accidents.

I would just say on this issue of ergonomics that we have been

debating this for over 20 years, and the people gathered here who

are in the nursing profession know that this is a serious problem

and part of the stress and difficulty of being a nurse today. We

have got to find a way to establish standards that make the workplace safer for these employees.

Let me ask you this, Mr. Mecklenburg. On the question of whistleblowers, this is painful for Senators and for Members of Congress; it must be painful for hospital administrators to protect, let

alone reward, those who point out deficiencies in their own management. Yet if you are going to deal with things in an honest fashion, how do you think the American Hospital Association would

suggest that we deal with protecting whistleblowers within hospitals who come forward and say, ‘‘Let me tell you, you are setting

up an unsafe situation here for the employees of this hospital and

for the patients’’?

Mr. MECKLENBURG. Senator, if I could comment one last time on

the technology and the previous issue of ergonomics. There are

technological helps that can be there, and if I can, I would link that

45

with the questions you asked this morning about Medicare reimbursement, because I think they are very important.

As you know, we opened a marvelous new facility 2 years ago.

Senator DURBIN. Yes. It is beautiful.

Mr. MECKLENBURG. When we did that, we were able to buy new

equipment for that facility. If you may recall, one of the features

is that every patient bed has a scale built into it.

One of the stresses for nurses is when they have to remove a patient from the bed to weigh them—and for some patients, that is

multiple times every day. The technology exists to put a scale in

that bed and not have to move the patient. That technology is expensive.

Senator DURBIN. How expensive?

Mr. MECKLENBURG. It is very expensive. These beds cost thousands of dollars each and are far more than the simplest bed available on the marketplace. But the cost of injuries, as is implied in

our conversation here, is also very high, and it makes sense for

that investment.

Hospitals are struggling with technologies like the beds, but also

when we talk about medical errors, the investment in information

technology that helps us get at that and also simplifies the nurse

and other professional work.

We have had hospital marketbasket calculations in the last 3

years of about 3 percent a year. We have gotten less than full

marketbasket. The investment in this technology requires more

than that.

You also asked a question about nursing salaries and what has

happened to them. If I may, I would like you to know what is happening in our institution, and it gets right back to this investment

question.

In the last 3 years at Northwestern Memorial, our average starting nursing salary has gone up 16.7 percent. The average starting

salary is at a 22.7 percent increase, plus increases in benefits, plus

an improved pension plan, plus a contribution to their 401(k). The

average nursing salary at Northwestern Memorial is $50,500 a

year, which is—I do not know that this data is wrong, but it is

looking at all nurses who may be working in schools and so on.

For us to afford the technology for ergonomics, the information

technology, and deal with the issue of increasing worker compensation, the Medicare program has got to recognize that a

marketbasket based on 1992 information just does not make it anymore.

We are not making a lot of profit on Medicare. Oftentimes—we

just talked about inpatient—we are losing our shirt on home care.

We are losing our shirt on outpatient care. When you put all of

that together, the data that MedPAC looks at is very different.

So I wanted to link those several things together if I may.

I think the issue of whistleblower is a very complicated one, and

it is difficult to give you the kind of response that you want. But

there is no question that the mechanisms have to be provided within the institution for people to make their criticisms, their concerns, and their suggestions well-known. I think we have adequate

laws that protect workers who are fired for the wrong reasons, and

I would not disagree with that whatsoever. I must tell you that I

46

am concerned about enhancing the whistleblower protections for

the obvious reasons.

Senator DURBIN. Does anyone else involved in this want to comment on the whistleblower issue? Ms. O’Sullivan.

Ms. O’SULLIVAN. Yes, I would like to comment. We agree that

there need to be systems within the facility. Nurses need to make

their concerns known where they can be solved, and that is within

the facility, within the organization. That requires that nurses be

a part of the decisionmaking process beforehand as well as after

issues get out-of-hand.

One of the problems that the crisis in staffing has caused is that

there is not the time to be as involved in these decisionmaking

meetings and decisionmaking times. So nurses need to be involved

ahead of time. They need to first report as they go along and have

issues within the system. We certainly support that.

The issue is getting fired but also retributions occurring within

the work environment if nurses whistleblow outside. So those are

some of the protections for sure that we are looking at.

We are not looking at enhancing the legal costs by any stretch

of the imagination, but nurses need to be protected if they are reporting in their patient advocacy role concerns that they have

about health care in their institutions.

Senator DURBIN. I have learned a lot this morning, and I hope

everybody has derived as much or more from the hearing as I have.

It has been a good experience.

We have talked a lot about retention and workplace situations.

I want to close by going back to the points that were raised by Secretary Martin as well as by Mr. Cox about recruitment and how to

bring people into the profession.

I recall part of your testimony, Mr. Mecklenburg about the Explorer Post at Northwestern Hospital and the fact that what you

are trying to do is introduce young people and others into the opportunities in this profession. And I think for all the negatives we

have talked about today, we should never overlook the positives

that can come with good nursing experience. It has to be a memory

that you carry for a lifetime. My family and I have been through

this with great nurses and great doctors, and we will never forget

it, and I think that bears repeating. But for a moment, if we could

just reflect on this recruitment question—what can we do to make

sure that the food worker at some hospital even considers the possibility of being an LPN or an RN? What can we do to make sure

that as tough as the nursing job might be, Secretary Martin, that

the idea of caring and loving and providing that professional need

is there and interests a young person, and how can we reach out

to bring them in?

I have some ideas in the legislation that I am working on, but

if anyone would like to comment, I welcome it; and I also hope that

if you think about it on your way home and want to jot me a note

with some ideas, and anyone in the audience is welcome to do the

same.

Would anyone like to comment on that? I think Mr. Cox really

said it pretty well.

Ms. BRAGG. Senator Durbin, I would like to make one comment.

I sat in a room with a think tank group, and there was an econoVerDate 11-MAY-2000 14:40 May 10, 2002 Jkt 000000 PO 00000 Frm 00050 Fmt 6633 Sfmt 6633 75471.TXT SAFFAIRS PsN: SAFFAIRS
47

mist there. After he heard everybody’s testimony, he said, ‘‘Throw

money, and throw a lot at it, but if you do not fix the systems behind it, if I cannot provide good care, I am not going to go there.’’ When I listen to people talk about the inflated salaries—I live in

the Washington metropolitan area, and if you read the newspaper

want ads for nurses like I do, we are looking at tremendous

amounts of money being thrown out to get nurses in, given them

a bonus for a 1- or 2-year commitment, and then they are gone. I

think that is why you are seeing inflated salary, because it is not

coming to those of us at the bedside for our stay at the hospital.

I think that the recruitment process aimed at the people in the

younger generation come up behind us is critical, because they

have got to follow us. But they are not going to be around for another 5 or 6 or 8 or 10 years, and in that process, we have got to

be able to retain the people that we have.

In my facility, the people who have been in the hospital system

between 15 and 25 years make up over 50 percent of the nursing

staff. We cannot afford to lose one of those people, and at the same

time, we have got to be able to bring people in. And it becomes so

inherent with the scheduling practice, with our mandatory overtime issues, with the workplace issues, with the ergonomics issues,

and every single one of those pieces—and you said it very eloquently—this is not a problem that has one solution, and it is not

a problem to be solved easily, because every one of those pieces is

going to impact the success of the other piece.

Senator DURBIN. I think Secretary Martin made a point that I

want to close on. That is, we are not just dealing with the nursing

shortage in the future, we are dealing with a family shortage.

There will not be as many children around to care as we might

have today, and there will be a lot of us who are in a position

where we are going to need it.

I thank this panel very much and all who have gathered here

today. We are going to take your ideas and move them forward in

the legislation.

Thank you very much.

[Whereupon, at 12:37 p.m., the Subcommittee was adjourned.]

(49)

A P P E N D I X

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

156

157

158

159

160

Æ