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81–404 PDF 2002

S. HRG. 107–630

LOOMING NURSING SHORTAGE: IMPACT ON THE

DEPARTMENT OF VETERANS AFFAIRS

HEARING

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS

UNITED STATES SENATE

ONE HUNDRED SEVENTH CONGRESS

FIRST SESSION

JUNE 14, 2001

Printed for the use of the Committee on Veterans’ Affairs

(
COMMITTEE ON VETERANS’ AFFAIRS

JOHN D. ROCKEFELLER IV, West Virginia, Chairman

BOB GRAHAM, Florida

JAMES M. JEFFORDS (I), Vermont

DANIEL K. AKAKA, Hawaii

PAUL WELLSTONE, Minnesota

PATTY MURRAY, Washington

ZELL MILLER, Georgia

E. BENJAMIN NELSON, Nebraska

ARLEN SPECTER, Pennsylvania

STROM THURMOND, South Carolina

FRANK H. MURKOWSKI, Alaska

BEN NIGHTHORSE CAMPBELL, Colorado

LARRY E. CRAIG, Idaho

TIM HUTCHINSON, Arkansas

KAY BAILEY HUTCHISON, Texas

WILLIAM E. BREW, Chief Counsel

WILLIAM F. TUERK, Minority Chief Counsel and Staff Director

(II)
CONTENTS

JULY 14, 2001

SENATORS

Page

Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, prepared statement ...................................................................................................................... 3

Cleland, Hon. Max, U.S. Senator from Georgia .................................................... 4

Rockefeller, Hon. John D. IV, U.S. Senator from West Virginia, prepared

statement .............................................................................................................. 2

Specter, Hon. Arlen, U.S. Senator from Pennsylvania, prepared statement ...... 28

WITNESSES

Cox, J. David, Vice President, National VA Council, American Federation

of Government Employees, AFL–CIO ................................................................ 17

Prepared statement .......................................................................................... 18

Garthwaite, Thomas L., M.D., Under Secretary for Health, Department of

Veterans Affairs ................................................................................................... 29

Prepared statement .......................................................................................... 29

Response to written questions submitted by:

Hon. Arlen Specter .................................................................................... 35

Hon. Ben Nighthorse Campbell ............................................................... 39

Janzen, Sandra K., Chief Nurse Executive, Tampa (James A. Haley) VA

Medical Center, Tampa, FL ................................................................................ 51

Prepared statement .......................................................................................... 53

McMeans, Sandra, representative, American Nurses Association, Martinsburg, WV ............................................................................................................... 11

Prepared statement .......................................................................................... 12

Myers, Sarah, President, Nurses Organization of Veterans Affairs, Atlanta,

GA .......................................................................................................................... 6

Prepared statement .......................................................................................... 7

Petzel, Robert, M.D., Director, VA Upper Midwest Health Care Network,

Department of Veterans Affairs, Minneapolis, MN .......................................... 54

Prepared statement .......................................................................................... 55

Raymer, Mary C., Associate Chief of Staff for Patient Care Services, Department of Veterans Affairs Medical Center, Salem, VA ...................................... 57

Prepared statement .......................................................................................... 59

APPENDIX

American Organization of Nurse Executives, prepared statement ..................... 68

Lyons, Kenneth T., National President, National Association of Government

Employees, prepared statement .......................................................................... 67

Regan, Mark, National Field Service Supervisor, The American Legion, prepared statement ................................................................................................... 65

(III)

(1)

LOOMING NURSING SHORTAGE: IMPACT ON

THE DEPARTMENT OF VETERANS AFFAIRS

THURSDAY, JUNE 14, 2001

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC.

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

SR–418, Russell Senate Office Building, Hon. John D. Rockefeller

IV (chairman of the committee) presiding.

Present: Senators Rockefeller, Wellstone, Nelson, Specter, and

Campbell.

Chairman ROCKEFELLER. The meeting will come to order.

We have some votes on the floor this morning beginning at 10,

but they have not yet begun. So we will start this hearing.

We are going to talk about nursing, and my theory on working

with the VA is that we do not play ‘‘gotcha,’’ which I think has

been a committee instinct sometimes, but that we try to look out

into the future and figure out in a positive, constructive way how

we can prepare for the future, what is going to be happening, and

what are we doing to fix the problem.

So the quality of care issues, which dominate so much of the VA,

obviously are tremendously important. The question of the nursing

shortage and the shortage in the health care system in general, is

a very, very serious one.

Experts caution that we are on the brink of a very severe, complex, and longer-lasting personnel shortage. While it is bad now; it

is going to be worse in the VA system and elsewhere.

There have been a lot of changes in health care delivery and

many providers are going to be retiring. That is true in teaching,

it is true in nursing, and it is true in health care. It is the changeover in generations. So the huge demand for nurses will exceed

supply for years to come unless significant steps are taken rather

quickly.

We have had some hearings on the nursing shortage, but, surprisingly, the Department of Veterans Affairs has not been included in these discussions. That is wrong. The VA is a health care

system not unlike all other health care systems in this country,

and I have said this before with regard to long-term care and the

patients’ bill of rights. The nursing shortage only brings all of this

home. Actually, the problem is magnified in the VA, and I expect

we are going to hear about that this morning.

So VA nurses are closer to retirement age than those in other

parts of our health care system and we will talk about that—a fact

that is huge. There is, however, a little bit of a silver lining, and
2

that is, the VA enjoys a very loyal nursing staff where the turnover

rate is lower than it is in the rest of the American health care system, which I find important and interesting. And part of that is because the VA nurses and managers have been able to carve out

some new ideas and thoughts and have done some interesting

things.

So we have to do what we can to foster good working environments. We have to face the future about potential shortages. Veterans are getting older—more difficulties associated with that—and

then we have to figure out what we can do for the short term. But,

again, that will not be enough. The VA has shown real leadership

in the past in making sure that nurses are valued and their potential is maximized.

So we have a lot of good witnesses today, and I am finished my

remarks.

[The prepared statement of Chairman Rockefeller follows:]

PREPARED STATEMENT OF HON. JOHN D. ROCKEFELLER IV, U.S. SENATOR FROM

WEST VIRGINIA

Good morning. As I again assume the chairmanship of this committee, it is altogether fitting that the first hearing we are holding is on the nurse shortage and

how it will affect VA patient care. Quality of care issues have always been important to this committee and to me, in particular, and the impending nurse shortage

has the potential to be a serious quality of care issue for the Department of Veterans Affairs.

We as a Nation have faced health care staffing shortages before. Experts, however, caution that we may be on the brink of an even more severe, complex, and

longer lasting personnel shortage now. Among other factors, experts point to recent

changes in health care delivery and the pending retirement of so many caregivers.

By all accounts, the huge demand for nurses will exceed supply for years to come,

unless significant steps are taken, and taken now.

There have already been several hearings in this session of Congress on the nursing shortage, but surprisingly, the Department of Veterans Affairs has not been included in these discussions. The VA is a health care system not unlike all other

health care systems in this country. I’ve said this before with regard to long-term

care and the patients’ bill of rights. The nursing shortage only brings this point

home. Actually, the problem is magnified in the VA, as I suspect we will hear about

this morning.

While the VA’s nurses are closer to retirement age than those in other health care

systems—a fact that looms large in all our minds—there is a bit of a silver lining

here. VA enjoys a lower turnover rate, and some VA nurses and managers have

managed to carve out some innovative programs, albeit few and far between.

We must do what we can to foster good working environments for our nurses, to

recruit the best and brightest to VA, and to encourage more enrollment in nursing

schools. These are tough issues. But we must start now to fix those things than can

be fixed in the short-term.

We should be able to agree upon and enact changes that can address the problem

in the short term. But that won’t be enough. VA has shown real leadership in the

past to make sure that nurses are valued and that their potential is maximized. For

the long term, I encourage a return to that leadership.

Today, we have a broad-based group of witnesses who will lay out for us the problem and suggest some remedies. I welcome all the witnesses.

Chairman ROCKEFELLER. Senator Campbell?

Senator CAMPBELL. With two impending votes, Mr. Chairman, I

think I will save the witnesses the pain of going through another

opening statement and submit mine for the record.

Chairman ROCKEFELLER. Was that painful? [Laughter.]

Senator CAMPBELL. No, it was not.

Chairman ROCKEFELLER. I understand. Thank you.

Senator CAMPBELL. I will submit mine for the record.
3

Chairman ROCKEFELLER. OK.

[The prepared statement of Senator Campbell follows:]

PREPARED STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SENATOR FROM

COLORADO

Mr. Chairman, thank you for holding this important hearing. First, I would like

to welcome Mr. Gordon Mansfield, and I look forward to discussing his potential role

as Assistant Secretary for Congressional Affairs. I would also like to welcome this

panel of witness, each of whom will undoubtedly shed a personal light on the issue

of America’s nursing shortage. I am confident that our discussion today will yield

positive results for folks not only in my home state of Colorado, but also for veterans

throughout this country.

As a veteran myself, I understand the importance of quality health care, and I

know that nurses play a crucial role in caring for those brave men and women who

have defended our country.

In 1997, the VA had the largest staff of any hospital system in the world. As the

veteran population is aging, patient needs are changing: home health care, spinal

cord therapies, psychiatric help, and disease treatment are just a few of the many

needs of today’s vets. Nurses not only have to be compassionate caregivers, but also

experienced specialists.

In Colorado, many nurses have been reluctant to fill positions because of their

fear of managed care, or their reluctance to accept low wages. Fewer young people

are choosing nursing as a profession, and the current nursing workforce is fast approaching the age for retirement. While we cannot predict that there will be an

across-the-board shortage of nurses right now, I understand that many analysts predict that our nursing needs will not be met in the next 10 years.

I do not believe that there is one specific reason for this potential shortage of

nurses, nor do I think there is one simple solution. But I am glad we have this

chance to address this issue, and to look at its impact on the Veterans’ Administration. Again, I would like to thank the witnesses who have come here from all over

the country, and I also welcome any Coloradans who are in the room. The issue of

a potential nursing shortage is a serious one for all of us here; I hope we can work

together.

Thank you Mr. Chairman.

Senator WELLSTONE. Mr. Chairman, I will just say a couple of

quick things, and I thank Senator Cleland for being here. I do not

think we could have anybody better talking about veterans.

I also want to thank the nurses for being here. Thank you for

your work. Senator Rockefeller was so right. The way in which you

sort of feel for your mission and take care of veterans is much,

much appreciated, I think sometimes you probably think not

backed up with the resources, and I think that is part of what this

is about.

I want to welcome Dr. Randy Petzel who is here and will be testifying later. He is the Director of VISN 13, and he has dedicated

his life to serving veterans. We do a lot of work in our State on

veterans’ issues, and everybody—as I said to Randy, Mr. Chairman, in our office—has the utmost respect for the work that you

do.

In addition to the RN’s, I also want to talk about the licensed

practical nurses and nursing assistants who also are doing the

work and deserve our support.

I do not think it is a question about a nursing shortage in the

future. It is now. We have got a great VA hospital in Minneapolis.

You have heard it in West Virginia. Ben, you have heard it, I am

sure, in Colorado, the same thing in Nebraska. I could talk about

the overtime now and all the hours, and not enough people to do

so much of what they need to do. And so my last point—and, boy,

am I ever really rushing this—is I go back to the budget resolution.

Money is not a sufficient condition, but it is a necessary condition.
4

We all worked together. We looked at that independent budget. We

had an additional $2.6 billion per year. We passed it. It got taken

out in the conference report.

We cannot do millennium, we cannot do Hepatitis C, we cannot

do mental health, and we certainly cannot provide the care for people on what we have got in this budget. It is just absolutely true.

And so I think we have got to stop trying to make the foot fit

the shoe because it is not going to work, and we have got to get

a bigger shoe. And I think we absolutely have to make that commitment, and I know we will under your leadership.

Thank you, everybody.

Chairman ROCKEFELLER. Senator Nelson?

Senator NELSON. Thank you, Mr. Chairman.

As my colleague from Minnesota indicates, nursing shortages

occur everywhere. We are short. I am very anxious and I hope that

you will be able to help us figure out how we do this even when

we have the money, because obviously there is some challenge involved in getting people to direct their vocation that way as opposed to heading into high-tech areas or other careers and other

professions. So I am very anxious, and I hope that, in addition to

learning that we will need to have more money, we will also have

a plan of how we are going to be able to get there if and when we

do have the money that is necessary to help promote the program.

So I appreciate your being here, I respect your profession, and

we are looking forward to learning more about it.

Thank you, Mr. Chairman.

Chairman ROCKEFELLER. Thank you, Senator.

Senator Cleland, we welcome you, sir, and I know that you are

going to introduce Sarah Myers.

STATEMENT OF HON. MAX CLELAND, U.S. SENATOR FROM

GEORGIA

Senator CLELAND. Well, thank you very much, Mr. Chairman.

This is, in Yogi Berra’s great phrase, deja vu all over again for me,

not only to be here with the wonderful employees of the Veterans

Administration but to be in a room that I worked in as a staff

member, actually a VA hospital investigator, right over there in

that corner over there, where we are going to put a little memorial,

a little brass plaque one day.

I came out of this committee, and I am indebted to it for taking

the offensive in this particular issue. I would say to you that I

think that for those of us who have been patients in the VA system, we know how critical VA nurses really are, and it is a shame

to see the nursing shortage bring our health care system and the

VA to a critical condition.

I would like to say it was the military and the VA nurses that

nursed me back to health. These nurses were more than caregivers,

they were also givers of hope. They gave me a reason for living.

So we are delighted to be with some leaders in the VA today who

are experts in the field. I want to thank the committee for getting

involved in this issue quickly. Quality patient care is actually directly linked to nursing. When I meet with health care groups from

Georgia and across the Nation, obviously the increasing need for

registered nurses is always a part of the discussion.
5

Now, statistics from the National League of Nursing and the

American Nursing Association demonstrate that the nursing work

force is shrinking. The Federal health care sector, employing approximately 45,000 nurses, may be hardest hit in the near future

with an estimated 47 percent of its nursing work force eligible for

retirement just in about 3 years from now. That is about half of

the nursing work force eligible retirement in about 3 years.

The VA is the largest single employer of nurses. Anticipated

nursing vacancies in the Federal health care agencies are particularly alarming with the increased nursing care needs of an aging

America. That means me and you. So I am particularly more and

more interested in quality health care in the VA since more and

more I will probably have to use it more.

Senator Rockefeller, thank you for your leadership on this committee. You and I, Senator, are working to develop legislative initiatives to help recruit and retain VA nurses to take proper care

of our veterans.

Now, the key to developing these initiatives and understanding

this complex issue is the testimony we will be hearing today from

our panelists. I am pleased to introduce Dr. Sarah Myers, president

of the Nurses Organization of the VA, better known as NOVA. Dr.

Myers brings an impressive understanding of the challenges facing

VA nursing, representing approximately 3,000 NOVA members

from across the Nation, and as a doctorally prepared registered

nurse working at the Atlanta VA Medical Center, Dr. Myers received her Ph.D. in nursing from Georgia State. Dr. Myers is clinical coordinator for geriatric care at the Atlanta VA and was appointed by the former Under Secretary for Health, Dr. Ken Kizer,

to serve on the Federal Advisory Committee to review VA longterm care programs.

Mr. Chairman, members of the committee, it is an honor to be

back here in the committee room with you and to present to you

a distinguished lady in the field of nursing, Dr. Sarah Myers.

Thank you very much.

Ms. MYERS. Thank you, Senator Cleland.

Mr. Chairman, I thank you for holding these hearings on the

nursing shortage—— Chairman ROCKEFELLER. Dr. Myers, what I want to do is to introduce all three of you. Senator Cleland, thank you very, very

much, and we will work on the plaque. [Laughter.]

I want to introduce the other two also and then go right through

so we have sort of a continuity of thought, and it is very brief. And

I think also Senator Miller wanted to be here to introduce you, and

he may pop in. So he will be able to do that when he comes.

Our second witness is Sandra McMeans, who is a nurse from

Martinsburg, WV. She will be representing the American Nurses

Association, and we are obviously very honored that you are here

and very happy about that.

The third witness is David Cox, who is first vice president of the

National VA Council of the American Federation of Government

Employees. Because I want to spend as much time as possible—

and this is why I really wanted to do all three at once—on conversation and questions, I hope and pray that you have been told

that all of your statements are made a part of the record and that
6

you will try to keep your thoughts delivered to about 5 minutes.

It is hard to do, but if possible.

Ms. Myers?

STATEMENT OF SARAH MYERS, PRESIDENT, NURSES

ORGANIZATION OF VETERANS AFFAIRS, ATLANTA, GA

Ms. MYERS. Thank you, Mr. Chairman. I thank you for holding

these hearings on the nursing shortage and its implications for the

Department of Veterans Affairs. I am presenting testimony before

this committee today on behalf of over 30,000 registered nurses employed by the DVA. NOVA is dedicated to providing quality care for

our Nation’s veterans, and nurses are the backbone of the DVA,

providing care to veterans 24 hours a day, 7 days a week. I am

pleased to have the opportunity to testify today on the nursing

shortage, an issue of grave concern to the DVA health care community, the veteran population, and the veterans’ families.

In April 2001, NOVA held its annual meeting in Crystal City,

Virginia, with over 110 registered nurses from around the country

in attendance. During the course of the meeting, several themes

emerged including: retirement and retention; inconsistent application of the locality pay law; loss of the framework for nursing due

to restructuring at headquarters, at the VISN level and at local facilities; and the environment in which care is currently being delivered. These themes will form the basis of this testimony as NOVA

addresses this very critical issue.

Consistent with the nursing shortage within the United States,

staffing levels are cut to the point where nurses are unable to meet

the needs of their patients, and they are beginning to leave the profession.

NOVA believes this has also happened in the DVA with the flatline budget and the inability of the budget to keep up with the rising health care costs. Health care providers in the DVA have the

opportunity to assist in turning this trend around, and we look forward to working with this committee to explore solutions to the

nursing shortage.

The autonomy nursing has traditionally had in the DVA has

made it an attractive place to work, but this, too, is changing. We

would like to offer the Senate Veterans’ Affairs Committee some

strategies to deal with the nursing shortage.

First, I would like to address workplace issues. DVA nurses are

extraordinarily dedicated and pride themselves on providing quality care to veteran patients. They always go the extra mile, but this

pace cannot be maintained indefinitely.

Too few nurses are caring for too many patients. Due to restrictions on hospital admissions and length of stay, the patients in hospitals are more acutely ill and in need of greater care. This is magnified in the DVA because veteran patients are older with multiple,

chronic problems.

As the level of nursing staff has decreased, the demands on nursing staff have increased. Nurses from coast to coast have been informing NOVA that the implementation of bar code medication administration takes longer and requires additional staff. At a number of facilities, due to a lack of needed equipment, the nursing
7

staff is forced to record information with pen and paper and then

retranscribe the information into a centralized computer system.

NOVA believes that it is critical that the DVA address these

workplace issues immediately. Some of our recommendations—and

they are included entirely in the testimony, but I will highlight

some here. They include: allocating an appropriate level of funding

to nurse staffing and technology; funding research patient care programs that would ease the physical work of the nurse and provide

safer care for the patient.

In regards to educational support, NOVA has several recommendations for the scholarship program which will make the

DVA more competitive with the private sector. These include: reduce the requirement for continuous employment from 2 years to

1 year; remove the award limit of $10,000 per school year for a 3-

year maximum to $30,000 by changing the provision to $30,000 per

employee.

Additionally, NOVA proposes the DVA consider implementing

the following programs: implement a national program such as the

VA Cadet program to recruit and provide incentives to high school

students for choosing nursing as a profession; to support internship

programs; and develop mentoring programs.

In regards to nursing leadership, the Nursing Strategic

Healthcare Group is one of the strategic health care groups that

comprise the Patient Care Services in the DVA headquarters.

NOVA proposes a senior advisory position be created, the Executive

Assistant to the Secretary. This new position would be unprecedented in DVA history, but would be consistent with similar positions at the Department of Health and Human Services as well as

the Office of the Surgeon General.

The appointment of this position would communicate that the

role of nursing is valued within the DVA and that nursing is important enough to the mission of the DVA to make this positive

change.

I again thank you, Mr. Chairman, for holding this very important meeting. A committed and satisfied nursing work force for our

Nation’s veterans is necessary to sustain the high-quality patient

care. NOVA seeks the assistance of the Senate Veterans’ Affairs

Committee and urges quick action to address these issues, as the

nursing shortage has reached crisis proportions. There is no relief

on the horizon without the help of this committee.

Thank you.

[The prepared statement of Ms. Myers follows:]

PREPARED STATEMENT OF SARAH MYERS, PRESIDENT, NURSES ORGANIZATION OF

VETERANS AFFAIRS, ATLANTA, GA

Mr. Chairman, I am Sarah Myers, a doctorally-prepared, clinical nurse specialist

in geriatrics at the Atlanta Veterans Affairs Medical Center and President of the

Nurses Organization of Veterans Affairs (NOVA). I thank you for holding these

hearings on the nursing shortage and its implications for the Department of Veterans Affairs (DVA).

I am presenting testimony before this Committee today on behalf of the over

30,000 registered nurses employed by the DVA. NOVA is dedicated to providing

quality care to our Nation’s veterans, and nurses are the backbone of the DVA, providing care to veterans 24 hours a day, seven days a week. I am pleased to have

the opportunity to testify today on the nursing shortage, an issue of grave concern

to the DVA health care community, the veteran population, and veterans’ families.
8

In April 2001 NOVA held its Annual Meeting in Crystal City, Virginia with registered nurses from around the country in attendance. During the course of the

Meeting, several themes emerged, including: retention and recruitment; inconsistent

application of the locality pay law; loss of the framework for nursing due to restructuring at headquarters, the VISN level and at local facilities; and the environment

in which care is currently being delivered. These themes will form the basis of this

testimony, as NOVA addresses this critical issue.

OVERVIEW

The DVA is facing serious challenges in providing care of a consistently high quality, and the nursing shortage is a major challenge now and will be a greater challenge in the future. The following statistics reflect the DVA nursing workforce: • The average age is currently 45.98 years. • Only 23 percent of DVA nurses are under 40 years of age. • Approximately 11 percent are under 35 years of age. • The average age of new hires is 41.65 years of age. • Registered nurse retirement eligibility through 2005 is projected at 35 percent. • It is estimated 35 percent of new hires will not advance beyond entry level with

the new Qualification Standards.

Peter Buerhaus, RN, PhD, an internationally-renowned nurse researcher on the

nursing shortage, predicts the total number of nurses per capita will probably peak

by 2007 and decline steadily thereafter. By 2020, the registered nursing (RN) workforce is forecast to be roughly the same size as it is today, declining nearly 20 percent below the RN workforce requirements. This nursing shortage is unprecedented

because it will be driven by a rapidly aging workforce that will not be replaced by

younger professionals.

Nursing has traditionally been a female profession, but women now have more career options and are no longer entering the profession of nursing. Enrollments in

nursing schools have been declining by nearly 5 percent annually for the past five

years. While nursing enrollments are going down, women comprise nearly 50 percent of enrollments at medical, business and law schools, and they are also entering

the technological fields in unprecedented numbers. In order to maintain a viable

nursing workforce, the DVA will need to develop long-term strategies to recruit both

women and men into the field of nursing.

In the short-term, the DVA needs to develop strategies to retain the current nursing workforce. It is projected 35 percent of the RN workforce will be eligible for retirement by 2005. In order to retain nurses past the minimum retirement age, the

DVA will need to address workplace issues such as work schedules, staffing levels,

rotating shifts, mandatory overtime, and patient/staff safety.

Initiatives to ease the nursing shortage by expanding tuition assistance and other

recruitment programs need to be addressed. NOVA believes these programs are a

step in the right direction, but putting resources into recruitment alone will only

create a revolving door. As long as the nursing staff is overloaded and unable to

provide quality care, nurses will continue to face high levels of stress, injuries and

low morale. Nurses unable to meet the needs of their patients will quit or retire

in order to find less demanding and more rewarding careers or lives.

Most nurses and policy analysts believe the current shortage is largely due to

workforce issues, as opposed to economic ones. Health care is not the attractive profession it has been historically, and nurses have entered the profession in order to

make a contribution. In addition, it is widely believed the health care industry created the nursing shortage long before the supply shortage began to emerge. Staffing

levels were cut to the point where nurses, unable to meet the needs of their patients, began to leave the profession. NOVA believes this has also happened in the

DVA with the flat-line budget and the inability of the budget to keep up with rising

health care costs.

Health care providers in the DVA have the opportunity to assist in turning this

trend around, and NOVA looks forward to working closely with this Committee to

explore solutions to the nursing shortage in the DVA. DVA nurses are proud of the

mission of the DVA and proud to care for our Nation’s heros; it is an honorable mission. The autonomy nursing has traditionally had in the DVA has made it an attractive place to work, but this is changing. NOVA would like to offer the Senate Veterans Affairs Committee some strategies to deal with the nursing shortage.

WORKPLACE ISSUES

DVA nurses are extraordinarily dedicated and pride themselves on providing

quality care to their veteran patients. They always go the extra mile, but this pace

cannot be maintained indefinitely. Staffing has been cut to the bare bones, and DVA
9

nurses are tired and frustrated. If nursing, the backbone of the DVA, breaks so does

the entire system.

Too few nurses are caring for too many patients. Nurses in hospitals and outpatient clinics are caring for many more patients or more seriously ill patients today

than they did a decade ago. Due to restrictions on hospital admissions and lengths

of stay, the patients in hospitals are more acutely ill and in need of greater care.

This is magnified in the DVA because veteran patients are older with multiple,

chronic illnesses. As a result, nurses throughout the system are sounding the alarm:

staffing levels are too low to provide the quality of care their patients deserve.

Medical and pharmaceutical costs continue to increase by double digits annually,

and the dollars appropriated to provide health care to these aging veterans do not

meet the demand. Nursing, the largest segment of the DVA workforce, has perceived a dramatic shift in staffing levels to the point quality care has become compromised and both patient and staff safety is an issue that must be addressed.

As the level of nurse staffing has decreased, the demands on the nursing staff

have increased. Support services such as clerical, housekeeping, transport and lab

staffing have been declining. This has increased the workload of nurses because the

tasks formerly handled by the support services staff still need to be taken care of.

Nurses are having to pick up the slack by changing beds, emptying trash and doing

a myriad of other tasks that should be provided by support services. This practice

is not viable from an economic point of view, but also removes nurses from performing tasks related to their professional training. This leaves other patient care

tasks undone with less time to spend with patients and their families.

Other staffing issues such as rotating shifts and mandatory overtime also contribute to stress, frustration and low morale. The literature supports the detrimental physical outcomes of rotating hours of work, and there is data that demonstrates a higher level of back and neck injuries in nurses who rotate shifts or

work overtime. For example, the nursing home setting has one of the highest rates

of workplace injury; in 1999 there were 13/100 compared to the construction industry which experienced 8/100. Additionally, the level of workplace violence continues

to rise which is due in large part to under staffing. In order to retain a nursing

workforce, it is critical these staffing issues be addressed. As nurses reach retirement age and are coping with a stressful and unsafe work environment, their decision to retire or continue working becomes an obvious one.

Technology is intended and has been designed to save patient’s lives and reduce

medical errors. It has created new demands on the nursing staff, and the need for

the most efficient computerization has never been greater. Technology cannot

achieve its mission unless there is adequate staff and equipment to implement the

technology. Nurses from coast to coast have been informing NOVA that implementation of BCMA takes longer and requires additional staff. At a number of facilities

due to the lack of needed equipment, the nursing staff is forced to record information with pen and paper and then retranscribe the information into a centralized

computer system. It is imperative that adequate funding for equipment be allocated,

as this double work stresses an already short-staffed nursing unit.

With 35 percent of the nursing population reaching retirement eligibility by 2005

and fewer nurses entering the profession, NOVA believes it is critical the DVA address these workplace issues immediately. Some recommendations include:

• Allocating an appropriate level of funding to nurse staffing and technology.

• Funding patient care research programs that would ease the physical work of

the nurse and provide safer care for the patient.

• Continuing to monitor, change and enhance the locality pay system to ensure

nurses are paid equitably throughout the DVA, not merely in certain VISNs or facilities where directors currently possess discretionary authority.

• Removing the salary cap on nurse executive positions throughout the system to

be more competitive with the private sector.

• Providing flexible work schedules, incentives for unpopular shifts, and premium

pay for working peak times.

• Reducing shift rotation and mandatory overtime by providing sufficient nurse

staffing.

• Providing adequate and reasonable support for technology implementation.

DVA nurses are dedicated to their veteran patients; they need to feel they have

treated their patients with respect, compassion, empathy, knowledge and skill.

Nurses are doing the nurturing, the caring, the reaching out to the whole family

involved with a particular patient. In the end, the nurse makes the difference in

terms of the experience of the patient, and nurses need to be given the time and

the tools to make a difference and feel proud of their contribution.
10

EDUCATIONAL SUPPORT

As recently noted by the President of the Student Nurses Association, nursing

education is the single most important factor a graduate is seeking in a prospective

employer. Graduates realize their education doesn’t end at graduation but continues

throughout their career. They are seeking employment with an employer dedicated

to funding continuing education. As the DVA moved to the VISN structure and

funding VISNs using the VERA model, educational support of nursing programs has

dropped and varied dramatically from VISN-to-VISN. NOVA believes the DVA

needs to develop a system-wide policy which addresses nursing education, tuition

reimbursement, authorized absence for educational development and loan repayment/debt reduction.

Several years ago, the National Nursing Education Initiative (NNEI) was implemented to address the BSN requirement, as a result of the implementation of the

Qualification Standards. Additionally, $50 million was allocated over a five-year period to fund nursing education. It is NOVA’s understanding this office is experiencing challenges to their mission. This needs to be addressed immediately because

nurses are experiencing difficulty in applying for and obtaining scholarships. Funding needs to be provided for additional staff to administer the program, counselors

to assist nurses in the application process, and program coordinators to monitor

credentialed programs. Currently, this is being handled at the facility level or by

individual nurses, and the disarray of this program has negatively impacted these

funds getting to the nurses who need them.

NOVA also has several recommendations for the scholarship program which will

make the DVA more competitive with the private sector: • Reduce the requirement for continuous employment from two years to one year. • Remove the award limit of $10,000 per school year for a three-year maximum of $30,000 by changing the provision to $30,000 per employee. • Make the scholarship program permanent and fully implement a loan reduction

program.

Additionally, NOVA proposes the DVA consider implementing the following programs: • Implement a national program such as the VA Cadette to recruit and provide

incentives to high schools students for choosing nursing as a profession. • Support nurse internship programs for new hires for 12 weeks with preceptors. • Develop mentoring programs.

The development of a sound education policy will have a tremendous impact on

the recruitment and retention of the nursing workforce in the years to come. There

needs to be an adequate number of nurse educators to train new employees, develop

mentorship programs and provide continuing education. Additionally, these nurse

educators need to oversee the implementation of residency programs in specialty

areas such as critical care and mental health to teach new and current employees

these skills and knowledge base. Currently, at one VA facility if a nurse decides to

become a critical care nurse, she/he must resign and find employment in the private

sector in order to receive this training. By funding education and implementing a

system-wide policy, the DVA will: have a better trained and educated nursing workforce; recruitment and retention will be positively impacted; morale will increase;

and the DVA’s mission of quality health care for our Nation’s veterans will be realized.

NURSING LEADERSHIP

The nursing workforce comprises approximately one-third of the Veterans Health

Administration (VHA), and nurses are at the veterans’ bedside day and night. Nursing staff provides the greatest proportion of direct health care service to the veterans served by the DVA. Nursing care has a direct impact on quality of care as

well as the satisfaction level of patients and their families. For these reasons, it is

critical the voice of nurses be heard throughout the system, and it is also imperative

nurses occupy leadership roles from the headquarters to facility levels.

The Nursing Strategic Healthcare Group (NSHG), one of the strategic health care

groups that comprise the Patient Care Services Office in DVA Headquarters, has

evolved from a Nursing Service in 1993 to a consultation-focused resource that supports the nursing workforce. NOVA believes the NSHG is critical to maintaining

visible and close communication with the nursing staff throughout VHA. The goal

of the NSHG has been to serve as a resource for planning, practice, regulations,

education and research activities that involve nurses.

The NSHG serves a critical role focusing primarily on the strategic direction and

administrative policies affecting VA nurses throughout the country. NOVA proposes

a new senior nurse advisory position be created: Executive Assistant to the Sec-
11

retary. The focus of this position would be broad in scope and focus on the specific

interests of the Secretary and provide assistance on a wide variety of health-care

areas related to the broader sphere of health care, women’s issues, and other related

topics.

This new position would be unprecedented in DVA history but would be consistent

with similar positions at the Department of Health and Human Services as well as

in the Office of the Surgeon General. This advisory position would also send a positive message to all VA nurses in the field, as well as to those in the broader nursing

community. It would communicate that the role of a nursing is valued within the

DVA and that nursing is important enough to the mission of the DVA to make this

positive change.

CONCLUSION

I again thank you Mr. Chairman for holding this very important hearing. A committed and satisfied nursing workforce caring for our Nation’s veterans is necessary

to sustain the high quality care our veterans currently receive. NOVA seeks the assistance of the Senate Veterans Affairs Committee and urges quick action to address

these issues, as the nursing shortage has reached crisis proportions. There is no relief on the horizon without the help of this Committee.

Chairman ROCKEFELLER. Thank you very much, and that was

perfect timing.

Ms. McMeans?

STATEMENT OF SANDRA McMEANS, REPRESENTATIVE,

AMERICAN NURSES ASSOCIATION, MARTINSBURG, WV

Ms. MCMEANS. Good morning, Chairman Rockefeller and members of the committee——

Chairman ROCKEFELLER. Could you pull that a little closer, the

microphone a little bit closer? Thank you very much.

Ms. MCMEANS. Good morning, Chairman Rockefeller and members of the committee. I am Sandy McMeans, RN. I am a staff

nurse at the Martinsburg, WV, VA Medical Center and president

of the West Virginia Nurses Association Local 203 bargaining unit.

I am pleased to be here today representing the American Nurses

Association, ANA, and its union arm, the United American Nurses.

I would like to begin by thanking the committee for the opportunity to testify on an issue of critical importance to the health of

our Nation’s veterans. Staff nurses like myself provide the vast majority of direct health care services to our Nation’s veterans, and

the Veterans Health Administration—or VA—employs the largest

nursing work force in the world.

America is experiencing a crisis in nurse staffing. Health care

providers across the Nation are having difficulty finding experienced RN’s that are willing to work in their facilities. Areas hardest hit include emergency room, critical care, labor and delivery,

and long-term care. Projections show that the situation will only

get worse.

My written statement provides information on the expert-panelbased methodology for nurse staffing and resource management.

When properly implemented, this tool allows staff nurses to have

meaningful input into staffing and other patient care decisions.

ANA and I support this model, and we urge this committee and the

VA to implement it or a comparable system across the 173 medical

centers.

Another problem that must be addressed is the use of mandatory

overtime. ANA has been hearing from nurses across the Nation

about the dramatic increase in the use of mandatory overtime as
12

a staffing tool. Many nurses report that their employers insist that

they stay on longer than their scheduled shift, regardless of the

level of their fatigue. We are in a situation now where 40- and 50-

year-old nurses are being forced to work 16- and 20-hour shifts.

Nurses in particular are placed in a unique situation when confronted by demands for mandatory overtime. We are ethically

bound to refuse to provide care when we are unable to do so safely.

And we know that fatigue leads to poor performance. At the same

time, we face the loss of our license—our careers and our livelihoods—when charged with patient abandonment. Without action

on this matter, nurses will continue to confront this dilemma.

For this reason, ANA supports legislative initiatives to ban the

use of mandatory overtime.

My written statement contains further recommendations on the

need to fund replacement nurses to allow staff nurses to take the

time they need to further their education and some concerns about

the implementation of changes in the locality pay system.

But I would like to use my remaining time to repeat what I think

are the most important points. It is critical that the committee understands that no effort to address the nursing shortage will be a

success unless we fix the problems in the work environment. Until

we address issues such as inappropriate staffing and mandatory

overtime, the health care providers across the Nation will continue

to experience 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.

ANA and I look forward to working with you and your partners

in the VA system to make the current health care environment

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

have a positive impact on the health care services that our Nation’s

veterans receive.

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

will be happy to answer any questions that you may have.

[The prepared statement of Ms. McMeans follows:]

PREPARED STATEMENT OF SANDRA MCMEANS, REPRESENTATIVE, AMERICAN NURSES

ASSOCIATION, MARTINSBURG, WV

Good Morning, I am Sandra McMeans, RN. I am a staff nurse at the Martinsburg,

West Virginia VA Medical Center and President of the West Virginia Nurses Association local 203 bargaining unit. I am pleased to be here today representing the

American Nurses Association (ANA) and its union arm, United American Nurses

(UAN). ANA is the only full-service association representing the nation’s registered

nurses through its 53 state and territorial member nurse associations.

As this Committee is aware, health care institutions across the nation are experiencing a crisis in nurse staffing, and we are standing on the precipice of an unprecedented nursing shortage. Certainly, the current and emerging shortage of registered

nurses (RNs) poses a real threat to the nation’s health care delivery system, and

to its largest integrated health care system—the Veterans Health Administration

(VHA). Registered nurses comprise the largest health care workforce in the nation,

and the VA has the largest nursing workforce in the world. The concerns that we

have all been hearing about the current nursing shortage underscore the fact that

having a sufficient number of qualified nurses is critical to the nation’s health.

The emerging nursing shortage is very real and very different from any experienced in the past. Hospitals, long term care facilities and other health care providers across the nation are currently experiencing a nurse staffing shortage. Employers are having difficulty finding experienced nurses, especially in emergency departments, critical care, labor and delivery, and long term care who are willing to
13

work in their facilities. Press reports about emergency department diversions and

the cancellation of elective surgeries due to short staffing are becoming commonplace.

In addition, workforce projections show that the current shortages are just a

minor indication of the systemic shortages that will soon confront our health care

delivery system. Today’s staffing shortage is compounded by the lack of young people entering the nursing profession, the rapid aging of the RN workforce, and the

impending health care needs of the baby boom generation.

It is important to realize that the causes, and therefore the answers, to the new

nursing shortage are complex and interrelated. It is critical to examine issues in the

work environment, education, and health delivery systems. ANA maintains that the

reasons for the current shortage, and the answers to the impending shortage are

multifaceted. Unfortunately, there is no single cure to what ails nursing.

RECENT CHANGES IN NURSE EMPLOYMENT

Current nurse satisfaction issues are inexorably tied to changes in nurse employment practices over the last decade. A quick review of nursing workforce data shows

that we have been directly impacted by the turmoil that has typified the health care

sector for the last decade. Throughout our entire health care system, innovative

methods of cost containment were the hallmark of the 1990’s. New models of health

care delivery were implemented in our health care facilities, and highly-trained, experienced—and therefore higher paid—personnel were often eliminated or redeployed. As RNs typically represent the largest single expenditure for hospitals (averaging 20 percent of the budget) we were some of the first to feel the pinch.

Analysis of census data shows that between 1994 and 1997, RN wages across all

employment settings dropped by an average of 1.5 percent per year (in constant

1997 dollars). Between 1993 and 1997, the average wage of an RN employed in a

hospital dropped by roughly a dollar an hour (in real terms). RN employment, which

had previously been growing in the hospital sector, reversed to the negative. In addition to reducing staff nurses, many providers eliminated positions for nursing middle managers and executive level staff.

As you are aware, the VHA has also undergone major restructuring. Since 1995,

its has downsized inpatient capacity and while adding 350 additional care sites.

Today, the VHA provides health care to more than 500,000 additional veterans with

25,000 fewer employees that it did just six years ago. In addition, the amount spent

per patient has been cut by 24 percent. Much like the rest of the private health care

system, VA nurse have been directly impacted by these changes. For instance—in

the five years between September 1995 and September 2000, the VA cut ten percent

of its total RN positions.

THE CURRENT EMPLOYMENT SITUATION

It is increasingly evident that the changes in the RN employment environment

over last decade have precipitated a downturn in the number of people choosing to

work in the nursing profession and growing discontent among those who remain.

Enrollments in four-year nursing schools have dropped by approximately 5 percent

per year over the last 6 consecutive years. As the image of professional nursing has

changed from a field that offered many opportunities and high job security to one

that holds great uncertainty, low starting wages, and difficult working conditions,

students have shied away from nursing programs.

A recent ANA survey of nurses revealed that nearly 55 percent of the nurses surveyed would not recommend the nursing profession as a career for their children

or friends. In fact, 23 percent of the respondents indicated that they would actively

discourage someone close to them from entering the nursing profession.

At the same time, an alarming number of existing RNs are choosing not to work

in nursing. The 2000 National Sample Survey of Registered Nurses shows that a

disturbingly large number of nurses (500,000 nurses—more than 18 percent of the

national nurse workforce) who have active licenses are not working in nursing. Another national survey commissioned by the Federation of Nurses and Health Professionals reports that 50 percent of all currently employed nurses have recently considered leaving direct care positions for reasons other than retirement. Clearly,

something in the practice setting is driving these people away.

THE ENVIRONMENT OF CARE

In an effort to ascertain the cause of nurse discontent, ANA recently conducted

an on-line survey of nurses across the nation. Nearly 7,300 nurses took the opportunity to express their opinions about their working conditions. The majority (70

percent) of the respondents work in hospitals or acute care facilities, 50 percent
14

were staff nurses. These nurses report that over the last two years they have experienced increased patient loads, increased floating between departments, decreased

support services and increasing demands for mandatory overtime.

This survey reveals that the recent reductions in the RN staffing have negatively

impacted patient care, the work environment for nurses, the perception of nursing

as a career, and the staffing flexibility needed to address temporary staffing shortages. Nurses in VA medical centers in particular are being confronted by staff

downsizing, increased patient acuity, shorter hospital stays, bed closures, and flatlined budgets. These changes have caused such a deterioration in the work environment that nurses are opting not to accept staff nurse positions. Hence the increasing

staff vacancy rate being reported by the VHA as well as private health care providers. After all, how many of us would want to work in an environment where we

have little to no control over the number of hours that we work, the quality of the

work we produce, or the ability to change our work environment?

SOLUTIONS

ANA supports an integrated state and federal legislative campaign to address the

current and impending nursing shortage. Many of these solutions are directly applicable to the VHA. Following are key federal initiatives we hope this Committee will

consider.

Overtime

Nurses across the nation are expressing deep concerns about the dramatic increase in the use of mandatory overtime as a staffing tool. ANA hears that overtime

is the most common method facilities are using to cover staffing insufficiencies. Employers may mandate that a nurse work an extra shift (or more) or face dismissal

for insubordination, as well as being reported to the state board of nursing for patient abandonment. Concerns about the use of mandatory overtime are directly related to patient safety.

We know that sleep loss influences several aspects of performance, leading to

slowed reaction time, delayed responses, failure to respond when appropriate, false

responses, slowed thinking, and diminished memory. In fact, 1997 research by Dawson and Reid at the University of Australia showed that work performance is more

likely to be impaired by moderate fatigue than by alcohol consumption. Their research shows that significant safety risks are posed by workers staying awake for

long periods. It only stands to reason that an exhausted nurse is more likely to commit an error that a nurse who is not being required to work a 16 hour shift.

Nurses are placed in a unique situation when confronted by demands for overtime. Ethical nursing practice prohibits nurses from engaging in behavior that they

know could harm patients. At the same time, RNs face the loss of their license—

their careers and livelihoods—when charged with patient abandonment. Absent legislation, nurses will continue to confront this dilemma. For this reason, ANA supports legislative initiatives to ban the use of mandatory overtime. ANA is seeking

relief from the use of mandatory overtime in the private sector through Medicare

provider contracts.

Currently, the VHA does not have a nationwide policy on mandatory overtime,

nor does the VA collect nationwide statistics on the use of mandatory overtime. Recent increases in overtime costs, however, do substantiate what ANA and the UAN

have been hearing—that mandatory overtime is being used regularly and routinely.

Reports show that the VA nearly doubled its annual overtime costs in the three

years between 1997 and 2000. These reports are disturbing and they highlight the

need to address the abuse of mandatory overtime in our VA medical centers. The

practice could be halted by an executive order, through regulatory action within the

VHA, or through federal legislation.

Adequate Staffing

Of course the use of mandatory overtime is a symptom of a larger problem, inappropriately low nurse staffing. ANA has long held that the safety and quality of care

provided in the nation’s health care facilities is directly related to the number and

mix of direct care nursing staff. More than a decade of research shows that nurse

staffing levels and skill mix make a difference in the outcomes of patients. Studies

show that where there are more nurses, there are lower mortality rates, shorter

lengths of stay, better care plans, lower costs, and fewer complications. In fact, four

HHS agencies—the Health Resources and Services Administration, Health Care Financing Administration, Agency for Healthcare Research and Quality, and the National Institute of Nursing Research of the National Institutes of Health—recently

sponsored a study on this very topic. The resulting report (Nurse Staffing and Patient Outcomes in Hospitals, released on April 20, 2001) found strong and consistent
15

evidence that increased RN staffing is directly related to the decreased incidence of

urinary tract infections, pneumonia, shock, upper gastrointestinal bleeding, and

shorter hospital length of stay.

In addition to the important relationship between nurse staffing and patient care,

several studies have shown that one of the primary factors for the increasing nurse

turnover rate is dissatisfaction with workload/staffing. ANA’s recent survey states

that 75 percent of nurses surveyed feel that the quality of nursing care at the facility in which they work has declined over the past two years. Out of nearly 7,300

respondents, over 5,000 nurses cited inadequate staffing as a major contributing factor to the decline in quality of care. More than half of the respondents believed that

the time they have available for patient care has decreased. This survey reflects

similar findings from a national survey taken by the Henry J. Kaiser Family Foundation (1999) that found that 69 percent of nurses reported that inadequate nurse

staffing levels were a great concern. The public at large should be alarmed that

more than 40 percent of the respondents to the ANA survey stated that they would

not feel comfortable having a family member cared for in the facility in which they

work.

Adequate staffing levels allow nurses the time that they need to make patient assessments, complete nursing tasks, and respond to health care emergencies. It also

increases nurse satisfaction and reduces turnover. The VHA, much like private

health systems, continues to struggle with the development of valid, reliable and

implementable nurse staffing guidelines. In 1985, the VA developed nurse staffing

guidelines. These were then suspended in the mid-90’s and a new methodology was

developed. This new expert-panel based methodology for nurse staffing and resource

management has been implemented to varying degrees of success across the 173

medical centers. In the best cases, expert panels consisting of shift supervisors,

nurse administrators, staff nurses and union representatives meet on a regular

basis to make recommendations on nurse staffing needs. These panels investigate

variables ranging from nurse experience levels, patient acuity trends, census data,

use of overtime, and changes in administrative workloads to determine nurse staffing needs. Recommendations are then made through the nurse executive.

ANA supports this model, and we urge this committee and the VHA to urge all

of the medical centers to implement the expert-panel methodology or a comparable

system. As my colleague from Florida will attest, one of the main components of the

magnet hospital designation, and one of the chief indicators of nurse satisfaction,

is the ability of the staff nurse—the individual who provides direct patient care—

to have meaningful input into staffing and other patient care determinations. When

implemented properly, the expert panel methodology provides an excellent opportunity for this communication.

Education Support

ANA applauds the VHA for its recent change in the nurse qualification standard.

This new standard makes a BSN (bachelors of science in nursing) a criteria for promotion. The ANA supports efforts designed to make the BSN the standard for entry

into nursing practice. The increasing acuity of today’s patients, combined with shortened lengths of stay and decreased staffing requires all nurses to be as clinically

prepared as possible. ANA is particularly pleased by the National Nursing Education Initiative (NNEI) which provides scholarships for RNs in the VHA who return to school to attain baccalaureate and advanced degrees. Nurses in the NNEI

are eligible for a maximum of $20,000 in scholarship funds. In return, nurses in this

program must meet a service obligation. For instance, a full-time student must

agree to serve as a full-time VHA employee for a period of one calendar year for

each year of school or part thereof for which a scholarship has been granted.

To date, more than $50 million has been obligated under NNEI. There are a total

of 1427 participants in the program; 67 percent are enrolled in baccalaureate programs and 30 percent are in advance degree programs. Six nurses in the Martinsburg facility have enrolled in RN to BSN program. In addition, our first application

for enrollment in a Masters Program has just been approved. I am thrilled that

these nurses are able to take this opportunity to further their education, and I urge

this Committee to be vigilant in ensuring that the promise of continuing education

is maintained.

With that said, I would be remiss if I did not point out the few bugs in this new

education initiative that need to be addressed. As current staff nurses are being

evaluated and promoted on basis of their educational preparation, it is important

that they be able to take the time needed to further their education. I am disturbed

by reports that staff nurses who would like to continue their education are being

told that their facility can not schedule the time off that they need to attend school.
16

Certainly it was not the intent of this program to base nurse promotions on educational attainment, while at the same time placing barriers to their education.

The NNEI does contain a provision that allows a medical center to pay a ‘‘replacement salary’’ to hire a new (typically temporary) staff nurse to carry out the duties

of an employee who is unavailable while pursing full-time education or training.

However, funding for these replacement salaries is conspicuously absent from the

NNEI, and the responsibility to find funding has been left to the Facility Director.

Nurses in facilities where the Director can not or does not locate funds needed for

replacement workers will continue to be disadvantaged until this problem is remedied.

Locality Pay

As this Committee is very well aware, the Veterans Benefits and Health Care Improvement Act (P.L. 106–419) was signed into law last year. ANA strongly supports

this law which makes a number of significant changes to the old nurse locality pay

system. The new system requires Facility Directors to use third-party industry wage

surveys in making such adjustments and authorized the Department’s Under Secretary for Health to modify any adjustment determination made by an individual

Facility Director. It also requires the Secretary to report annually to this Committee

on the staffing of covered positions and on pay adjustments.

ANA urges this Committee to remain vigilant in your oversight of these programs.

It is too early to evaluate the effectiveness of this new system, but a few potential

problem areas have already emerged. For instance, it may be difficult to obtain accurate wage surveys because most private facilities deem this information proprietary. Additionally, the B.S.N. requirement discussed above makes the VA staff

nurse population significantly different than those found in many private facilities.

ANA is concerned that there may not be an appropriate mechanism for gathering

the information needed to update VA nurse executive compensation. In addition,

ANA maintains that nurse practitioners should qualify for the enhanced program

of specialty pay that the VHA offers physicians and dentists (as authorized under

Subchapter III of Chapter 74, 38 U.S.C.). We look forward to working with you on

these important issues.

CONCLUSION

In closing, I would like to reiterate the point that the problems that the Veterans

Health Administration is experiencing with nursing recruitment and retention will

remain and likely worsen if changes in the workplace are not addressed. In fact,

the profession of nursing as a whole will be unable to compete with the myriad of

other career opportunities available in today’s economy unless we improve working

conditions across the board. We must strive to make direct care an attractive vocation for our high-caliber RNs. Nurses, administrators, other health care providers,

health system planners, and consumers must come together in a meaningful way

to create a system that supports quality patient care and all health care providers.

We will have to begin by improving the environment for nursing.

ANA looks forward to working with you, and our health care provider and union

partners to make the current health care environment conducive to high quality

nursing care. Improvements in the environment of nursing care, combined with aggressive and innovative recruitment efforts will help avert the impending nursing

shortage. The resulting stable supply of high quality nursing care will make great

strides in your continuing efforts to address the health care needs of America’s veterans.

Chairman ROCKEFELLER. Thank you very, very much.

What I have to do, Mr. Cox, if you will forgive me, because we

have a few minutes to vote, so I have to leave now. And, unfortunately, there are two votes.

So we are going to stand in recess for a few minutes while I cast

my vote, wait impatiently for the second one to start, cast it immediately and out of order, and then rush back here, all with your

hopeful forgiveness.

Mr. COX. That will be fine, Mr. Chairman. [Laughter.]

Chairman ROCKEFELLER. So we stand in recess for a few minutes.

[Recess.]

Chairman ROCKEFELLER. Mr. Cox?
17

STATEMENT OF J. DAVID COX, FIRST VICE PRESIDENT, NATIONAL VA COUNCIL, AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, WASHINGTON, DC

Mr. COX. Mr. Chairman, we were glad to give you a break to go

vote, but we would also call to the committee’s attention that very

rarely do nurses in the VA get to take a break. [Laughter.]

Chairman Rockefeller, members of the committee, my name is J.

David Cox, and I proudly worked as a registered nurse at the Salisbury, NC, W.G. Bill Hefner VA Medical Center for 17 years. My

stepfather and my father-in-law have both been treated at that facility. Caring for veterans 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, I thank

you for giving AFGE the opportunity to tell you about the harmful

effects of understaffing that front-line workers experience and see

every day. AFGE applauds you for holding this hearing on the

nursing shortage at the VA and urges you to be bold and innovative in addressing the crisis in health care. I ask that my written

statement be included in the record.

The nursing shortage at the VA is not impending. It is here, sir.

Since 1995, VA has cut RN staff by 10 percent, its licensed practical nurses by 13 percent, its nursing assistants by a whopping 30

percent. The majority of these reductions occurred because the VA

balanced its budget by not replacing nurses who left the VA.

Because of our budget, my facility in Salisbury won’t even be

able or does not even try to replace the 50-plus RNs and LPNs and

nursing assistants that have left within the last year.

Let me describe some of the effects that understaffing has on patient care and hospital staff. At our facility we have two long-term

care wards that each have 30 beds. Previously there was an RN for

each ward. Now there is a single RN for both wards. This change

in staff-to-patient ratio was not done in accordance with patient

needs or any rational standard of care but to meet the level of staff

on duty. Because that nurse must now give care to twice as many

veterans, research indicates that these veterans will be more at

risk for urinary tract infections, they will be more likely to develop

painful bedsores, and the infections of these sores can be an outcome of a life-threatening situation.

Because of the increased workload for the nurse, those veterans

will have a greater likelihood of falling down in the hospital. For

a frail and elderly patient, a single fall has serious medical consequences. If these veterans experience a medical complication or

go into shock, the success rate in saving them is much lower because of the reduced nurse-to-veteran ratio.

What happens when the lone night nurse quits or takes a vacation or has to take care of a sick child? More and more the VA is

using mandatory overtime as a routine method of filling shifts. For

the 60 patients on these two long-term care wards, this means

their nurse is working a double shift for 16 hours. Forcing an already overloaded staff to work an extra shift is a prescription for

medical errors. Even when medical errors are avoided, patients

still suffer. Weary, exhausted nurses will lack the keen level of concentration and emotional stamina necessary to deliver high-quality

and compassionate care. Medications, basic care, and other critical
18

medical interventions will be delayed, forgotten, mixed up because

the nurse is being spread too thin and is just bone tired.

Mandatory overtime usually occurs on wards that are already operating at unsafe staffing levels. The use of mandatory overtime is

a short-sighted response to inadequate staffing that is worsening

the staffing problem.

And, sir, I want to go ahead and raise to you two issues that we

would like for you to explore in your legislative framework, and I

would like to highlight those. The policy and practice of excessive

mandatory overtime is risky and unsafe and must be limited. Senator Kennedy and Senator Kerry plan to introduce legislation that

will curb mandatory overtime for licensed nurses. Chairman Rockefeller, AFGE asks that you support the Kennedy-Kerry legislation

and ensure that VA nurses have the ability to stop the overtime

clock unless there is a real emergency.

VA must also use a rational process for setting safe staffing levels. Research shows that increasing the numbers of RN’s and other

nursing staff in a hospital makes a difference in patient outcomes

and quality of care. Currently, VA only maintains staffing standards for intensive care units and operating rooms. Other wards arbitrarily set personnel ceilings on the number of staff on duty.

AFGE urges you to include in your legislation a provision to

begin to address the longer-term solution to the nursing shortage,

setting meaningful standards for staffing, sir.

Thank you very much.

[The prepared statement of Mr. Cox follows:]

PREPARED STATEMENT OF J. DAVID COX, VICE PRESIDENT, NATIONAL VA COUNCIL,

AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL–CIO

Chairman Rockefeller and members of the Committee: my name is J. David Cox.

I am a Registered Nurse and I am testifying on behalf of the American Federation

of Government Employees, AFL–CIO (AFGE). I am the 1st Vice President of

AFGE’s National VA Council. I am also the President of the AFGE local at the

Salisbury, NC, VAMC.

AFGE applauds you for holding this hearing on the nursing shortage in the DVA

and its impact on patient care. The lack of adequate staffing at the DVA is the primary concern for the 135,000 DVA employees AFGE represents who are struggling

to do right by our veterans. AFGE looks forward to working with you and the Committee on legislation to improve working conditions for DVA nurses and the safety

of their patients.

The nursing shortage is not impending it is here. From September 1995 to September 2000, DVA cut Registered Nurses (RNs) by 10 percent, Licensed Practical

Nurses (LPNs) by 13 percent, and Nursing Assistants (NAs) by 30 percent. These

cuts have meant a loss of 1 in 6 direct patient caregivers. These reductions are attributable to DVA’s reorganizations and budgetary contraints. From 1995 to 1999,

management either could not or did not try to replace a third of the 15,851 RNs

who left DVA. At my facility in Salisbury, NC, we cannot even try to fill the 50 RN

vacancies because of our budget.

At every DVA Medical Center facility I have visited across the country from East

Orange, NJ to San Francisco, CA, from Minneapolis to New Orleans the impact of

the nursing shortage is devastating and broad in scope.

• Employees struggle to fulfill DVA’s core mission of providing veterans high

quality care because of the shortage in direct patient care staff. Veterans are being

denied access to care at the DVA and veterans are being diverted to private sector

hospitals at what we presume is a great expense to DVA facilities because DVA

lacks sufficient numbers of RNs.

• Reductions in staff-to-patient ratios and excessive overtime is damaging quality

of care and endangering patient safety.

• DVA’s ability to conduct cutting-edge medical and clinical research is erroded

because of the DVA nursing shortage and impending shortage of pharmacists.
19

• The training of medical and nursing students is suffering because current DVA

nurses have no time or energy to provide them with the needed review and feedback

that is crucial to their education as health care professionals.

• DVA’s approach to its nursing shortage (stagnant wages, excessive overtime,

unscheduled tours of duty, reliance on agency nurses and creating new qualification

standards which in effect limit nurse promotions) has resulted in placing nurses in

increasingly difficult and untenable working conditions, which in turn makes DVA

a less desirable workplace for employee candidates.

THE NURSING SHORTAGE AT THE DVA IS GOING TO GET WORSE

DVA’s staffing problem is likely to get worse as nurses and the veterans they care

for grow older. DVA patients are already older, sicker and poorer than the non-DVA

patient population treated in the private sector. Although the overall veteran population will decrease in the coming decades, the demand on the DVA for the most

labor intensive medical care for elderly veterans with chronic and multiple illnesses,

and disabling conditions will increase.

The increase in demand will occur when DVA’s workforce is approaching retirement at a faster rate then the nursing workforce in the private sector. According

to the American Hospital Association, the average age of nurses providing inpatient

care is 45; in the DVA the average age for a full time RN is 48. Within four years

35% of DVA’s RNs will be eligible to retire. At the same time, 29% of the LPNs and

34% of the NAs will be eligible to retire. DVA will not be able to provide care for

the most vulnerable veterans—the poor, elderly and disabled—when they are most

in need of DVA’s care, unless we act expeditiously.

ADDRESSING THE NURSING SHORTAGE AT THE DVA

AFGE greatly appreciates that your draft legislation will mandate Saturday premium pay for Title 38-Title 5 hybrid employees, like LPNs and pharmacists. We ask

that you also include DVA’s Title 5 employees, such as Nursing Assistants and medical clerks. We also appreciate that you will address some problems with the pay

of part-time RNs. We also support enhancing the current employee education initiatives to encourage and support current DVA staff to become RNs, LPNs, and NAs.

AFGE is concerned, however, that the draft legislative framework does not address the core working conditions that are sending DVA nurses out the door and

driving RN candidates away from the DVA.

Chairman Rockefeller, it is essential that your legislation address the following

working conditions at DVA which have negative effects on quality of care and patient safety:

1. Excessive and dangerous use of overtime;

2. Lack of safe staffing standards;

3. Inadequately involving front-line nurses in key policy decisions affecting patient

care;

4. Stagnant wages and the failure to reward nurses for their years of experience

in promotions to Nurse Level II and III;

5. Lack of a systemic and focused upward mobility program for current staff to

become RNs.

1. Excessive Mandatory Overtime Is Risky and Unsafe; It Must be Limited

Working RNs 16 hours or more a day takes a toll on patient care. The cumulative

impact of DVA’s use of mandatory overtime is that RNs and other nursing staff are

overworked, overwhelmed, and fatigued from working too many hours day after day.

Under these working conditions RNs are more likely to make medical errors. Even

when medical errors are avoided, patients still suffer. Weary and worn out nurses

may not be as observant of the subtle changes in a patient’s condition that signal

a medical problem. Overwhelmed and overtired nurses may also lack the keen level

of concentration and emotional stamina necessary to deliver high quality and compassionate care. Medications, basic care, and critical medical interventions are delayed, forgotten or mixed up because staff is spread too thin and exhausted.

The DVA does not have a nationwide policy on mandatory overtime, nor does DVA

take disciplinary actions against Medical Directors or nurse managers who rely

upon mandatory overtime excessively in lieu of adequate staffing. Only the patient

and the RN suffer the consequences when a bleary-eyed RN makes a medical error

at the end of two consecutive tours of duty. AFGE regards DVA’s failure to hold

management accountable for excessive overtime as a disturbing indication of DVA’s

lack of commitment to patient safety and in becoming the employer of choice.

DVA’s use of mandatory overtime ignores the reality of what is required to deliver

high quality care. Nurses are the quality and safety monitors of health care. They
20

are responsible for providing the first warning and swift intervention for those too

vulnerable and sick to help themselves. When nurses are exhausted from working

16 or more hours a day, day after day, how can we expect them to recognize an

impending or actual complication and mobilize intervention from physicians and

other staff to save a patient’s life?

The DVA should not be allowed to use mandatory overtime as a routine method

of filling shifts instead of an emergency response to urgent circumstances. It is not

an acceptable substitute for adequate nurse staffing levels. The use of mandatory

overtime is a short-sighted response to inadequate staffing because it worsens the

problem, places patients at risk and puts extraordinary burdens on direct patient

care staff.

For public safety, airline crews, air traffic controllers, train operators and truckers

have limits on the maximum hours they can work. Isn’t it time that we set similar

public safety protections for patients and the workers who care for them?

Senator Edward Kennedy (D-MA) and Senator John Kerry (D-MA) plan to introduce legislation that will curb mandatory overtime for licensed nurses. Chairman

Rockefeller, AFGE asks that you support the Kennedy-Kerry legislation and provide

DVA nurses the ability to stop the overtime clock unless there is a real emergency,

not a failure of management planning. Curbing mandatory overtime is an immediate step that would improve quality care, working conditions and protect patients

at the DVA.

2. Rationalizing Safe Staffing Levels Would Improve the Quality of Care

Research shows that increasing the numbers of RNs and other nursing staff in

a hospital makes a difference in patient outcomes and quality of care.

• The 1998 study ‘‘Nurse Staffing Levels And Adverse Events Following Surgery

In U. S. Hospitals’’ (Kovner and Gergen) showed that patients who have surgery

done in hospitals with fewer registered nurses per patient than other hospitals run

a higher risk of developing avoidable complications following their operations. The

study found hospitals that provided one more hour of nursing care per patient day

than the average nursing care hours per patient day had almost 10 percent fewer

patients with urinary tract infections and 8 percent fewer patients with pneumonia.

One estimate is that an additional one hour per day of nursing care is about a seventeen percent increase in nurse staffing levels.

• A 1995 study, ‘‘Comparing the Contributions of Groups of Predictors: Which

Outcomes Vary with Hospital Rather than Patient Characteristics’’ (Silber, Rosenbaum and Ross) found that RN-to-bed ratio was the most important factor in predicting the differences among hospitals’ success rates in saving patients who experienced serious adverse events. Silber’s research found that nurse staffing levels were

even more significant than the board certification of physicians in rescuing a patient

because nurses are the ones who first recognize a complication and call the physician.

• Studies have shown that even slight increases in nurse-to-patient ratios reduce

the likelihood of patient falls in nursing homes. For the elderly a single fall may

have significant medical consequences.

• This February the Department of Health and Human Services released a study

on ‘‘Nurse Staffing and Patient Outcomes in Hospitals’’ that found facilities with

more RNs on staff had a 3 to 12 percent reduction in rates of unfavorable outcomes

for patients, like urinary tract infections, pneumonia, and shock/cardiac arrest. The

study also showed that a reduced rate of unfavorable outcomes for patients subsequently lowered hospital costs.

Currently DVA only maintains staffing standards for Intensive Care Units (ICU)

and the operating room. These standards have forced DVA to maintain minimal

staffing ratios on these wards. In other wards, like psychiatric and medical, staffing

standards are determined by the number of staff on duty, not the needs of the patients. In other words, staffing standards at the DVA are not consistent from facility

to facility. Nor are the staffing levels adequately measured or rational. Moreover,

there is no accountabiity for unsafe staffing levels.

Chairman Rockefeller, AFGE urges you to include in your legislation a provision

to begin to address the longer term solution to the nursing shortage setting meaningful standards for staffing. The problem of understaffing in DVA is serious. It can

only be solved if we have all stakeholders at the table, including nurses and other

front-line health care workers, and the unions which represent them. We urge you

to require DVA to create a joint labor-management committee to develop factors for

establishing safe staffing levels at all DVA facilities. These factors should then be

used by a facility labor-management committee to establish ward and facility specific safe staffing standards. DVA should report to the Senate Veterans Affairs Com-
21

mittee on the development of these factors and standards, and whether facilities are

meeting the safe staffing standards.

3. Increasing the Ability of Front-line Nursing Staff to Advocate for Their Patients

It’s common sense that the staff most responsible for providing bedside care, for

being the primary surveillance system of a patient’s condition, and for communicating and coordinating medical treatment and interventions be involved in decisions about the delivery of patient care. AFGE urges this Committee to amend 38

U.S.C 7422 to permit AFGE the opportunity to sit down at the bargaining table

with DVA to discuss working conditions that affect the quality of patient care.

A study by the American Academy of Nursing in the early 1980’s showed that

hospitals where nurses have greater control over their practice environment and

where there is a culture of respect for nurses were magnets for the recruitment of

high quality nurses. Other studies suggest that patient outcomes improve when

nurses are truly valued and respected and given the support they need to care for

patients.

Loosening the current restrictions on labor-management negotiations would give

front-line nurses and other care givers a stronger voice to advocate for their patients.

4. Improving the DVA Nurse Pay and Promotion System Would Enhance Recruitment and Retention

If DVA wants to be the employer of choice its working conditions must improve.

In addition to safe staffing, limiting the abuses of mandatory overtime and enhancing nurses’ ability to advocate for patients, a key area in need of improvement is

pay. AFGE greatly appreciates the hard work by Senators Rockefeller and Specter

in reforming the nurse locality pay system last year. The guarantee of an annual

nationwide raise was welcome relief to DVA nurses.

Unfortunately, some medical directors continue to exercise their discretion to deny

nurses a locality pay increase. For example, Medical directors at Clarksburg, WV,

Altoona, PA, Erie, PA , Philadelphia, PA, Wilkes-Barre, PA, Dublin, GA, Gainsville,

FL, Lake City, FL, Miami and West Palm Beach, FL, Spokane, WA, Honolulu, HI,

and White River Junction, VT, all did not provide RNs with a locality pay increase

(only the 2.7 percent nationwide increase). AFGE urges that the legislation to address the nursing shortage include correcting the continuing inequities in the nurse

locality pay system.

AFGE would also urge you to address the mounting of problem of nurses who are

on pay retention and, therefore, do not even receive the full GS nationwide pay increase. Between 1994 and 1997 the wage growth for nurses fell by 1.5% annually,

according to a 1999 Buerhaus and Staiger study. In order for DVA nurses to maintain a decent standard of living and for DVA to become an employer of choice, locality pay and full pay raises for nurses on pay retention must be addressed.

DVA is implementing Nurse Qualifications Standards that would practically shut

the door on promotions to a Nurse Level II unless a nurse has a Bachelor in Nursing Science (BSN). A licensed RN of 15 years who does not possess this type of degree, but has an Associate Degree in Nursing, is expected to work at the DVA at

the Nurse I level solely because of her or his educational degree. How can DVA expect to retain or recruit employees who are highly qualified, experienced, licensed

RNs, who happened to choose a different course of education? DVA does permit a

waiver for RNs who do not have their BSN degree, but we are concerned that this

waiver is not being fully used. AFGE urges this Committee to encourage DVA to

rethink these qualifications standards and the potentially punitive effect of the education component.

5. DVA is in a powerful position to increase the number of qualified nurse candidates

Given the current nursing shortage, DVA must aggressively recruit new nurses

in anticipation of the retirement of a significant portion of its nursing workforce.

The DVA has a pool of qualified staff who with proper encouragement and support

would become RNs, LPNs or NAs. AFGE strongly believes that DVA would benefit

from a revitalized upward mobility program for current staff to encourage them to

go into the field of nursing and other health care professions on the verge of shortages, such as pharmacy and social work. An upward mobility program could also

enhance the diversity of DVA’s RN staff.

AFGE supports the following improvement to the Employee Incentive Program

Scholarship program:

• Require each DVA facility to recruit and fund a minimum number of scholarships for current staff to become RNs, LPNs, or NAs.

• Link the the overall scholarship limit to increases in education cost inflation;
22

• Reduce the the scholarship requirement for continuous employment from 2

years to 1 year, provided that more senior employees receive preference when funds

are limited;

• Make the scholarship and debt reduction programs permanent.

AFGE would also urge the Committee to direct the DVA to work with nursing

schools and colleges to provide classes at the DVA facility either in person or

through teleconference to facilitate greater participation in the scholarship program.

In sum, AFGE recognizes that many approaches to the nursing shortage must

occur to resolve a problem that has been years in the making. But addressing these

adverse working conditions at DVA is a necessary and prudent course to improve

quality of care and protect patients at the DVA .

When DVA fails to create favorable working conditions by treating its staff with

respect and dignity it sends a profound message to not only its workforce but to candidates for employment. Moreover, the way that DVA management treats its workforce ultimately redounds to DVA’s genuine desire and capability to honor veterans

with compassionate and high quality care.

Thank you for considering AFGE’s views.

Chairman ROCKEFELLER. Thank you, Mr. Cox.

Ms. McMeans, you used the words ‘‘ethically bound,’’ and that interested me very much, and I would like to have each of you maybe

comment on that, because it is true in teaching, half of all American teachers are retiring. It is true in nursing in the non-VA system as well. I want to get your comments on whether it is more

true in the VA, in your judgment, than in non-VA health care.

A shortage is defined as not enough people, and if you are ethically bound, on the one hand, but exhausted on the other, you have

mandatory overtime. I just want to try and draw you out in a question here. What happens, let’s say, if the OR is staffed but other

departments are not because there is a shortage plus a reduction

in hours because of legislation? And how does that, in your minds,

work with the whole idea ethical responsibility. All patient care is

important, and a nurse becomes not just a giver of care but a giver

of hope, as Senator Cleland said, and of love or self-esteem.

So how do we deal with this? One, is it worse out there in the

non-VA system as you talk with your counterparts? Second, how do

you square the phrase you used, ‘‘ethically bound,’’ if there is a

mandatory reduction in hours, with what happens then to the patients if it is in effect and there is still a shortage of nurses? And

I was looking at you, but I am directing these questions to everybody.

Ms. MCMEANS. I see what you are saying. If the mandatory overtime is reduced, we can get more staff nurses to come to work.

Chairman ROCKEFELLER. How do you do that?

Ms. MCMEANS. We just put out the word that there is no more

mandatory overtime. Right now in the community in Martinsburg,

that is one of the things out there. Nurses have quit and left the

VA, and the word is you do not want to go to work there because

you do not know when you are going home. You can come into

work at 7:30 in the morning, and you think you are supposed to

get off at 4. Then you find out at 3:30 that you have to stay another 8 hours. Then you are obligated to come back in the next day.

This is the word that is out in the community. So nurses will not

come to the VA for those reasons.

At the outside hospitals and other areas, they do not have this

mandatory overtime, so nurses coming out of school, they are

thinking, OK, well, I will go there and give it a try and see what

it is like.
23

Chairman ROCKEFELLER. And do they also work shorter hours?

So are these nurses available?

Ms. MCMEANS. Yes, I believe, if the VA starts to be creative in

their retention and how they are going to bring nurses in. Right

now they are not really thinking part-time. We have no part-time

in Martinsburg. There are nurses out there that are willing to

come back part-time, work fee basis, some of the older nurses who

have gone out and retired who are willing to come back and help.

We do not have that at this moment. This would really help with,

you know, the shortage right now, with the staffing shortage.

Chairman ROCKEFELLER. OK.

Ms. MYERS. I would like to also add to that the notion of looking

at retired military nurses as a option for bringing more nurses into

nursing. I would also like to respond to your comment about—I

guess it was a question as to whether it is as bad on the outside,

non-VA. Having had some recent personal experiences in several

hospitals in Atlanta with family members, I do not believe that it

is as bad as it is at the VA.

Chairman ROCKEFELLER. Because of the budget.

Ms. MYERS. Because of the budget. That is the main reason, because of the budget. I see traveling nurses. I see agency nurses.

Even though the VA is using some agency nurses, I do not believe

that the situation is as worse as it is at the VA.

Chairman ROCKEFELLER. So you must be really happy about the

tax cut bill, aren’t you? [Laughter.]

Carefully taking a drink of water. [Laughter.]

Mr. Cox?

Mr. COX. Mr. Chairman, I recently had a cardiac catheterization

and a stent put in my heart in the private sector, and I can tell

you, it was a medical center that I used to work at. I was never

forced on mandatory overtime. I was asked if I wanted to work

overtime. But, also, if the workload went up, they were able to offer

whatever price it took to hire the staffing, and still yet that medical center does not force overtime.

We have mandatory overtime in the VA simply because there is

not enough staff in the very beginning.

Chairman ROCKEFELLER. And there is not enough staff because

there is not enough funding.

Mr. COX. That is exactly right.

Chairman ROCKEFELLER. And it is going to get worse.

Mr. COX. Yes, sir.

Chairman ROCKEFELLER. Because of this tax cut bill, right?

Mr. COX. Yes.

Chairman ROCKEFELLER. So how do we handle that?

Ms. MCMEANS. I will give my money back, my little——

Chairman ROCKEFELLER. That will help, but it will not solve the

whole problem.

But I am serious. How do we handle it? Because that is the ultimate issue. You know, this is not political, but I did not agree with

the tax cut bill. I think it was wrong for about 150 reasons. But

one of the ultimate casualties from that bill is going to be the VA

system. And, therefore, we have to be very, very sure as we go

through the appropriations process that we are very even and fair
24

between hospitals so that each hospital has the most it possibly can

for all purposes.

But it is a budget-run system. It is a national health care system. It does not have the ability to rise above a budget. And so how

do we do that? What can we do to make up? If you reduce the mandatory overtime, which if somebody told that to me that I had to

work 18 hours or 20 hours a day, even if it did not bother me, the

fact that I was being told that I had to would bother me. I might

choose to do it because the need was there, but I would not want

to be told to do it. But, on the other hand, with the shortage, will

people be there for the non-critical type of care that patients in VA

hospitals deserve?

Mr. COX. I think they would, Mr. Chairman. When I reviewed

the number of licensed nurses in many States, there is a large

number of licensed nurses. But at the same token, when you review how many of them are actually in the work force practicing

as registered nurses and licensed practical nurses, that number has

shifted down. About 96 percent of the nurses in this country are

women who have children, have family responsibilities and things.

Forcing them over, telling them they have got to leave children at

home alone, things like that, all those contribute to, they say, well,

no, I just cannot do nursing anymore, I am going to choose another

job.

Chairman ROCKEFELLER. All right. We all have responsibility

with this. Obviously the main responsibility is ours because we

have increased the budget.

But AFGE is a very powerful and large organization. What are

you all doing to try to work at this solution of the shortage of

nurses?

Mr. COX. One of the things that I advocate continuously to our

membership, those that are nursing assistants and LPNs, is to

strive to go back to school to become registered nurses. We have

worked with community colleges and universities and things to develop programs where people can actually work and go to school

and do those type of innovative things. And that has helped and

figured out ways that people can proceed to pursue an education

to deliver better quality of care. Those are things that we have

done.

Also, many AFGE members go around to local hospitals, and now

more than just hospitals, they are going into community groups because many nurses do not go into nursing right out of high school.

Many of them are 20, 30 years old nowadays when they enter the

nursing profession, and we are trying to work in that arena.

Also, we are doing such things as talking to many of your colleagues over here on the Hill about the problems with nursing, and

particularly about the VA.

Chairman ROCKEFELLER. OK. Other points on this subject?

Ms. MYERS. In terms of NOVA, we are looking at the VA Cadet

Nurse Program, the model that is at the Salem, Virginia, VA. We

are challenging our members to go out and assist in mentoring programs and recruiting nursing students who have not chosen a career to come into nursing.

We are also monitoring the Nursing Education Initiative, which

was put into place a couple of years ago, the $50 million that was
25

allocated, and as you can see in the testimonies, recommendations

are made there for ensuring monitoring by having someone hired

at the specific VAs to implement that program and ongoing monitoring.

Chairman ROCKEFELLER. Maybe this will have to be the final

question because we have two more panels, and this is terrible to

do, to have three panels in such a short time, with two votes mixed

in, and I apologize to all of you for that.

I expressed myself and my views on the tax cut. It does not necessarily express your views. But I would like to have each of your

views on the record as to what you think a flat-line VA budget will

mean in terms of nursing shortage in the VA health care system?

Starting with you, Dr. Myers.

Ms. MYERS. I believe that it will continue to jeopardize the safety

of patients in terms of not having sufficient registered nurses or

nurses in general to take care of patients. I believe that the morale

of the current work force, nursing work force, will continue, and

the availability in terms of the supply of nurses that are needed

in terms of the demand, the gap is going to widen because the

nurses who are not comfortable and unsatisfied being at the VA

are going to leave.

Chairman ROCKEFELLER. And you hear that conversation already?

Ms. MYERS. Yes.

Chairman ROCKEFELLER. And they say what kinds of things?

Ms. MYERS. It also jeopardizes the 50 percent of the work force

who are eligible for retirement. Those nurses, it is possible that

those nurses could leave at any time. So that will further complicate the problem.

Chairman ROCKEFELLER. Ms. McMeans?

Ms. MCMEANS. I believe personally that you will see, I will say,

a decrease in the patient load in the Martinsburg VA, because I

look for the nurses to leave. I really do. And I do hear it. In fact,

I lost a nurse practitioner just this week who has been in the system for like 5 years. She was an ICU nurse, and she left. She has

a master’s degree, and she left because she could not even get a

Nurse 3. I am an associate degree nurse, and she makes like

$2,000 more than what I do. And she could not because she was

told that there was no money in the budget for it.

I have seen nurses walking out the door. I see a lot of nurses

that are eligible for retirement who are tired because of the mandatory overtime, because of having to stay late shifts, and working

short, and they are afraid of the responsibility. I see them leaving

and going to the private sector. I can go out now and get a job for

$25 an hour and work 8 hours any day I want of the week, any

shift that I want. And all I have to worry about is the insurance

benefits. So why would I come to the VA and work for you?

I hear this all the time. And I look for nurses to really leave the

work force.

Chairman ROCKEFELLER. So the statement that I made earlier

about that the VA being blessed by an unusually low amount of

turnover among nurses is now jeopardized?

Ms. MCMEANS. Yes. And the nurses that are leaving are the ones

with the 25 and 30 years of service.
26

Chairman ROCKEFELLER. If the ‘‘mandatory’’ overtime was eliminated, in legislation but the funding was not changed, would the

result be the same—that is, nurses continuing to leave or leaving

at a faster pace?

Mr. COX. I think taking the mandatory overtime off would certainly help curtail some of the nurses’ leaving because we lose

nurses who will say, ‘‘I have worked other places, and no one forced

me to work overtime. They asked me if I wanted to work it.’’ And

nurses are compassionate, caring people. They do not just walk off

and leave patients of any type uncared for. They make arrangements. But to force them I think is what is causing some of them

to leave and go other places.

Chairman ROCKEFELLER. Could you each—and this will be the

final question—give me an example, a real-life example of what

happens when a nurse is exhausted into his or her 15th hour?

What is the fatigue factor? What kinds of things can happen or do

happen as a result of that condition?

Ms. MYERS. As a charge nurse in a nursing home care unit working on the evening shift, a nurse is giving bar code medication administrations in a 32-bed unit with a census—excuse me, a 32-bed

unit with approximately six or seven nursing personnel. It is suppertime. Patients need to be toileted, fed. A patient falls out of the

bed, and the nurse who was supposed to be monitoring that patient

was down helping with another patient or has gone off the floor to

have supper.

Medication errors, forgetting to administer a medication, not

being attentive to a patient’s pain, need for pain control. A patient

asks for pain medication, and the patient does not get the pain

medication.

Chairman ROCKEFELLER. Because they push the button and

there is no——

Ms. MYERS. The nurse is busy doing something else.

Chairman ROCKEFELLER [continuing]. Nurse at the other end?

Ms. MYERS. Correct.

Chairman ROCKEFELLER. Ms. McMeans?

Ms. MCMEANS. I will agree with her on the medication errors. I

have seen IV’s not being hung, not getting hung. I see paperwork

being left behind, important information and things that need to be

passed on maybe to the next shift not being done because the

nurses just totally forgot—not that she wanted to, but because she

is exhausted and just really cannot remember.

I will see a nurse the next day getting ready—— Chairman ROCKEFELLER. In other words, you mean they postpone it. They say they will do it in a half-hour, and then do three

or four other things in between, and then the memory is a little

less clear, because they are tired, of what it was that they wanted

to write down.

Ms. MCMEANS. If I am working on an admission and I am doing

an admission paper right now on a patient, and then all of a sudden this patient goes into cardiac arrest over here, and I run over

and take care of him, and then this patient is having a seizure,

well, I have to run over there. Well, guess what got left behind?

The paperwork.

Chairman ROCKEFELLER. Right.
27

Ms. MCMEANS. And it is going to sit there because I do not have

time. I am going to take care of my patients first.

Now, what will be the final result, probably——

Chairman ROCKEFELLER. And that is part of your ethic, isn’t it?

Ms. MCMEANS. Right.

Chairman ROCKEFELLER. That is a no-brainer, what you are

going to do.

Ms. MCMEANS. Right, exactly. So, therefore, important information is not passed on. Whatever I was typing or writing or doing

at that time will not be passed on to the next shift. Maybe they

will not get some information that they need to, you know, review

or talk over with the doctor. And I see a nurse possibly calling in

the next day sick because they are just too exhausted to make it

back in.

Chairman ROCKEFELLER. Thank you.

Mr. Cox?

Mr. COX. I guess I would give an example of when I was a child

in school, we always had the hardest subjects first in the day. You

usually had math first out in those first few years. And I also know

that any time that we have had physicians who have had surgery

and so forth in the hospital, they purposely want their cases scheduled first in the day. And I guess there has to be a reason because

when people are starting fresh, they are relaxed, and there are less

errors and less chances of things going wrong.

Now, if we are doing those things for what is a normal maybe

8-hour day, think about what the end results can be at a 16-hour

day or maybe even sometimes longer. People are tired. They do not

think as well. They get more frustrated. They do not feel as well

at the end of a 16-hour day. Things happen. They are not as caring

and compassionate either with how they treat and take care of people.

So lots of things I think can go wrong. I could enumerate those

medication errors and things of that nature, but I say look at what

physicians themselves do if they have to have some medical procedures. They purposely make their colleagues schedule them first off

in the day.

Chairman ROCKEFELLER. I thank all of you very, very much. I

think again this underscores the brutality of what happens if you

do not adequately fund nursing. So I really appreciate what you

have said, and I apologize for making you wait, and I thank you.

Ms. MYERS. Thank you.

Ms. MCMEANS. Thank you.

Mr. COX. Thank you, sir.

Chairman ROCKEFELLER. Senator Specter has arrived, and we

would welcome any comments you have, sir.

Senator SPECTER. Thank you very much, Mr. Chairman.

I regret not being here for the entire session. I have been working on a committee on reorganization, trying to get the Senate reorganized after the shift in majority control, and I commend Senator

Rockefeller, Chairman Rockefeller, for convening this session.

The problem with nurses is an enormous one. I hear about it

wherever I travel. I was in Scranton this past Monday, and it is

a major area of concern in the private sector as well as in the pub-
28

lic sector as to how we persuade more professionals to become

nurses. It is a matter of major concern in Scranton and elsewhere.

On the Appropriations Subcommittee, which has jurisdiction over

the Department of Health and Human Services, we have looked

into a very difficult issue—nurses performing anesthesiology. There

has been quite a bit of controversy over whether a nurse ought to

be able to do that, subject to a certain amount of supervision by

a medical doctor. And after studying the issue, it is my view that

rural areas are very different from cities based on the experience

I had growing up in a rural area.

Finally, we worked it out so that there would be State control

over the issue with the Governors making the primary decision. I

think that is going to encourage nurses to go into the profession if

they have greater latitude in anesthesiology. That might be an illustration of giving more professional responsibility to nurses.

The scholarship program is a good idea. Tax incentives are another idea. But there is no doubt that we have to be innovative to

try to provide professionals in this very important line of endeavor.

[The prepared statement of Senator Specter follows:]

PREPARED STATEMENT OF HON. ARLEN SPECTER, U.S. SENATOR FROM PENNSYLVANIA

Good Morning. Our purpose here today is two-fold: first, the Committee meets

today to vote on—and, I hope, approve—the nomination of Mr. Gordon H. Mansfield

to be VA’s Assistant Secretary for Congressional Affairs. Second, we will receive testimony on a vexing issue—projected shortages of nurses to staff VA—and other—

hospitals, clinics and long term care facilities.

This is a nomination that is of particular interest to the Members of this Committee since the nominee will coordinate VA activities on Capitol Hill—activities designed to communicate VA’s message to us . . . and to transmit, from time to time,

Congressional messages back to VA and to the Administration. The Assistant Secretary for Congressional Affairs also assists us in securing needed constituent services from VA—one of the most vital, to us, services that VA can perform.

In short, the job of the Assistant Secretary for Congressional Affairs is an important one—and I think Gordon Mansfield is highly qualified to perform it. So I

have—and I will—support his confirmation.

The other issue we will address today is the issue of projected shortages of nurses

to staff VA—and other—hospitals, clinics and long term care facilities. Anyone who

has ever been in a hospital—as I have—will confirm a point on which most already

agree: that the nursing staff is the backbone of any health care facility. VA hospitals—any and all hospitals—simply could not operate without a full compliment

of nursing staff. Surely, the physicians and health care executives could not run the

place without nurses; they would be the first to agree to that point. So we must

assure that VA is thinking ahead to prevent, or minimize, the impact of shortages

that most experts seem to agree are just over the horizon.

I am pleased to note that—at least in VISN IV (Pennsylvania)—there does not

appear to be a insurmountable problem. If I am informed correctly, VISN IV employs approximately 2600 nurses and it currently has approximately 160 vacancies.

That is not good news—particularly when three VA medical centers in Pennsylvania

(in Coatesville, Erie, and Philadelphia) have unfilled vacancy rates of over 10%. But

it does not appear to me to be a extraordinary problem.

Obviously, however, VA needs to assure that it prevents nurse shortages. It needs

to assure that it remains competitive in the hiring environment—both by offering

competitive salaries and, perhaps more importantly, by addressing the intangible

issues that nurses advise need attention. VA needs to cut back on mandatory overtime. VA needs to offer cutting-edge training opportunities—and child care assistance and time away from work to put these opportunities within reach of real world

employees. And VA needs to offer to nurses the respect and empowerment to which

they are entitled. I am most troubled by a University of Pennsylvania study which

found that:

• only 39% of surveyed nurses thought hospital administration listened and responded to nursing staff’s concerns;
29

• only 40% thought nurses had an adequate opportunity to participate in policy

decisions; and

• only 39% thought that nurses’ contributions to patient care were publicly acknowledged.

This cannot be the environment within which VA nurses work—not if VA is to

continue to attract and retain the quality staff it has now.

We will be looking to our witnesses this morning for tangible, specific ideas on

what VA must do to get—and remain—competitive in the future marketplace for

nurses. Perhaps VA cannot solve the overall national nursing shortage issue—

though I am anxious to hear how it might contribute to solving a broader national

problem. But it can—and it must—position itself to compete successfully in the environment of staffing scarcity caused by that broader national problem. VA’s survival—and the care of the Nation’s veterans requires it.

Chairman ROCKEFELLER. Thank you, Senator.

Could Dr. Garthwaite and Cathy Rick please come forward?

Again, I would note that your full statement is in the record, and

the 5-minute limit is actually becoming increasingly important, and

I know you both understand that.

Dr. Garthwaite, we welcome you.

STATEMENT OF THOMAS L. GARTHWAITE, M.D., UNDER SECRETARY FOR HEALTH, DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY CATHERINE J. RICK, CHIEF NURSE

CONSULTANT, NURSING STRATEGIC HEALTH CARE GROUP,

DEPARTMENT OF VETERANS AFFAIRS

Dr. GARTHWAITE. Thank you, Mr. Chairman, Senator Specter. I

appreciate the committee’s interest in nursing issues in VA and in

society in general and for holding this hearing and for legislation

passed last year, Public Law 106–419, that allowed us to pay additional salaries to nurses.

I would just make three points so we can get on with the questioning.

First, I think today VA is largely meeting the needs of veterans

with 35,000 skilled and dedicated registered nurses throughout our

system. There is no question that in some areas, in some nursing

specialties, we have significant difficulties in recruiting nurses.

Second, we are worried about tomorrow. We are worried because

of the age of our nursing work force. We are worried about the projections of a shortage in nursing. And we are worried by the demographics which basically show that as baby boomers age and need

nursing care, they leave the work force and leave a much smaller

total work force in which fewer people are going into nursing. So

we are, too, concerned about tomorrow in nursing.

Finally, I would just say that we have numerous strategies, and

we look to work with this committee in trying to develop others

that induce people to go into nursing, and especially to get nurses

to want to come into the VA and stay with us for a long time.

With that, I will stop and entertain your questions.

[The prepared statement of Dr. Garthwaite follows:]

PREPARED STATEMENT OF THOMAS L. GARTHWAITE, M.D., UNDER SECRETARY FOR

HEALTH, DEPARTMENT OF VETERANS AFFAIRS

Mr. Chairman and Members of the Committee:

I am pleased to appear before the committee to discuss VA’s nurse staffing situation and the looming crisis in nursing.
30

1 Buerhaus, P.I.; Staiger, D.O.; Auerbach, D.I. Implications of an Aging Registered Nurse

Workforce. Journal of the American Medical Association, 2000, 283:2948–2954. 2 Bednash, G. Nursing Schools’ Enrollments Decline as Demand for RNs Continued to Climb.

American Association of Colleges of Nursing, February 2000 3The Registered Nurse Population: Findings from the National Sample Survey of Registered

Nurses. U.S. Department of Health & Human Services, March 1996. 4Searching for Trust: America’s Message to Hospitals and Health Systems. Reality III, National Focus Group Research, American Hospital Association, 1998–1999 5 Aiken, L. et al. Nurses’ Reports on Hospital Care in Five Countries. Health Affairs, May–

June 2001:43–53

NURSING SHORTAGE: A NATIONAL PERSPECTIVE

VA is able to provide quality care to veterans, and meet most of the demands for

nursing staff. However, there are increasing difficulties in filling positions in some

locations, and extreme difficulty filling some specialty assignments. We recognize

that if national nursing workforce projections are accurate, a shortage of nurses

could adversely affect our ability to provide health care for veterans.

The future supply of registered nurses is not assured given the current aging of

the registered nurse workforce and the decreasing number of students who choose

nursing as a career. National nursing leaders and health care organizations are projecting a shortage of registered nurses that will be unlike any experienced in the

past. Additionally, the demand for registered nurses is expected to increase as baby

boomers age and require more health care services.

Noted nursing economist Dr. Peter Buerhaus has predicted that the total number

of nurses per capita will likely peak in 2007 and decline steadily thereafter. The

number of nurses in the workforce is projected to fall nearly 20% below requirements by the year 2020. One-half of the 2.1 million nurses currently in the United

States workforce will reach retirement age in the next 15 years. (Buerhaus; DHHS).

At the same time, changes in the way health care is delivered will require larger

numbers of well-educated nurses who perform increasingly complex functions. These

changes are projected for health care delivery in all settings, whether in hospitals

or in community settings. Based on current trends, the demand for nurses will grow

23% between 1999 and 2006.

The projected shortage will result in part from a number of substantial changes

that continue to take place in the profession. Factors identified that will intensify

the nursing shortage include:

• A decline in enrollment in schools of nursing 2

• Aging of the nursing workforce 1, 3

• Average age of a new graduate in nursing has climbed to 30.5 in 1995–2000

versus 24.3 in 1985 or earlier 2

• Poor image of nursing as a career choice and more career choices for women 1, 2

• Pay stagnation, after inflation adjustment 1

• Perceived negative work environment 5

• Inadequate numbers of qualified faculty to educate the numbers of nurses needed 2

RN STAFFING WITHIN VA

Registered nurses comprise the largest segment of health care workers within the

Veterans Health Administration (VHA). Currently, VHA employs over 35,000 registered nurses and nurse anesthetists. VA nurse employment is stable at this time.

VA enjoys a lower turnover rate (9.5 percent in 2000) than the national average of

15%. However, VA is experiencing difficulty in recruiting nurses with certain special

qualifications such as intensive care, nurse practitioners or nurse anesthetists.

While the difficulties are occurring nationwide, the types of nurses for which there

are shortages vary by geographical region. Certain VA medical centers also report

difficulties recruiting Licensed Practical Nurses (LPNs) and nursing assistants

(NAs).

Based on the new reporting requirement established in Public Law 106–419, after

September 30, 2001 we will have a more complete picture of the RN staffing levels

and recruitment and retention difficulties at each VHA facility, as well as throughout the system.

VA is more successful than the rest of the healthcare industry at retaining nurses.

VA’s nurse turnover rate is 9.5% vs.15% for the U.S. This means that when nurses

take positions with VA, they are more likely to continue their careers in VA. However, the age of a new nurse hire in VA is 41.65 years. If younger nurses were attracted to VA, they would be more likely to stay with VA, and VA would be less

exposed to the looming nurse supply shortage in future years.
31

Today, 12 percent of the VA nursing population is eligible to retire. Each year,

an additional 3.7 to 5.3% of VA nurses become eligible to retire. By 2005, 35% of

the current VA nursing workforce will be retirement eligible. Based on past experience, we predict that about two-thirds of these nurses will actually retire by that

date. That means that over 1 in 5 VA nurses today will be gone by 2005. VA has

been able to successfully recruit to fill these vacancies as they occur. However, as

the labor market tightens considerably, recruitment difficulties can be expected.

The retirement eligibility projections for allied nursing occupations are similarly

high with 29% of LPNs and 34% of NAs will be retirement eligible by 2005.

CHANGING SKILLS FOR FUTURE NURSING WORKFORCE

The current trends in health care delivery increased focus on outpatient settings

delivering comprehensive wellness and health care, with patients experiencing

shorter hospital stays for acute illness episodes will continue to force changes in the

nursing profession.

Nurses must possess clinical decision-making and critical thinking skills, with

preparation in community health, patient education and nursing management/leadership. They will require a breadth and depth of knowledge to make rapid patient

assessments during critical stages of an acute illness, as well as to assist patients

in making the transition from one care setting to another.

Based on this intense and complex care environment, the National Advisory

Council on Nursing Education and Practice has proposed that by the year 2010 twothirds of all practicing nurses must possess a baccalaureate degree if optimal care

is to be provided. VA’s new Nurse Qualification Standard, with its emphasis on educational achievement, and VA’s commitment to funding academic education for

nurses completing baccalaureate and higher education are positioning VA to attain

this desired mix of educational attainment.

VA is taking steps to ensure that our workforce is ready to meet the challenges

by offering career tuition assistance to nurses. VA has implemented two educational

assistance programs to enhance recruitment and retention of health professionals

such as nurses—the Employee Incentive Scholarship Program (EISP) and the National Nursing Education Initiative (NNEI). The EISP provides scholarships of up

to $10,000 per year for up to three years for employees to pursue degrees or education in health care occupations for which VA is experiencing staffing problems. In

return for VA’s tuition and expenses support, employees agree to serve a period of

obligated service. As of this month, VHA has awarded 189 scholarships amounting

to over $1.7 million, primarily for nursing and pharmacist degrees.

In addition, VA has implemented the NNEI to help ensure that we are able to

meet our staffing needs for registered nurses. The NNEI functions like the EISP,

but awards scholarships solely to nurses to obtain baccalaureate or post-graduate

degrees and training. Already, 1,639 VHA nurses have been awarded more than

$18.5 million support for tuition and expenses. The investment that we are making

in educating our nurses and other health care professionals, coupled with the requirement that scholarship recipients serve a period of obligated service, will help

VA retain quality health care staff, even during times of shortages. It is also noteworthy that the implementation of the EISP and the NNEI has stimulated interest

in working for VA.

VA STRATEGIES TO ADDRESS THE NURSING SHORTAGE

VA is actively addressing the projected future nurse supply shortage through several initiatives. First, I appointed a VHA Staff Focus Group to develop a comprehensive plan aimed at increasing employee job satisfaction that enables VHA employees

to fully develop and use their talents. I have just received this Group’s recommendations and am reviewing them now.

Second, the VHA Office of Patient Care Services, Nursing Strategic Healthcare

Group (NSHG) has implemented a Future Nursing Workforce Planning Group to advise the Chief Consultant on issues that impact VA’s future supply and utilization

of registered nurses. This group will make recommendations before the end of this

fiscal year for specific actions to address the impending shortage of registered

nurses and other nursing staff.

In addition to the work of the national VA groups noted above, a number of VA

facilities are initiating programs to combat an impending nursing shortage. Facilities are actively recruiting through the media. Relocation, recruitment and referral

bonuses are being used. New youth programs are being developed in several facilities. Structured programs for new hires are in place in many facilities. Facilities report partnerships and special programs for students in middle school and high

schools.
32

Recruitment and retention efforts include the EISP and NNEI described above.

These programs provide great benefit to VHA and our nurses. In addition, the Education Debt Reduction Program (EDRP), being readied for implementation this summer will provide an additional recruitment and retention tool. The EDRP will provide tax-free payments to newly hired employees to help pay the costs of obtaining

their training or degrees. This program enables VA to pay up to $24,000 over three

years to employees enrolled in the program.

I have attached to my prepared statement a comprehensive listing of all the strategies VA is using to recruit and retain nurses. I will continue to encourage all facilities to use these authorities to the extent necessary to assure quality nursing care

for veterans.

We appreciate the opportunity to comment on the committee’s draft legislative

framework to address nursing shortages in VA. However, we have not yet had the

opportunity to develop a departmental position on it, but will do so expeditiously

and submit it in writing.

CONCLUSION

VA will continue to devote talent and resources to averting the impending national shortage of nurses and minimize any impact on the care we deliver. Interventions will be designed and implemented that will ensure the health care system’s

ability to maintain a highly qualified workforce to provide care for the Nation’s veterans.

ATTACHMENT—RECRUITMENT AND RETENTION STRATEGIES FOR NURSES

The following is an overview of the numerous authorities available to enhance

VA’s ability to recruit and retain highly qualified nurses:

FLEXIBILITIES IN THE NURSE LOCALITY PAY SYSTEM SURVEY PROCESS

Deviations to Periodic Step Increase (PSI) Waiting Periods

The normal waiting period for a PSI to advance to the second, third or fourth step

of a level in Nurse I is 52 weeks of creditable service. The waiting period to advance

to all other steps in Nurse I and all steps in grades II through V is 104 weeks. Facility directors may request deviations to these waiting periods if necessary to enhance

recruitment and retention. This would typically be requested to mirror the advancement and promotion patterns in the community and should be supported by evidence of staffing difficulties related to those patterns.

Exceptions to the 133 Percent Rate Range

The rate range under the Locality Pay System (LPS) is normally 133 percent of

the beginning rate of the grade (12 steps). Facility directors may request extension

of the rate range for a grade, up to 175 percent (26 steps), if such an extension is

necessary to recruit or retain well qualified nurses. Facilities submitting requests

must exhibit staffing problems specific to the grade for which the extension is requested, and show that the problems are related to higher maximum rates in the

community. This authority is particularly useful for retention as it gives on-board

employees greater earning potential.

Expanding the Local Labor Market Area (LLMA)

Facility directors may expand the survey area for any covered nurse occupation

or specialty if the survey area does not adequately represent the LLMA for an occupation or specialty or if there are less than 3 job matches per grade. LLMAs may

be expanded differently for different occupations or specialties. LLMAs may be expanded as far as necessary to obtain the required survey data.

Higher Rates of Pay for Specialized Skills

When a nurse is appointed above the minimum step rate of the grade because

they possess specialized skills, particularly specialized skills that are difficult or in

demand, the facility director may adjust the salary rates of other nurses in assignments requiring the same specialized skills up to the same number of steps. For instance, if a critical care nurse is hired at Step 5 based on specialized skills related

to critical care, the director may authorize an increase of up to 4 steps for all onboard critical care nurses.

Pay Retention Upon Transfer

Nurses who transfer between VA facilities normally receive the rate of pay at the

gaining facility applicable to their existing grade and step. This may result in a salary decrease if the employee transfers to a facility with lower rates of pay. Facility
33

directors may authorize the individual to receive pay retention or an intervening

rate of pay (a rate which is above the rate of pay for the corresponding grade and

step but less than pay retention) based on a special recruitment need or solicitation

of an employee to fill an assignment requiring special qualifications. Use of this authority enhances recruitment abilities by attracting experienced VA nurses who are

seeking to relocate.

Scheduling Salary Surveys

Facilities are required to conduct LPS surveys within 120 days of any GS adjustment in order to determine if an adjustment to LPS rates should be made coincident

to the GS adjustment. Facility directors may also order salary surveys at any other

time it may be deemed appropriate. For instance, facility directors may wish to conduct additional surveys simultaneous to scheduled salary increases in the community or if evidence, such as increased turnover or difficulty recruiting, suggests that

the facility’s rates are no longer competitive in the community.

Setting Beginning Rates of Pay

Passing on Amount of GS Adjustment. Every LPS schedule receives the full

amount of the nationwide General Schedule (GS) adjustment each January. If appropriate, facilities may grant larger adjustments. This automatic increase is in addition to any other adjustments granted throughout the year.

Setting Beginning Rate up to Community Maximum. The beginning rate for

any grade for which survey data was collected may be set equivalent to, but not exceed, the highest beginning rate for corresponding non-VA positions in the LLMA.

Facility directors should consider all factors that affect the facility’s staffing abilities

when choosing the beginning rates of pay, including the geographic relationship of

their facility to major non-VA health care facilities in the LLMA, the rates paid by

the facility’s major competitors, and benefit packages offered by competing establishments.

Setting Beginning Rate up to 7th Step of Next Lower Grade. When data

is not available for a grade and an adjustment is necessary to recruit or retain wellqualified employees, the facility director may increase the beginning rate of Nurse

II, III, IV, or V up to the 7th step of the next lower grade. The beginning rate for

Nurse I may be adjusted so that that the beginning rate for Nurse II falls in the

range from the 4th through 7th step of Nurse I. The beginning rate for the levels

with Nurse I may be adjusted to provide a 3-step differential between them.

Special Salary Rates

When differences in local pay interferes with VA’s ability to recruit and retain

health care personnel, special salary rates may be authorized to achieve adequate

staffing or to recruit personnel with specialized skills. These rates may be competitive with, but not exceed, pay for comparable positions at non-Federal facilities in

the same local labor market. This authority has not been widely used for nurses because pay comparability is normally achieved through the LPS.

Specialty Schedule

A separate LPS salary schedule may be established for any clinical nursing category by conducting a survey of pay rates for the corresponding specialty in the local

labor market. This allows the facility to pay higher rates for assignments that are

typically difficult to fill, such as critical care nurse, operating room nurse and nurse

practitioner.

Third Party Survey Data

Recent legislative changes expand the sources of salary information that can be

used to set salary rates. In addition, that legislation provides for collection of various salary data, including average rates, rate ranges, bonuses, and the value of

benefits. These new flexibilities will enhance VA’s ability to accurately measure and

set salaries for nurses.

ADDITIONAL RECRUITMENT AND RETENTION TOOLS FOR NURSES

Advances in Pay

VA has the flexibility to grant nurses an advance in pay of up to 4 week’s salary.

This is particularly beneficial for new hires particularly those who incur extraordinary expenses in relocating or setting up separate households with their first jobs.

In VA, new employees have to wait three weeks to receive their first paycheck.

This advance in pay serves as an interest-free loan that the nurse repays from regular allotments from future paychecks. This is a no-cost feature to VA that can

serve as a beneficial recruitment tool to new hires.
34

Appointments Above the Minimum Rate of the Grade

Individuals with superior qualifications, candidates for hard-to-fill specialties, and

those with specialized skills may be appointed at a rate above the minimum of the

grade. This flexibility permits the employing agency to offer pay rates up to 30 percent higher than the established minimum.

For individuals with years of experience or high qualifications, a higher entry rate

is appropriate and necessary to offer a competitive salary.

Higher Rates of Additional (Premium) Pay

Facility directors may authorize higher rates of premium pay (tour differential,

Sunday pay, Saturday pay, holiday pay, overtime and on-call) for nurses when necessary to address recruitment or retention problems being caused by higher nonFederal rates of premium pay in the community. For instance, VA may have difficulty staffing positions because VA’s tour differential rate is 10 percent and other

establishments in the community pay 15 percent for similar tours. This gives facilities a mechanism to ensure all areas of pay are competitive to meet staffing needs.

Exemplary Job Performance and Exemplary Job Achievement

A cash award of up to $2,000 may be granted to nurses who demonstrate both

exemplary job performance and exemplary job achievement.

Special Advancement for Achievement (SAA)

Advancements of up to 5 steps within the grade may be granted to recognize professional achievement provided the individual has demonstrated excellence in performance above that expected for the grade level or assignment and potential for

assumption of greater responsibility.

Special Advancement for Performance (SAP)

Advancements of 1 step within the grade may be granted when there has been

a demonstrated high level of performance and ability over and above that normally

expected of nurses in the particular grade.

Employee Recognition and Incentive Awards Programs

Recognition and awards programs motivate employees to make contributions that

support and enhance organizational goals and objectives. The types of awards available to recognize nurses include special contribution awards (e.g., time-off awards

and on-the-spot awards), suggestion awards, gainsharing awards, honor awards, and

non-monetary awards.

Managers also are encouraged to consider non-traditional forms of recognition,

such as products or services in lieu of a cash payment.

Payment of Education Expenses

VA has the flexibility to pay for training that leads to an academic degree. VA

has a long tradition of offering career tuition assistance to nurses.

VA has implemented two new educational assistance programs to enhance recruitment and retention of health professionals such as nurses—the Employee Incentive

Scholarship Program (EISP) and the National Nursing Education Initiative (NNEI).

The EISP allows VA to provide its employees, who agree to serve a period of obligated service, substantial scholarships to pursue education in selected healthcare

disciplines. The NNEI is a targeted scholarship program for employees pursuing degrees in nursing.

The EISP and NNEI provide scholarships to pursue higher level education. The

scholarships range up to $10,000 per year, with a maximum award of $30,000 over

three years.

VA is implementing the Education Debt Reduction Program (EDRP), which will

help VA recruit health professionals with educational loan obligations. The program

will allow VA to make payments to new appointees in certain healthcare positions

(including nurses) over a specified period of time to help them reduce or pay off the

balances on loans used for healthcare education. The EDRP policy is in the final

concurrence process.

Recruitment Bonuses, Relocation Bonuses, and Retention Allowances (3 Rs)

Nurses may receive payments of up to 25 percent of basic pay for accepting positions with VA.

Recruitment Bonuses: Lump sum payments to new hires or former employees following a break in service of at least one year.

Relocation Bonuses: Lump sum payments to nurses currently employed

with the Federal Government who physically relocate to a position in a different

commuting area.
35

Retention Allowances: Biweekly payments included in regular paychecks to

retain employees for critical work, who are likely to leave Federal employment.

Reemployment of Civilian Retirees

VA may request that the Office of Personnel Management waive the dual compensation restrictions in those instances where we need to hire retired nurses due

to special circumstances.

These needs might be temporary, as VA encountered in Operation Desert Storm.

In that instance, VA was given delegated authority to grant waivers to fill behind

critical healthcare personnel in the reserves who were activated for military duty.

Additionally, the authority can be used to reemploy nurses who elect to retire, but

whose services are critical to the completion of ongoing projects.

Specialty Certification

A cash award of up to $2,000 must be granted to nurses who become certified,

while employed by VA, in a specialty related to the accomplishment of VA’s health

care mission.

Travel Expenses for Interviews and New Appointments

VA may pay the travel expenses of a nurse to travel to a pre-employment interview. Additionally, we may pay the moving expenses for newly hired nurses’ relocation to their first post of duty.

This flexibility permits VA to supplement pre-employment evaluation activities

with a face-to-face interview, if desired. Additionally, the payment of moving expenses enables VA to recruit new employees from outside the local area. In instances where the available skills are distant from the facility, the payment of moving expenses can serve as an incentive to a nurse to relocate.

NON-CASH TOOLS

There are a variety of things that managers can do to attract and retain employees with critical skills. They include:

Family-Friendly Policies

A number of initiatives in this area include flexible leave policies for family care,

including the Family and Medical Leave Act and Family Friendly Leave Act, leave

sharing programs, paid time off for adoption, bereavement leave, on-site day care,

subsidized day care, etc.

Flexible Work Arrangements

In some situations, nurses can be given flexible work hours, compressed work

schedules, and variable work hours/days to accommodate employees’ personal preferences. In addition, nurses may be able to work from home or a satellite location,

improving productivity, morale, and productivity.

Non-Cash Perquisites

These incentives can include such items as a close-in parking place, a computer

upgrade, or special work-related software. For some individuals, occasionally providing support staff to assist in work tasks will help the critical employee be more

productive. It also sends the message that the nurse is appreciated.

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. ARLEN SPECTER TO THOMAS

L. GARTHWAITE, M.D.

Question 1. The collaboration between medical schools and VA in educating the

Nation’s doctors is well known. Does VA have affiliations or similar arrangements

with the Nation’s nursing schools? Would nursing schools with which VA has such

affiliations not be fertile sites for recruiting VA nurses—just as they are for VA physicians? What efforts are being made to better establish such relationships with the

schools that train nurses and, therefore, with nursing students themselves.

Answer. VA maintains academic affiliations with more than 546 schools and colleges of nursing. In FY 2000, there were at least 20,182 unpaid undergraduate (associate and baccalaureate degree) and 458 paid graduate and post-graduate nursing

students who received all or part of their clinical education at any one of the more

than 1,300 sites of care in VA. The total funding for the 458 paid trainees in FY

2000 was $1.3 million. Funding is projected to be $1.1 million in FY 2001 (421 trainees), and $1.4 million dollars in FY 2002 (492 trainees).

VA’s nursing affiliations are somewhat different than it’s medical affiliations, in

that VA nurses are not as strongly aligned in paid teaching and faculty roles and
36

* The information referred to can be found on page 32.

the preponderance of nursing affiliations are not funded. Schools of nursing do,

nonetheless, provide fertile sites for recruitment. Positive student experiences influence new graduates’ employment decisions. VA facilities utilize a variety of approaches to recruit affiliated nursing students.

VA has initiated Memoranda of Understanding with both the American Association of Colleges of Nursing (AACN) and the American Association of Community

Colleges (ANCC) and meets with representatives of these organizations regularly to

discuss issues that impact on the recruitment and retention of nurses. In addition,

VA is involved in a collaborative effort with the University Health Services Consortium and AACN to develop a Post Baccalaureate Residency Program for new graduates that, when implemented, will provide an organized transition for new BSN

graduates into the work setting and will contribute to VA’s ability to recruit new

graduates.

VA is the sponsor of the nationally acclaimed Veterans Affairs Learning Opportunities Residency Program (VALOR). Administered by local VA facilities, VALOR is

an honors program that provides specialized summer educational and clinical experiences to nursing students with GPA’s of 3.0 or higher. VALOR participants are

paid 80 percent of RN pay, and if they elect VA employment after graduation, they

are given special salary consideration. Currently there are 267 VALOR students

being supported in 77 VA medical centers. VA also hires nursing students for summer employment and part-time employment during the schoolyear.

Question 2. The VA patient population tends to be older—and more seriously and/

or chronically ill—than its private sector counterpart. Thus, demands placed on the

VA nurse are—I believe—more difficult than those of private hospitals. In order to

compete for the highest quality nursing staff, it would seem appropriate to offer

more benefits and higher salaries than those of the private institutions. Will this

be a possibility given the probable financial constraints of the medical care budget?

If salary increases are not—or cannot be—the solution, what other mechanisms

exist to reward VA nurses appropriately?

Answer. VA is committed to offering a competitive pay and benefits package to

nurses and other health care providers. VA can offer to nurses a variety of recruitment and retention incentives, as well as forms of recognition and reward for exceptional performance and achievement. These flexibilities are described in the Attachment to these responses.*

VA has responded to the issue of patient acuity and mix of veterans’ health conditions through the enhanced qualifications standard for nurses, which emphasizes

additional education and preparation for a more diverse and demanding clinical care

environment. Another mechanism that VA has used to respond to any unique clinical demands in a patient care environment is through the mix of clinical skills in

staff assigned to a unit.

Question 3a. There are numerous hospitals across the country which go into high

schools to attract and recruit students who might be interested in nursing—and

offer them scholarships to nursing school in exchange for a commitment to work in

that hospital after training is complete. Such programs, it seems to me, are no different than the military services going into high schools and recruiting students for

ROTC in exchange for service commitments. Does VA have any programs like this?

Does it have authority to do this? If not, has it ever asked for such authority?

Answer. VA does have authority to implement outreach programs to interest elementary and high school students in nursing and health care careers.

Question 3b. What programs are being developed by VA to target and attract high

school students into nursing—particularly minority students and young men who

may not have considered nursing in the past?

Answer. VA medical centers across the country are developing outreach programs

to interest students and adults in nursing as a career:

The Salem VA Medical Center has implemented a Nurse Cadet Program for high

school students. This Nurse Cadet Program provides basic health care education

and exposure to health careers through an organized volunteer experience. The

Greater Los Angeles Healthcare System, holds a youth day in collaboration with the

Health and Biotechnology Consortium of the local school system. Teens are given

tours of that tertiary care facility, have formal presentations by health care providers, receive handouts and have the opportunity for one-on-one discussions with

health care providers. In the Western New York Healthcare System, the Buffalo

VAMC sponsors a number of activities among which is an Explorer Troop that enables youth to become familiar with health occupations.

Question 4. I am told that it is common knowledge within the nursing profession

that if you go to work at a VA hospital, you can expect greater responsibilities—
37

and less support in executing those responsibilities. Does a bias against working for

VA exist within the nursing profession—particularly among young people? Is VA

viewed as a place where you will work harder than elsewhere—and get less compensation and prestige in return for your effort? What sort of efforts have been discussed to end the stigma—if it exists—of working at VA?

Answer. VA has no data to corroborate the contention that any stigma attaches

to employment by VA. We believe that because the turnover rate for VA nurses is

well below that of the private sector, this is an indication that VA nurses understand and embrace the mission of care for veterans. When newly hired RNs are

asked why they chose to work at VA, typical answers include ‘‘I’ve heard such good

things about VA.’’, or ‘‘When I was a student at VA, I had a great experience.’’ VA is acknowledged as a leader in quality care and patient safety in the health

care industry, as demonstrated by the frequency with which VA nurse leaders are

invited participants in local, state and national professional conferences to share

success stories and innovations.

VA is committed to being an Employer of Choice. We will continue to address any

areas of concern and dissatisfaction that employees may express.

Question 5. In my visits to VA hospitals, I have observed that the nursing staff

is fiercely loyal and, in many cases, is long-tenured. This surely is a good thing— but I sometimes do not see many young nurses in place to replace long-tenured

nurses who are approaching retirement age. Are VA nurses older, on average, than

nurses elsewhere? Has VA in the past failed to target what are now mid career

nurses? Can VA now reestablish itself within the population of nurses in the 35– 45 age range? How?

Answer. VA nurses are only marginally older, on average, than the general population of nurses (VA 46, Nation 45.2). In addition, 23 percent of VA nurses are

under the age of 40, as compared to 31.7 percent in the general U.S. nurse population. VA has, in fact, already established itself within the population of nurses age

35–45, since the average age of a newly hired VA nurse during FY 2000 was 41.65.

However, we agree that it is important that VA focus recruitment strategies and

resources on attracting nurses from all age groups into VA careers.

Question 6a. Three VA Medical Centers in Pennsylvania—at Coatesville, Erie and

Philadelphia—currently have at least 10% of their ‘‘authorized’’ nursing slots unfilled. When a VA Medical Center says it has a certain number of ‘‘authorized’’ nurs- ing slots, what does that number mean? Is it the number of nurses needed to meet

existing demand for services? Or is a number one which an official in Washington— or in the hospital’s executive suite—figures the VA ought to be able to afford to

hire?

Answer. This number is usually termed the ‘‘authorized ceiling,’’ which refers to

the number of nurses authorized for the nursing service. The authorized ceiling is

the number negotiated at least yearly on the basis of suggested staffing as determined by each facility’s staffing methodology (which takes into consideration patient

acuity and workload) and budget. In most cases, recruitment and hiring can occur

to fill up to the authorized ceiling. Sometimes, however, in very tight budget situations, secondary approval may be required to hire, or hiring may be frozen or delayed.

Question 6b. When a VA Medical Center is operating on less than the full compliment of ‘‘authorized’’ nurses, does that mean the medical center has the money

to hire nurses—but it cannot find them? Or does it mean that the medical center

lacks funds to hire the full compliment of staff?

Answer. This generally means that the medical center has the money to hire

nurses, but cannot find them. However, as mentioned above, in very tight budget

situations secondary approval may be required to hire or hiring may be frozen or

delayed, resulting in staffing being under ceiling.

Question 6c. If I am told that the Philadelphia VA, for example, is ‘‘authorized’’

to have 550 nurses on staff but it has 55 vacancies, what should I infer about care

being provided there? Are 10% of patients who seek services turned away because

of a 10% nurse staff shortfall? Are nurses asked to work 10% more hours to make

up for that shortfall? Or does the medical center just cut corners and somehow muddle through?

Answer. A variety of scenarios could be presumed if a facility has 55 vacancies.

In the event of staffing variances, nursing and administration staff review overall

patient care and staffing requirements to consider which options would be best to

ensure safe and adequate patient care. Possible options that would be considered

and utilized include:

• changing patient mix;

• coordinating shared staff resources among units;

• obtaining better support services and/or adding additional support services;
38

• decreasing bed capacity per unit;

• changing staff mix;

• increasing use of overtime and/or use of ‘registry’ or fee basis nurses;

• modifying the role/function on care providers;

• increasing float personnel;

• changing practice patterns; and

• developing new programs to alter staff needed (i.e., same-day surgery, telephone

triage, etc.).

A facility may also experience difficulties meeting all its patient care demands.

For example, clinic appointments may take a longer time to complete, and time required for scheduled procedures or surgeries may be lengthened. The many interrelated factors in the health care environment make creative problem solving and

organizational redesign a critical and essential requirement for a successful nursing

and medical center management team.

Question 7. It is suggested that the root cause of projected nursing shortages is

the fact that young women today have more career choices than in earlier generations, and that even higher salaries will not entice today’s young woman into this

traditionally woman-dominated profession. Is there truth to this assertion? If so,

what will it take to again interest young women in nursing? Can money solve the

problem? Would salary increases draw more people into nursing jobs at VA—or

would it just better reward those who are already there?

Answer. It is true that one cause of the nursing shortage is seen to be the wider

variety of career options available to women. The projected shortage however, will

result in part from a number of substantial changes that continue to take place in

the profession. Factors identified that will intensify a nursing shortage are:

• a decline in enrollment in schools of nursing;

• aging of the nursing workforce (average age nationally, 45.2 years; VA, 46

years);

• increased average age of a new graduate in nursing (30.5 in 1995–2000 vs. 24.3

in 1985 or earlier);

• poor image of nursing as a career choice and more career choices for women;

• pay stagnation after inflation adjustment;

• perceived negative work environments; and

• inadequate numbers of qualified faculty to educate the numbers of nurses needed.

We believe that salary increases alone will not prevent the impending nursing

shortage. While competitive salaries are absolutely necessary, other actions as well

are necessary. More men and minorities must be attracted to nursing as a career

choice; and, more work must be done to address the concerns of current and prospective nurses over workplace issues.

It is important to be able to attract new and more diverse people to the career,

but we must also be able to retain the current workforce. Therefore, increased salaries, along with improved career image and work environments, would certainly

help.

Question 8. As you may know, the University of Pennsylvania recently completed

a survey of 43,000 nurses practicing in more than 700 hospitals in five countries

(and 13,000 nurses in PA alone). It found that:

• only 39% of surveyed nurses thought hospital administration listened and responded to nursing staff’s concerns;

• only 40% thought nurses had an adequate opportunity to participate in policy

decisions; and

• only 39% thought that nurses’ contributions to patient care were publicly acknowledged.

Are these findings consistent with your experience? Is the solution to VA’s problems to be found in rectifying the alienation that many nurses, apparently, experience?

Answer. A recent ‘‘ONE-VA’’ Employee Survey asked similar questions. Approximately 22,500 licensed nurses gave the following responses:

• 37 percent agreed or strongly agreed that ‘‘Sufficient effort is made to get the

opinions and thinking of people who work here.’’

• 35 percent agreed or strongly agreed that ‘‘Supervisors/team leaders ask for employee ideas and opinions before making important work decisions.’’

• 43 percent agreed or strongly agreed that ‘‘Supervisors personally recognize the

contributions of individuals and teams.’’

This survey will be repeated in upcoming months. The questions from the OneVA survey do not allow for an exact comparison to the questions in the University

of Pennsylvania survey, since wording and survey methodology are not the same.
39

* The information referred to can be found on page 32.

However, they do quantify the experiences of VA nurses and provide an indication

of how VA nurses opinions compare to the private sector on very similar issues.

VA recognizes that the retention of a qualified nursing workforce must be a priority. Providing nurses greater recognition of professional contributions, involvement in decision-making, and opportunities for self-governance are strategies that

will enhance retention.

Question 9. If I am not mistaken, in the armed services, men occupy health care

professional and support slots in proportions higher than in the civilian sector. Why

do you think that is? Is it more acceptable somehow for a man to perform nursing,

or nursing-related, duties in the military than in a civilian hospital? Whatever the

whys and wherefores of that point, does VA recruit nurses and related staff in the

military?

Answer. VA does have an active outreach effort to recruit members of the armed

services when they muster out. Two indicators of VA’s success in recruiting former

military members are the number of veterans in VA’s workforce and the number

of men working as nurses in VA. As of September 30, 2000, 61,628 individuals in

VA’s workforce (28.1 percent) were veterans. The number of VA nurses who are veterans is 3,249, or 9.3 percent. Men constitute 13.8 percent of the VA nurse workforce, compared to only 5.4 percent of the nursing workforce in the United States

generally.

RESPONSE TO WRITTEN QUESTIONS SUBMITTED BY HON. BEN NIGHTHORSE CAMPBELL

TO THOMAS L. GARTHWAITE, M.D.

Question 1. What types of incentives could the VA offer to young nursing students

about to enter the workforce?

Answer. VA can offer a variety of incentives. A comprehensive list of these recruitment and retention incentives, as well as rewards, is attached to these questions.*

In addition, VA is the sponsor of the nationally acclaimed Veterans Affairs Learning Opportunities Residency Program (VALOR). Administered by local VA facilities,

VALOR is an honors program that provides specialized summer educational and

clinical experiences to nursing students with GPA’s of 3.0 or higher. VALOR participants are paid 80% of RN pay and if they elect VA employment after graduation

they are given special salary consideration. Currently there are 267 VALOR students being supported in 77 VA medical centers. VA also hires nursing students for

summer employment and part-time employment during the school year.

VA also offers tuition assistance for support of academic education, debt reduction

assistance for graduates, and continuing education support for employees to maintain and enhance their clinical skills.

Question 2. Nurses from the Denver Medical Center have been in to talk about

the nursing shortage. They are concerned that the new regional restructuring of the

VA health care system is downgrading the nursing profession. Their nursing executives are taking a backseat to administrators—this lowers morale. They believe that

the nurses are the only advocates for the patients’ total needs. If nursing is downgraded, they are afraid that no one will really care for the VA patients. In your experience, is this something that is happening throughout the VA health care system? And, how would you address it?

Answer. A variety of reorganization models are being considered or implemented

at VA medical centers. While there is a trend toward the product line philosophy,

no particular model has been mandated. Nurse involvement in decision-making is

identified as an element that impacts the retention of nurses. VA recognizes the significant contributions made by nurse executives and nurses at all levels of the organization. The Joint Commission on Accreditation of Healthcare Organizations, as

well as § 201 of Public Law 106–419, mandates the involvement of nurses in decision making. VA fully endorses and is a proponent of such involvement, because VA

recognizes that providing nurses greater recognition of professional contributions,

involvement in decision-making, and opportunities for self-governance are strategies

that will enhance retention of a qualified nursing workforce.

Question 3. A recent article in the Washington Post discusses how local hospitals

are hiring nurses from overseas to fill their vacant slots. While many hospitals are

focusing their efforts on retaining current nurses and on hiring American nurses,

there are still a number of foreign-born nurses being hired in our hospital systems.

How do you think hospitals can best address the differences between foreign and

American nurses to make sure that all nurses work at the same standards and are

fully acclimated to their jobs?
40

Answer. To date, VA has no plans to recruit significant numbers of foreign?educated nurses. VA regulations require that all nurses hired have passed the

National Council Licensure Examination (NCLEX) and be licensed in a state or territory. NCLEX serves as the ‘‘gate keeper’’ to ensure competency to practice nursing.

Further, in order to be eligible to take NCLEX, foreign applicants must have successfully passed a standardized language test and have their course of study evaluated using standard American curricular criteria.

Notwithstanding this rigorous review and testing, all hospitals hiring foreign

nurses should initiate on-site clinical evaluations and education, similar to the

structured orientation programs commonly implemented in VA medical centers for

all newly employed nurses.

Question 4. Within the VA nursing workforce, what is the ratio of nurses who are

veterans to those who are not? Could the difference between vets and non-vets be

a cause for concern, and how could the VA best address this issue?

Answer. As of September 30, 2000, there were 3,249 veterans employed as nurses

with VA (9.3 percent of the VA nurse population).

VA has no data, nor is there any subjective evidence, to suggest that there is any

difference between nurses who are veterans and those who are not. The veteran status of VA nurses does not appear to be a cause for concern. We are extremely proud

of the dedication shown by all our nurses in meeting the health care needs of our

veteran patients.

Chairman ROCKEFELLER. Cathy Rick is VA’s highest-ranking

nurse. We welcome you.

Ms. RICK. Good morning and thank you, Mr. Chairman. I do not

have prepared testimony, but I would like to make just two brief

points: that is, to recognize the individuals who are leading our

Nursing Workforce Work Group that I chartered in September of

last year, Rebecca Williams and Cynthia McCormack, two nurse

execs in the field, who are co-chairing that group; and a special recognition to Dr. Charlotte Beason from my office, taking a leadership role in pulling issues related to priorities and recommendations to my office through that work force. Dr. Beason and Rebecca

Williams are in the audience as well.

The other point I would just like to make is in my past year, my

first year in this position, it has been clear to me that we have a

very caring and committed nursing work force in VA. And when I

ask nurses in our system what they like about their job, what I

hear most often is caring for veterans, and that I think is a strong

commitment to our mission and to what we are all about.

I just offer my continued support with my passion for both nursing and veterans in working with the nursing staff, nursing leaders

in the field, our professional nursing organizations, VHA nursing

leadership, and our union partners as we work toward continued

efforts to address our nursing work force needs.

And I will leave it at that so we can have time for discussion.

Chairman ROCKEFELLER. Thank you very, very much.

To both of you, Dr. Garthwaite, you wrote me a letter in which

you said you felt that the nursing employment is basically stable

at this time. And I do not want to try to draw controversy here.

It is not my purpose to draw controversy. I want to draw out things

that are useful so that we could do a better job in the future.

There is a little bit of difference between your letter, your testimony, and what the previous panelists said. There was the implication that nurses are leaving already; they are planning to leave;

they are getting out because of fatigue and exhaustion. But comment on that for me, could you, both of you?

Dr. GARTHWAITE. Mr. Cox is correct in terms of the total nursing

staffing over the last 5 years, largely because we have moved from
41

an inpatient setting to an outpatient setting where we need fewer

nurses total to deliver care. As you know, we have significantly decreased the amount of care provided for patients in the hospital. So

a significant part of a decrease in total nurse staffing across VA

has been that change in the locus of care.

Over the last 2 years, we are up 606 nurses, which is, you know,

essentially stable to slightly increased. So I think that was really

the point I was trying to make. But I would say that within certain

nursing specialties we see significant problems in ICU nurses and

nurse practitioners and others.

So, overall, we are up 606 nurses in the last 2 years. That does

not mean we are not experiencing difficulties.

Chairman ROCKEFELLER. Systemwide?

Dr. GARTHWAITE. Yes. But that does not imply that everywhere

we can hire every nurse that we want or that if nurses walked in

the door in several of our facilities we would hire them instantaneously. So because we are operating in every State in the Union,

there are significant differences in our needs and our ability to recruit in those different areas.

Chairman ROCKEFELLER. Ms. Rick?

Ms. RICK. It is the big picture that makes it look like it is stable

at this point. So when you look at the whole system, the impact

is not as significant as you get to a point of care in a particular

unit or particular patient care area or a facility. There are targeted

areas that there is significant difficulty, as Dr. Garthwaite mentioned. And I think the areas that were referred to in the earlier

testimony are on target, those areas that are those with less attractive schedules to work, so those are the acute-care areas with days,

evenings, nights, and weekends that are more difficult to recruit to.

And there is more competition because of the increasing opportunities in the outpatient, ambulatory, health promotion, and disease

prevention opportunities for nurses. Those roles typically fall in a

more attractive working schedule that nurses find in ambulatory

care. So there are competing forces.

But when you look at the overall picture of our nursing work

force at this point in time, when we look at our paid system and

how many nurses were paid in a previous time period to this time

period, we are actually up about 2 percent.

I do not think that that should imply that there is lack of recognition or insensitivity to the significant struggles with recruitment in many facilities.

Chairman ROCKEFELLER. There was a very obvious and clear

point made about the use of mandatory overtime. How would you

respond to that?

Ms. RICK. I think your impression is accurate. Anytime someone

mandates anything of us as human beings, it is not the same as

volunteering, and it is not the same as doing something out of compassion.

We do have a very slight increase in use of overtime over the

past 3 years, and anticipating needing to have a better understanding of where we are with mandated overtime in our system,

I have asked for information from the field, surveying the field,

asking for how much mandatory overtime is being used, is it be-
42

coming an increasing problem, and I am starting to get some of

those responses back.

There are very few areas that have responded that it has been

a significant problem, but it is increasing because the demand is

there.

Dr. GARTHWAITE. I think it is clear that we also desire not to use

mandatory overtime. That is not our intention. But we also have

patients in beds with certain needs, and nurses are required to

meet those needs. We fully recognize the safety issues that people

who are fatigued are not going to perform as well as those who are

not. And so we just need to get more aggressive and creative, I

think, about good, innovative practice in different parts of our system that have avoided using mandatory overtime and see if we can

replicate those practices in other areas.

Chairman ROCKEFELLER. Senator Specter?

Senator SPECTER. A nursing survey by the University of Pennsylvania—a very expansive survey, 43,000 nurses and more than 700

hospitals, five countries, 13,000 in Pennsylvania alone—disclosed

that some 40 percent of nurses are dissatisfied with their present

job, 22 percent are planning to leave within the next year, and 33

percent of those under 30 plan to leave within the next year. So

it appears that younger nurses are disproportionately unhappy.

Ms. Rick, how would you account for that, the overall dissatisfaction of nurses and the differential with respect to younger nurses?

Ms. RICK. Dr. Aiken’s study points to several factors, the study

that you are referring to, that influence people’s decisions about

whether they like their workplace or not. And a lot of it has to do

with career progression, advancement opportunities, supporting environment with working relationships. Those are the kinds of

things that are articulated in that study, and I think those are significant components.

Senator SPECTER. Career opportunities? What is meant by that?

Ms. RICK. Career advancement, a learning environment, continuing education not only being offered but supported by time and

money. Those are the kinds of things that were articulated in that

article, and I do think they are significant.

Senator SPECTER. Dr. Garthwaite, to what extent has the Veterans Administration been concerned about the shortage of nurses?

Dr. GARTHWAITE. Significantly. I have three groups working on

work force issues from slightly different perspectives. Cathy has

her own specific group looking very specifically at nursing issues.

There are some more generic issues in work force planning, retention, recruitment, and development that John Gardner’s committee

has been examining.

Senator SPECTER. When did the Veterans Administration first

begin to focus on the problem with nurses?

Dr. GARTHWAITE. Well, I think we have always been concerned

about our nursing work force. I personally chartered these committees shortly after I was confirmed by the Senate. So I have taken

a personal interest because I really do believe that work force development is the way to improve the VA health care system.

Senator SPECTER. Has there been any focus of attention prior to

the activities which you initiated?
43

Dr. GARTHWAITE. Absolutely. We have had nursing education initiatives. We previously had scholarship initiatives. We have taken

steps to improve the educational basis of nursing with the nurse

qual standards. That has had some controversy surrounding it, I

think largely because of communication issues and implementation

issues. We are still trying to work through those.

We’ve had a nursing innovations program and a nursing research

program to attract nurses to the VA. We certainly supported local

initiatives like the Cadet program that we will hear about in a few

minutes.

So there are a series of things that we have done and supported

to try to improve nursing throughout VA.

Senator SPECTER. How big a factor has compensation been?

Dr. GARTHWAITE. I think it is significant but not the total picture. I think you have to be competitive. You cannot lag behind.

But you also have to pay attention to other work force issues or

workplace issues.

Senator SPECTER. Ms. Rick, is there any issue within the Veterans Administration medical care system analogous to the nurse

anesthetist issue which I discussed a few moments ago?

Ms. RICK. Which issue? The study that Dr. Aiken did?

Senator SPECTER. Well, no, the——

Ms. RICK. Oh, nurse anesthetist. I did not hear what you said.

Senator SPECTER. About wanting more professional standing.

Ms. RICK. I am sorry.

Senator SPECTER. More comparability with medical doctors.

Ms. RICK. Yes, yes. I think that is a good analogy, and it does

apply to the professional nurses as well.

Having respect and opportunity to have—some of it is the career

progression and the clinical advancement and clinical partnership

that I mentioned earlier. I do think it has a significant impact on

nurses’ feeling good about their work, feeling respected for their

work, and being a full partner at the table and making not only

clinical decisions but resource decisions and innovative designs.

Senator SPECTER. What action would each of you like this committee to take to assist in the problem?

Dr. GARTHWAITE. My sense today is that with better salary rates,

many of the things are in our control, and we are aggressively pursuing those. I think looking more broadly, though, I think that anything that Congress is already taking up that will promote people

going into the nursing profession more broadly would be helpful.

Senator SPECTER. What is that? Can you be specific? You are

much closer to the problem than we are. Tell us what you would

like us to do.

Ms. RICK. I think——

Senator SPECTER. Let’s let Dr. Garthwaite finish the specific

terms, and then we will turn to you, Ms. Rick.

Dr. GARTHWAITE. I had the opportunity to deliver a commencement address at Miami-Dade County Community College where

people were getting associate nursing degrees, and we are trying

to work with community colleges to bring in associate degree

nurses and then through our national education initiative to allow

them to go on to get their bachelor degree and hopefully go on to
44

become advanced practice nurses or clinical nurse specialists, and

so forth.

Senator SPECTER. How would that relate to what this committee

can do?

Dr. GARTHWAITE. Well, I think that continued support of basic

education for entry level education as was evident in this group of

people in this community college is important. This is a clear way

up for them, and they seem to be very dedicated and interested in

nursing as a profession. I would think that if there are ways that

we can work through providing the financial support to get them

started, the VA might bring them in and help further develop their

careers. I think that is something we could work on.

Senator SPECTER. Ms. Rick, what would you suggest the committee do to help alleviate this problem?

Ms. RICK. I think working together to continue to address flexibility in work force hiring and benefits. I think the salary and benefits issue is always going to be an issue, and I think that continuing to work together on that is important. And anything that

we can do to stay in the game with all of the other competitive

forces that are going to be out there related to other initiatives that

VA will need to compete with, and some of that has to do with that

same learning environment opportunities and the scholarship options that Dr. Garthwaite mentioned.

I think that there will be many specific things that will come out

of the recommendations of the Nursing Workforce Work Group that

I look forward to working with you on.

Senator SPECTER. Thank you very much, Ms. Rick, Dr.

Garthwaite.

Thank you, Mr. Chairman.

Chairman ROCKEFELLER. Thank you, Senator Specter.

I think the scholarship program is incredibly important and is

part of a legislative proposal. I have a whole bunch of letters which

I am going to put in the record from people who have benefited

from the scholarships because they get education in return for service, and incentives of any kind are obviously desperately important.

[The information referred to follows:]

June 8, 2001.

After being an LPN for 18 yrs I decided to go back to school to further my education. My husband is unemployed and now has several medical problems that prevents him from being able to get a job. I have a daughter who is turning 16 next

month and she has plans on going to college. In my present position financially this

would be impossible for her to attend college.

I decided I would get student loans and go back to school to get my BSN. Then

I heard about the EISP and applied for it. Now that I have this scholarship I do

not have to worry about paying back student loans and can concentrate on school

work. I can also concentrate on my daughters future.

I will continue working at the VA after graduation. I presently work with restraints and restraint alternatives and give inservice to employees. I feel this scholarship is a great opportunity and the VA can only benefit by making it available

to new employees and easier to obtain.

JENNIFER KING, LPN.

When I graduated with my Bachelor’s of Science in Nursing (BSN) in 1995, and

came to work at the Beckley, Veterans Affairs Medical Center (VAMC), I knew I

wanted to obtain a Master’s of Science of Nursing (MSN). Being a single mother of

two children, the extra money and time needed away from work to go to class often

made this dream seem hopeless. Many scholarships provide full or partial tuition
45

* EDITORS NOTE: The NNEI (National Nursing Education Initiative) is administered by VA

under the authority of the Employee Incentive Scholarship Program. As a component of the

EISP, the NNEI is targeted to VA employees who are registered nurses and seeking additional

education to enhance their capability to provide high quality care to veterans.

but no guarantee of being able to get off work to go to class or any assurance of

a job in your area after graduation.

As soon as I heard of the availability of the NNEI scholarship program,* I knew

this was the answer. I applied to WVU FNP program and the NNEI scholarship last

spring. I was accepted at WVU for fall enrollment. The NNEI scholarship has been

a godsend. I could not have returned to school without it. Although it is still difficult

to work full time, raise two teenagers, and go to school. I don’t have to worry about

how I’m going to pay for school or how I’m going to get off work for class. I will

graduate in May of 2003 with my MSN and will be eligible to sit for the Advanced

Practice Certification. After graduation, I plan to continue working for the Beckley

VAMC. I am interested in pain management and am currently the team leader of

a process improvement team working to develop a comprehensive, interdisciplinary

pain management policy for our hospital. I would, in the future like to help establish a nurse managed pain management clinic at the Beckley VAMC.

The VA would benefit from this scholarship program being available to new employees. We are in the middle of a nursing shortage. The VA must be able to recruit

and retain quality-nursing staff. These motivated individuals will provide a secure

long term return on the financial investment of this scholarship program.

TERESA HANFT, BSN.

June 10, 2001.

TO WHOM IT MAY CONCERN: My name is Margie Drake. I have worked for the

Federal Government for the past 27 years; the last eight with the Department of

Veterans Affairs. In my last assignment, I worked as a Program Assistant in the

Public Relations Office at the Baltimore VAMC but always had the desire to become

a Registered Nurse. During the fall of 1995, I entered the Nursing Baccalaureate

Degree program at Villa Julie College because it offered a part-time, weekend-evenings program. I was able to obtain some limited funding through the Tuition Reimbursement program to assist with the hefty tuition bills and for that I was grateful.

The thought of where money will come from to pay for education is always stressful.

Then I saw a new program that the VA was offering. It was called the Employee

Incentive Scholarship Program (EISP) and was available to VA employees who were

seeking degrees in Title 38 positions. Hoping I would be eligible, I applied for and

was accepted into the program. The EISP paid for not only my tuition but for books,

fees and other related expenses. I was extremely pleased to have received this

award. Having received my degree in December 2000, I am now working as a staff

nurse at the Baltimore VAMC. I guess you can say it’s my dream come true.

The EISP is an extremely worthwhile program It allows VA employees the opportunity to pursue their education without the financial burden. However, participants

need to be aware that hard work and motivation must be present in the pursuit

of their education. There is a service obligation connected with this scholarship

(anywhere between 1 and 3 years). I have a desire to work for the VA for many,

many more years so the service obligation is merely a ‘‘thank you’’ in return for

their financial support. And as a new nurse, I hope to serve the veterans of our nation in a knowledgeable, compassionate and competent manner. It is common

knowledge that a severe nursing shortage exists nationwide. Scholarship programs

such as EISP are desperately needed to retain our seasoned nurses. It would be

great to offer scholarship programs to recruit nurses into the VA.

I am sincerely grateful for being selected as a recipient of the EISP funds and

the opportunity to serve as VA registered nurse. Hopefully many more VA employees will be able to benefit from the EISP.

MARGIE DRAKE, RN,

VAMC, Baltimore, Maryland.

June 8, 2001.

TO WHOM IT MAY CONCERN, I would like to take this time to show my gratitude

for the scholarship funds I received to complete the studies required for my BSN

(Baccalaureate of Science in Nursing). While completing my studies, I continued my

full-time employment at the McGuire VAMC in Richmond, VA. With other financial

obligations, it was indeed a great help to receive extra reimbursement for my edu-
46

cation. I was able to afford the tuition and books without having to take out another

loan.

With the education I received, I have a wider knowledge base to care for the

women veterans I serve in the Women’s Health Center.

I plan to attend graduate school next fall to receive my Masters Degree as a

Nurse Practitioner. I hope that this program will continue, not, only to be of assistance to me next year, but to all others who choose to further their careers in order

to help those who have fought and continue to fight in defense of our country.

Thankfully yours,

SHAUN M. MILLER, RN,

Hunter Holmes McGuire VAMC,

Women’s Health Center.

JUNE 8, 2001

TO WBOM IT MAY CONCERN, My name is Cheryl Winston, I work at McGuire VA

Medical Center Hospital in Richmond, Va. I would like to express my sincere appreciation for the scholarship I received toward obtaining my Bachelors Degree in

Nursing. I am looking forward towards my fall semester, which ends in December

at Old Dominion University. I am anxiously preparing towards graduation. I would

like to reinforce the need to continue with this education program toward tuition

reimbursement as it has benefited me through my educational experience. The

scholarship has indeed helped me financially. in December 2001 I will be graduating

from Old Dominion University with Honors in Nursing. With my degree I will be

able to share my knowledge with my patients and to provide a more theoretical approach towards patient care.

With much appreciation,

MS. CHERYL WINSTON.

June 8, 2001.

TO WHOM IT MAY CONCERN: I have benefited from the EISP Scholarship. I feel

fortunate that I’m a single mother with 3 children, trying to advance my career in

Nursing (BSN). I will be able to work at home while enrolled with Excelsior College,

University of the State of New York. My children and myself are blessed to benefit

from this scholarship by supplying the scholarship money to continue my education

and study at home and be with them.

MARY CONLEY, LPN.

June 8, 2001.

TO WHOM IT MAY CONCERN: It is a tremendous relief to have the EISP Scholarship. For years I have struggled to raise two children as a single parent, obtain a

General Educational Development Certificate and to gain a BSN degree at a snail’s

pace. My tedious journey has been fuelled with less than enough money and insufficient time to attend classes on full-time bases. Now thanks to the VA for awarding

me an EISP Scholarship and granting me the opportunity to work only 32 hours

every two weeks. So since January 1, 2001, I have been attending NC A&T State

University full-time. During the years of journey, I could have settled for less than

my dream, but I held out. Because, I think I can better serve those who suffer mental illness with a BSN for a couple of years then advance to get my Masters. Thanks

VA! Thanks! Thanks!

THERESIA MCGEE, NA.

June 8, 2001.

TO WHOM IT MAY CONCERN: I have been a VA nurse for 17 years and am grateful

everyday for the many opportunities the VA has provided, especially the NNEI program. When I made the decision to return to school for a graduate degree, I was

specifically interested in a school with an oncology CNS/NP program (there are only

about 36 in the country), in a city where there was also a VA. I chose Duke University and the Durham VA. Duke was challenging and expensive, but I earned a great

education. The Durham VA was flexible in accommodating my class and clinical

schedule. The Kansas City VA was supportive and helpful with my transfer. I borrowed $18,000 from the college foundation for my education. . . . When the NNEI

came through with $10,000 to reimburse my 1999 tuition I was extremely grateful,

and the money helped me pay down my student loans. I have been a loyal and dedi-
47

cated VA nurse for my entire career . . . and will remain that way until I retire.

The NNEI program rewards and assists VA nurses and I have no doubt that the

VA will get a return on their investment from all the NNEI scholarship recipients

. . . you can count on it from me.

SUSAN DIAMOND, RN, MSN.

June 8, 2001.

TO WHOM IT MAY CONCERN: Since I earned my ADN in 1987, I have wanted to

return to school to increase my knowledge and skills in nursing. It was financially

impossible for me to do so at that time. Now, 14 years later, and the single mother

of 4 children, it is not only financially impossible to fund my own further education,

but also impossible to find the time to go to classes. I had resigned myself to waiting

until my last child was grown (2008) before attempting to take classes toward my

BSN and eventually towards a Nurse Practitioner degree. However, I knew that

someday I would do that, and just kept working and saving. When I heard about

the scholarship program, I was excited, but also knew that none of the local programs would suit my needs, as I would have to take too much time away from my

children to attend classes according to their requirements. Very soon after I heard

of the NNEI program. I also got a tip about the University of Wisconsin-Green Bay

distance learning program for RN–BSN. After completing all the necessary paperwork and having all the necessary forms submitted, I was pleased to have been

awarded the NNEI scholarship and to have been accepted into Green Bay’s program. I am taking one class a semester (3 per year) and am working from home.

The VA has been very supportive of me and many advance practice nurses have

been generous with their knowledge and mentoring support. Without this scholarship program, it would not have been possible to further my education at this time

of my life, confining me to the same educational and professional level for many

years to come.

SUZANNE HIXSON, RN.

June 8, 2001.

TO WHOM IT MAY CONCERN: I want to extend my very personal and heartfelt

thanks to the VA for making the National Nurses Educational Initiative (NNEI)

available. Obtaining my master’s degree in nursing has always been a goal for me.

More important was an advanced degree in a specialty field of my interest. I have

been in research for 10 years and thoroughly enjoy the field. January 1999, I

learned of a master’s program offered at Duke University School of Nursing in Clinical Research Management. I enrolled with great concern but no idea how I would

fund a Duke education. Being awarded the NNEI has afforded me the opportunity

to complete my degree without worry of tuition and to realize my goal. I am most

grateful for the support of the NNEI. I know of no other program of its magnitude

offered to nurses through their employer, I feel very fortunate to be a nurse in the

Veteran’s Health Administration. The NNEI has given me a sense of pride in knowing the VA considers the level of education of the VA nurse to be an important factor in the delivery of quality health care to the veteran patient. I have been a VA

nurse for 18 years. I love working with veterans and consider veterans a very special and unique population. ‘‘Nurses are the mainstay of VA healthcare.’’—Hershel Gober.

AILEIN WARD, RN.

June 8, 2001.

TO WHOM IT MAY CONCERN: It was always in my plans to return to school to receive a BSN degree. However, trying to budget the cost of attending a university

while everyday life was a challenge, but thanks to the NNEI, I was able to attend

school and not worry about my other life expenses. The NNFI scholarship has provided me with an unlimited amount of college tuition to complete my degree. Words

can’t explain, but this scholarship was a big help and it came just in the knick of

time! Thanks NNEI!

JODI JOHNSON-THOMAS, RN.

June 8, 2001.

TO WHOM IT MAY CONCERN: I am truly grateful to the VA/NNEI for allowing me

the opportunity to return to school. I am presently doing an internship involved
48

with my pursuit to get my masters in Health Education/Health Promotion. Upon returning to the school scene after 20 years, I really did not think that I could do it.

With the incentive (NNEI), it has encouraged me to realize my unlimited potential.

My success in this endeavor is truly measured by the collaborative decisions of all

involved. I encourage nurses nationally to consider the opportunity that the NNEI

has given me.

PAULETTA FULLER, RN.

June 8, 2001.

TO WHOM IT MAY CONCERN: I am very thankful to the VA because I have earned

my BSN and now I am working on my HSA. Both times have been financially challenged events for me, The scholarships came as blessings for me. I am able to serve

those who serve me in the military times and I can return my service to them.

ANNE ZIPP, RN.

Chairman ROCKEFELLER. The burnout factor would strike me as

very important, even on an 8-hour shift much less a more intensive

shift. Does the VA have a way of monitoring that? I think just this

week, VA asked its network directors to provide a report on the

nursing situation, which in my opinion, would be a little late.

So how do you monitor the fatigue factor? How do you watch

this, if you do?

Ms. RICK. We do not have a systematic, systemwide structure or

mechanism to do that. It is——

Chairman ROCKEFELLER. Wouldn’t that be important to have?

Ms. RICK. Well, it is incumbent on each point of care manager

and facility director to make staffing decisions and assignment decisions based on those factors. But we do not currently have a systemwide structure to monitor them.

Chairman ROCKEFELLER. Well, I will state I think it is important

to have a system, and we need to pursue it. But then if it is not

there, how do you monitor staffing decisions? You have heard testimony—I did not have to hear that testimony because I had heard

it before in my own visits to hospitals. As the VA head nurse, how

do you deal with that question, because it has to weigh on you,

about people who are overworked and underpaid? And I am going

to ask you one more question about pay, but please go ahead.

Ms. RICK. Well, the process that is in place to keep me informed

and to help me help the field, since I work for the——

Chairman ROCKEFELLER. Who keeps you informed?

Ms. RICK. That is what I was getting to. We have a national

Nursing Executive Council. There is a nurse exec from each network who represents nursing from that network. That council was

put in place as I started in my position. We had our first meeting

last November. So that council was put in place to develop a national nursing strategic plan. Nursing work force is one of the six

goals identified in that plan. And that group is in place to look to

develop realistic strategies and actions to address each of the six

goals. And it is my job to then take those initiatives forward and

look at a systemwide approach.

So that is the process that I have put in place in the time that

I have been there.

Chairman ROCKEFELLER. OK. I would be interested in pursuing

what you get back, but I cannot do it here because of time constraints.
49

My final question would be on the question of funding. It was interesting, Dr. Garthwaite, when Senator Specter asked what you

want us to do. I would have thought you would have jumped right

across the table and grabbed us both by the throat and said, ‘‘Get

us some more darn money.’’ Dr. GARTHWAITE. I am trained not to do that, sir. [Laughter.]

Chairman ROCKEFELLER. No, but, you see, that is bad training.

That is bad training, because your first obligation is not to the second largest agency in the Federal Government but to those patients. I mean, I read it that way. I think that is the oath you took.

Dr. GARTHWAITE. I agree.

Chairman ROCKEFELLER. Isn’t the basis of a lot of this the lack

of money?

Dr. GARTHWAITE. Well, certainly decisions to——

Chairman ROCKEFELLER. You cannot hedge on that.

Dr. GARTHWAITE [continuing]. Staff are related to money.

Chairman ROCKEFELLER. You cannot hedge on that.

Dr. GARTHWAITE. Yes. The only point I would make is that we

get a certain amount of money from the Congress and through the

President, and we have a set of priorities, priority veterans to see

based on resources available. The tough bind that we get put in is

that we attempt to see as many as possible, and that takes us to

the edge of staffing, and I think that is probably what you heard

from the previous panel. We obviously try to stay inside the staffing ratios that are good for patient care.

But the alternative, unless more money comes forward, is for us

to see fewer veterans, and then they do not get any care, often.

Maybe they get alternative care in other health systems, but some

do not get any as opposed to getting care from us. So I think that

is the bind I feel that we are in.

Would we like more money and would life be a lot easier? Absolutely.

Chairman ROCKEFELLER. Well, that is the first thing. If you had another $2.7 billion, would the nursing shortage be relieved and

the overtime question become less of an issue?

Dr. GARTHWAITE. Yes, certainly. I mean, I think it would make

it a lot easier.

Chairman ROCKEFELLER. I just want you to say that.

OK. My final point, and this, again, for the record, to be explored

later. It is my understanding that there is no staff at VA headquarters who monitors the problems involved with mandatory overtime. Network directors are also not judged by their abilities to

keep nurses working in safe shifts.

I just sort of posit that at you, and you can respond if you wish.

Dr. GARTHWAITE. I have to say that, to the extent that we can

develop meaningful monitors that allow us to improve the working

conditions for nurses and a variety of our other professionals, I

would favor that, and we will go back and look at that. I think that

could be helpful.

Chairman ROCKEFELLER. But there are not people in VA now

who are assigned to that type of monitoring?

Dr. GARTHWAITE. Well, we have a significant number of folks in

H.R. who look at our ability to recruit and retain and track the

overall general trends. We have not specifically targeted mandatory
50

overtime. In a way, you know, mandatory overtime, when you say

you must stay, but if your boss asks you to stay over in a voluntary

fashion and your boss is the one who rates you, it is not quite as

non-mandatory as it would appear. So that the whole use of overtime is something that we try to minimize, and the fact that it is

creeping up suggests that we have some staffing challenges. We are

needing to use overtime more often. It is not in our employees’ best

interest. It is certainly more expensive for us to use overtime. So

it is our goal to minimize the use of overtime.

Chairman ROCKEFELLER. OK. I appreciate both of you coming. I

have other questions. How can you compete with the private sector,

or can you, based upon salaries that you now offer to nurses?

Ms. RICK. The process for competing with local market pay scales

is a survey process, so we survey the local market and look to come

up with a competitive pay scale related to that survey process.

Chairman ROCKEFELLER. I honestly did not understand the answer.

Ms. RICK. OK. Sorry. How do we compete? How do we determine

our pay so that we are competitive with the local market is your

question?

Chairman ROCKEFELLER. Yes. Can you compete? Do you pay as

much as they do? Do they pay more than you do?

Ms. RICK. We are not the pay leader in any market. We do compete with the market. It is a local decision how much additional

pay is offered to the nursing staff based on the survey data that

is collected.

With the new public law that was passed, there is the annual increase, and then each facility needs to determine what additional

increases, if any, are necessary in order to be competitive in the

local market, and that decision is based on surveys, salary surveys.

Dr. GARTHWAITE. One of the problems with the survey process,

just to amplify a little bit, it is relatively easy to survey other hospitals and find out the starting salary. But how quickly people get

advanced is not quite so simple. Staff salaries are a competitive advantage to the other hospitals so that they do not readily want to

tell you how much they pay because they do not want you to just

go a little bit higher and recruit away their staff. So there is no

incentive for telling us their complete pay range.

Chairman ROCKEFELLER. A non-VA hospital can give bonuses for

signing and you can’t? Am I right on that?

Dr. GARTHWAITE. We can.

Ms. RICK. We have the authority for sign-on——

Chairman ROCKEFELLER. You do have the authority to give bonuses.

Ms. RICK. And many facilities are using that authority.

Chairman ROCKEFELLER. Do you have the money to give bonuses, signing bonuses?

Ms. RICK. Balancing our checkbook is always difficult.

Chairman ROCKEFELLER. All right. I thank you both very, very

much. I will not even get into long-term care. I will probe that

issue by post-hearing questions and expect a prompt answer. I really do want those long-term care rules and regulations done. I think

OMB is going to try and make that very hard, but I want you to

do that.
51

Dr. GARTHWAITE. I think we are making progress.

Chairman ROCKEFELLER. I know. It is the regulations that I

want, not the progress.

Dr. GARTHWAITE. I meant on the regulations.

Chairman ROCKEFELLER. In any event, I appreciate both of you

being here very, very much.

Ms. RICK. Thank you. We appreciate the opportunity.

Dr. GARTHWAITE. Thank you.

Chairman ROCKEFELLER. Thanks an awful lot.

Very promptly, our third panel—will Sandra Janzen please come

forward? Sandra is the chief nurse executive at the Tampa VA

Medical Center, and Dr. Robert Petzel, who is a network director

who oversees health care delivery in the Dakotas and Minnesota.

Within your network, Doctor, you have established nurse-managed

clinics that provide very good care to veterans and great working

environments for nurses, and you are accompanied by Karen Robinson and also Mary Raymer. Or are you here on your own, Mary?

Ms. RAYMER. I am here on my own behalf.

Chairman ROCKEFELLER. OK. You are here on your own. Mary

Raymer is associate chief of staff for patient care services of the

Salem, VA, hospital.

Sandy, perhaps you could lead off?

STATEMENT OF SANDRA K. JANZEN, CHIEF NURSE EXECUTIVE, TAMPA (JAMES A. HALEY) VA MEDICAL CENTER,

TAMPA, FL

Ms. JANZEN. Yes, I would be pleased to. Mr. Chairman and members of the committee, I am honored to be here to present the

Tampa VA Hospital and Clinics’ journey for nursing excellence and

to describe our environmental characteristics that support professional nursing. In March, we became the first VA organization to

achieve the prestigious Magnet designation—recognition by the

American Nurses Credentialing Center for excellence in nursing

services.

Chairman ROCKEFELLER. Sandy—I should not say ‘‘Sandy.’’ I

should say ‘‘Ms. Janzen.’’ I apologize for that.

Ms. JANZEN. ‘‘Sandy’’ is fine.

Chairman ROCKEFELLER. But we have got a little bit of a time

problem, and so what I would like you to do is—I want to know

about your awards, but I also want to know about what you are

doing to make things better.

Ms. JANZEN. OK. Well, we use the process of the Magnet designation to address our environment, and that is part of the award

and recognition that looks at the milieu that supports professional

nursing practice. That is one of the objectives of the Magnet recognition that relates to our discussion.

Because Magnet recognition requires strong organizational support for professional nursing practice, it requires a positive work

environment that recognizes the nursing contribution to the organization, a culture of excellence, and nursing input into the organizational decisionmaking process. A Magnet culture needs to be real

because you are site-visited, and it depends almost entirely on the

nursing staff at the bedside to validate the written application and

the working environment.
52

Hospital leaders at our organization provide organizational support with an adequate staff mix and strong educational support for

new and existing staff. Nurses are highly integrated into all clinical

programs, are leaders in our organization, and they are allowed

clinical autonomy. The nurse executive has the ability to pilot programs within existing resources to enhance clinical practice. In my

paper I give you an example of evening and night nursing supervisor positions were eliminated several years ago to augment clinical nursing staffing and to empower nurses to make clinical and

administrative decisions on those shifts.

A positive work environment is recognized individually and for

team contributions within our organization. We have a Gold Star

program that recognizes exceptional customer service. Thank-you

letters for outstanding patient care performance are sent from hospital leadership. Nurses receive peer recognition in nursing recognition ceremonies. Nurses are respected for their knowledge, evidenced by their leadership and membership in clinical teams.

As a result of our self-assessment, using the Magnet criteria we

enhanced our opportunities for nurse managers because they are

the ones who really make a difference at the unit level, whether

or not nurses stay in your organization. We are also systematically

addressing nurse satisfaction issues. There is a commitment of our

organization to really become an employer of choice.

Magnet criteria also addresses the quality of clinical care. The

organizational expectation at our facility is clinical excellence and

veteran-focused care. We have a longstanding record of measuring

nursing quality, and we participated in a national quality indicator

project to really improve our practice and our nurse satisfaction.

The Magnet criteria also emphasizes a positive work environment for our nurses. Our VA Patient Safety Center is systematically using ergonomic analysis to identify ways to ease patient care

burdens on an aging nursing staff.

The nurse executive is involved in decisions regarding allocation

of facility resources. Our Facility Quality Council ensures nursing

membership on quality improvement teams. Nursing staff decisions

regarding patient care are respected. Nurse managers make critical

bypass decisions based on patient needs and staff availability, and

that decision is respected.

One outcome of nursing involvement in decisionmaking is the installation of ceiling-mounted patient lifts in patient care rooms in

our new Spinal Cord Injury Center. This is a direct result of nursing research and nursing input.

I think Magnet recognition is not a quick fix for the recruitment

and retention problems for the VA, but I do think that the Magnet

criteria can be used to measure progress toward creation of a Magnet culture that supports professional nursing practice and respects

the voice of nursing in organizational decisionmaking. We must

really listen and hear what nurses’ concerns are if we are to improve the environment for nursing practice and address the nursing shortage.

We do have a Magnet culture at the Tampa VA not only for nursing staff but for all members of the organization. Magnet designation has raised the bar for employees in terms of higher standards

for performance.
53

Chairman ROCKEFELLER. Ms. Janzen, I have to ask you to wind

up.

Ms. JANZEN. OK. Nurses are proud to work at the Tampa VA.

Chairman ROCKEFELLER. That is good. That is a good way to do

it.

[The prepared statement of Ms. Janzen follows:]

PREPARED STATEMENT OF SANDRA K. JANZEN, CHIEF NURSE EXECUTIVE, TAMPA

(JAMES A. HALEY) VA MEDICAL CENTER, TAMPA, FL

Mr. Chairman and members of the Committee, I am honored to be here to present

the Tampa VA Hospital and Clinics’ journey for nursing excellence and to describe

our environmental characteristics that support professional nursing. In March, we

became the first VA organization to achieve the prestigious Magnet designation recognition by the American Nurses Credentialing Center (ANCC) for excellence in

nursing services. We were the 30th of only 34 facilities nationally to achieve this

designation since the program’s inception in 1994.

Magnet recognition is an organizational certification process based on quality indicators and standards of nursing practice defined by the American Nurses Association for nurse administrators and nursing services. The primary objective of Magnet

recognition relating to this discussion is ‘‘to promote quality in a milieu that supports professional nursing practice.’’ Achieving Magnet recognition requires strong organizational support for professional nursing practice, a positive work environment recognizing the nursing contribution, a culture of excellence, and nursing input into organizational decisionmaking. A Magnet culture must be real the site visit depends almost entirely upon

the front line nursing staff to validate the written application and working environment.

The Tampa VA set its goal for Magnet recognition to acknowledge the nursing

contribution to the organization’s quality journey. The Magnet criteria would serve

as a guide for self-evaluation. The nursing shortage was beginning and I knew Magnet organizations had less difficulty with recruitment and retention. Lastly, I wanted public validation of our already strong reputation and for VA nursing.

Organizational support for professional nursing practice. Hospital leaders

provide strong organizational support for nursing at the Tampa facility with an adequate staff mix and strong educational support for new and existing staff. Nurses

are highly integrated in all clinical programs, are leaders within the organization,

and are allowed clinical autonomy. The nurse executive has the ability to pilot programs within existing resources to enhance practice. For example, evening and

night nursing supervisory positions were eliminated to augment clinical staffing

thus empowering nurses to make clinical and administrative decisions.

Positive work environment that recognizes the nursing contribution.

Nurses are recognized individually and for team contributions. A Gold Star Program

honors employees for exceptional customer service. Thank you letters for outstanding patient care performance are sent from hospital leadership. Nurses receive

peer recognition in semi-annual nursing ceremonies. Nurses are respected for their

knowledge evidenced by their leadership and membership in clinical teams. As a result of the self-assessment process, enhanced educational opportunities for nurse

managers are now provided and a work plan to address nurse satisfaction issues

is in place. There is a real commitment to become an Employer of Choice.

Culture of excellence. Magnet criteria address the quality of clinical care. Our

organizational expectation for patient care is clinical excellence and veteran-focused.

And, our record of measuring nursing quality prepared us for participation in a national quality indicator project to improve nursing practice and satisfaction. Magnet

also emphasizes a positive work environment for nurses. Our VA Patient Safety

Center is systematically using ergonomic analysis to identify ways to ease the patient care burdens on an aging nursing staff.

Organizational decision-making. The nurse executive is involved in decisions

regarding allocation of facility resources. The Facility Quality Council assures

nurses are on all Quality Improvement Teams. Nursing staff decisions regarding patient care are respected—nurse managers make critical care bypass decisions based

on patient needs and staff availability. One outcome of nursing involvement in decision-making is the installation of ceiling mounted patient lifts in patient care rooms

for the new Spinal Cord Injury Center—a direct result of nursing research and

input.

Achieving Magnet recognition is not a quick fix for the recruitment and retention

problems facing the VA. But the criteria should be used to measure progress toward
54

creation of a Magnet culture that supports professional nursing practice and respects the voice of nursing in organizational decision-making. Really hearing and

understanding nurses’ concerns are critical if we are to improve the environment for

nursing practice and maintain a high quality VA nursing workforce.

The creation of a Magnet culture at Tampa is evident, not only for nursing staff

but also all members of the organization. Magnet designation raises the bar for employees by establishing higher standards for performance. As a result, Tampa

nurses recognize the increased expectation for providing exceptional care and customer service. They face many workload challenges due to an unrelenting and growing demand, yet remain optimistic. Nurses are proud to work at the Tampa VA.

This concludes my statement. I will be happy to respond to the Committee’s questions.

Chairman ROCKEFELLER. Doctor?

STATEMENT OF ROBERT PETZEL, M.D., DIRECTOR, VA UPPER

MIDWEST HEALTH CARE NETWORK, DEPARTMENT OF VETERANS AFFAIRS, MINNEAPOLIS, MN; ACCOMPANIED BY

KAREN ROBINSON, CHAIRPERSON, VISN NURSE MANAGED

CARE INITIATIVE, FARGO, ND

Dr. PETZEL. Mr. Chairman, members of the committee, we appreciate the opportunity to participate in this hearing on work force

strategies. I want to acknowledge my colleague to my right, Dr.

Karen Robinson, who is a nurse executive at the Fargo VA Medical

Center and is the individual responsible for establishing the program I am about to describe in our network.

I want to discuss primary care clinics run by nurse practitioners

in the VA’s Upper Midwest Network. In an effort to improve access, nurse-managed primary care delivery clinics were established

in 1999 across our Upper Midwest Network. These communitybased outpatient clinics use nurse practitioners as independent

practitioners with prescriptive authority. To qualify as a nursemanaged clinic in our network, the following criteria need to be

met: We need a master’s prepared advanced practice nurse with

national certification as a primary care provider; that individual

must be credentialed and privileged at the institution that sponsors

the clinic. In the case of one of the sites, it is the Fargo VA Medical

Center. So they have credentials and privileges that are very similar to other members of the medical staff, such as physicians. In

addition to that, there is ancillary help provided, a registered nurse

is a part of the program, and in place needs to be a program to

evaluate outcomes in relationship to the practice of the clinic.

Four clinic sites include the Chippewa Valley clinic in Wisconsin;

Grafton, ND; and Fergus Falls and Maplewood, MN. The average

staffing at these clinics is from 4 to 6.5 FTE, and on average, these

advanced practice nurses carry a panel of approximately 1,000 patients.

Patient satisfaction survey results are excellent. The patients appreciate the availability of these clinics in their communities and

are particularly complimentary of the style of care that they receive

in a nurse-managed care clinic.

Our measures of quality, the prevention——

Chairman ROCKEFELLER. Could you explain what you mean by

that?

Dr. PETZEL. They particularly enjoy the sense of connection

and—it is difficult to put into words, but the relationship that a

nursing individual in that role provides to the patient.
55

Our measures of quality, prevention, and chronic disease index

and the implementation of clinical practice guidelines in these

nurse-managed clinics are consistent with all of our other primary

care clinics in their host hospitals.

In terms of cost, the cost per visit is less expensive, it is less costly per episode of care in these clinics than it is in our host medical

centers, which logically makes sense.

In summary, the world of health care is in the state of transformation and change. There are demands for high quality, greater

accountability, and lower cost which are driving the way we do

business presently. Nurse practitioners are effective providers of

safe, high-quality, cost-effective primary care which results in a

high degree of patient satisfaction. We plan on extending the program within our network, and we plan on specific research-based

outcome studies to be certain that the outcomes in these patients

are similar to or better than the outcomes of patients being treated

in other clinics.

We also think this provides an excellent opportunity for professional growth for nurses, and we believe it is something that will

and should attract nurses and nurse practitioners to the Veterans

Health Administration.

[The prepared statement of Dr. Petzel follows:]

PREPARED STATEMENT OF ROBERT PETZEL, M.D., DIRECTOR, VA UPPER MIDWEST

HEALTH CARE NETWORK, DEPARTMENT OF VETERANS AFFAIRS, MINNEAPOLIS, MN

Mr. Chairman and members of the Committee:

I appreciate the Committee’s invitation to participate in this very timely hearing

on nursing workforce strategies.

For today’s hearing, I am going to discuss primary care clinics run by nurse practitioners in the U.S. Department of Veterans Affairs Upper Midwest Health Care

Network, in the states of Minnesota, North Dakota, and South Dakota.

Health care presently is an ever-changing environment for all Americans, including the veteran population. New and innovative approaches to health care must include goals that maximize quality care, improve access and cost effectiveness, facilitate patient satisfaction, and optimize the functional status of patients. Recognizing

the opportunities in this challenging environment, nurse practitioners are being effectively utilized as competent primary care providers who can meet these goals.

In an effort to improve access, nurse-managed primary care delivery clinics were

established in 1999 across the VA Upper Midwest Health Care Network. These community-based outpatient clinics (CBOCs) use nurse practitioners as independent

practitioners with prescriptive authority. To qualify as a nurse-managed clinic in

our Network, the following criteria must be met: (1) a Masters degree-prepared advanced practice nurse with national certification as a primary care provider; (2) a

qualified registered nurse as a case manager on site; (3) credentialing and privileging in place that includes prescribing authority; (4) provisions in place for ancillary help and access to medical records, laboratory, pharmacy, and radiology services; (5) establish outcomes research in the future; (6) establish academic partnerships.

The four clinic sites include Chippewa Valley, WI; Grafton, ND; Fergus Falls and

Maplewood, MN. Staff at each site includes a nurse practitioner, a registered nurse,

and a clerk with total FTE ranging from 4–6.5 FTE. Some sites also have a licensed

practical nurse. Panel sizes for the nurse practitioners range from 600 to 1,100 patients.

Evaluation of the program outcomes includes market penetration, patient satisfaction, financial analysis, clinical indicators, and workload analysis. These clinics have

enrolled and are providing primary care to an average of 1,000 veterans, most of

whom are new to the VA system. Patient satisfaction survey results are excellent;

patients appreciate the availability of these clinics in their communities and are

complimentary of the care they receive. For example, when a nurse practitioner

from the Minneapolis VA Medical Center transferred to the Maplewood clinic, a

number of her patients requested to move with her; this certainly demonstrates a

high level of satisfaction when a patient changes their site of care to remain with
56

their provider. It is also important to note availability of appointments. Even though

the nurse practitioner at the Grafton clinic has a panel size of 1,100, a patient can

be seen within 48 hours of a requested appointment.

Prevention and chronic disease index ratings and clinical practice guideline implementation in these nurse managed primary care delivery clinics are consistent with

the other primary care clinics at the host VA medical centers in VISN 13. In fact,

the nurse practitioners strive to meet the indicators and place greater emphasis on

patient education. Cost per visit at the clinics range from $98.00 (Chippewa Valley) to $140.00 (Ma- plewood) as compared to $137.00 per visit at the host Minneapolis VA Medical Center and $102.00 (Fergus Falls) to $108.00 (Grafton) as compared to $162.00 per visit

at the host Fargo VA Medical Center.

The following case is just one example of the care individuals receive when they

come to a nurse managed clinic in our Network. Mr. K. is a 87-year-old veteran who

has been receiving care at the Fergus Falls Clinic since April, 1999. He has a history of chronic obstructive pulmonary disease, prostatic carcinoma, valvular heart

disease, and congestive heart failure. He cares for his wife who has been blind for

many years. Initially he came to the clinic for daily dressing changes to a leg ulcer.

The nurse at the clinic arranged for a community health nurse to change his

dressings on the weekends. However, during his visits to the clinic for the dressing

changes, he was noted to be more short of breath with activity, ankle swelling, and

have a hemoglobin of 7.7. He was given a blood transfusion and medications were

adjusted. As stated by Donna Hendel, R.N., nurse at the clinic, ‘‘I am convinced

Peggy (the Nurse Practitioner at the Clinic) has been responsible for preventing at

least one hospitalization so far.’’ As a result of the interventions of the staff at the

Clinic, Mr. K. is able to remain in his home, caring for his wife, and is able to travel

to Fergus Falls rather than having to come to Fargo, a distance of 65 miles, for his

care. In summary, the world of health care is in transformation. Demands for higher

quality, greater accountability, and lower costs are currently driving the system.

Nurse practitioners are effective as providers of safe, high-quality, cost-effective primary care, which results in high patient satisfaction. Additionally, patients generally select a provider whom they feel will listen and address their needs; nurse

practitioners have a history of providing patient-focused care. Therefore, it made

sense to move forward with the establishment of nurse managed primary care delivery clinics throughout our Network. However, our work is not done. We must now

demonstrate in terms of outcomes-based research the services that nurse practitioners provide and their positive impact on client outcomes.

This concludes my remarks. I will be pleased to respond to any questions you may

have.

Chairman ROCKEFELLER. Thank you, sir.

Ms. Robinson?

Ms. ROBINSON. Thank you for inviting us today to this hearing

and——

Chairman ROCKEFELLER. You came a long way.

Ms. ROBINSON. I have. And I think Dr. Petzel explained the program very well, and I am open to any questions.

Chairman ROCKEFELLER. You have got to say something else

about why what you do, in your judgment, works?

Ms. ROBINSON. OK. With these nurse-managed clinics, this came

about from Dr. Kenneth Kizer, who felt that we needed to utilize

advanced practice nurses, nurse practitioners, to their fullest capacity. And so Dr. Petzel, our network director, charged me with

looking at this, and I had a fantastic committee to work with. We

looked at how could we enhance the role of nurse practitioners, and

we did have several nurse practitioners on the committee. And we

came up with this concept, and we find that it is working very well.

For example, we had a nurse practitioner at the VA Medical Center in Minneapolis who transferred her practice to Maplewood, one

of the nurse-managed clinics. A majority of her patients in her

panel transferred with her. And so we think that really says it all.

The nurse practitioners are excellent practitioners as well as edu-
57

cators, researchers, and managers, and we feel with these clinics

we have the best of both worlds.

Chairman ROCKEFELLER. Thank you.

Ms. Raymer?

STATEMENT OF MARY C. RAYMER, ASSOCIATE CHIEF OF

STAFF FOR PATIENT CARE SERVICES, DEPARTMENT OF

VETERANS AFFAIRS MEDICAL CENTER, SALEM, VA

Ms. RAYMER. Thank you, Chairman Rockefeller.

It is a pleasure to be here, and my focus of my presentation is

going to be to tell you about the VA Cadet program, which you

have actually heard mentioned a few times by my colleagues on

former panels.

We implemented this program in Salem, VA, at our medical center this year, and basically it was implemented due to my growing

concern about the shortage of nursing, the decline in school enrollments, and what could I personally do about that as a nurse executive.

You have heard statistics, of course, earlier about what the average age of the VA nurse is and so forth, and I am kind of a typical

profile of that person. I have been in the VA for 27 years, graduated from the University of Nebraska, and I am one of those people that, by 2005, the 35 percent of us, that are eligible for retirement. And I looked with growing concern at the decline in school

enrollments. Who is going to take our place?

When I went to the Internet to see what kind of youth programs

were in place, I found a great void. I personally had my first experience in a health care environment as a Candy Striper. This was

a youth volunteer program that was sponsored by the American

Red Cross many years ago. It was interesting as I talked to my colleagues last evening. All four of us of approximately the same generation had been a Candy Striper. Yet when I looked for those kind

of programs today, there were none.

So it occurred to me, well, it really doesn’t take a mental giant

to figure out that if you have no programs to give a positive message to the youth, then how can you possibly expect that children

are going to enter into the work force in a nursing career.

Chairman ROCKEFELLER. I am interrupting, but that is an extraordinarily interesting and important point. I would never have

guessed that those do not exist.

Ms. RAYMER. Actually, I did not either when I first——

Chairman ROCKEFELLER. Why?

Ms. RAYMER. Well, I think due to a variety of issues, the first

being that, as has been said, nursing is still a 96 percent female

profession, 95, 96 percent. So as that started to change in the

1970’s and 1980’s for women, women were presented with many

other options for careers.

When I was growing up in the 1950’s and 1960’s, women primarily chose to be nurses, teachers, or secretaries. And all of that

changed, of course, to the good for women that they had all these

other choices. But, unfortunately, that work force—those choices

were not replaced by other people, i.e., men. The profession did not

really address that decline and how can we then encourage young

men to go into the field or remain competitive in workplace prac-
58

tices, which is some of the things that you have heard earlier, so

that women continue to choose nursing.

And I think the youth volunteer program kind of went by the

wayside at that time because it was not considered—it was not

really considered good to want to be a nurse there for a while. You

ought to want to do other things if you were a young woman. And

so those programs just pretty much went by the wayside.

Over the last 5 years, I have also chaired the Nurse Qualification

Standards Implementation Committee for the new standards for

the VA, and I have been very appreciative of the VA’s commitment

to the funding for that program. You have heard a little bit about

that already as well. So that was addressing some of our needs at

Salem in educating the current nurses that we had to go back and

get degrees. It still did nothing to answer the induction of new people.

So, ultimately, what I came up with was a program that was

geared to a youth volunteer program specifically for nursing, and

we called that the VA Cadet. We did mass mailings to the local

community, private and public high schools, to the home-school organization, to specialty interest groups such as the pregnant teens,

to the organizations, the civic organizations like Girl Scouts, Boy

Scouts, and so on. That is how we did our marketing, basically.

We designed a program that consists of a 5-hour orientation for

the youth. The faculty for that come from myself and my nurse

leaders volunteer to do that, and we bring them in and we give

them didactic information so that they are safe in the workplace:

how to do infection control, how to wash your hands, how to make

beds for the patients, how to answer a patient call light, how to

communicate with patients, how to maintain patient confidentiality. We cover all of those things. And then we do a little skills

lab, and they get to do return demonstrations, and then we take

them on a tour of the facility and kind of target where we are going

to have them work.

I think there are two really key components of success for the

program. The first is you have to have a dedicated cadre of nurses

that are willing to mentor these young people. You cannot just turn

them loose in a hospital setting, obviously. But along with that, you

cannot make that mentor be the already overworked staff nurse on

the unit. They are already dealing with patients, and so that has

been a central point that we have consolidated that with other people other than the staff nurse.

Second, you have to be very responsive to the student. You have

to be flexible. These children—they are marvelous, by the way, just

marvelous children to work with, but they are very busy. They

have very demanding schedules, the youth of today. And so you

cannot just say, well, you can only come from 10 to 12 on Wednesday. That is not going to work. You have to look at their school

schedules and individualize their experience so that it meets their

needs as well.

So, basically, we have had at this point two orientation classes,

and we have inducted 11 new cadets. We have ten young women

and one young man. They come from five different schools in the

Roanoke-Salem area and range in age from 14 to 17. And they

have given us in a period of 4 months 140 volunteer hours, which
59

1 Cournoyer, Paulette, VA Nursing Data Trends—FY 2000. Unpublished. 2 Health Resources and Services Administration, Bureau of Health Professions, Division of

Nursing National Sample Survey of Registered Nurses—March 2000. website. Available at: http/

/www.HRSA.gov. Accessed June 10, 2001.

translates to approximately an hour a week that they have served

at the VA.

We developed as part of our marketing strategy a badge, which

is here on this coat, and this is the coat that they wear so they

have a sense of identity and people respond to that.

There have been some other outcomes other than direct patient

outcomes that we actually did not anticipate, and the first one of

those was the very positive influence they had on the nursing staff,

on the current nursing staff. They are delightful to work with, and

they give a real morale booster to the nursing staff on the units,

as well as us as faculty who have the joy of teaching them.

The Girl Scout Council endorsed the program for a merit badge,

so that gave added incentive for them to come. The scholarship program from the Disabled American Veterans that they sponsor for

youth scholarships, that has been a powerful incentive. And in

order to qualify for that, they have to serve 100 hours in the year

that they are applying.

Chairman ROCKEFELLER. You are going to have to wind up.

Ms. RAYMER. OK. I am just about finished. I got so carried away,

I forgot my notes here.

In summary, then, I would only say that I would highly recommend that the Cadet program be expanded across the system

and used by other people, and I would close with a comment from

one of the VA Cadets. She was from our charter class, and she was

talking to a fellow student who was considering enrolling in the

program. And she said to that student, ‘‘You will love it. The

nurses are awesome and the patients are great. It really makes you

feel good to come here.’’ And I believe that that is a youth that we

want in nursing, and we definitely want that person taking care of

our veterans.

Thank you.

[The prepared statement of Ms. Raymer follows:]

PREPARED STATEMENT OF MARY C. RAYMER, ASSOCIATE CHIEF OF STAFF FOR PATIENT CARE SERVICES, DEPARTMENT OF VETERANS AFFAIRS MEDICAL CENTER,

SALEM, VA

Mr. Chairman and Members of the Committee:

I am pleased to be here today to discuss a program we have implemented at the

VA Medical Center in Salem, Virginia, to address the nursing workforce shortage.

The VA Cadet Program was initiated in response to my growing concern for future recruitment of youth into nursing careers. As a child of the 1950’s with 27

years of VA experience, I represent the typical profile of the registered nurse of 2001

in the Department of Veterans Affairs. The average age of the VA nurse is 46 with

77% of all VA nurses over 40. Sixty percent of us have a bachelors or higher degree.

In addition, I am one of the 35% of VA Nurses who are eligible to retire by 2005.1

Many of my generation had their first experience in a health care setting through

programs such as the Candystriper Program sponsored by the American Red Cross.

Yet, when I looked for such programs today, I found a great void for structured

mentoring programs to provide incentives for the youth of today to choose nursing

as a career. As reflected in the 2000 National Sample Survey of Registered Nurses

(NSSRN),2 conducted by the Division of Nursing at the Federal Health Resources

and Services Administration, nursing is primarily (94%) a female profession and the

young women of today are presented many choices for careers. Nursing must compete with the workplace practices of all other disciplines. The factors that will in-
60

3 Aiken, Linda et al., ‘‘Nurses’ Report On Hospital Care In Five Countries’’ Health Affairs, Vol

20, No. 3 (2001), pp. 43–53. 4 Bednash, Geraldine, ‘‘The Decreasing Supply of Registered Nurses—Inevitable Future or

Call to Action?’’ JAMA, Vol 283, No 22 (2000), pp.2985–2987 5 Raymer, Mary, VA Cadette—A Nursing Youth Volunteer Program (2000), Unpublished. 6 National Student Nurses’ Association, Inc. Nursing: The Ultimate Adventure (Produced by

Envision, Nashville, TN 2000)

duce young people to choose a nursing career are the same as those cited for retention of the current nursing work force. As recently stated by Aiken et al in the

Nurses Reports On Hospital Care In Five Countries, ‘‘hospitals will have to develop

personnel policies and benefits comparable to those in other lines of work and businesses, including opportunities for career advancement, lifelong learning, flexible

work schedules, and policies that promote institutional loyalty and retention. Popular short-term strategies such as signing bonuses and use of temporary personnel

do not address the issues at their core.’’ 3 However, with no formal mentoring programs and frequent media attention to the problems and hazards of the nurses’

work environment, there are few positive messages to choose nursing. Interventions

to correct workplace issues must be made in concert with developing and expanding

mentoring programs, such as the VA Cadet, that provide the youth opportunities

for positive experiences in the health care setting. The NSSRN also reported a 5.4%

increase from 1996 to 2000 in the number of registered nurses. This is the lowest

increase ever reported by the survey, which has been conducted every four years

since 1975. The increase from 1992 to 1996 was 14.2%. Enrollments in all types of

entry level programs have continued to decline for several years.4

Having served as the Chairperson of the Nurse Qualification Standards Implementation Committee, I am appreciative of the commitment the Department of Veterans Affairs has made for supporting nursing education for current staff. This support for nurses to acquire a bachelors and higher degree will make major strides

in meeting the needs for these nurses in the future. The need remains for a formal

mentoring program to promote nursing as a career.

The VA Cadet Program provides a structured volunteer experience designed to

give the student, age 14 or older, a sampling of the nursing care environment and

interest them in choosing nursing as their life’s work. I will briefly describe the program and the marketing strategies we have implemented.

VA CADET—PROGRAM OVERVIEW 5

A detailed position description and orientation curriculum was developed and

processed through the nurse leadership and clinical practice forums for review, revision and ratification. This is a critical element as it achieved endorsement of the

concept by these nursing leadership groups and assured that the youth were engaged in activities that were appropriate. The orientation includes general safety

and work environment topics and focused nursing skills lab for eleven different

functions. Some of the tasks include handwashing, making beds, and distributing

fresh drinking water to patients. Conceptual skills include communication with the

patients, infection control, and confidentiality issues. The Cadet is presented a Certificate of Achievement on completing the five-hour orientation session. A key component in the program is flexibility for the student. We conduct the orientation sessions on Saturday and design their volunteer experiences to mesh with the very demanding schedules of today’s youth. The next crucial component is a cadre of dedicated nurses willing to mentor the Cadets. In today’s health care environment, it

is not realistic to expect the staff nurse who is already stressed with a myriad of

patient care demands, to also be responsible for the Cadet. Thus, we have centered

the supervision and mentoring role with medical center nursing supervisors. They,

as well as other nurse leaders at the medical center, also volunteer as faculty for

the orientation.

The program is designed to progress from the Junior Cadet to the Senior Cadet

after 60 hours of service. The position description for the Senior Cadet includes additional tasks, which are more complex. The rationale for the progression is to keep

the young person interested and to expose them to more types of nursing care tasks.

A marketing plan includes mailings to all area public and private high schools;

youth volunteer organizations, PTA groups, home school organizations, special interest groups such as the teen mother group, and regional church newsletters. Additionally, we utilized the excellent video produced by the National Student Nurses’

Association entitled, Nursing: The Ultimate Adventure,6 which is targeted at junior

and senior high school students. The marketing plan also included the development

and production of a logo and badge worn on the Cadets’ lab coat and a lapel pin.
61

7Disabled American Veterans National Commander’s Youth Volunteer Scholarship (2001).

To date, the program has had two orientation sessions and has inducted eleven

VA Cadets. The students and faculty rated the program at the exceptional level on

the post orientation evaluation. The ten young women and one young man represent

five different schools in the community and range in age from 14 to 17. Thus far,

the Cadets have volunteered a total of 140 hours in four months, averaging one

hour per week per student. Orientation is scheduled quarterly with the next session

on July 14.

Other direct outcomes from the project have been RN recruitment as a result of

the extensive media coverage of the Program and positive exposure to the volunteer

and school community. The Girl Scout Council has endorsed the VA Cadet for badge

work and the program has been featured at several civic organization meetings. The

Cadets contribute to a positive working environment for the nursing staff and the

faculty providing the orientation.

The scholarship program sponsored by the Disabled American Veterans for youth

volunteers 7 has been a significant drawing point for the students and their parents.

We also provide other information on funding available and nursing schools in the

local area and surrounding community.

I highly recommend that programs such as the VA Cadets be included as one of

the strategies for addressing the nursing workforce issue. I will close with a comment from a VA Cadet of our Charter Class. In discussing the program with another

student the Cadet said—‘‘you’ll love it—the nurses are awesome and the patients

are great—it really makes you feel good to come here’’—this is surely a young person we want in nursing and providing health care to our veterans.

Thank you again for this opportunity to discuss the Salem VA Medical Center’s

VA Cadet Program. I will be happy to respond to the committee’s questions.

Chairman ROCKEFELLER. Thank you very much.

Ms. Janzen, I would think that there would be a direct relationship between a nurse’s satisfaction and his or her ability to act

with as much autonomy as can be possible.

Ms. JANZEN. Absolutely.

Chairman ROCKEFELLER. And so we agree on that. But then

going back to the first panel and the question of being overworked

and tired. How much autonomy is there in the VA for nurses? And

how does it compare to non-VA facilities?

Ms. JANZEN. I think it is probably stronger in VA facilities than

in some non-VA facilities. I do believe that Magnet organizations

in the country have figured out a way to increase the clinical autonomy of nurses and increase the respect for nurses’ decisionmaking.

Chairman ROCKEFELLER. Can you give me some examples of

that?

Ms. JANZEN. Many of the Magnet facilities in the country have

a shared governance model. They are very well represented at all

levels of the organization in terms of designing new places for people to work, not just having the architects look at it, really having

nursing involvement, really listening to what is going to make the

nurses’ lives easier; listening when they say, you know, I do not

want the equipment room way down at the end of the hall, it needs

to be close by; buying nurse-friendly equipment that eases the

workload of nurses; listening to those kinds of things. They are

more than happy to work with patients. That is why they are

there. But we need to make it easier for nurses to really work with

patients.

Chairman ROCKEFELLER. And can that be done more broadly—

assuming the funding level for VA hospitals. VA hospitals are 90

percent Government funded, and VA cannot spend more than they
62

have. So, again, I believe that VA is going to suffer more the huge

tax cut than any other group that I can currently think of.

Does the autonomy help?

Ms. JANZEN. Of course it helps with that because, you know, if

the decisions are made at the unit level, you are not wasting time

going up the hierarchy. You can really make decisions based on the

clinical unit. You have to listen to the nurses when they say they

have too much to do, and then you need to pull back in terms of

the demands of patient care and respect that.

Chairman ROCKEFELLER. Now, how can you do that information?

Ms. JANZEN. Well, we—— Chairman ROCKEFELLER. How do you do it?

Ms. JANZEN. We have had to divert patients and go on critical

care bypass when we have no more beds and our ICUs are plumb

full. We have had to delay surgery. I mean, that is the direct result. We delay surgery. We ask nurses to take care of patients they

do not normally take care of.

We have been relatively successful at Tampa because we have

really listened to the nurses, but it is a very fragile edge that we

walk. And any, you know, future budget cuts that impact the number of nurses who can be at the front line will be serious because

the VA will not be able to provide the care. And nurses will not

stay in an environment that they do not perceive is supportive of

their work because there might be another organization down the

street that is doing it a bit better. And I think that that is a risk

that the VA runs.

Chairman ROCKEFELLER. Let me ask something I was not intending to ask. If we are going into a period of recession—and the

news from the Federal Reserve this morning is that we are just flat

as—is Fargo flat? [Laughter.]

Dr. PETZEL. Quite.

Ms. ROBINSON. It is really flat.

Chairman ROCKEFELLER. As flat as Fargo. And that is not good

news. But what it also means is that the various choices that

women now have or that men now have will become fewer. But do

you think that a downturn in the economy could spark more interest in people coming to work with you in nursing?

Ms. JANZEN. Well, no. Peter Buerhaus in his study said that one

of the reasons for the current shortage is the very good economy.

So that many nurses who are nurses do not have to work because

they can elect not to work. So that is one of the issues for the general nursing shortage.

That may indeed have a factor, but we have to look at the fact

that we are not looking at people with value systems that, you

know, Mary and Karen and I came with, you know, from the

Candy Striper days and, you know, we will give all—these people

want a life other than just nursing and other than just VA. And

they will not select a career that does not give them a balanced life.

Chairman ROCKEFELLER. Yes. So that is a big, big problem, isn’t

it? Young people want time for all sorts of things in their life.

Ms. JANZEN. They want a balanced life. They want an exciting

career, and they want a balanced life. Nursing can be an exciting

career, and I really believe that. And the options to work in all different kinds of nursing settings, change your career several times,
63

and still, you know, end up with a retirement in the VA, these are

very attractive things. But it needs to be an exciting environment.

We need to be very responsive to what they want, and that goes

back to an organizational culture that supports saying, OK, we are

going to try that.

Chairman ROCKEFELLER. So it makes it so much more important

to do what you are all talking about?

Ms. JANZEN. That is right.

Chairman ROCKEFELLER. Because just speaking personally—and

none of you have reached my generation yet, but you will someday.

But I understand exactly what you are all saying because if I had

to criticize myself, which I frequently have to do, it would be that

the amount of time that I spent, for example, with my children

when they were growing up because I was a Governor was seriously reduced because I had to take care of the State.

Ms. RAYMER. You have to have that environment to induce them

to come into that kind of career field. I think that is what many

people today have said, that there is not really a quick fix. I mean,

you cannot go out and implement a Candy Striper or a Cadet program if then when the young person comes into the setting they

see this, you know, terrible situation. They are obviously not going

to want to come to work there. And so you have to create an environment like Sandy is talking about in order to promote those kind

of people to come into nursing.

Ms. ROBINSON. I would echo those comments. When you interview an individual for a position, you have to listen very carefully

to what they are wanting and describe to them the setting that

they will be working in. And I use as an example our nurse-managed clinic in Grafton, ND. We were recruiting for a nurse practitioner, and we had an interview with just an excellent young man

who was a nurse practitioner, had been in the role for about 5

years, and his resume was just outstanding. And he was very interested in this concept. But he lived in a community about 30 miles

away, and he was all set to sign up with us, and he went back to

his community, and they said, ‘‘How can you leave us? How can

you leave us?’’ And so he called me, and he said, ‘‘I just cannot do

it.’’ He had a sense of community.

So there is still that out there, and we were able to match his

salary, et cetera. He liked the idea of the nurse-managed clinics,

but it was a sense of community.

Chairman ROCKEFELLER. Nurse clinics are famous for spending

more time with patients. One, if you agree with that, why is that

so? And what can we do with that?

Ms. ROBINSON. That is true. There are some nurse-managed clinics that do that. When we developed the model, we looked at the

Columbia University model in New York. We looked at Vanderbilt

in Tennessee, and we also looked at Rutgers in New Jersey. And

we found that not to be the case in all of those settings.

With our particular nurse-managed clinics, we utilized the same

guidelines as we do in our host medical centers for appointments.

If it is a first-time appointment, you know, they have X amount of

time. If it is a return appointment—so it is the same as it is at our

host medical centers. But I know that that is not the case nationwide.
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Dr. PETZEL. There is a perception, however, in the nurse-managed clinics that the provider is spending more time with the patient on the patient’s part. We are not sure what that is about, but

there is that perception.

Chairman ROCKEFELLER. That is interesting.

Well, to be honest with you, if the perception is there, you are

going to have happier health professionals.

Dr. PETZEL. It is important. You are absolutely right.

Ms. ROBINSON. And I think it is developing that rapport. I think

nurse practitioners are more comfortable in the area of patient education, teaching, working with family.

Chairman ROCKEFELLER. OK. Well I have to wind this up. This

is an enormous problem. It is a problem throughout America.

If we do have a recession, one of the things that is going to happen is that a whole lot of people, not just in the veterans community, but a whole lot of people out there are going to lose health

insurance. And so, the whole sort of urgency about the health care

system will come back. The outrage is that we still have so many

who have no health insurance at all.

So if you add that concern with some of the frustrations that we

have heard this morning and some of the positive solutions that we

have heard this morning health care delivery could benefit. But the

need to deliver good health care to veterans and to non-veterans

alike could focus more of a public spotlight.

Do you agree? You do not have to.

Dr. PETZEL. It is certainly possible, absolutely possible.

Chairman ROCKEFELLER. It is a good way to end a hearing,

though.

Dr. PETZEL. Yes. [Laughter.]

Chairman ROCKEFELLER. OK. Thank you all very, very much.

The hearing is in recess. And Senator Specter’s statement goes

in the record.

[Whereupon, at 12:35 p.m., the committee was adjourned.]
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A P P E N D I X

PREPARED STATEMENT OF MARK REGAN, NATIONAL FIELD SERVICE SUPERVISOR, THE

AMERICAN LEGION

Mr. Chairman and Members of the Committee:

The American Legion appreciates the opportunity to submit this statement addressing a problem that continues to grow each day—a shortage of nurses within

the Department of Veterans Affairs (VA) and its potential to decrease the Veterans

health Administration’s (VHA’s) ability to deliver quality health care to America’s

veterans. Clearly, sufficient and high quality nursing care is one of the most important and necessary components of VHA’s healthcare delivery system or any

healthcare delivery system.

In fact, nurses continue to serve as the backbone of direct patient care. Quality

nursing care is synonymous with quality patient care. One aspect of ensuring quality nursing care is ensuring there is sufficient coverage for the range and complexity

of medical issues. This is essential if VHA is to meet its obligations and keep the

promise of quality medical care to veterans.

Articles appearing in nursing publications argue that the nurse shortage is evident by rising nursing vacancy rates, which have resulted in closed beds, non-urgent

surgery cancellations, and the diversion of patients from emergency rooms. Moreover the nursing shortage can be attributed to the diminishing supply of new talent

entering the profession coupled with a growing demand for health care services.

Preliminary results of the latest National Sample Survey of Registered Nurses

showed a 5.4 percent increase in the total RN population, but it was the lowest increase in the previous national surveys, which dates back to 1977. The latest numbers from the American Association of Colleges of Nursing indicate that enrollments

in five year baccalaureate nursing schools dropped 16.6 percent during the past five

years. Furthermore, the supply of nurses, reported as insufficient, will slow even

further. In addition, the registered nurse (RN) workforce is getting older. As those

RNs retire, the supply of working RNs is projected to be 20 percent below requirements. Consequently, this is not just a cyclical nursing shortage, but a significant

issue that could impact the delivery of health care for some time.

Overall, VA nurse staffing was relatively stable in 2000. The turnover rate was

9.5 percent, while the percentage of new nurses brought on board was 9 percent.

VHA’s turnover rate of 9.5 percent compares very favorably to the US turnover rate

of 15 percent. Nevertheless, VHA is still experiencing nursing shortages. This often

involves positions with special qualifications that vary by region. However, The

American Legion has seen several long-term care programs, for example, the nursing homes in Tuskeegee, AL; Augusta, GA, and Amarillo, TX, that are not at capacity due to the lack of nursing coverage.

Additionally, The American Legion has seen large voids in the nursing staff positions, for example, 40 RN vacancies in Richmond, VA. There is also a significant

nursing shortage at the Albuquerque VA Medical Center (VAMC), which threatens

its ability to provide quality care and treatment to veterans. Inpatient beds in medicine, surgery and psychiatry have been closed since May 2000, and elective surgeries are being delayed because the facility must limit its operations to ensure

quality care and to maintain a safe patient environment. Referral facilities have

looked elsewhere because a VAMC can not accommodate their workload. The facility

has taken aggressive measures and conducted nation wide recruitment.

Salary surveys were conducted. Consequently, salaries were increased on several

occasions. Recruiting bonuses were also used as an incentive to attract qualified

candidates. Yet, despite these efforts, many vacancies still exist with no apparent

light at the end of the tunnel. There are simply not enough nurses in the geographic

area to meet the demands, and the situation has been compounded by a reduction

in the number of slots for students at the university’s nursing school. The facility
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has stemmed the net loss of personnel, but it has not substantially increased the

number of nurses on board to offset the previous losses.

The American Legion’s strongly believes that what happens at VAMCs often reflect the general state of affairs within the health care community as a whole.

Therefore, when there are difficulties recruiting Intensive Care Unit (ICU) nurses

at a VHA facility, there are often difficulties in finding ICU nurses in the surrounding community facilities. When VHA is diverting veterans from the emergency

room, community facilities are often doing the same.

The American Legion commends Congress for passing Public Law 106–419, because it provided the framework to help revitalize VHA salaries in a number of disciplines, including nursing. While there are reports that some stations still have

work to do to resolve significant salary discrepancies between VHA and the community and VHA must remain competitive in its benefits package, this is only one component of the equation of retention and recruitment.

A study by the Center for Health Economics and Policy at the University of Texas

Health Science Center in San Antonio Texas identified three essential factors that

affect the retention of nurses:

1. Work environment practices that may contribute to stress and burnout,

2. The aging of the RN workforce combined with the shrinking applicant pool

for nursing schools, and

3. The availability of other career choices that makes the nursing profession

less attractive.

Other factors cited most frequently for leaving nursing included:

• lack of time with patients, • concern with personal safety in the healthcare setting, • better hours outside of nursing, and • relocating.

It should also be noted that 63 percent of those surveyed said that RN staffing

is inadequate and that current working conditions jeopardize their ability to deliver

safe patient care.

Other studies reinforce and expound these themes and factors. A study, which included five Countries, found that nurses in Countries with different health systems

reported similar problems in their work environment. Less than half of the nurses

surveyed said that the administration listens and responds to their concerns. Less

than 38 percent said that there is enough staff to get the job done. Nurses also commented that staffing shortages forced many RNs to perform non-nursing duties. Finally, the results suggest a large number of young nurses plan to leave their jobs.

Health care institutions are struggling with and searching for solutions. ‘‘Experts’’ say that improving the work place and polishing the image of nursing are among

the steps that must be taken. The National Association of Government Employees

(NAGE) has been on record saying that VHA must embrace staffing practices that

are favorable to employee and family needs, such as hiring staff for permanent tours

instead of rotating shifts, and providing alternative work schedules. NAGE also

noted that rewards and recognition for employees in the field must improve, and

advocates VHA increasing its educational resources to allow VHA nurses to pursue

a Bachelor of Science in Nursing (BSN) or Masters Degrees.

It is clear the nursing profession faces significant challenges imposed by an aging

workforce (the average age of VHA nurses is 46 years), the increasing medical care

demands of an aging population, a declining interest in the profession, prompted by

more preferable career alternatives for women, and a perceived lack of appreciation

and respect for the profession. In a survey released in February 2001 by the American Nurses Association, 56 percent of those surveyed said they would not recommend their profession to their children or their friends.

VHA has two committees looking at the nurse shortage and they will provide proposals to address the needs and issues within VHA. However, VHA should have the

capabilities to aggregate data relative to its nursing coverage to include the number

of vacant positions in the system. Data would also be useful regarding the associated consequence of those vacancies - bed closures, delayed delivery of care, etc. This

would help to clarify and define VHA’s needs. VHA is currently working to improve

in this area.

VHA should continue to explore ways to enhance the work environment. Morale

among nurses is deeply impacted by the amount of non-nursing functions they are

required to perform. Therefore, it is imperative VHA make sure there is sufficient

clinical and ancillary support to maximize the nursing skills of nurse providers.

Similarly, local facilities have a number of practices to facilitate hiring, but their

use varies across the country reflecting local decisions on the use of limited resources. The ability to provide recognition rewards, likewise, can be affected by the

local budget. Thus, adequate funding is imperative.
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VHA must draw upon its models of collaborative efforts to use the talent among

its clinical staff to help address the issues that surround the availability of teachers

for nursing programs. VHA continues to be a leader in the fields of the electronic

medical record and patient safety initiatives. Finally, VHA must ensure that such

efforts are widely recognized because this will enhance its ability to attract those

looking to be part of the cutting edge of nursing practice.

VA’s Chiefs of Nursing have said that one of the most effective recruitment tools

is to capture student nurses while they are in training or as they graduate. One

state has considered legislation providing starting bonuses, while a private sector

facility has established programs for new nurses that involve preceptorships, mentoring and financial incentives to stay. VHA must not only stay abreast of these initiatives, but it must be placed in a position to excel in these initiatives.

The American Legion is appreciative of the many contributions of VHA nursing

personnel and recognizes their dedication to veterans who rely on VHA health care.

Every effort must be made to recognize, reward and maximize their contributions

to the VHA healthcare system because veterans deserve nothing less.

Mr. Chairman and members of the Committee, The American Legion sincerely appreciates the opportunity to submit testimony and looks forward to working with

you and your colleagues to resolve this critical issue. Thank you for your continued

leadership on behalf of America’s veterans.

PREPARED STATEMENT OF KENNETH T. LYONS, NATIONAL PRESIDENT, NATIONAL

ASSOCIATION OF GOVERNMENT EMPLOYEES

Mr. Chairman and Members of the Committee:

The National Association of Government Employees (NAGE) represents 150,000

public sector employees throughout the United States, including 15,000 at VA facilities nationwide. On behalf of these dedicated employees, NAGE would like to thank

the committee for this opportunity to submit this written testimony for the record.

An alarming trend is occurring throughout the United States health care system,

and more specifically within these Department of Veterans Affairs (VA) hospitals,

nursing homes, and clinics. This trend is the nursing shortage that is creating a crisis for quality patient care and the overall future of the nursing profession. Registered nurses make up the largest health care workforce in the nation, and the VA

has the largest nursing workforce in the world, but even with these distinctions, the

ever-dwindling supply of nurses continues its trend. In the 2000 National Sample

Survey of Registered Nurses it was found that a disturbing 18% of nurses who have

active licenses are not working in the field, and from another survey, 55% would

not recommend the profession as a career choice to those interested. Why is it that

these dedicated nurses who sacrifice themselves day in and day out for the good of

the patient are turning their backs on the profession?

Numerous factors combine together to bring about the state of today’s VA hospitals. One such reason is the fact that the profession primarily consists of women,

as 94% of nurses are female, and women today are offered countless more career

choices than they were even a few years ago. Suddenly becoming a nurse does not

hold the same appeal as it once did and one reason for that is a lack of mentoring

programs and successful recruiting. At this time the average age of new graduates

from nursing school is 30.5, and the average age for active nurses is about 46 years

old. Twelve percent of the VA nursing staff is eligible for retirement at this time,

and every year another 3.7 to 5.3% become eligible as well. This shows that the majority of active VA nurses have been in the profession for some time, while they are

not getting the younger, fresher recruits who are needed for the next generation of

nursing professionals. And with enrollment in all types of entry level programs declining, it is evident that something must be done to stimulate interest and growth

in the field. Programs such as the VA Cadet Program offer firsthand volunteer nursing experience to students 14 and older, where hands on nursing skills are learned.

So far, several sessions of the program have been held, with the curriculum receiving an ‘‘exceptional’’ review from those involved, and the program plans on an indepth marketing campaign to increase awareness and interest to a more youthful

demographic. This is a much-needed step in the positive direction, but many other

issues must be resolved within the profession to retain those that are recruited.

It is increasingly evident that changes in nursing circumstances have created a

strained working environment. Staffing shortages, stagnant pay, and career advancement opportunities are some problems facing nurses. As opposed to six years

ago, VA hospitals have increased care to more than 500,000 veterans with 25,000

less employees. Common sense tells anyone that with such a disproportionate

change in quantity, the quality of care is going to decrease drastically. In a recent
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ANA survey, over 40% of the nurses surveyed stated they would not feel comfortable

having a loved one cared for in the facility they worked in. Because of the understaffing at veterans’ hospitals nurses are forced to work mandatory overtime to compensate the insufficiencies. It is common for a nurse to go into work thinking he

or she will be leaving at their scheduled time, yet, once there find that he or she

is required to work an extra shift to cover gaps in the staffing. Nurses may log on

15 to 16 hour shifts for several days a week, and this kind of exertion is mentally

and physically taxing, draining the caregiver of focus, patience, and motivation, all

leading to impaired performance and decreased patient care and safety. At this time

there is no nationwide policy for mandatory overtime nor are statistics collected.

Until legislation is passed, nurses will face the problem of being forced to work beyond their limit, potentially putting their patients in harm’s way, or suffering the

repercussions of being charged with patient abandonment, it is a catch twenty-two.

To further accentuate the problems caused by these long, tedious hours is the pay.

Census data from 1994 to 1997 shows a decrease in average wages every year, with,

for instance, a Registered Nurses’ salary dropping by more than a dollar an hour.

Numerous strategies are being proposed to reverse this situation. Waiting periods

between Periodic Step Increases (PSI) in pay can be deviated at the request of facility directors, shortening the time it would take a hardworking nurse to receive increased compensation, and offering incentive to a prospective nurse. A four-week

salary advance could also be offered, which is attractive to newly hired staff who

tally large expenses relocating and training. Also advancements in steps could be

awarded for excellence in achievement and performance beyond what is expected for

the grade level. Such recognition boosts self-confidence and morale, easing some of

the mounting pressures constantly placed on these nurses. It also creates a workplace atmosphere where hard work is actually recognized and rewarded, a very positive aspect in the recruitment of new nurses. Several changes can also be made in

the Locality Pay System such as using third-party industry wage surveys to make

adjustments in salaries, and expanding the Local Labor Market Area (LLMA) as

needed to adequately obtain these surveys. Changes such as these promote much

needed opportunities for career advancement.

In accord to these opportunities are two new educational assistance programs the

VA has to offer. The Employee Incentive Scholarship Program (EISP) is available

to employees who want to seek further education in various healthcare disciplines.

In return the employee is obligated to a period of service. The National Nursing

Education Initiative (NNEI) is a scholarship offered to nurses who want to return

to school and receive their baccalaureate or advanced degrees. This coincides with

the new nurse qualification standard that makes a bachelors of science in nursing

(BSN) mandatory for a promotion. However, a large number of nurses, especially

minority populations, only have an associate degree, and limiting promotions to

strictly educational criteria, as opposed to performance, discriminates against those

who have not attained that level yet. This is complicated by the fact that while

these scholarships, especially the NNEI, are available, funding to hire temporary

staff to cover while the nurse pursues his or her education is missing. So some employees are disadvantaged in their career advancement opportunities, a fact that

does not help in attracting new and potential nurses.

Mounting pressures including mandatory overtime, increased volumes of patients

with decreased numbers in staff, and flat-line pay are enough to steer away new

nurses, while also driving away the current, dedicated nurse force, more of whom

are eligible for retirement every year. There is an unbalance of both numbers and

rewards between direct patient care staff and administration, where directors in the

ever-increasing management are making up to $20,000 bonuses a year while those

on the ‘‘frontline’’ are told there is not enough in the budget. When will they be recognized? Something must be done to curb the downward spiral of the nursing profession because the problem will not correct itself. NAGE urges that measures be

taken and supports legislation capping overtime and adding to the budget to allow

for the necessary staff and pay increases. The Department of Veterans Affairs has

been historically viewed as a stable, secure, and desirable workplace, and with

changes such as these we can once again make the VA the number one employer

of choice.

PREPARED STATEMENT OF THE AMERICAN ORGANIZATION OF NURSE EXECUTIVES

The American Organization of Nurse Executives (AONE) welcomes the opportunity to provide testimony on the critical issue of the nursing shortage and its impact on all aspects on the health care system.
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AONE represents over 3800 nurse executives, managers, consultants, and educators dedicated to providing leadership, professional development, advocacy, and

research in order to advance nursing practice and patient care, promote excellence

in nursing leadership, and shape healthcare policy. Many of AONE members are

current and former Department of Veterans Affairs nurse executives and some have

served in leadership positions within AONE.

For nurses in management positions and the over 2 million registered professional

nurses licensed in the United States, the nursing shortage is a critical problem that

has serious implications for all of health care, both today and in the future. Over

the years, hospitals and health systems including the VA have repeatedly experienced temporary shortages of personnel, such as the nursing shortages of the 1960s,

1970s, and the late 1980s. These shortages responded to quick fix solutions of higher salaries and the importation of foreign-trained nurses. Unfortunately the demographics of today’s shortage as outlined in AONE’s October 2000 monograph Perspectives on the Nursing Shortage: A Blueprint for Action, reveals a looming health

care situation crisis that, if not reversed, will find Americans critically short of the

registered professional nurses needed to address the health needs of an aging American society.

As America ages so does the nursing workforce. The average age of the 2.1 million

US registered nurses is 45.2 years, for VA nurses it is 48 years, and for those is

academia it is over 52 years of age. In 2000, only 9.1 percent of nurses were under

the age of 30. This figure signals significant erosion in the nursing pipeline showing

the reluctance of younger individuals to enter the nursing profession. In fact, the

traditional source of nursing students (white, females) has seen a significant decline

as new and varied career opportunities have been opened to women.

Over the last five years, enrollments in baccalaureate nursing programs have declined by 20 percent and all RN education programs have declined by 50,000 students or 22 percent since 1993. The drop in enrollment is attributed to declining

interest, program cuts and inability to attack sufficient faculty.

Most regions of the United States are currently experiencing a major nursing

shortage. A June 2001 survey by the American Hospital Association of their member

hospitals revealed that currently 125,000 nursing positions are unfilled. This translates to a nationwide vacancy rate of 11 percent. The shortages are particularly

acute in such specialty areas as the emergency room, labor and delivery, the operating room and critical care units. Recruitment in these areas especially difficult because programs to produce such skilled clinicians have been reduced or terminated

in many US hospitals, and the cohort of younger nurses from which to recruit has

been greatly reduced. The seminal work of Dr. Peter Buerhaus in his

groundbreaking research published in the June 2000 edition of the Journal of the

American Medical Association has drawn national attention to the nursing shortage

as a problem of unparalleled proportions. Dr. Buerhaus and his colleagues estimate

that by the year 2020 the US, under the current nurse workforce scenario, will be

short over 400,000 nurses.

In the view of AONE, the solution to the nursing shortage lies in a multipronged

approach that addresses the short-term supply problem but also stimulates

long?term solutions that address all facets of the nursing workforce issue. Solutions

can be found in three nursing bills that have been introduced in the House and Senate. They are S. 706/H.R. 1436 the Capps-Kerry Nurse Reinvestment Act and S. 721

the Hutchinson-Mikulski Nursing Employment and Education Development Act.

These bills in whole or part address the AONE agenda for nursing shortage relief

through:

• Increased funding of the Nurse Education Act.

• Increased funding for loans and scholarships for nursing students who agree to

work in shortage areas.

• Increased funding for nursing research.

• Support for faculty development and mentoring to ensure that nursing programs are fully operational.

• Funding for specialty nurse internship and residency programs.

• Support to make educational expenses tax-deductible and loan forgiveness programs.

• Support for collaborative models to provide career ladders within the nursing

profession.

• Enhanced recruitment of minorities into the nursing profession.

• Development of private-public partnerships to assist in the marketing of the

nursing profession.

• Establishment a nurse corps.

AONE is supportive of Senator Rockefeller’s draft legislative framework to address nursing shortage as it affects the Department of Veterans Affairs. In par-
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ticular AONE welcomes the elevation of the nurse consultant position, the expansion of education initiatives, and the encouragement of pilot programs to expand

nurse-directed health clinics.

AONE is hopeful that Congress will act quickly to implement legislation to solve

the nursing shortage. It welcomes the opportunity to support the over 34,000 nurses

of the Department of Veterans Affairs who tirelessly care for our Nation’s veterans

and looks forward to continued cooperation with the Committee and the VA to support the nursing profession.

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