- Contact the Committee

Good Morning Mr. Chairman, thank you for the opportunity to comment on
HR 4020 State Veterans’ Homes Nurse Recruitment and Retention of 2004 and HR 4231 The Department of Veterans Affairs Nurse Recruitment and Retention Act of 2004. I have also added my comments on HR 3849 Military Sexual Trauma Counseling Act of 2004.

Thank you for your interest in recruitment and retention of nursing personnel for services to America’s veterans. The insights gained as a professional nurse and experiences in academic nursing programs have been very helpful in my new position as Connecticut Commissioner of Veterans’ Affairs. Before addressing the particulars of the legislation suggesting the remedies for the shortage of nursing personal in veteran health care systems, it is important to acknowledge that this shortage is a symptom of a larger problem of the declining numbers of students entering the nursing field and the increased numbers of nurses eligible for retirement.

I believe this is the third “nursing shortage” I have encountered in my 38 years of nursing. Ten years ago, it was easy to predict that the bulk of the nursing population would “hit” retirement age in the early years of the 21st Century. Indeed, general shortages in most health professions have continued unabated for some time. The difficulties in recruitment and retention of nursing staff are not exclusive to the Veteran Health Care System. However as the largest health care system in the Nation, it is unwise to overlook the dynamics this drain on the nursing profession has on our discussion today. Nurses and care givers at the patient’s side are the backbone of America’s health care delivery systems system and a national resource that needs to be nurtured and enhanced. Problems associated with the increasing nursing crisis merit the attention of Congress and all providers of health care. The dynamics of the basic problem do influence the success any proposed legislative measures may suggest to help the US Department of Veterans Affairs and State Veteran Homes.

Recently, Dean Catherine Gilliss of Yale School of Nursing and member of the Leadership and Policy Work Group on the Future of Nursing in Connecticut identified the salient points of the situation. In CT, the shortage is estimated to be among the worst in the nation. By 2020, it is estimated that the demand for nurses will outstrip supply by 808,000 RNs in our state. This ranks Connecticut as the fifth worst case scenario in the nation. The average age of CT's RN work force is 45 years, and few replacements are in the educational pipeline for the anticipated retirements. By 2020, the CT population will be older and there will be a significant shortage of nurses to care for the aging population.

The national shortage is the result of several intersecting causes:

1. Fewer entries into the profession of nursing

2. A significant shortage of faculty to prepare new nurses, even where
applicant pools are increasing;

3. The absence of clinical sites for training new nurses

4. The loss of prepared nurses from the work force, secondary to the demands of the work environment (e.g., increased pt. acuity; shorter pt. stays; limited scope of work and focus on administrative rather than clinical work.

5. Lack of participation in clinical decision-making and institutional governance.

Contributing to the problem in Connecticut is the significant lack of qualified faculty. In our state, Deans and Educational Program Directors believe this is among the most important leverage points for solving the nursing crisis. The Deans and Directors have begun to develop job sharing for faculty and pooling the incoming expressions of interest in the many open faculty positions throughout the state's programs. In fact, they are exploring alternative approaches to preparing nurses to serve as faculty so that they can open their doors to additional students. Teacher preparation is a priority. That same group is now developing an education master plan for nursing that will take into consideration the work force demands and supply to plan the enrollments and resources needed for the educational programs. The Connecticut Nursing Career Center was initiated to guide those interested in nursing toward programs and a Connecticut Career Ladder Program is assisting those who are prepared at the entry levels in health careers (e.g., CNAs and LPNs) to accomplish educational articulations to advance their careers.

“Veterans Homes Nursing Care at the Crossroads”

Nearly 32,000 veterans rely on long term care provided by 128 state veterans’ homes. VA considers the relationship between States and the federal program to be a “partnership”, which in fact exists in the per diem payments and the State Veteran Home Construction program. For example the national average cost per diem for a State is $171.85, which is offset by a payment of $57.78 for nursing home and hospital care and $27.19 for domiciliary care. A case has been made that many veterans in State Homes would be eligible for full support (veterans with Service Connected Disabilities (SCD) rated 70 or greater or who require nursing home care for their SCD) should be reimbursed at the rate any other nursing home in the state would receive $170/day. VA General Counsel has ruled that because
State Homes were constructed using VA dollars the greater rate of reimbursement does not apply. I would point out that Rocky Hill Veterans Home was not built with VA dollars. We are on the list for much needed assistance from the VA State Home Construction program. I believe the General Counsel ruling is pejorative to States, like Connecticut who took the initiative to serve veterans before the Home Construction program began.

Some of the same root causes of the national nursing shortage were also identified in the recent “Veterans Homes Nursing Care at the Crossroads” (2002-2003), which was a survey conducted by the Armed Forces Veterans Homes Foundation with support from the Kellogg Foundation. Namely the demands of the workplace with respect to the great burden of workload, acuity levels among residents, inadequate time to care for veterans, uncertain work schedule, lack of professional development opportunities, inadequate support and respect and low pay. Interestingly, benefits were cited as a positive feature in State Homes.

Just as all politics are local, there are variations in needs and solutions to the question of adequate nursing personnel to care for veterans. My first suggestion is that this is a “systems issue”. You may know that the State of Connecticut Department of Veterans’ Affairs is making a concerted effort to avoid duplicating the services and programs of VA Connecticut with the idea in mind that we could create a seamless continuum of care for the veterans in our state. This “Partnership” extends from referrals of eligible veterans among the agencies and shared resources like transportation and
Staff development opportunities.

HR 4020 offers relief in the form of grants to State Homes to effect incentives programs, including scholarships to reduce the nursing shortages. There are advantages to the implementation of such a program. At the same time, Hr 4231 suggests a “pilot program” to study innovative recruitment tools, including measures which would relieve pressures of the workplace and make VA Nursing more attractive with provisions to relieve the shortage by appointing nurses who do not have a Baccalaureate to positions in the VA.

I think it is important to say “headhunters” or professional recruiters are sometime not the answer. Career advancement and investment in educational opportunities are very attractive especially with the costs of preparing nurses in undergraduate and graduate programs. VA once attracted nurses by offering tuition assistance and a stipend as well as opportunities for part time work while attending school. In return nurses acquired an obligation to work for VA on a scale commensurate with the investment made in the educational support of the nurses. This program was attractive in recruiting and retaining nurses in the VA.

My response to the State Veteran Home is that it is hard to generalize the needs of each of these programs. I do, however, believe that the program seems hard to implement. It is important to say that Connecticut and other states have spent time studying the problems and are in the process of implementing changes. Not all states have given the problems this amount of consideration. I would suggest criteria for this program developed by both VA and State Veteran Homes to assure the best investment of time and funding.

HR 3849 Military Sexual Trauma Counseling Act of 2004
As you may remember, I served as Chairman of VA’s Advisory Committee on Women Veterans. I have been asked to testify several times on this same issue and could not pass up this opportunity to stress the importance of making this program permanent. Unfortunately sexual trauma associated with military service is not going to go away. As long as we have military members living and working in communities they are going to experience the same difficulties as any community. This program has been in place since the early 90’s in VA and the training and start up costs were absorbed long ago. Putting this program up for “sunsetting” as long as it is being used does not make sense. I urge the Committee to put an end to these pilgrimages and require VA to make it a permanent program for veterans.

SUMMARY
Most importantly some of the measures needed to recruit and retain nurses in any system cannot be legislated or funded. Respect for the work of nurses in our State Homes and VA facilities must come from the top down and must be tracked. Adequate scheduling of overtime demands all pivot on adequate funding of the programs to begin with. State Homes relieve VA of having to construct new long term care beds. They are cost effective because operational costs are the burden of the State. Recently, increases in VA per diem were made. For veterans in the domiciliary programs it was and increased from $26.95 to $27.19 an increase of $0.24 What can you buy for $0.24 in America today? And, what message did this send us and our veterans?