Mr. Chairman and members of the Subcommittee on Health, I am Margaret Kruckemeyer, RN, MA, MSN, CRNH, ARNP, an Advanced Practice Nurse in the Hospice Unit of the Dayton Veterans Affairs Medical Center. The Nurses Organization of Veterans Affairs (NOVA) is the professional organization of the over 35,000 registered nurses employed by the Department of Veterans Affairs (DVA). As President of NOVA and a disabled, Vietnam Veteran, I am pleased to present testimony on the 1999 VA Nurse Appreciation Act, H.R. 1216 on behalf of the NOVA Board of Directors and membership.

The DVA Nurse Pay Act of 1990, PL 101-366, and amended in 1992 as PL 102-585, was a viable concept. Its purpose was for the salaries of registered nurses to be market driven in order to be competitive with their counterparts in the community. Although the Nurse Locality Pay System (NLPS) is functioning properly at some facilities, at many facility it has been applied in a discriminatory and inconsistent manner . It has been known since 1993 the NLPS survey process is flawed and inconsistently applied. Since its inception, the goal of matching DVA nurse pay to the private sector has grown difficult and not achieved the goal of maintaining the community average. DVA nurses have become the target of budget juggling, and now perceive the survey process as unfair and inequitable.

When this law was first introduced, DVA nurses were enticed with the promise of surveys which would provide pay increases based on the local labor market area. In 1991, 1992 and 1993, it was required reports be submitted to Congress about pay adjustment increases or the basis for not providing an increase. Subsequent to 1993, reports were no longer required. The NOVA Board was informed at our 1998 Legislative Roundtable by Congressional staff members that Congress was not aware of any DVA nurse pay problems.

In 1997 and 1998, the unfairness and inequality of the NLPS was brought to the attention of Secretary Jesse Brown and Under Secretary for Health Dr. Kenneth Kizer by frustrated nurses around the country. Many facility directors had refused to implement pay increases which were indicated by the survey process. Increases were being refused due to budget shortfalls and because they are discretionary. Medical centers do not have to be experiencing recruitment or retention problems in order to adjust nurse pay rates. The primary purpose of the NLPS was to give increased authority to facility directors to address salary needs before recruitment and retention problems developed.

The NLPS was designed to allow the DVA to adjust nurse pay and be competitive with the private sector, thus, easing severe retention and recruitment issues facing the DVA. The prior system of adjusting nurse pay was cumbersome and untimely with submissions to DVA Central Office for approval. Action for better pay adjustments could have taken six months or longer, but by then, many staff had left for jobs. Now despite a law to facilitate timely response to nurse pay issues because of budget shortfalls and directors’ discretion a problem still exists. Nurses are frequently informed there is no money in the budget for any kind of nurse pay adjustment. The same facility directors who denied nurse pay raises annually receive a pay increase, plus locality pay and pay bonuses.

NOVA applauds The Honorable Representative Steven C. La Tourette (R-OH) for introducing the VA Nurse Appreciation Pay Act of 1999, HR 1216, to rectify pay injustices DVA nurses have suffered. Even with legislative changes, however, the basic inability to obtain accurate pay information from local labor markets will not be solved unless the NLPS survey data can be collected by the Bureau of Labor Statistics or another third party without time frame limits. Additional changes in the law or all of the recommendations of the Hay Report should be taken into consideration.

Job matches are extremely difficult and only starting salaries are currently surveyed. When competing facilities do participate, published pay schedules are not indicative of the actual beginning salaries offered to new hires and published scales do not reflect the rates of pay for continuing employees. Since 98% of VA nurses are in steps I, II, and III, survey data needs to include mean salary rates. Facilities are hesitant to provide accurate information and some have refused to provide any information at all. The DVA cannot be the pay leader in any area. The VA Nurse Appreciation Pay Act of 1999 will help ensure DVA Registered Nurses receive fair annual pay increases and will reinforce the NLPS to assure nurse salaries are based on accurate and timely salary survey data collection by a third party.

Registered nurses at DVA hospitals are working harder. As one nursing colleague put it, "we have cut past the meat into the bone". Staff downsizing, increased patient acuity, shorter hospital stays, bed closures, flat-line budgets, and realignment into service lines have resulted in work overload and increased adverse events, including medication errors, and patient and staff injuries. DVA nurses are functioning in roles not envisioned when the NLPS was created. This is very disheartening to registered nurses who are managing nurse run clinics and improving quality care outcomes daily.

Nurses are essential to the delivery of high quality health care to veterans and research proves that an hour of care provided by a registered nurse improves patient outcomes significantly. Studies show when nurses are present, there are lower mortality rates, shorter lengths of stay, lower cost, and fewer complications. More than a decade of research demonstrate that nurse staffing levels and skill mix make a difference in the outcomes of hospitalized patients.

Ensuring quality patient care is a priority, and appropriate nurse staffing is a critical component to achieving quality of care. Nurses are the best value in health care. The DVA has taken the lead by requiring registered nurses to have a Bachelor of Science degree as a minimum, entry level requirement in the recently implemented qualification standards. In the DVA environment, education and the maintenance of credentials are important factors, in addition to experience, in determining where a nurse is within a step.

The Hay Report noted research and technology-based organizations, those affiliated with universities, as well as those with specialty needs, tend to pay toward the upper end of the scale. DVA is noted for research, technological advances, and developing programs for special needs populations, such as those with spinal cord injuries, PTSD, geriatrics, and long-term care. DVA nurses are involved in every aspect of the research process.

A critical shortage of nurses across the nation has arrived. It is more imperative than ever to retain as well as recruit a competent nursing staff. DVA nurses work harder than their counterparts in the private sector, as staffing levels and diminishing support services are consistently less than in the private sector.

A recent study funded by the American Nurses Association found that the aging nursing workforce, combined with declining enrollment in nursing programs, has fueled this nursing shortage. Research by the American Association of Colleges of Nursing demonstrated enrollments of nursing students in entry-level Bachelor Degree programs fell by 4.6 percent in the fall of 1999 which was the fifth consecutive drop. Additionally, enrollment in Masters Degree programs decreased by 1.9 percent.

Double shifts, cross-training and mandatory overtime are causing immeasurable stress. Nurses are constantly worrying about their practice, and most feel the joy of nursing is gone for them. Nurses are finally saying, "We can’t do this anymore." Recently at a VAMC, the evening nurses refused to accept their assignments at shift change because of unsafe staffing levels which would put their patients and licenses in jeopardy. This issue was resolved when the supervisor found two nurses willing to work overtime to safely staff the unit for the evening.

Benefits that once made the DVA an attractive place to work are gone. Some examples include:

• Funds for continuing education have become more restricted due to budget constraints.

• Authorized Absences have been cut back or staffing has been reduced so significantly, nurses, are unable to attend educational programs without using annual leave.

• Incentive awards are no longer given. Most nurses are told there is no money for them even before their proficiency is due.

• Incentive award funds for specialty certification or re-certification is no longer given.

• Nurse managers are told not to submit any requests for advancements for nursing staff due to budget constraints, and to find other methods of rewarding staff.

• Adequate staffing levels are gone, causing dangerous working conditions that deter new hires from staying at the DVA.

• Overtime

NOVA supports the recommendations in the October 1998 Final Report of the Hay Group, A Study of the Nurse Locality Pay System within the Veterans Health Administration.

• Use independent third party surveys.

• Acquire data on averages and ranges, as opposed to beginning pay only.

• Survey hospitals on actual pay rather than published minimums.

• Do job analysis and detailed job matching on a less than annual basis, using standard industry terms and definitions.

• National adjustment that is a general across-the-board pay adjustment for all VA nurses.

• Locality-based differential that reflects local market conditions or cost-of-living differences.

NOVA also believes the issue of locality pay is only one issue affecting the DVA nursing workforce. Solving this inequity will help with the low morale problem but will not solve it. NOVA recommends the following as retention strategies:

• Reduce workplace stress by giving nurses the time they need to do their jobs effectively.

• Provide nurses with educational and career opportunities.

• Ensure appropriate staffing levels.

• Offer more flexible schedules.

• Building mentoring programs.