Testimony
of
Elaine T. Gerace, RN On behalf of the Service Employees International Union (SEIU), AFL-CIO Before the U.S. House of Representatives Health Subcommittee of the Committee
on Veterans’ Affairs On the “Current State of the Veterans’ Health
Care System” April 3, 2001 Mister
Chairman, Members of the subcommittee, thank you for giving me the
opportunity to address you here today regarding the current state of
the Veterans Health Care System and any recommendations we may have to
improve the delivery of health care to our nation’s veterans. My
name is Elaine Gerace. I am a registered nurse at the Syracuse VA Medical Center and
I have been in the VA system for 12 years.
I am also a veteran. But
I am here today representing the Service Employees International
Union. SEIU represents
1.4 million workers nationwide. This
includes over 700,000 health care workers, of which approximately six
thousand are VA workers. Before
I begin I would like to thank the members of this Subcommittee and the
full committee for approving the pay adjustment last year for nurses.
This pay increase meant a great deal to our nurses and went a
long way to improve morale. The first issue I
would like to focus on today is the nurse staffing crisis that exists
in the VA system. Understaffing of registered nurses has reached a critical
level in this country and it is only expected to worsen. The so-called “shortage” is not causing short staffing.
It’s the other way around.
Inadequate staffing created poor conditions for nurses as well
as patients, leading nurses to seek jobs elsewhere.
Nursing is no longer the desirable career that it once was.
This is evidenced by the decreased enrollments in nursing
schools across the country. Nurses
are also leaving the profession for careers in other fields that offer
higher salaries, better working conditions and better hours.
Currently the average age of VA nurses is 47 years old and is
increasing. In 8 to 15 years, the VA will have to replace the majority of
its current registered nurse workforce due to retirements. The VA is
facing a crisis. This crisis in staffing is directly related to the
quality of care that the veterans receive. The
health and well being of veterans around the country depends on safe
staffing levels. Specifically,
we sufficient numbers
of appropriately qualified nursing staff to meet the individualized
quality care needs of the patients. We must not just look at the
number of nurses per unit but also at the staffing mix, RN’s,
LPN’s, and nursing assistants.
We must also consider the acuity of the patients and the
intensity of the care that is required. Approximately
10 years ago the VA established an expert panel to develop minimum
staffing levels that determined the minimum
amount of staff each unit should adopt.
These minimum staffing levels, which vary from VA to VA, have
become the maximum levels and are no longer adequate to provide
quality care to today’s patients.
When these standards were developed there was ancillary support
for the nursing staff and the acuity of the patients was much lower.
Today, nurses are required to perform the duties that were once
assigned to others such as blood draws, inserting IV’s, doing
EKG’s etc. In addition
to these duties, we are changing over to a computerized system of
documentation and have implemented Bar Code Medication Administration,
both of which put additional burdens on the nurses.
At the same time, the patients that are admitted to the
hospital now are much sicker and require much more complicated care. In addition to these increased responsibilities, the
current nursing shortage has pushed nurses to their limit. They are no longer able to provide the care that they were
trained to give and that our veterans deserve. All
of these factors have resulted in several problems for the nursing
staff. Mandatory overtime
is one of the most troublesome. Imagine
going to work and not knowing when you will be going home.
Finding out two hours before the end of your shift that you are
required to work 4 more hours, or maybe 8, leaves you frantic to
figure out how you are going to pick up your child at day care or be
home to take care of a sick parent.
This one factor alone causes severe morale problems for the
staff. In addition, it
also contributes to increased stress levels, as well as an increased
risk for medication errors and the inability for nurses to properly
assess the patients. It
has been documented in many studies that a nurse’s judgement and
reaction time is reduced after an eight hour shift, after 12 hours it
is severely impaired. For
those nurses working mandatory overtime, they are usually required to
work an additional mandatory 8-hour shift for a total of 16 hours.
The
fear of making a medication error or an in incorrectly assessing the
status of a patient causes constant stress for the nurse and obviously
can be disastrous for the patient.
Requiring mandatory overtime has also resulted in increased use
of sick leave, which only compounds the staffing problem.
During a 6 month period, from October 1,1999 to March 31, 2000,
I monitored the overtime use on the medical and surgical inpatient
units at the Syracuse VA hospital.
This study did not include the other units in the hospital or
the outpatient clinics. The total number of overtime hours worked by
80 nurses was 4,589. I am
certain that this number would have been much higher if all of the
units had been included. Nurses
cannot refuse to work overtime or they can be charged with abandonment
of duty and be disciplined and/or fired.
Mandatory overtime has been the reason that many nurses have
left the VA, which we can ill afford.
I cannot stress enough how important nurses feel about
providing good care, the kind of care they are trained to provide.
Nurses are leaving because of the stress and because they too
often feel they cannot provide the level of care that our veterans
have a right to receive. In
order to minimize the use of overtime, floating nurses from one unit
to another has become a standard practice.
This is also demoralizing to nurses.
Nurses are very aware of the staffing on the floor.
When staffing is adequate for the floor, which seldom happens,
the nurses look forward to going to work because they know that they
will be able to provide the care that they should be giving.
If other units have sick calls or increased acuity, then nurses
will be floated to that unit. It
is particularly difficult for registered nurses that are at times
expected to do charge on an unfamiliar unit.
Competencies must also be considered.
Nursing has become specialized and although nurses are all
taught the same curriculum in school, once they begin working they
hone certain skills and lose others depending on what unit they work
on. Would you want a
nurse who is very competent in nursing home care unit working on your
father who just had surgery when they have no experience in
post-surgical care, or vice versa? Members
of SEIU in conjunction with management representatives conducted a
survey of the registered nurses at the Syracuse VA concerning the
effects that understaffing and floating had on their respective units.
Fifty percent of the respondents said they knew of injuries on
their unit that may have resulted from decreased staffing.
Seventy-two percent stated they were not able to take lunch or
other breaks on a daily basis. Ninety-one
percent said that they were not able to meet the 30-hour continuing
education requirements (this requirement has since been increased to
40 hours) because they had no time with 83% of that number stating
they were only able to complete 8 hours or less.
Eighty-eight percent of the respondents felt that their work
group had the potential to produce better work.
These are very sad statistics.
Each and every one of these issues can and does effect patient
care to some degree. This survey was done in the first quarter of 2000
and these same conditions continue to persist. Although I have
highlighted the conditions at the Syracuse VA, the same problems
related to understaffing can be found at any VA hospital. The
VA does not allow its nurses to work permanent day shifts.
They must rotate to the evening and/or night shift.
Nurses can bounce from one shift to another.
Studies have also shown that this practice is not only
detrimental to a nurse’s health but also to their performance.
Community hospitals allow nurses to work permanent shifts and
in some cases will also provide permanent days off.
This allows nurses to have a life outside of the hospital and
allows them the ability to arrange for the care of their children,
schedule doctors’ appointments and do the things that most people
with a nine to five job take for granted.
The VA needs to meet these community standards as well.
If we do not we will continue to lose qualified nurses to area
hospitals. Medication
errors and be directly linked to inadequate staffing.
The VA should be commended for taking the lead in attempting to
prevent medication errors with the implementation of Bar Code
Medication Implementation (BCMA).
However, the demands that BCMA puts on the nurses must be
addressed. Initially,
users of BCMA require extensive training in order to access and use
the system. This training
is a continuous process as the system is frequently being updated. Currently, Version I software is being used but it will soon
be updated with Version II software that will include an IV package.
The training time for Version II for the “trainers” is
expected to be 40 hours (Version I was 23 hours).
The “trainers” bring back the information to their
respective hospitals and teach the staff nurses how to use the
software. Usually, the
nurses are given 4 hours of instruction to learn what the trainers
learned in 40 hours. This
training is usually conducted on the units where there are numerous
interruptions and distractions. Adequate
training is negatively impacted by the inability of nurses to leave
the floor for classroom training due to inadequate staffing. BCMA
requires additional staff to pass medications.
Prior to the implementation of BCMA, one nurse could pass
medications for 30 patients within the required timeframe.
BCMA requires 2 nurses to pass the same amount of medications
because the system is not user friendly and is cumbersome.
The software/hardware has been found to be unreliable and
frequently breaks down. Because
of this unreliability, it is necessary to document medications using
the traditional paper records while also using the BCMA system.
This system also has a negative impact on charge nurses as they
must also do double documentation. Medications
need to be verified on each patient in the computer and then the
orders must be transcribed to the paper medication administration
record. As a charge
nurse, it would take me approximately 3 hours to take off all of the
orders written during a shift. Since
the implementation of BCMA, that number is now closer to 6 hours. This
takes time away from assessing the patients and giving them the care
they require and deserve. BCMA
has essentially double the amount of work that both the medication
nurse and the charge nurse must do; yet staffing levels have not been
adjusted. Although BCMA
can reduce the number of medication errors made, it is also having a
negative impact on other aspects of direct patient care.
I believe that BCMA has the potential to become a very useful
tool to nursing and will prevent medication errors but we cannot
sacrifice other aspects of care in order to accomplish this.
Staffing must be increased in order to provide the kind of care
that veterans expect and deserve. VERA
(Veterans Equitable Resource Allocation) Funding has also negatively
affected staffing. VISN’s
are budgeted according to the number of patients that are seen each
year. Most VISN’s
function within budgetary restraints but some have found it necessary
to request supplemental increases for various reasons.
These supplemental increases are given at the expense of the
remaining VISN’s. VISN
2, which includes Syracuse, lost $2.9 million dollars this fiscal year
due to supplemental increases. These
budget cuts put an incredible strain on those VISNs that work hard to
reduce patient costs while at the same time increasing the number of
new patients utilizing the VA. The
VISNs that have been able to operate successfully within their budgets
are being punished for being fiscally responsible.
These budget cuts put restrictions on the ability to hire
additional staff, on the range of services provided to the veterans,
and in some cases can result in the reduction of beds or the closing
of wards. All VISNs
should be held accountable to operate effectively and efficiently
within their budget allocations.
If supplemental allocations are necessary then there should be
another mechanism in place to finance them rather than taxing VISNs
that have made the hard decisions in order to operate efficiently. Another
important aspect of understaffing is the increased risk for
occupational injuries and illnesses.
In the survey I discussed earlier, 50% of the nurses responding
reported a direct link between low staffing levels and increased
on-the-job injury rates. This
is supported by that latest data from the US Bureau of Labor
Statistics (BLS) that found that healthcare workers report a rate of
work-related injuries greater than that of construction workers,
farmers, miners, or manufacturing workers.
Nursing
as practiced in most healthcare facilities in the US is a very
physical job, requiring a lot of lifting.
Manually lifting patients is a difficult task even when
staffing is good, with reduced staffing it becomes immeasurably
harder. Injuries can and
do occur on a more frequent basis.
Perhaps this is why in one-third of all workplace
ergonomic-related injuries; the victim is a healthcare worker. The
most common injury is back strain which can result in lost time claims
(worker’s compensation) and/or light duty status. This puts an
additional burden on the remainder of the staff that now must also
pick up the duties of the injured nurse.
Although lift equipment is available, it is limited in numbers
and most lift equipment requires two nurses in order to be operated
safely. The minimum
staffing levels requires nurses to lift significantly more patients
each day, which increases the likelihood of injury.
These injuries are compounded by the aging workforce.
Yet
we know the solution. We know that lift teams using mechanical lifting and transfer
equipment can have a profound impact on reducing injuries to nurses
and other healthcare workers. One published study that looked at ten
hospitals found that such ergonomic programs can reduce the incidence
of back injuries by an average of 70%, reduce lost workdays by an
average of 90% and pay for themselves many times over by reducing
workers compensation costs by an average of 75%.
In
addition to back injuries, we are beginning to see more repetitive
motion injuries due to the increased use of computers in the
workplace. A nurse can
use a keyboard everyday day
between Bar Code Medication Administration, charting on patients and
verifying orders. Yet
most computer workstations are not properly designed, and therefore
cases of tendonitis and carpal tunnel injuries will only increase.
Although
I have concentrated my comments on the staffing crisis as it impacts
licensed nurses and quality care, the fact is many of the same
problems exist for nursing assistants and wage grade employees in our
VA health facilities. From
1995 to1999, there was a cutback in wage grade employees of 15%. Not only do support staff, such as housekeeping and dietary
workers, feel the stress resulting from understaffing, but it puts
additional burdens on nursing staff who must take time away from
critical patient care to do other tasks that should be done by
overworked service and maintenance staff. The VA should be
commended for instituting a safe needle program years before the
federal safer needle that passed last year.
However needlesticks continue to happen because the VA is not
evaluating and selecting the best “safer” needles due to their
increased costs. But what is the cost to the nurse that is infected
with hepatitis or HIV? One case of hepatitis C can cost up to
$750,000, and is the leading reason for liver transplants today.
The solution is the purchase of the best, not the cheapest,
safer needles. There are
safer needles on the market that retract the needle inside the syringe
immediately after the injection, virtually eliminating most
needlesticks and the associated health risks.
However, these are not available to my co-workers and me. On-the-job
assault is another leading threat facing nurses and other healthcare
workers. According to the
BLS, thirty-eight percent of all workers who are assaulted at
on-the-job are healthcare workers. The threat of violence is always present in hospitals as we
deal with agitated, confused, and intoxicated patients daily.
Where I work, due to understaffing, nurses has been required to
work alone on a locked psychiatric on several occasions. This not only
puts the other patients at risk, but it endangers nurses as well.
When staff request extra help they are usually told that there
is no other help available, and that there is no money in the budget
for overtime. Again the
nurse cannot refuse to work under these conditions but can only report
injuries after the fact. Having
addressed some of the serious staffing issues that exist throughout
the VA system, we would hope that this Subcommittee will use its
authority to explore these issues in more depth and take the necessary
legislative action that would result in improved quality care for our
veterans and in retaining and attracting more licensed nurses into the
VA system. Specifically,
SEIU urges that the VA:
Setting
system-wide nurse staffing standards that includes a prohibition on
mandatory overtime will go a long way to correcting some of the
workplace problems that are driving nurses away from the VA.
It would also ensure staffing levels that can result in better
quality patient care and fewer medical errors.
We are doing the veterans of our country, who have sacrificed
so much, a disservice by allowing understaffing to continue at the
present rate. We
do commend the Committee for recommending a budget that exceeds the
Administration’s proposed budget.
That fact is that the VA continues to lose ground because in
terms of adequate staffing for nurses, other health professionals, and
support staff funding for the VA has failed to keep up with medical
inflation. The VA should be funded at a higher level and we would hope
that the any increase in the medical care budget for the VA is
earmarked for staffing and for essential services that have suffered
some severe cutbacks. This includes mental and substance abuse
services, long-term care, and other specialized rehabilitative
services. In
the area of health and safety, SEIU recommends that 1.
To protect nurses and other healthcare workers from needlestick
injuries, the VA should amend their policies on the evaluation and
selection of safer needles to ensure that purchasing decisions are
based first and foremost on safety, not just on cost. 2.
To prevent the epidemic of back injuries, and until we have an
OSHA ergonomics standard, the VA should dramatically expand their
current pilot programs to implement the use of lift teams with
mechanical lifting and transfer equipment.
3.
To prevent on-the-job assault of their employees, the VA should
require that written workplace violence prevention plans be developed
and implemented at each VA facility. Finally,
I would like to address the issue of contracting out.
Last year Congress considered legislation to create a pilot
program that would have allowed certain veterans to receive inpatient
medical care at private sector hospitals.
To make matters worse the VA would pay the out-of-pocket costs
not covered by the veteran’s own health insurance.
This legislation did not pass.
SEIU is opposed to such efforts that would contract out medical
services that should continue to be provided by the VA.
Such efforts undermine the VA health system and sets a
dangerous precedent to further whittle away VA health services.
We must continue to support the specialized veterans’ health
care services that is the cornerstone of VA medical services.
Again, thank you for the opportunity to testify. I would be happy to take any questions. Back to Witness List |