- Contact the Committee

Mister Chairman, Members of the subcommittee, thank you for giving me the opportunity to address you here today regarding the impact of the nursing shortage on the Department of Veterans Affairs.

The American Nurses Association (ANA) is the only full-service association representing the nation’s 2.7 million registered nurses through its 54 constituent member associations. The ANA recognizes that the first VA nurses have served the needs of the veterans of the Spanish-American War and have continued that tradition of outstanding service to our nation’s veterans. Today, the Veterans Health Administration is the largest employer of registered nurses in the world and serves as a model in the delivery of health care within today’s tight fiscal environment.

Nurses are the foundation of the health care system-providing preventive, acute and long-term care across the lifespan. Nurses are at the bedside, 24/7. Quality of care for our veterans will not improve without nurses’ active involvement in policy development and implementation strategies.

America is experiencing a crisis in nurse staffing. Health care providers across the nation are having difficulty finding experienced RNs that are willing to work in their facilities. Areas hardest hit include emergency room, critical care and long term care. Projections show that the situation will only get worse.

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 looming health care needs of the baby boom generation. As we gather here today, the U.S. is experiencing a nurse staffing crisis and a growing shortage of registered nurses. A report, last year, by the U.S. Department of Health and Human Services says that we already are facing an RN shortage of more than 136,000 nurses in this country. This is a 7 percent RN shortage. By the year 2020, the HHS report estimates this country will be short of more than 808,000 RNs. Translated, this is a staggering 29 percent nurse shortage.

However, as farsighted as the VA can be in terms of improving nurses’ working conditions, changes to the health care delivery system and its program have diminished the VA’s ability to attract and retain the best and the brightest.

The Department of Veterans Affairs is experiencing a shortage of nursing personnel similar to national trends and if the available supply of nursing personnel remains constant, the ability of Veterans Health facilities to meet the health care needs of veterans will be adversely affected. The Veterans Health Administration (VHA) provides inpatient, outpatient and home care across various settings. Over the last decade, VA implemented a substantial restructuring of its health care delivery system. Veterans Health Administration (VHA) moved to a community-based system delivering primary care. According to VA records for the calendar year ending December 31, 2002, there were 162 VA hospitals, 137 nursing homes, 681 community clinics, 11 mobile clinics and 43 domiciliaries. VHA reported over 550,000 admissions. During the same period, more than 49 million outpatient visits were reported (Department of Veterans Affairs, 2002). VHA patient workload continues to rise in the midst of a growing nurse shortage.

In response to this anticipated shortage, the VA has established a task force to focus specifically on nursing workforce planning. The National Commission on VA Nursing was established through P.L. 107-135 and was charged to:

1) Consider legislative and organizational policy changes to enhance the retention of nurses and other nursing personnel by the Department of Veterans Affairs.
2) Asses the future of the nursing profession within the Department.
3) Recommend legislative and organizational policy changes to enhance the recruitment and retention of nurses and other nursing personnel in the Department.

The Commission held four field hearings across the country last year and received hundreds of witnesses who spoke on ways to improve nursing in the VA. Dozens of VA nurses advocated for changes in the way the VA does business in order to remain an “employer of choice” by nurses.

The Commission will submit its final report to the Secretary of the Department of Veterans Affairs in May of 2004 with specific legislative and organizational recommendations to assure the availability of a qualified nursing workforce to meet the needs of America’s veterans. The ANA looks forward to the release of this report and working with the Veterans Affairs Department to achieve their goals for nursing.

While the VHA is a leader in providing quality care, supporting nursing research and advocating on behalf or its nurses, lack of nursing staff at the VA has had a devastating impact on the delivery of quality of care to our veterans. From September 1995 to September 2000, the VA cut RN positions nationwide by 10 percent. These cuts are in contradiction to research findings last fall in the Journal of the American Medical Association that found RN staffing levels had a significant impact on preventable hospital deaths among surgical patients. Lack of staff to provide support services (Ward Secretaries, Escort Services, Lab, Janitorial Services) has further reduced effective patient care by shifting work to an already depleted clinical staff. The training of medical and nursing students also suffers because current staff has little time or energy to provide students with review and feedback crucial to their education as health care professionals.

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. While some issues regarding nurse recruitment and retention were addressed with the Nurse Reinvestment Act, many issues remain that relate to the RN work environment. I would like to highlight some key future strategies that deal directly with the nurse shortage:

HEATH & SAFETY

The American Nurses Association conducted an on-line health and safety survey in August, 2001. A total of 4, 826 nurses participated in the survey. The respondents represented a broad cross section of nurses with extensive frontline nursing experience-70% had worked more than 10 years as a nurse and 61% spend more than half their time engaged in direct patient care activities. I would like to highlight just a few key findings regarding workplace health and safety concerns.

Eighty-eight percent (88%) of the nurses’ respondents reported that health and safety concerns influence their decisions to continue working in the field of nursing as well as the kind of nursing they choose to perform. Eighty-three percent (83%) of nurse respondents continue working despite experiencing back pain. Over three-quarters of the nurses surveyed (76%) indicated that unsafe working conditions do, in fact, interfere with their ability to deliver quality care.

The Department of Veterans Affairs has been historically viewed as a stable, secure and desirable workplace for potential employees. Just a few weeks ago, the American Nurses Association launched a proactive, multi-faceted campaign aimed at promoting safe patient handling and preventing musculoskeletal disorders (MSD) among nurses. The campaign aims to stem the nation’s growing nursing shortage by reducing the number of nurses who are leaving the field because of unsafe lifting practices and resulting back pain. This campaign will be launched with a Safe Patient Handling Conference, to be held at the Tampa Veterans’ Health Administration Patient Safety Center of Inquiry and the University of South Florida in March of 2004. The ANA has partnered with Audrey Nelson, PhD, RN, FAAN, director of the Tampa Veterans’ Health Administration Patient Safety Center of Inquiry, in implementing the goals of the campaign.

OVERTIME

Nurses across the nation are expressing deep concern about the dramatic increase in the use of mandatory overtime. ANA hears that overtime is the most common method facilities are using to cover staffing gaps. Employers may mandate that a nurse work an extra shift (or more) or face dismissal, 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 care of our veterans.

We know that sleep loss influences several aspects of performance, leading to a 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 add 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 the demands of overtime. Ethical nursing practice prohibits nurses from engaging in behavior that they know could harm their 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 the American Nurses Association supports legislative initiatives to limit the use of mandatory overtime. Federal laws and regulations set maximum hours in the interest of public safety for airline pilots, train engineers and truck drivers. Shouldn’t we afford the same precaution for our patients in our VA hospitals?

The VHA has continued the antiquated practice of rotating staff instead of hiring permanent tours of duty. This practice does not allow staff to be creative in their scheduling to accommodate work and family and personal obligations.

In order to minimize the use of mandatory overtime, floating nurses from one unit to another has become a standard practice. If other units have sick calls or increased acuity, then nurses will be floated to that unit. Nursing has become specialized and although nurses are all taught the same basic curriculum in school, once they begin working to hone certain skills their knowledge base in some other areas may not render current with changes in practice. Therefore, a registered nurse should not be assigned to work in a particular unit without first having established the ability to provide professional care in that unit.

STAFFING

Mandatory overtime is a symptom of a larger problem, inappropriately low nurse staffing. The American Nurses Association has long held that the safety and quality of care provided in the nation’s health care facilities are directly related to the number and mix of direct 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 they are more nurses, there are lower mortality rates, shorter lengths of stay, better care plans, lower costs, and fewer complications. Four HHS agencies recently sponsored a study on this very topic. The resulting report (Nurse Staffing and Patient Outcomes in Hospitals, released in April 20, 2001) found strong and consistent 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 nursing staff and patient outcomes, several studies have shown that one of the primary factors for the increasing nurse turnover rate is dissatisfaction with workload/staffing. The American Nurses Association’s 2001 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 the nearly 7,300 respondents, over 5,000 nurses cited inadequate staffing as a major contributing factor to the decline of quality of care. More than half of the respondents believed that the time they had 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 the 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 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.

The development of nurse staffing guidelines has always been a sensitive topic to bring up. Nurses provide the front line of patient surveillance, monitoring patients’ conditions, detecting problems and initiating life-saving interventions.

The American Nurses Association Magnet hospital program has had a proven success in raising the standards of nursing practice and improving patient outcomes.

In 2002, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) released a report on the nursing shortage that recommended that facilities adopt the characteristics of Magnet hospitals to foster a workplace that empowers and is respectful of nursing staff.

A growing body of research indicates that the Magnet program is making a positive difference for nurses, its patients and employers. For example, studies indicate that patients experience lower mortality rates, shorter lengths of stay and increased satisfaction in Magnet facilities, while nurses also have increased satisfaction, as well as increased perceptions of productivity and the quality of care given. Employers benefit too, as studies indicate that Magnet facilities have lower incidence of needlestick injuries, lower nurse burnout rates and higher retention rates, increased ability to attract new nurses, and higher JCAHO scores. Average nurse retention at Magnet hospitals is twice as long as that of non-Magnet facilities.

The first Magnet hospital, the University of Washington was designated in 1994. Today, there are 85 organizations that are designated Magnet hospitals in the United States and England, including the James A. Haley Veterans’ Hospital in Tampa, FL.

Characteristics of a Magnet facility include:

• Strong administrative and organizational support for nursing practice
• Adequate nurse staffing
• Strong nurse-physician communication and relationships
• Nurse autonomy and accountability
• Control over nursing practice and practice environment
• Paramount focus on the patient and patient’s family


Magnet hospitals are living evidence that creating professional nursing practice environments is the solution to the flight of nurses from hospital practice.

EDUCATION

The VA has been a leader in providing nurses the incentive and opportunity to advance their education and improve patient care. Through the Nurse Qualification Standards and the National Nursing Education Initiative (NNEI) the VA has created a “career ladder” program for its nursing workforce. The VA has committed significant resources to nurses seeking to advance to their next level of their nursing career. The National Nursing Education Initiative (NNEI) program awards tuition support to nurses to obtain their baccalaureate or post-graduate degrees and training. The average awardees receive $11,000 in tuition assistance. The latest NNEI program statistics indicate that there are 2,702 total participants with 61% enrolled in a baccalaureate program. Nursing is a knowledge-based profession. The ANA has always maintained that nurses have a responsibility for lifelong learning and works to make higher education accessible to both new students and practicing nurses.

The Department of Veterans Affairs approved new Nurse Qualification Standards on November 10, 1999. These standards define the performance and education requirements for a RN to be appointed and promoted within the VHA. The development and implementation of the new standards involved numerous parties including the American Nurses Association. The Nurse Qualification Standards create a framework for advancement and appointment based on the education and practice requirements of the veterans health care system. These standards ensure that RNs are educated to provide the highest quality health care to our veterans, but are flexible enough to recognize and reward performance. This new standards 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 VA has changed in its delivery of health care, and I am proud to say that the VA nurses have adopted new roles for meeting these changing needs. However, the role of a registered nurse as the direct care giver for patients needs to remain regardless of changes in the VA healthcare system and with all due respect to the advances in medical technology it is the nurse, at the bedside, whose expertise will determine the patient’s outcome. For the VA to remain an “employer of choice” it must continue to recognize the professionalism of nurses.