[Senate Hearing 107-150]
[From the U.S. Government Publishing Office]
S. Hrg. 107-150
FINDING A CURE TO KEEP NURSES ON THE JOB: THE FEDERAL GOVERNMENT'S ROLE
IN RETAINING NURSES FOR DELIVERY OF FEDERALLY-FUNDED HEALTH CARE
SERVICES
=======================================================================
HEARING
before the
OVERSIGHT OF GOVERNMENT MANAGEMENT,
RESTRUCTURING, AND THE DISTRICT OF COLUMBIA
SUBCOMMITTEE
of the
COMMITTEE ON
GOVERNMENTAL AFFAIRS
UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION
__________
JUNE 27, 2001
__________
Printed for the use of the Committee on Governmental Affairs
75-471 U.S. GOVERNMENT PRINTING OFFICE
WASHINGTON : 2002
____________________________________________________________________________
For Sale by the Superintendent of Documents, U.S. Government Printing Office
Internet: bookstore.gpr.gov Phone: toll free (866) 512-1800; (202) 512�091800
Fax: (202) 512�092250 Mail: Stop SSOP, Washington, DC 20402�090001
COMMITTEE ON GOVERNMENTAL AFFAIRS
JOSEPH I. LIEBERMAN, Connecticut, Chairman
CARL LEVIN, Michigan FRED THOMPSON, Tennessee
DANIEL K. AKAKA, Hawaii TED STEVENS, Alaska
RICHARD J. DURBIN, Illinois SUSAN M. COLLINS, Maine
ROBERT G. TORRICELLI, New Jersey GEORGE V. VOINOVICH, Ohio
MAX CLELAND, Georgia PETE V. DOMENICI, New Mexico
THOMAS R. CARPER, Delaware THAD COCHRAN, Mississippi
JEAN CARNAHAN, Missouri ROBERT F. BENNETT, Utah
MARK DAYTON, Minnesota JIM BUNNING, Kentucky
Joyce A. Rechtschaffen, Staff Director and Counsel
Hannah S. Sistare, Minority Staff Director and Counsel
Darla D. Cassell, Chief Clerk
------
SUBCOMMITTEE ON OVERSIGHT OF GOVERNMENT MANAGEMENT, RESTRUCTURING, AND
THE DISTRICT OF COLUMBIA
RICHARD J. DURBIN, Illinois, Chairman
DANIEL K. AKAKA, Hawaii GEORGE V. VOINOVICH, Ohio
ROBERT G. TORRICELLI, New Jersey TED STEVENS, Alaska
THOMAS R. CARPER, Delaware SUSAN M. COLLINS, Maine
JEAN CARNAHAN, Missouri PETE V. DOMENICI, New Mexico
MARK DAYTON, Minnesota THAD COCHRAN, Mississippi
Marianne Clifford Upton, Staff Director and Chief Counsel
Andrew Richardson, Minority Staff Director
Julie L. Vincent, Chief Clerk
C O N T E N T S
------
Opening statements:
Page
Senator Durbin............................................... 1
Senator Cleland.............................................. 4
Senator Voinovich............................................ 4
WITNESSES
Wednesday, June 27, 2001
Rachael Weinstein, RN, Director, Clinical Standards Group, Office
of Clinical Standards and Quality, Centers for Medicare and
Medicaid Services, U.S. Department of Health and Human
Services, accompanied by Thomas Hoyer, Director, Chronic Care
Purchasing Policy Group........................................ 7
Denise H. Geolot, Ph.D., RN, FAAN, Director, Division of Nursing,
Bureau of Health Professions, Health Resources and Services
Administration, U.S. Department of Health and Human Services... 8
Rear Admiral Kathleen Martin, Nurse Corps, Director, Navy Nurse
Corps, U.S. Navy............................................... 11
Janet Heinrich, Director, Health Care--Public Health Issues, U.S.
General Accounting Office...................................... 13
Ann O'Sullivan, MSN, RN, President, Illinois Nurses Association,
on behalf of the American Nurses Association................... 26
Gary A. Mecklenburg, President and Chief Executive Officer,
Northwestern Memorial Hospital, Chicago, Illinois, on behalf of
the American Hospital Association.............................. 29
Carol Anne Bragg, RN, President, Professional Staff Nurses
Association SEIU Local 998, on behalf of the Service Employees
International Union............................................ 31
Hon. Lynn Martin, Chair, Panel on ``Future of the Health Care
Labor Force in a Graying Society,'' accompanied by Mary Jo
Snyder, Director, The Nursing Institute, University of Illinois
at Chicago, College of Nursing................................. 35
J. David Cox, RN, Vice President, National Veterans Affairs
Council, American Federation of Government Employees, AFL-CIO.. 37
Alphabetical List of Witnesses
Bragg, Carol Ann, RN:
Testimony.................................................... 31
Prepared statement with an attachment........................ 129
Cox, J. David, RN:
Testimony.................................................... 37
Prepared statement........................................... 152
Geolot, Denise H., Ph.D., RN, FAAN:
Testimony.................................................... 8
Prepared statement........................................... 58
Heinrich, Janet:
Testimony.................................................... 13
Prepared statement........................................... 94
Martin, Hon. Lynn:
Testimony.................................................... 35
Prepared statement........................................... 142
Martin, Rear Admiral Kathleen:
Testimony.................................................... 11
Prepared statement with attachments.......................... 64
Mecklenburg, Gary A.:
Testimony.................................................... 29
Prepared statement........................................... 115
O'Sullivan, Ann, MSN, RN:
Testimony.................................................... 26
Prepared statement........................................... 107
Weinstein, Rachael, RN:
Testimony.................................................... 7
Prepared statement........................................... 49
Appendix
Prepared statements submitted for the record:
Brigadier General Barbara Brannon............................ 73
Brigadier General William T. Bester.......................... 85
Diane Sosne, Service Employees International Union, AFL-CIO.. 136
FINDING A CURE TO KEEP NURSES ON THE JOB: THE FEDERAL GOVERNMENT'S ROLE
IN RETAINING NURSES FOR DELIVERY OF FEDERALLY-FUNDED HEALTH CARE
SERVICES
----------
WEDNESDAY, JUNE 27, 2001
U.S. Senate,
Subcommittee on Oversight of Government Management,
Restructuring, and the District of Columbia,
of the Committee on Governmental Affairs,
Washington, DC.
The Subcommittee met, pursuant to notice, at 10:02 a.m., in
room SD-342, Dirksen Senate Office Building, Hon. Richard J.
Durbin, Chairman of the Subcommittee, presiding.
Present: Senators Durbin, Cleland (ex officio), and
Voinovich.
OPENING STATEMENT OF SENATOR DURBIN
Senator Durbin. Welcome to this hearing of the Oversight
Subcommittee of the Committee on Governmental Affairs and my
first hearing as Chairman, so please forgive me as I learn how
to do this. I have usually been listening to gavels, and now I
am banging one, so it is a little different role for me to
play. I know that some of my colleagues are on their way to
join us for this hearing this morning, and I thank all of you
for joining us this morning.
This is a hearing that we have decided to kick off our
Oversight Subcommittee with on the subject of the nursing
shortage which faces our country. The Federal Government has an
important role in retaining nurses for the delivery of
federally-funded health care services and other services.
We have to face the possibility that America may ring for a
nurse some day, and no one will respond. As our population gets
older and fewer nurses are graduated and fewer stay in the
profession, that is a very real possibility.
The issue and challenge for us is what we can do today to
address this problem, and you will hear from witnesses on both
panels that there are things that need to be done.
This issue defies any easy solutions. There is no magic
switch that we can flip or handy button that we can push that
will solve it. We have nearly half a million trained nurses in
America who are no longer practicing their profession. In my
home State of Illinois, over 19 percent of nurses are no longer
working as nurses.
When I talk to nurses, including relatives of mine who are
nurses, they tell me they are burned out, exhausted because of
inadequate staffing levels; they are being asked to do double
shifts and are unable to balance their nursing responsibilities
with their personal and family commitments. I know that many
nurses feel that all of the problems of our current health care
system, including its finances, are being forced upon them, and
it is really just too much to ask.
If their daughters or sons were to contemplate a career in
nursing, many say they would advise against it--not because
they do not love caring for patients, but because of all the
stresses that are brought to bear on them today with inadequate
compensation.
Since 1992, wages for nurses after inflation have risen by
less than 1 percent. But managed care has pushed the finances
of our hospitals to a near breaking point. This leaner face of
health care is described by many nurses as both leaner and
sometimes meaner.
A recent survey by the Federation of Nurses and Health
Professionals found that half of the current employed nurses
surveyed had considered leaving the patient care field for
reasons other than retirement over the past 2 years. Of those
thinking about leaving, 56 percent indicated that they wanted a
less stressful and physically demanding job; 22 percent said
they were concerned about the schedules and hours; and 18
percent sought higher pay. Annual turnover rates among hospital
staff nurses have increased to 15 percent, up from 12 percent
in 1996. A recent survey of nursing home chains found turnover
among RN's and LPN's to be over 50 percent.
The situation is even more drastic in some of our Nation's
poorest rural and inner city communities. They may soon have
inadequate or no hospital health care because finding nurses
who are willing to work in their neighborhoods is almost
impossible. Some of these hospitals operate amid the harshest
poverty and crime in our country. The employees of these
hospitals often treat the worst and most troubling cases.
I recently supported the effort of a hospital in Chicago
that was desperate for nurses to try to find some way to change
the immigration law to deal with the issue. But generally,
immigration is not a long-term solution to the underlying
problem of poor workplace conditions and in some instances
actually threatens patient safety, and at the very least drives
more and more professionals away from the caring profession of
nursing.
Last year, The Chicago Tribune ran a three-part series on
medical errors caused by nurses. It was an eye-opener. And the
Institute of Medicine released a sentinel report on medical
errors throughout the health care system, reporting that
annually, we might have almost 98,000 deaths due to medical
errors. This can only be described as alarming and really
points to the need to overhaul our health care system.
We will be hearing from several nurses today about the
conditions under which they work which contribute in many cases
to a less than safe environment for patients. I was shocked to
learn recently that most nurses now work shifts of 10 to 12
hours and that some are forced to work double shifts even when
they are exhausted. How could a 20-hour day be safe for
patients, let alone good for a nurse or his or her family? I
will be very interested to hear from some of the nurses who are
here today to testify as to how they deal with the care of
their children and other family members if their schedule can
be forced to change without notice.
If you think the situation is bad now, wait until we get to
2010. The nursing work force is aging just like the overall
U.S. population is aging. Fewer and fewer young people are
going into the career of nursing just as we move to a time when
we need nurses more and more.
I had a recent visit from a head nurse in a nursing home in
the Chicago area, and she told me a story which was incredible.
She said, ``I have been at this all my life''--she is about 60
years old--``I love nursing, and I love working with nurses. I
recently had a surgery scheduled at a major hospital in
Chicago, and before I went in for that surgery, I hired a
private nurse to come with me.''
It almost takes your breath away to think that that is a
possibility. It really suggests that if we do not address this,
we may reach a stage where we are dealing with graduated health
care even within our hospitals. Who can afford to bring their
own nurse or their own doctor to make sure they get the care
they think they need? And certainly, when it comes to nursing,
if this nurse, who has dedicated her life to it, thought she
needed a private nurse to be by her bedside in a major hospital
in Chicago, that is worrisome for all of us.
I have a chart here which shows the distribution of nurses
in 1980 and then in the year 2000. If you took your statistics
course, you can probably follow this a little more carefully.
What it shows us is that the average age of nurses is 45 today;
it was 37 in 1983.
A comprehensive approach is needed not only to attract more
young people but also to improve the work environment.
Retention is just as important as recruitment. I will be
introducing a comprehensive bill to address the nursing
shortage. It will focus on outreach to young people to
encourage them to think about careers in nursing and other
caregiving professions; scholarships and loans for those who
serve in underserved areas, be they urban or rural; and
financial incentives to address inadequate staffing levels that
put the public in danger. The bill will also provide additional
educational opportunities to those who are in the process of
transitioning to the work force as the welfare reform bill is
fully implemented.
But beyond recruitment and training, we really cannot solve
this problem without looking at workplace conditions. Spending
money on recruitment and training is wasted if health
professionals quit early because they cannot live with the
excessive hours, work load, and stress. We have rules in many
other public safety-oriented professions. For instance, the
Federal Government does not allow pilots to work continually.
We have limits on truck drivers and train engineers. Shouldn't
we also give protections to nurses so they are not forced to
work hours that put them and their patients in danger due to
fatigue?
Many other countries are experiencing similar demographic
changes and are challenged to meet their own health and long-
term caregiving needs. It is not at all clear that immigration
can solve this problem given the global need for more
caregivers.
As I said earlier, the issue defies easy solutions.
However, what is clear is that we need to invest more
significantly in recruitment, education, and retention if we
are to address this long-term need.
At this point, I would like to recognize the ranking member
of the Subcommittee, Senator Voinovich.
OPENING STATEMENT OF SENATOR VOINOVICH
Senator Voinovich. Thank you, Mr. Chairman.
I am pleased that the Subcommittee is holding this hearing
today to examine the nursing shortage in the United States and
how it is impacting federally-funded health care programs.
I would like to welcome our two panels of witnesses and
thank them for being here today.
As you know, Mr. Chairman, over the past 2\1/2\ years, the
Subcommittee has conducted a thorough examination of the human
capital crisis confronting the Federal Government's work force.
In profession after profession, the story is the same: A lack
of skilled people, an aging work force, or both.
It would seem that this is a similar problem in the nurse
work force--and not just those who work for the Federal
Government or through federally-funded programs. Just as the
average age of Federal employees has risen over the years,
today's average registered nurse is 45 years old, up from 37 in
1983. This increase has taken place at the same time that the
average age of Americans has risen.
With people living longer, the need for quality health care
professionals will only increase with time. Exacerbating the
problem is the fact that hundreds of thousands of nurses are no
longer working in the field of nursing, and the number has
increased 11 percent in the last 4 years. It will be
interesting to discuss why that is and if there is a
correlation with the fact that during the same period of time,
nursing wages have remained stagnant, rising approximately 1
percent.
Mr. Chairman, we have two excellent panels of witnesses
with us today. I am especially pleased to welcome Rear Admiral
Kathleen Martin. As you know, Mr. Chairman, last year, Congress
passed legislation that I sponsored to provide work force
reshaping authorities in the Department of Defense. I will be
interested in hearing Admiral Martin's testimony on what is
being done to address the nursing shortage in the Armed Forces.
Thank you again, Mr. Chairman, for holding this hearing,
and I look forward to the witnesses' testimony.
Senator Durbin. Thank you, Senator Voinovich.
Senator Cleland.
OPENING STATEMENT OF SENATOR CLELAND
Senator Cleland. Thank you very much, Mr. Chairman, and
Senator Voinovich. It is nice to be with you, my dear
colleagues, today, focusing on the nursing shortage and the
challenge of being a nurse in America today.
I might say first off that nurses helped save my life. I
would not be here were it not for nurses. The second person to
me on the battlefield, Admiral Martin, was a Navy corpsman, and
one of the first hospitals I was evacuated to was the Navy
hospital in Danang. So I have a special appreciation for
nurses, especially Army dust-off pilots, Army medics, Navy
medics, and Air Force medivac teams. So I want you to know that
I am here today because of nurses and a whole complement of
people who go out there and do an incredible job.
I again commend my colleague Senator Durbin and other
Subcommittee Members for today's hearing on the critical role
of nurses, particularly in the Federal health care system. I am
a former head of the Veterans Administration, and I know the
critical role that nurses play there.
In the Federal health care system, we have military and
Veterans Affairs nurses. They are not only life-sustaining
givers of care but also givers of hope. As someone who was in
the military and VA health care system for more than a year and
a half, I can certainly attest to that.
When I meet with health care groups from Georgia and across
the Nation, the increasing need for nurses is always part of
the discussion. At the June 14 Senate Veterans Affairs
Committee hearing on the looming nursing shortage, I emphasized
an alarming statistic--that the Federal health care sector,
employing approximately 45,000 nurses, may be the hardest hit
in the near future, with an estimated 50 percent of its nursing
work force eligible for retirement by the year 2004--almost 50
percent of the nursing work force in the Federal Government and
in the military eligible for retirement in 2004.
Current and anticipated nursing vacancies in all health
care settings are attributed to a variety of factors, including
more career choices for women and worsening workplace
conditions with mandatory overtime and increasing patient care
work loads. It sounds a little bit like what they said when I
was in the Army, that ``Good duty is rewarded with more duty.''
I think our nurses in America are in that position.
I believe that today we are really facing more widespread
and complex challenge with the nursing shortage. There are no
quick fixes, but I do think that part of the key to developing
legislative initiatives and understanding this complex issue is
the testimony we are going to hear today from our panelists. I
think it is crucial that we have nurses recommend to us how
they can take safe and effective care of their patients and for
us to assist health care facilities in recruitment and
retention of qualified nurses.
One answer that I have is some legislation that I have
introduced, S. 937, which is a bill to amend Title 38 of the
U.S. Code to prevent members of the armed services to transfer
their Montgomery GI bill educational benefits to spouses and
children, and that assistance could be used for undergraduate
or graduate nursing education. It is an effort to retain
service men and women, but it is also an effort to keep spouses
and children in the military with their spouses and to give
them an educational opportunity as well, and give them hope.
I have also introduced S. 1080, the Federal Nurse
Retirement Adjustment Act, which will allow Federal nurses in
the Federal Employee Retirement System to retain unused sick
leave and retirement calculations comparable to nurses
currently in the civil retirement system.
I urge my colleagues to carefully consider the testimony of
today's witnesses as they develop initiatives to help recruit
and retain qualified nurses.
Thank you all very much for being with us.
Thank you, Mr. Chairman.
Senator Durbin. Thank you, Senator Cleland.
I would first like to introduce two people who will not be
testifying on the first panel, but I want to acknowledge their
presence and thank them for joining us.
Brigadier General Barbara Brannon \1\ is commander of the
89th Medical Group at Andrews Air Force Base. Thank you for
being with us today. She is the Assistant Air Force Surgeon
General for Nursing.
---------------------------------------------------------------------------
\1\ The prepared statement of Brigadier General Barbara Brannon
appears in the Appendix on page 73.
---------------------------------------------------------------------------
And Brigadier General William T. Bester \1\----
---------------------------------------------------------------------------
\1\ The prepared statement of Brigadier General William T. Bester
appears in the Appendix on page 85.
---------------------------------------------------------------------------
Colonel Gustke. He is not here today, Mr. Chairman.
Senator Durbin. Could you introduce yourself, please?
Colonel Gustke. I am Colonel Deborah Gustke. I am the
Deputy Chief of the Army Nurse Corps, sir, representing General
Bester.
Senator Durbin. Thank you very much for joining us today.
I will now introduce the panel that will testify first.
Rachael Weinstein is a registered nurse and Director of the
Clinical Standards Group at the U.S. Department of Health and
Human Services.
Dr. Denise Geolot is a registered nurse and Director of the
Division of Nursing at the U.S. Department of Health and Human
Services. She administers the Federal program that enables
national nursing work force development.
Admiral Kathleen Martin joins us from the United States
Navy. She will deliver testimony on behalf of the Tri-Service
Nurse Corps. She is a Rear Admiral and Director of the Nurse
Corps.
Janet Heinrich is Associate Director of the Health,
Education, and Human Services Division at the U.S. General
Accounting Office.
Thank you all for coming. We are looking forward to your
testimony.
It is the custom of this Subcommittee to swear in all
witnesses; therefore, I will ask all of you to stand and raise
your right hand as I give an oath for the first time in my
life.
Do you swear that the testimony you are about to give
before this Subcommittee is the truth, the whole truth, and
nothing but the truth?
Ms. Weinstein. I do.
Dr. Geolot. I do.
Admiral Martin. I do.
Ms. Heinrich. I do.
Senator Durbin. Thank you.
Let it be noted for the record that all witnesses answered
in the affirmative.
I would like to ask you to limit your oral statements to no
longer than 10 minutes and remind you that your entire
statement will be made part of the record.
Ms. Weinstein, please proceed.
TESTIMONY OF RACHAEL WEINSTEIN, RN,\1\ DIRECTOR, CLINICAL
STANDARDS GROUP, OFFICE OF CLINICAL STANDARDS AND QUALITY,
CENTERS FOR MEDICARE AND MEDICAID SERVICES, U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES, ACCOMPANIED BY THOMAS HOYER,
DIRECTOR, CHRONIC CARE PURCHASING POLICY GROUP
Ms. Weinstein. Chairman Durbin, Senator Voinovich, and
distinguished Subcommittee Members, thank you for inviting me
to discuss the need for adequate nurse staffing levels.
Accompany me today is Tom Hoyer, Director of our Chronic Care
Purchasing Policy Group, who is an expert in Medicare payment
policy, who is with me to respond to your technical payment
questions.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Weinstein appears in the Appendix
on page 49.
---------------------------------------------------------------------------
As a registered nurse, the issue of nurse staffing is
important to me personally. It is a priority for Administrator
Scully and Secretary Thompson, and we look forward to working
with you to address this growing concern.
Nurses and nurse aides play a critical role in caring for
Medicare and Medicaid beneficiaries, sometimes working more
than the equivalent of two 8-hour shifts in 1 day. Their work
can be exhausting, emotionally as well as physically, and too
often they perform their duties without receiving the credit
that they deserve.
Nursing requires great dedication, and research has shown
that it is becoming more and more difficult to recruit and
retain professionals to perform this difficult work. Moreover,
studies continue to demonstrate that higher nurse staffing
levels, especially registered nurse staffing levels, directly
influence positive outcomes in patient care.
We recognize the important role that nurses play in our
health care system, and we value their dedication and hard
work. In our role as the largest health insurer in America, we
need to ensure that we pay health care providers adequately and
appropriately, and my written statement goes into the details
of how we fulfill this responsibility.
Numerous objective observers including the General
Accounting Office, the Health and Human Services Inspector
General, and the Medicare Payment Advisory Commission have
found that Medicare payment levels in the last few years are
more than adequate to cover the costs of providing high-quality
fare in hospitals, skilled nursing facilities, and home health
agencies.
Despite the appropriateness of Medicare reimbursement
levels, our country faces an emerging shortage. We are hearing
that a higher proportion of patients with more complex care
needs has expanded the need for nurses with specialized
training. We also hear that the increased use of technology has
driven up the demand for a higher skill level of registered
nurses. And the expansion of care delivery settings has
increased the demand for nurses in general.
Job dissatisfaction, difficult working conditions, and low
compensation may also contribute to the emerging nurse
shortage. In fact, studies indicate that dissatisfaction with
working conditions is a major source of frustration for nurses,
both domestically and in foreign countries. This frustration
has led to a decline in enrollment in nursing schools and an
increase in the number of nurses leaving the profession.
Additionally, the majority of actively employed nurses is
aging.
We are analyzing the situation to determine the best way to
ensure that our beneficiaries continue to receive the high-
quality care they need, and we are committed to reducing
unnecessary burdens and complexities in Medicare. We are
sponsoring research into nurse staffing levels in nursing
homes, and we are considering ways to guarantee that nursing
homes provide the appropriate staffing levels based on the
results of our research.
In addition, our current conditions of participation for
home health agencies, skilled nursing facilities, and hospitals
which these facilities must meet in order to receive Medicare
reimbursement requires that they maintain adequate nurse
staffing levels. And we propose a new hospital condition of
participation that would ensure staffing levels reflect the
volume of patients, patient acuity, and the intensity of the
services provided to achieve desirable patient outcomes.
Additionally, we have been working with our partners,
including the Health Resources and Services Administration, to
sponsor nurse staffing studies. A study that we cosponsored
with HRSA, ``Nurse Staffing and Patient Outcomes in
Hospitals,'' was just released a few months ago. The results of
this study and other efforts will help inform the public and
private sectors as we work collaboratively to find solutions to
the emerging nurse shortage problem.
Nurses play a crucial role in caring for our beneficiaries,
and we are concerned that the nurse staffing shortage could
have a profound impact on the care that our beneficiaries
receive. We must continue to be vigilant and ensure that we are
paying health care providers appropriately so they can hire and
retain adequate levels of nursing staff. We must continue to
make the issue of the emerging nurse shortage a priority. We
are working closely with our HHS partners, and we want to
continue to work with you and others to find ways to address
this growing concern.
Thank you for this opportunity to speak with you today
about this important issue. I am happy to answer your
questions.
Senator Durbin. Thank you, Ms. Weinstein. Dr. Geolot.
TESTIMONY OF DENISE H. GEOLOT,\1\ Ph.D., RN, FAAN, DIRECTOR,
DIVISION OF NURSING, BUREAU OF HEALTH PROFESSIONS, HEALTH
RESOURCES AND SERVICES ADMINISTRATION, U.S. DEPARTMENT OF
HEALTH AND HUMAN SERVICES
Dr. Geolot. Good morning, Mr. Chairman and distinguished
Members of the Subcommittee.
---------------------------------------------------------------------------
\1\ The prepared statement of Dr. Geolot appears in the Appendix in
page 58.
---------------------------------------------------------------------------
I am pleased to appear before you today to discuss issues
related to the nurse work force. In my brief statement this
morning, I will provide an overview of the characteristics of
the nursing work force, speak about the extent of current and
projected nurse staffing levels, and review what the Health
Resources and Services Administration is doing to plan for
future nursing staff needs.
In March 2000, the Division of Nursing, Bureau of Health
Professions, conducted the National Sample Survey of Registered
Nurses, the seventh in a series of surveys on the
characteristics of the nursing work force. The previous survey
was completed in 1996.
This survey provides the latest and most comprehensive data
on the characteristics of the registered nurse work force. The
full report of this survey is to be released this summer. I
will just mention a couple of points in terms of the data. The
rest are in my testimony.
There are estimated to be 2.7 million registered nurses in
the United States. This reflects a 5.4 percent increase between
1996 and 2000. Over 2.2 million of the 2.7 million nurses are
employed in nursing. Nearly 72 percent of those nurses work
full-time. Sixty-eight percent of the staff nurses working in
hospital settings indicated that they were satisfied with their
jobs.
When we looked at the educational preparation of registered
nurses, we found that 23 percent had a nursing diploma as their
highest level of preparation, 34 percent an associate degree,
and 43 percent had a baccalaureate or higher degree.
The RN population is aging. Nine percent of nurses are
under the age of 30, and 51 percent are over the age of 45.
Nursing students are also older. The average age for a
basic nursing graduate is 30.5.
An estimated 12.3 percent of the RN population reported
being from one of the racial and ethnic minority groups, up
from 10.3 percent in 1996.
An estimated 5.4 percent of the RN population are men, up
from 4.9 percent in 1996.
There are pockets of nursing shortages throughout the
country, especially for registered nurses with clinical
expertise and specialty preparation. Some hospitals are
reporting that they must close beds and divert patients to
other hospitals because of nursing shortages.
The aging of the nursing population, declining student
enrollments in nursing schools, and the current working
conditions may have an effect on future nurse staffing needs.
Enrollment in all nursing programs has declined. Enrollment
data from the American Association of Colleges of Nursing
reveals that baccalaureate nursing program enrollments fell 4.6
percent in fall 1999--the fifth straight year of declining
enrollments. Figures for 2000 revealed a slowing decline to 2.1
percent.
Graduation data from the National League for Nursing
indicated that there was a 13.6 percent decrease in registered
nurse graduates between 1995 and 1999.
The answer to whether there is a national nursing shortage
is complex. No single direct measure exists for indicating a
shortage of nurses at the national level. The Division of
Nursing has historically used a comparison of the projected
supply of nurses and the projected demand or requirements for
nurses to assess imbalances.
Ideally, the number of nurses available to provide services
in a given setting should be in balance with the requirements
for nursing services in that setting. Based on outputs from the
supply projection model and the demand projection model
published in the mid-1990's, the supply of and requirements for
full-time equivalent RN's is expected to be roughly in balance
until the year 2010 at the national level. A projected leveling
off of the supply and steep increases in demand over the years
between 2010 and 2020 will result in a widening gap between the
number of nurses expected to be required and the number of
nurses expected to be available.
By the year 2020, the model indicates a shortfall in the
number of nurses and the number of needed registered nurses.
However, because of the recent rapid changes in the health care
system, it is difficult to make precise predictions about what
the demand for nursing services will be in the future.
Preliminary estimates from the revised demand forecasting
model and supply projections indicate that at the national
level, there is roughly a balance at this time. However, this
does not negate reports from other sources of current shortages
in specific areas, health care sectors, or types of registered
nurses.
The demand forecasting model identifies a systemic problem
that will continue to increase through 2020. If these current
trends continue, all health care settings, all geographical
areas, and all needed specialty nurses may experience nursing
supply challenges. But there may also be advances in technology
that may reduce future demands. HRSA will continue to monitor
nursing data to chart future nurse staffing needs.
When we look at the RN-to-population ratio for the Nation
as a whole, our data show that the overall ratio of employed
RN's per 100,000 population has varied from 688 in 1988 during
the previous shortage to 798 in 1996 and 782 in 2000. After
more than a decade of increases, the rates appear to be
dropping.
In addition, data show that the variation among States is
considerable. The numbers range from a low of 520 employed RN's
per 100,000 population in Nevada to a high of 1,675 in
Washington, DC.
HRSA administers programs authorized under Title VIII of
the Public Health Service, often referred to as The Nurse
Education Act. Title VIII was instituted by the Nurse Training
Act of 1964 in response to a qualitative and quantitative
shortage of nurses as a key vehicle for Federal support for
nursing work force development. Title VIII programs are
primarily administered by the Bureau of Health Professions,
Division of Nursing.
Specific activities helping to mitigate the shortage of
nurses include: Support for basic and advanced nursing
education programs; diversity programs targeting minority and
disadvantaged students; scholarship, traineeships, and loans;
and nursing work force analysis.
In fiscal year 2001, the budget for the Division of Nursing
Programs is $76.5 million. The administration's fiscal year
2002 budget would increase the funding for HRSA's nursing
programs by $5 million.
The Bureau's Division of Student Assistance provides $12.7
million in support to 3,600 nursing students through the
Scholarships for Disadvantaged Students Program and $22 million
in support for 10,000 nursing students through the revolving
Nursing Student Loan Program.
Within the Bureau of Primary Health Care, the Nursing
Education Loan Repayment Program provides $2.3 million to
assist 200 registered nurses by repaying up to 80 percent of
their qualified educational loans in return for their
commitment to work at health facilities in shortage areas. In
addition, the National Health Service Corps Scholarship and
Loan Repayment Program provides $6.3 million to support 94
nurse practitioners and 29 nurse-midwives providing services to
people in underserved areas.
HRSA has been working with the Centers for Medicare and
Medicaid Services to examine work force issues, and my
colleague has mentioned them.
So in summary, Mr. Chairman, I appreciate the opportunity
to share with you the latest information on the characteristics
of the nursing work force, the status of what our data show
from a national perspective, and the types of activities being
undertaken in HRSA to address the needs of the nursing work
force.
Senator Durbin. Thank you very much, Dr. Geolot. Admiral
Martin.
TESTIMONY OF REAR ADMIRAL KATHLEEN L. MARTIN,\1\ NURSE CORPS,
DIRECTOR, NAVY NURSE CORPS, U.S. NAVY
Admiral Martin. Good morning, Mr. Chairman and Senator
Voinovich. It is my pleasure to testify today as the Director
of the Navy Nurse Corps and the Commander of the National Naval
Medical Center in Bethesda.
---------------------------------------------------------------------------
\1\ The prepared statement of Admiral Martin appears in the
Appendix in page 64.
---------------------------------------------------------------------------
I am also here to speak on behalf of the Chief of the Army
Nurse Corps and the Director of the Air Force Nursing Services.
My colleagues are here to answer specific questions.
Today I would like to discuss one of our principal
concerns--the nationwide nursing shortage and its impact on the
military health care system. I will address this in terms
related to both military nursing and civil service nursing.
As you are well aware, the demand for professional nurses
in America is increasing while the supply continues to decline.
The impact of this diminishing pool affects health care
delivery nationwide. Along with the civilian and Federal
sectors, the military now finds itself in a critical struggle
to attract and retain nurses for active duty, reserves, civil
service, and contract positions.
Our nursing issues, such as compensation, job stress,
quality of life and workplace, are similar to those in the
civilian sector. However, due to the distinctive mission of the
military, we are not equally affected by the same challenges.
I would first like to discuss factors having a positive
effect on military nursing. Unlike our civilian and Federal
counterparts, military nurses have long relied upon the medical
enlisted forces to assist in the delivery of health care. These
technicians, medics, and hospital corpsmen possess higher skill
levels than their unlicensed civilian colleagues and are
considered an integral part of the nursing team.
Additionally, staffing levels in military hospitals have a
tendency to remain more stable. This can be attributed to the
turnover rate for new military nurses and enlisted being
controlled by obligated service contracts and predictable
timing of change of duty assignments.
Additionally, on average, military nurses experience a
higher nurse-to-patient ratio, greater collaborative nurse-
physician relationships, additional leadership opportunities,
diverse practice environments, and broadened career paths.
However, despite the unique military advantages, the
effects of a dwindling supply of best qualified nurses have a
detrimental effect on military nursing. Currently, our greatest
challenges lie not only in recruiting new nurses but also in
retaining junior to mid-grade level experienced nurses.
An adequate force structure is critical to maintaining a
high quality of peacetime health care while ensuring that our
fighting forces and operational commitments are fully
supported.
Success with recruiting nurses into the military has varied
among the services, but filling the Reserve Officer Training
Command, or ROTC, billets has been difficult for all services.
One reason for this could be that fewer high school graduates
are choosing nursing as a career or seeking a military
experience while in college. Additionally, nurses with 1 to 5
years of experience are becoming more difficult to attract to
the military. This has a direct impact on health care delivery
system and operational readiness because of the nursing
shortfalls in critical specialties such as operating room,
critical care, mental health and obstetrics, to name a few. In
addition, the nurses who we are able to recruit are often 40
years and older, leading to an older, limited-term, non-career-
track force.
A fundamental part of the recruiting strategy for all
services is the current nurse accession bonus. Active-duty
accession bonuses may attract individuals, but without
additional incentives, it may be difficult to retain nurses
after their initial commitment. Currently, only nurse
anesthetists, nurse practitioners, and nurse-midwives are
authorized to receive incentive special pay or a board
certification pay. These programs have been successful
retention tools thus far, but the civilian-military pay gap is
rapidly widening for advanced practice nurses. Further,
retention bonuses may be needed to retain all types of nurses
as compensation for increasing the ever demanding supply.
Because up to half of the nursing force in the Navy and
Army military treatment facilities is comprised of civilian
nurses, it is also necessary to comment on the civil service or
government service and contract nurse work force. Current
vacancy and turnover rates vary between the services but are at
levels that have a significant impact on mission capabilities.
Because of considerable differences in compensation and hiring
practices between the government and private sector, we cannot
maintain an adequate level of civil service nurses to meet our
needs.
Our civilian competitors are able to provide timely hiring
actions in some instances in less than 1 week from application
to first day in facility. Conversely, the average length of
time to bring a new civil service RN into a military treatment
facility is as long as 93 days.
Government-civil service hiring practices and bureaucracy
constraints entangle what must be an expeditious process.
To fill the needed vacancies in a timely manner, many
military treatment facilities are forced to hire contract
nurses, often at much higher salaries. Military and civil
service nurses work side-by-side these higher-compensated
peers, creating additional dissatisfaction for our military and
civil service nurses.
Compensation is a powerful driver in the decision to remain
with a military health care organization or to leave. Each of
the services has established open communication and interviews
with nurses to ascertain all reasons for departing military or
government service. All services are instituting proactive
initiatives within given constraints to enhance recruiting and
retention.
Our military and civil service nurses are extremely
dedicated to the success of the military health care system and
our operational missions. They have been the backbone of our
health care facilities and have served proudly for over 100
years. I truly believe that they are the finest professional
nurses in the world.
Therefore, we must take action to ensure that our patients
of the future will benefit from the services provided by these
professional nurses.
In summary, I believe the main obstacles to first
recruiting and then retaining quality nurse corps officers and
civil service nurses are pay, benefits, and antiquated civil
service hiring processes.
Mr. Chairman, on behalf of my colleagues, I thank you for
allowing me to share this information and for your support in
keeping military and Federal nursing strong for the future.
Senator Durbin. Thank you, Admiral Martin.
I might add that there is a vote on, and Senator Voinovich
has gone over to vote, and he will return, and then I will take
off, and we will try to keep things moving.
Ms. Heinrich.
TESTIMONY OF JANET HEINRICH,\1\ DIRECTOR, HEALTH CARE--PUBLIC
HEALTH ISSUES, U.S. GENERAL ACCOUNTING OFFICE
Ms. Heinrich. Thank you.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Heinrich appears in the Appendix
in page 94.
---------------------------------------------------------------------------
May I ask that we put the chart up, please?
Mr. Chairman, I also am pleased to be here today as you
discuss issues related to the current difficulties in the
recruitment and retention of nurses and concerns about the
future supply.
My remarks will focus on what is known about the current
supply of nurses, factors contributing to current recruitment
and retention difficulties, and factors that will affect the
supply of and demand for nurses in the future.
Yes, the U.S. health care system has changed dramatically
in the last 2 decades, affecting the environment in which
nurses provide patient care. Advances in technology and greater
emphasis on cost-effectiveness have led to changes in the
structure, organization, and delivery of health care services.
We now see more patient care shifting to the ambulatory and
community care settings, home care, and nursing homes. This has
increased the demand for nurses outside the hospital. This
change in service settings has also resulted in decreased
lengths of patient stay in hospitals and a decline in the
number of beds staffed.
At the same time, the acuity of patients increased as those
patients remaining in hospitals were those too medically
complex to be cared for in other settings.
National data are not adequate, as we have heard, to
describe the extent of nurse work force shortages, nor are data
sufficiently sensitive or current to allow a comparison of the
adequacy of the work force across States, specialties, or
provider types. Evidence suggests emerging shortages of nurses
available or willing to fill some vacant positions in
hospitals, nursing homes, and home care agencies.
The nationwide unemployment rate for RN's declined to 1
percent in 2000, the lowest level in more than a decade.
Vacancy rates as reported by providers, often used as an
indicator of possible excess demand, vary for all providers
across all States, urban/rural areas.
For example, California reported a RN vacancy rate of 20
percent for hospitals in 2000, up from 9.6 percent in 1997. On
the other hand, Vermont in a 2000 survey reported a RN vacancy
rate of 4.8 percent in hospitals. It is difficult to understand
what those vacancy rates really mean, because they are figured
out in different ways in different facilities.
Job dissatisfaction may play a significant role in both
current and future recruitment and retention problems. In all
of the recent surveys we have reviewed, RN's reported
themselves as ``somewhat'' or ``very'' dissatisfied with their
jobs in a very high proportion. Inadequate staffing, heavy work
loads, and the use of overtime to address staffing requirements
were frequently listed as reasons. Nurses have also cited the
lack of respect and recognition given them, along with their
perceived lack of autonomy and ability to participate in
decisionmaking, as areas of concern.
Overall compensation is also expressed as an area of
concern. As we show in this chart, earnings have been
relatively flat throughout the decade, with only a slight
increase in recent years. While surveys indicate that increased
compensation might encourage nurses to stay at their jobs,
money is not always cited as the primary reason for job
dissatisfaction. Often, it is the third or fourth issue that is
reported.
Nurses also have expressed dissatisfaction with the
decrease in the amount of support staff available to them. As
reported by the American Hospital Association, current nurse
work force issues are part of a larger concern for shortages of
pharmacists, lab technicians, and others.
There is also a shortage of nurse aides who support nurses
and assist patients with personal care. In the studies that we
reviewed, we found that many of the factors that are concerns
for nurses are also concerns for nurse aides and explain the
problems that people experience with retention of nurse aides
in all settings.
Growth in the number of new RN's has slowed, as we have
heard. It is also interesting to hear that there has been a
reduction in the number of RN's taking and passing the
licensing exam. This declined by 23 percent from 1997 to 2000--
it was 96,679 in 1996, and it dropped to 74,787 in 2000.
Even with the relatively large increasing in the nursing
work force over the 1990's--I think that 2.7 million figure is
rather astounding--we can expect a serious shortage in the
future as pressures are exerted on both demand and supply. The
future demand for nurses is expected to increase dramatically
when the baby boomers reach their 60's, 70's and beyond. During
that same period, the number of women in the age groups who
have traditionally formed the core of the nursing work force is
expected to remain relatively unchanged. This mismatch between
future supply and the demand for caregivers is illustrated in
the change in the ratio of women age 20 to 54 to the population
age 85 and older. That ratio will change from 16.1 in 2000 to
8.5 in 2030, and 5.7 in 2040.
In conclusion, providers' current difficulties recruiting
and retaining nurses may worsen as the demand for nurses
increases with the aging of the population. Certain changes in
the current labor market are similar to those that occurred in
past shortages. However, the impending demographic changes are
widening the gap between the numbers of people needing care and
those available as caregivers. Moreover, the current high
levels of job dissatisfaction among nurses due to management
decisions to restructure health care delivery and staffing may
play a crucial role in determining the extent of future nurse
shortages.
Efforts undertaken to improve the areas of workplace
environment that contribute to job dissatisfaction may reduce
the likelihood of nurses leaving the profession and increase
the number considering it.
More data that can describe the scope and nature of the
current problem is needed to assist in planning and targeting
corrective actions.
Mr. Chairman, that concludes my statement. I would be happy
to answer questions.
Senator Durbin. Thank you.
I have a number of questions for the panel. First, for the
record, Ms. Weinstein, CMS used to be HCFA.
Ms. Weinstein. Yes. We have to get used to that as well.
Senator Durbin. Right. For years, we have had hospital
administrators coming to us from across the Nation saying that
because of the cutbacks in Medicare reimbursement, many of them
are facing some very serious budgetary problems. And many of my
colleagues, including myself, did everything we could to
increase hospital reimbursement from the Medicare program to
deal with what we thought was an overreaction by Congress of
cutbacks in Medicare.
What I would like to ask you is whether the money that we
have been sending back to the hospitals has been reaching the
nurses. Have they seen increases in their salaries and their
wages as a result of this increased Medicare reimbursement?
Ms. Weinstein. I would like to answer your question by
saying that we do not earmark any of the dollars for any
specific services provided by the providers. The providers are
paid prospectively, and they are then charged with determining
how they are going to allocate those resources.
I would like to defer to my colleague, Mr. Hoyer, to
elaborate on the response.
Senator Durbin. Mr. Hoyer.
Mr. Hoyer. That gets to the response that we do not know.
We do know the payment levels are adequate in all of the
settings, but we do not know the extent to which the hospitals,
SNFs, and home health agencies have used the money to hire
nurses or raise salaries.
Senator Durbin. My understanding is, and I think the
testimony shows, that over the last decade, nurses really have
not seen any substantial increase in their wages--I think it is
less than 1 percent--but there has been in the last year, I
think, an increase slightly higher. Are you aware of those
statistics?
Mr. Hoyer. I am not aware of the nurse salary statistics,
Senator.
Senator Durbin. Well, maybe we can get some of that
information from the next panel.
Can you comment on what you are finding as to the profit
margins in hospitals after the Medicare increases went into
effect?
Mr. Hoyer. Well, I can say that hospitals have done
reasonably well. There was some concern after the Balanced
Budget Act of 1997, but MedPAC's latest recommendations, with
which we agree, are that hospital payments are on track, and
there is no compelling reason to change the update.
Senator Durbin. You have also testified, Ms. Weinstein, as
to a study involving staffing ratios. Are you going to be
publishing these recommended ratios for nurse-patient, doctor-
patient treatment?
Ms. Weinstein. Mr. Chairman, are you speaking of the study
related to nursing home staffing or the study related to
hospital nurse staffing?
Senator Durbin. Nursing homes.
Ms. Weinstein. Last summer, we completed the first phase of
our nursing home staffing study, and that study did show that
there was a link between nurse staffing levels and quality of
care for nursing home residents. We are in the process of
completing the second phase of that study. We expect it to be
completed by the end of this calendar year. At that time, we
will review the results, and it will inform us as to what
direction we should take for policy in the long-term care
setting.
Senator Durbin. Will you also be addressing the issue of
medical errors in relation to ratios?
Ms. Weinstein. We have been looking at the issue of medical
errors across the board. We have been working collaboratively
with other HHS partners, looking at medical errors in all
settings, and it is something that we will consider as we look
at all the evidence.
Senator Durbin. Good.
I am going to ask that the Subcommittee be in a short
recess now, as I race over to try to make this vote. Senator
Voinovich, if he returns, will ask his questions, and then I
will resume.
Thank you.
[Recess.]
Senator Voinovich [presiding]. I will call the meeting to
order. Senator Durbin will be back as soon as he casts his
vote.
I would like to ask a few questions now. The first question
that I have is for Ms. Weinstein and Dr. Geolot. How does the
Bush Administration believe that we need to address the problem
that the two of you have made mention of today? Is there
anything that you have heard thus far from the administration
in terms of what they think we ought to be doing about it?
Ms. Weinstein. Senator Voinovich, I would like to address
that question by saying that we believe that we have to
continue to monitor the situation and to ensure that we are
paying the providers adequately so that they can appropriately
care for our beneficiaries.
We have to continue to collaborate with our colleagues in
the Department, including HRSA, the National Institute for
Nursing Research, the Agency for Healthcare Quality Research.
We have to look at the studies that they are doing and try to
convene partnerships, private and public together, where
possible.
Senator Voinovich. One of the things that interested me in
your testimony was that you indicated you really believe that
Medicare adequately reimburses providers for nurses; is that
correct?
Ms. Weinstein. We had support for that in the recent MedPAC
report, which showed that we are paying hospitals
appropriately. We are in agreement with that report. Also, the
Inspector General and the General Accounting Office have
studied the nursing home issue and reimbursement in nursing
homes and have concluded that we are paying adequately in
nursing homes as well.
I would add that the payments we give to providers are not
earmarked specifically for nursing services. It is up to the
providers to determine how to use the dollars that they receive
and provide services to beneficiaries, patients, and residents.
Senator Voinovich. Dr. Geolot, would you like to comment on
that?
Dr. Geolot. Senator, we also think it is extremely
important to continue to monitor the work force and intend to
carry out the sample surveys which give us the national
perspective.
In terms of specific programs to support the work force,
the Title VIII programs address basic and advanced nursing
education programs, diversity programs targeting minorities and
underrepresented individuals, and we have scholarships,
traineeships, and loans, and the administration has proposed an
increase for funding of the programs under this authority in
Title VIII.
Senator Voinovich. Do you think that is going to be
adequate to deal with the current situation?
Dr. Geolot. Well, we realize that there are many competing
priorities, and the administration did suggest increases for
the Title VIII programs.
Senator Voinovich. So, if I heard you right, you are saying
that on the national level, you think that the number of nurses
is in balance with the demand for care and that should continue
for the next several years but that you see a real problem from
2010 to 2020; is that correct?
Dr. Geolot. That is correct.
Senator Voinovich. So you would not say that on the
national level you have a real problem right now; things seem
to be in balance?
Dr. Geolot. Well, from a national perspective, our
projections indicate that the supply and requirements from a
national perspective look like they are in balance. However, I
would also mention that does not negate the shortages that have
been identified, and the national sample survey cannot
necessarily get at what is happening at the local level.
Senator Voinovich. So that nationally, it looks like it is
OK, but then, when you go back and look at regions, you find
there is a problem. Is that what you are saying?
Dr. Geolot. What I am saying is that the national sample
survey cannot necessarily capture that information, but we are
certainly hearing that there are shortages in geographic areas,
there are shortages for specialty nurses--there are shortages
in certain types of settings, yes.
Senator Voinovich. The next question, then, you have just
answered. You said you thought that what was being done by the
government at the current time is adequately dealing with the
problem. If the shortages are there, do you think we should be
doing more?
Dr. Geolot. Well, I realize that there are really competing
priorities in terms of dollars, and the administration has
increased funding for nursing work force development, or has
proposed to increase funding.
Senator Voinovich. So what you are saying is that they
recognize that there is a problem, and they have increased the
funding, but that it is not enough to deal with what some would
say is a shortage around the country, and that more needs to be
done?
Dr. Geolot. I am saying that the administration has
proposed an increase in the nursing programs and recognized
that there was a need to increase those programs.
Senator Voinovich. Would anyone else like to comment on my
question?
Ms. Weinstein. Yes, I would like to comment. We have heard
through the testimony today that this problem is really
multifaceted and that the solution to an emerging shortage is
certainly going to require different types of interventions.
We believe that the Federal Government needs to continue to
monitor the situation, sponsor research where we can, look at
the results of that research, and then go ahead and make
Federal policy with adequate data to address the concerns.
Senator Voinovich. Do you think, then, that we need to get
more data in order to properly address the problem?
Ms. Weinstein. More data will definitely help us address
the problem, and then we can determine exactly what types of
interventions are appropriate.
Most recently, the Centers for Medicare and Medicaid
Services worked very closely with HRSA to sponsor a nurse
staffing study in hospitals. That study was just released in
February of this year, and the results of that study showed
that there are strong links between adequate levels of nurse
staffing and good patient outcomes. In fact, the higher numbers
of RN's led to better outcomes for patients. We need to
continue to sponsor such research in order to use the
information to guide Federal policy, but I think we also need
to collaborate with our partners in the private sector, look at
what they are doing, and work together to solve the problems.
Senator Voinovich. Senator Durbin has mentioned the fact
that he is looking at some legislation, and I am sure he is
going to be looking for cosponsors of that legislation. We
should make sure that we have the information we need to make
good decisions so that what we are doing on the national level
is going to be responsive to the real problems and that if we
are going to allocate resources, we are allocating them in
areas where they will make the most difference.
You just alluded to the correlation between more nurses and
fewer medical errors. Has there been any authoritative study
done where people admit to medical error? Each year, I attend
the John F. Kennedy School of Government's 2-day seminar for
Members of Congress. I found it interesting that participants
said that in the government-operated hospitals, there was more
being done about the issue of medical error than in private
hospitals because they were less vulnerable to potential
lawsuits. This provides greater freedom to deal with some of
the problems. But lawsuits are another issue. Do you know of
any studies where they have identified medical error and have
directly attributed it to the lack of nurses?
Ms. Weinstein. Not specifically, but I can tell you that
the Agency for Healthcare Research and Quality is funding
numerous studies to look into the issue of medical errors as
well as nurse staffing issues, and I believe that research will
inform us on this issue.
Ms. Heinrich. I could add something to that, Senator.
Senator Voinovich. Yes, Ms. Heinrich.
Ms. Heinrich. Linda Aiken, from the University of
Pennsylvania, has a team that has been doing work on hospital
structure, organization, and staffing and linked it with
patient outcomes, and part of that is error. That study is due
to come out this summer.
The other thing you allude to is the program that is
currently in place and being developed within the VA system in
terms of identifying medical errors and then moving to the root
cause, which I think is going to be interesting and could
possibly be a model for the country.
The other information that I think is very interesting is
from JCAHO, and their sentinel events. As they go in and do
root cause analysis of those sentinel events, serious problems
in patient care, they are finding that 24 percent of those are
related and linked directly to nursing issues.
Senator Voinovich. Thank you. Senator Durbin.
Senator Durbin. Thank you very much, Senator Voinovich.
May I ask Ms. Geolot to address the issue of scholarships
and loans for nursing students? I noticed in your testimony
that there are some 3,600 scholarships that we are making
available and some 10,000 loans for nursing students. What is
the population of nursing students in our country--the
numbers--if you know.
Dr. Geolot. I do not know offhand, but I can provide that
information to you.\1\
---------------------------------------------------------------------------
\1\ The information provided by Dr. Geolot appears in the Appendix
on page 00.
---------------------------------------------------------------------------
Senator Durbin. Fine. Can you tell me if there has been a
trend in this area as in other Federal reimbursement for
education to provide more loans and fewer scholarships?
Dr. Geolot. I can provide that for the record as well.
Senator Durbin. OK. I will just tell you that it has been a
general trend over the last 10 or so years to provide more
loans to the students, which of course means more indebtedness
and affects their choice of jobs and where they are going to
work. I think that when you consider nursing, it appears to be
more difficult to attract students to nursing school. The
ability to graduate them and attract them to rural areas or
inner city areas or areas of special needs may be a decision
that is often dictated by the level of their indebtedness and
how quickly they can be making significant salaries in other
places.
I know that nurses are in national demand. I met one at
Georgetown University Hospital who has a very interesting life.
She flies from one interesting part of the country to another
interesting part of the country and works for 10 or 12
hospitals at a time. She is single, and she just got back from
California, and wanted to see what Washington was like, so she
ended up at Georgetown Hospital for several weeks, and then off
again, always a pretty good contract waiting for her. But of
course, she is single and is not raising a family and is in a
different situation.
Let me ask you if you think the current nursing shortage is
really driven more by a lack of retention than by a shortfall
in the number of nurses who are being trained. Could you make
that call as to what is the more dominant reason?
Dr. Geolot. I think we are seeing a combination of factors.
We are seeing decreased enrollments in schools, and we are now
seeing decreased graduations. So that has to do with the
pipeline.
But I think that we are also very concerned about the
working conditions and the need to focus on the retention of
the nurses that we have. So it is essentially a three-prong
approach--one that looks at improving the pipeline or focusing
attention on the pipeline; another that focuses on the working
environment; and the third is the retention of the nurses that
we have.
Senator Durbin. Let me ask you this, Ms. Heinrich,
following up on that. If we are dealing with a national nursing
shortage, and we have stagnant wages and deteriorating working
conditions, should we be surprised?
Ms. Heinrich. I think you have answered the question.
Senator Durbin. I am afraid I have.
I would ask you, based on what you have seen, if you have
any data on nurses' wages that we referred to earlier, as to
what has happened to them in the last decade?
Ms. Heinrich. It is actually very interesting to map that
out, and at your request, we did develop this chart that
actually shows what has happened. It appears that after the
last shortage, there was an upswing in wages, and after that--
--
Senator Durbin. And what happened in nursing schools?
Ms. Heinrich. There was a dramatic increase in enrollments,
yes.
Senator Durbin. Cause and effect.
Ms. Heinrich. Well, you know GAO; we are a little hesitant
to----
Senator Durbin. It is as close as I can pin you down.
Ms. Heinrich. Right. Then, in the mid-90's, there was a
leveling out and even a dip in adjusted earnings. And then,
just in the last couple of years, there has now been an
increase in average earnings.
Senator Durbin. And were you able to pinpoint the current
situation with managed care, where fewer people are being
hospitalized, but when they are hospitalized, they have more
acute and critical conditions and need more attention?
Ms. Heinrich. We did not necessarily link it with managed
care. Other researchers--Peter Buerhaus, for example, did do a
very interesting paper that showed a link of nurse employment
and wages with geographic areas that had more concentrated
managed care.
I think what is interesting now is that we are seeing so
much play in the industry, and I sometimes wonder if people
know what to pay attention to in the market because there is
such disequilibrium.
Senator Durbin. I noted in your testimony that State
legislatures have, in at least 10 States, entertained
legislation to limit mandatory overtime to protect nurses. Is
this one of the complaints that you have heard from the nurses
in terms of their work conditions, the mandatory overtime
requirement?
Ms. Heinrich. In all of the surveys that we reviewed, that
certainly is one of the top issues that the nurses in these
surveys are concerned about.
Senator Durbin. Let me ask you this. We will hear testimony
later from the hospital association about paperwork burden that
nurses face. Has this been a complaint that you have heard?
Ms. Heinrich. That certainly is reported in the surveys,
not to the same extent as some of the other issues around
working conditions. Certainly, you hear a lot about the burden
of paperwork, and some people say that IT, information systems,
in the future will do a great deal to alleviate that. On the
other hand, GAO, of course, feels very strongly about the fact
that we have to be able to document and be accountable for the
care that is being provided. So, of course, we always want
better information on the patient care, the minimum data sets
in nursing homes, for example, than we feel we have.
Senator Durbin. Ms. Weinstein, have you looked at that
issue in terms of the paperwork requirements coming out of the
Federal Government imposed on hospitals and transferred
ultimately to nurses and other medical professionals?
Ms. Weinstein. I can tell you that this new administration
is committed to reviewing paperwork requirements, to reviewing
regulations and requirements for excessive red tape and burden.
It is a top priority for Administrator Scully, and we are
looking at that.
Senator Durbin. Thank you.
Admiral Martin, let me close my questions by asking you
this. You said that you have a higher nurse-patient ratio in
the military. What is the ratio? Is there an established,
published ratio?
Admiral Martin. No, sir. I cannot give you that. But
generally, overall, it is felt that we have a higher nurse-
patient ratio. Our staffing tends to be a little bit more
predictable and stable.
Senator Durbin. How does military nurse pay compare to
civilian nurse pay?
Admiral Martin. We have a study going on right now by the
Center for Naval Analysis to compare military and civilian
nursing pay, and they are fairly close to publishing it.
Senator Durbin. If you saw these figures here that have
been given, the $41,000 as an average annual salary for nurses,
by your experience--and I will not hold you to this as to an
exact dollar amount--what is the average annual pay for nurses
serving in the military?
Admiral Martin. That is about an average pay for our
government civil service nurses that we hire. However, for
military nurses, because we continue if we stay in to go up in
rank, our average pay is probably either equal to or a little
higher. However, it is the retention that we really have to
work on.
Senator Durbin. Do you have any rules in the military
regarding the number of hours a nurse may work without rest?
Admiral Martin. No, sir.
Senator Durbin. So a nurse in the military could be working
more than one shift at a time and be asked to take overtime?
Admiral Martin. Well, active-duty military are obligated
24/7, and we all come in knowing that. However, I believe that
you will find that in our military hospitals--I do not know of
any Navy hospital that has mandatory overtime. Many of our
military nurses are on call, so if they work one shift and go
home and have the next day off, we might ask them to come in
for several hours to relieve somebody. That is not mandatory or
mandatory overtime.
Senator Durbin. But they are expected to be there.
Admiral Martin. I would say we are very flexible now. As
the Commander of Bethesda, if I called a nurse who said, ``I
have a child at home,'' we would call somebody else.
Senator Durbin. OK. My last question is this. The civil
service problems that you have talked about caught my
attention, and I called them to the attention of Senator
Voinovich, and this is something that we are both looking at.
Ninety-three days to hire a nurse--is that what you are
suggesting?
Admiral Martin. Yes, sir. Right now, at Bethesda, we have
taken a considerable amount of action, and I have gotten it
down to 45 days. But overall, it had been running 90 to 93
days, yes, sir.
Senator Durbin. And in the private sector, it is a week or
two; is that my understanding?
Admiral Martin. For many of the contract nurses, we can
hire them in about a week or two.
Senator Durbin. Thank you. Senator Voinovich, any other
questions?
Senator Voinovich. Yes. In terms of hiring, you were able
to bring it down from 93 to 45 days?
Admiral Martin. Yes, sir.
Senator Voinovich. So you had the discretion to do that--in
other words, from a management point of view, you were able to
do that. You did not need any legislation or regulatory
changes; you were able to just look at the system and
streamline it and improve on it.
Admiral Martin. Sir, I believe that I screamed loud enough
that individuals heard me and realized that it had not just an
effect on the patients and patient care, but it had an effect
on graduate medical education programs as well. A tiger team
came to my rescue at Bethesda to the detriment of several other
places.
Senator Voinovich. Who is in charge of that? Where do you
have to go to deal with that kind of problem? Who handles that?
Admiral Martin. Our HRO, Human Resources Office.
Senator Voinovich. In the Navy?
Admiral Martin. Yes, sir. Each service has its own single
HR branch.
Senator Voinovich. So you had the problem, you went to them
and said this has to be taken care of, you screamed loud enough
so that they got involved and looked at the situation, and they
were able to, just by moving some things around, streamline the
process.
Admiral Martin. Yes, sir. They put a small team together to
come over to Bethesda to work. I established a small office
space for them. However, there are other Navy commands, and
therefore, their length of time to hire civil service, maybe
not nurses but other employees, only lengthened because
individuals came to Bethesda to assist me.
Senator Voinovich. So would you say they need more people
in human resources?
Admiral Martin. I would say they are looking at the entire
HR system in the Navy and trying to really put some corrective
actions in place. It is truly a system problem.
Senator Voinovich. In terms of hiring civilians, do you
think you have enough flexibility to do that? Does the private
sector have more flexibility in hiring people?
Admiral Martin. I do not have as much flexibility as a
civilian hospital because of some of our constraints. I am
constrained in what level I can bring a civil nurse in at
because of our classification system and then even retaining a
nurse. We do not have a good career progression ladder for
civil service nurses; they often get stuck at the level they
come in at.
Senator Voinovich. So that has to be reviewed in terms of
being competitive.
Admiral Martin. Yes, sir.
Senator Voinovich. I think I recently told Senator Durbin
that one of our nurses here just got her graduate degree and
wants to get a better job, and she applied for an opening at a
Federal facility. She is a GS-12 and the job is a GS-14. She
sent her application off on the internet to this place, and
they sent her back a form letter saying, ``I am sorry, we are
not interested in you. In order to be hired, you have to be a
GS-13.''
Admiral Martin. It is an antiquated system. The same system
has been in place every since I have come into the military. I
understand that there is a whole task force looking to change
the classification and hiring system. I have not heard any
recent reports or read any recent reports on it, though.
Senator Voinovich. I would like to personally have you
share with me in the next 2 or 3 months just how things are
going in that regard, because this is kind of a cause celebre
for Senator Durbin and me. We just think the Federal
Government's hiring process and human capital is in crisis, and
we need to move very quickly if we are going to deal with these
problems.
I have just a couple of other questions. One is getting
back to the issue of paperwork. The kinds of complaints I get
from nursing home staff and others who deal with the Federal
Government are that the paperwork requirements are just
crushing them, and in so many instances, the people who have to
fill out the paperwork are the nurses. I hear from nurses who
work in some of these facilities who say, ``One of the things I
do not like about my job anymore is that I spend all my time at
a desk, filling out pieces of paper, and I do not really get a
chance to get out and spend very much time with patients. One
of the reasons I got into this business was to have a
relationship with people and get that satisfaction. I did not
come to work to be a secretary; I came to work to deal with
patients.'' I would like you to comment on that.
Ms. Weinstein. I will reiterate my earlier response, which
is that we are looking at paperwork requirements for Medicare
and Medicaid, and Administrator Scully is committed to trying
to reduce the paperwork burden where possible. We are looking
at things like the minimum data set for nursing homes, the
OASIS document for home health agencies, and we are looking to
see where we can reduce burden where possible.
Senator Voinovich. That is terrific. It would be
unbelievable the burden that would remove in terms of hospital
staff right across the board, because they are just bitter
about it. I hear our hospital folks complain about Medicare and
their reimbursement, by the way; they do not feel that it is
adequate. Of course, when I talked to Donna Shalala, she said
it was more than adequate. But then it is compounded by all the
paperwork.
I do not know how it is in Chicago, but what I am hearing
from our administrators in the Cleveland area is that nursing
wages have gone up in the last couple of years pretty rapidly
because of the lack of nurses. In order to attract people and
keep people, they have had to increase wages.
Does anyone want to comment about where wages have been,
say, in the last year or 2 years? The testimony I hear is that
the wages have stagnated, and that is a longitudinal study, I
think, over a period of time. Where are we right now on that
issue?
Ms. Heinrich. You are correct that in the last couple of
years, the reports do show that on average, wages have gone up
for nurses. I think it is hard to say, however, in terms of
have they been adequate or are they enough to attract nurses
into particular facilities, because it is very interesting to
see that--wages are only one factor for nurses. There are other
factors about the work environment that they are looking at and
deciding whether they want to work in those environments, and
those have to do with work load, work stress, and the other
organizational factors that affect how nurses can provide
patient care.
Senator Voinovich. So when you are talking about
``environment,'' you are talking about the hours, the number of
patients, physical facilities--could you elaborate on that a
little bit more?
Ms. Heinrich. Yes. And it also goes to other people who are
there to support nurses in providing the patient care.
Certainly we have heard testimonial evidence, but it was also
shown in the AHA survey that they recently released, that there
are shortages not only in nursing but across the board.
How that plays out is that if you are short a pharmacist,
and a nurse on a medical/surgical floor needs a particular
medication and is not getting it from the pharmacy, what often
happens is that the nurse is filling in the gap there, and she
is running to the pharmacy to pick it up. That should not be
happening. Or, you have reports by nurses that they are passing
out food trays and emptying the garbage, and they are also
expected to be your hands-on, 24/7 surveillance system for
these very complex patients.
Senator Voinovich. My sister-in-law had cardiac arrest
during the Inauguration, and she went over to George Washington
University Hospital, so I had the chance to talk with some of
the nurses over there. The impression I got was that many of
them were independent contractors; they are there, but they are
not really on the hospital payroll.
Ms. Heinrich. I think that is a very interesting
phenomenon, and we have not done a study on it, but again,
certainly testimonial evidence suggests that many of the young
nurses have found it more beneficial to be in a temporary
agency or a temporary pool. They are paid more, their benefits
go with them wherever they go, they have a great deal of
flexibility in terms of when they work and when they do not
work. I think it would be very interesting to study that
further.
Senator Voinovich. Getting back to what you mentioned,
Senator Durbin, about the nurse that you ran into who can go
wherever she wants to in the country and always find a job. It
would be interesting to know if she works for an independent
third-party organization that handles that.
Senator Durbin. I think Mr. Mecklenburg can tell us about
those nurses. I think that when hospitals face severe
shortages, they sometimes hire contract nurses at considerably
higher salaries to fill in, and we can learn about that.
Thank you all very much. I want to thank the panel for your
testimony. We may be sending you some follow-up questions, and
I hope that you will be able to respond to us in a few days.
Senator Durbin. I would now like to introduce our second
panel of witnesses and ask them to come forward.
Ann O'Sullivan, welcome. Ms. O'Sullivan is a registered
nurse and President of the Illinois Nursing Association.
Gary Mecklenburg is President and Chief Executive Officer
of Northwestern Memorial Hospital in Chicago. He is also
Chairman of the American Hospital Association Board of
Trustees. Gary, thank you for being here.
Carol Anne Bragg is a registered nurse and a member of the
Service Employees International Union's Nurse Alliance, with
the Professional Staff Nurses Association, and is President of
SEIU Local 1998, from Maryland. Thank you for coming.
My former colleague from the U.S. House of Representative,
the Congresswoman from the State of Illinois and City of
Rockford, Hon. Lynn Martin joins us on behalf of the Labor
Panel and the Nursing Institute at the University of Illinois.
She is the chairman of the Panel on the Future of the Health
Care Labor Force in a Graying Society. She is accompanied by
Mary Jo Snyder, Director of the Nursing Institute at the
University of Illinois-Chicago College of Nursing.
And J. David Cox is a registered nurse and Vice President
of the National Veterans Affairs Council for the American
Federation of Government Employees, AFL-CIO.
Thank you all for coming. We look forward to hearing from
you, and now I am going to administer the oath. Prepare, if you
will, by standing.
Do you swear that the testimony you are about to give
before this Subcommittee will be the truth, the whole truth,
and nothing but the truth?
Ms. O'Sullivan. I do.
Mr. Mecklenburg. I do.
Ms. Bragg. I do.
Ms. Martin. I do.
Ms. Snyder. I do.
Mr. Cox. I do.
Senator Durbin. Thank you.
Let the record reflect the witnesses answered in the
affirmative and therefore will be allowed to continue.
I would ask you to limit your oral statements to no more
than 10 minutes and remind you that your entire statement will
be made a part of the record.
Ms. O'Sullivan, please proceed.
TESTIMONY OF ANN O'SULLIVAN, RN,\1\ PRESIDENT, ILLINOIS NURSES
ASSOCIATION, ON BEHALF OF THE AMERICAN NURSES ASSOCIATION
Ms. O'Sullivan. Good morning, Mr. Chairman and Members of
the Subcommittee.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. O'Sullivan appears in the
Appendix in page 107.
---------------------------------------------------------------------------
I am Ann O'Sullivan, a registered nurse and President of
the Illinois Nurses Association. I am pleased to be here today
representing the American Nurses Association, or ANA, in
support of your efforts to improve the recruitment and
retention of America's registered nurses. ANA is the only full-
service association representing the Nation's RN's through its
54 constituent member nurse associations.
As the Subcommittee is aware, health care institutions
across the Nation are experiencing a health care crisis in
nurse staffing, and we are facing an unprecedented nursing
shortage. As RN's are the largest single group of health care
professionals in the United States, the current and emerging
nursing shortage poses a real threat to the Nation's health
care system.
As you may remember, the last nursing shortage was just
over 10 years ago. At that time, health care providers did
respond by instituting aggressive recruitment campaigns and by
increasing RN wages. In fact, the average real annual salary of
all RN's employed full-time rose 33 percent between 1980 and
1992. At the same time, RN employment in hospitals grew by a
steady rate of 2 to 5 percent annually. By the early 1990's,
reports of nurse shortages had significantly diminished.
However, in the mid-1990's, the picture changed. During
this time, the influx of managed care and changes to Medicare
reimbursement began to exert downward pressure on provider
margins. Providers responded by implementing cost containment
programs.
As RN's typically represent the largest single budget item
for a hospital, we were some of the first to feel the pinch.
Between 1993 and 1997, the average wage of RN's employed in
hospitals dropped by roughly $1 an hour in real terms. RN
employment in the hospital sector significantly decreased, and
lesser skilled, assistive staff were hired as our replacements.
In addition, many providers eliminated positions for nursing
middle managers and executive-level staff.
These staff reductions occurred at the same time that
patient acuity increased, the use of sophisticated technology
increased, and the length of stay deceased.
In the end, these changes increased the pressure on staff
nurses who were required to oversee unlicensed aides while
caring for a larger number of sicker patients. The elimination
of management positions shortened the career ladder and
decreased the support, advocacy, and resources necessary to
ensure that staff nurses could provide adequate care.
Not surprisingly, these changes caused a downturn in the
number of people working in the nursing profession and growing
discontent among those who remain.
A recent ANA survey of 7,300 nurses across the Nation
revealed that nearly 55 percent of today's nurses would not
recommend the nursing profession to their children or friends.
In fact, 23 percent of the nurses surveyed indicated they would
actively discourage someone from entering the profession.
In fact, an alarming number of experienced RN's are opting
to leave the profession. The 2000 National Sample Survey of
Registered Nurses showed that half a million nurses who have
active licenses, more than 18 percent of the nurse work force,
are no longer working in nursing. In Illinois alone, the number
of licensed RN's who are not working in nursing increased by 8
percent in the years between 1996 and 2000.
As you will hear today, the American Hospital Association
reports that there are 126,000 current openings for RN's in
hospitals across the Nation and that these positions are
increasingly hard to fill. We maintain that the reason for
these vacancies and for the recent exodus from nursing is
dissatisfaction with the work environment.
The large number of nurses with active licenses who are no
longer working in nursing indicates that there is not a current
shortfall in the number of RN's per se. Rather, there is a
shortage of positions that these nurses find attractive.
With that said, I would like to look forward to solutions
to these problems. There are a number of initiatives that the
ANA and I support to improve the environment of care for
nursing.
The first of these is the need for adequate nurse staffing.
More than a decade of research shows that nurse staffing levels
and skill mix make a different in patient outcomes. In fact,
four HHS agencies recently sponsored a joint study on this very
topic. The resulting report found consistent and strong
evidence that increased RN staffing is directly related to the
decreased incidence of urinary tract infections, pneumonia,
shock, upper gastrointestinal bleeding, and decreased 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 increasing nurse turnover is
dissatisfaction with work load and staffing. Understandably,
nurses do not want to work in environments with poor outcomes.
For these reasons, we support your efforts to require
health care facilities to develop and use valid and reliable
staffing plans.
Another problem that must be addressed is the use of
mandatory overtime as a staffing tool. I have heard over and
over again that mandatory overtime is being used regularly to
cover staffing shortages. Many nurses report that employers
insist they work an extra shift regardless of their level of
fatigue. In these situations, nurses who refuse to work past
their regular shift could face dismissal for insubordination as
well as the threat of being reported to the State board of
nursing for patient abandonment.
Certainly it only stands to reason that an exhausted nurse
is more likely to commit a medical error than a nurse who is
not required to work a 16- to 20-hour shift.
Unfortunately, nurses are placed in a unique situation when
confronted by demands for overtime. We are ethically bound to
refuse to engage in behavior that we know could harm our
patients. At the same time, we face the loss of our license,
our careers and our livelihoods when charged with patient
abandonment. Without legislation, nurses will continue to
confront this dilemma.
I applaud you, Chairman Durbin, for your efforts to develop
legislation to ban the use of mandatory overtime.
In addition, we support legislative initiatives that
provide nurses the ability to speak out about quality of care
problems without fear of retaliation. This issue is addressed
by a provision in the bipartisan patient protection act which
we strongly support.
Looking even further into the future, one thing is certain.
The current nursing shortage is nothing in comparison to the
projected systemic shortage that will become a reality in the
next 10 to 20 years. Current vacancies are compounded by an
increased number of retirement-age nurses, a shrinking pool of
new nurses, and the impending health care needs of the baby
boom generation. These demographic forces will soon produce an
unprecedented nursing shortage. In fact, current projections
estimate that the overall number of nurses per capita will fall
nearly 20 percent below requirements by the year 2020.
Now is the time to address this impending public health
crisis. Chairman Durbin, I understand that you are developing
legislation that contains enhanced loan repayments,
scholarships, career ladder programs, and public service
announcements designed to attract more people into the nursing
profession. The ANA and I support you in these efforts. We
believe that America must take steps now to develop its
internal nurse work force.
We agree with you, Chairman Durbin. We do not believe that
immigration is the answer to the emerging nursing shortage. We
have been down this road many times before without success.
Experience shows that the influx of foreign-trained nurses
only serves to further delay debate and action on the serious
workplace issues that continue to drive American nurses away
from the profession. In addition, there are serious ethical
questions about recruiting nurses from other countries when
there is a worldwide shortage of nurses. And sadly, there are
numerous disturbing examples of the exploitation of foreign-
trained nurses. Let us not make this mistake again. We should
not look overseas when the real problem is the fact that the
United States health care system has failed to maintain a work
environment that is conducive to safe, quality nursing practice
and that retains experienced American nurses in patient care.
I also want to comment on the issue of too much paperwork
and nurse dissatisfaction. While we are open to discussing
streamlining paperwork, this is not the primary reason why
nurses are leaving the bedside.
In summary, it is critical that this Subcommittee
understand that no effort to address the nursing shortage will
be a success unless we first fix the serious problems in the
work environment. Until we address issues such as inappropriate
staffing and mandatory overtime, health care providers across
the Nation will continue to experience worsening 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.
We look forward to working with you and our partners in the
health care community to develop an environment that is
conducive to high-quality nursing care. Efforts in this
direction will have a positive impact on health care services
for all Americans.
Thank you for the opportunity to provide this testimony,
and I would be happy to answer any questions that you might
have.
Senator Durbin. Thank you very much.
Gary Mecklenburg, from Northwestern in Chicago and the
American Hospital Association.
TESTIMONY OF GARY A. MECKLENBURG,\1\ PRESIDENT AND CHIEF
EXECUTIVE OFFICER, NORTHWESTERN MEMORIAL HOSPITAL, CHICAGO,
ILLINOIS, ON BEHALF OF THE AMERICAN HOSPITAL ASSOCIATION
Mr. Mecklenburg. Thank you, Mr. Chairman.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Mecklenburg appears in the
Appendix in page 115.
---------------------------------------------------------------------------
I am Gary Mecklenburg, CEO of Northwestern Memorial
Hospital in Chicago. I am here today as Chairman of the
American Hospital Association, representing the AHA's nearly
5,000 hospital and health system members. We appreciate this
opportunity to testify on both the immediate and long-term
shortage of nurses.
Northwestern Memorial is a nationally-known teaching
hospital affiliated with Northwestern University's Medical
School. We employ more than 5,000 caregivers, including 1,100
registered nurses, and we have 1,200 physicians on our medical
staff.
Northwestern Memorial is growing rapidly, and that growth
presents many challenges. However, the single greatest
challenge today and in the future is the recruitment and
retention of high-quality staff to serve our growing number of
patients. A recent survey of AHA members revealed that
hospitals have close to 168,000 open positions; 126,000 of
those positions, or 75 percent, are for registered nurses.
Several factors contribute to this shortage. First, sicker
patients have resulted in an increasing demand for nurses.
Second, there is a shrinking supply of experienced nurses due
to an aging workforce. And finally, a diminishing enrollment in
nursing schools has resulted in a dearth of younger nurses to
replace retirees.
At the same time, the number of patients in need of
hospital care is increasing. Seventy-eight million baby boomers
are approaching retirement age and Medicare, but they already
are experiencing a need for more health care. Due to medical
advances, we are diagnosing and treating cancer, heart disease,
orthopedic conditions at an earlier age. The resulting demand
for health care may soon exceed our capacity to provide it. In
fact, some hospitals are being forced to reduce the number of
inpatient beds available, postpone or cancel elective
surgeries, or tell ambulances to bypass their overflowing
emergency departments.
But these are not acceptable solutions; they are merely
short-term responses. Hospitals are taking actions to cope with
caregiver shortages. Northwestern Memorial, like other health
care facilities around the country, employs a variety of
strategies to attract and retain nurses, including flexible
hours, enhanced compensation and benefit strategies, onsite
child care, and programs to attract youth to health careers.
Innovative programs aimed at ensuring a current and future
supply of staff come at a significant cost. Many of these
expenses are not recognized as costs by the Medicare program or
other payers, making it difficult to be creative in finding
solutions.
The AHA recently convened a Commission on Workforce for
Hospitals and Health Systems. This diverse group of
stakeholders includes hospital administrators, nurses,
academics, as well as business and organized labor leaders. The
Commission will develop joint solutions to address worker
shortages and release its final recommendations next spring.
While the hospitals of the AHA are taking steps to tackle
the shortage of caregivers, there are actions that Congress can
take to help alleviate this problem.
The American Hospital Association supports the following
bipartisan legislation:
The Nurse Reinvestment Act, introduced by Senators Kerry,
Jeffords, and Hutchison establishes a national nursing services
corps and supports individuals wishing to advance in or enter
nursing careers.
The American Hospital Preservation Act, introduced by
Senators Bayh and Hutchison, provides a full inflationary
payment update for fiscal years 2002 and 2003. This would help
hospitals provide fair and reasonable wage increases and to pay
for the work incentives hospitals must use to attract and
retain qualified staff. I would note that in the past 17 years
of the Medicare Program, it has provided a full inflationary
update only three times.
The Area Wage and Base Payment Improvement Act, introduced
by Senators Hutchinson and Cleland, recognizes the increased
competition for caregivers by providing a floor on the Medicare
wage index to help improve workforce compensation.
Mr. Chairman, this Nation faces a critical shortage of
women and men in health care careers. Collectively, we must
take action before the crisis worsens, and the first steps
toward a solution are for all stakeholders to enter into a
discourse and for the Federal Government to restore remaining
Medicare and Medicaid reductions, provide greater support to
rural hospitals, and establish new nursing education
initiatives. Together, we can develop solutions that protect
the future of health care for the Nation.
Thank you very much.
Senator Durbin. Thank you.
I now call on Carol Anne Bragg for her testimony.
TESTIMONY OF CAROL ANNE BRAGG, RN,\1\ PRESIDENT, PROFESSIONAL
STAFF NURSES ASSOCIATION, ON BEHALF OF SERVICE EMPLOYEES
INTERNATIONAL UNION, AFL-CIO
Ms. Bragg. Thank you, Senator Durbin, for allowing me this
opportunity to speak on behalf of the Service Employees
International Union on the current nursing crisis in this
country.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Bragg with an attachment appears
in the Appendix in page 129.
---------------------------------------------------------------------------
I am a full-time registered nurse working in a cardiac
unit, a member of SEIU's Nurse Alliance, and President of my
Local 1998, Professional Staff Nurses Association, in Maryland.
Today I am speaking on behalf of the 1.4 million members of
SEIU, more than 710,000 of whom work in the home health
industry and more than 110,000 of whom are nurses. I speak also
as someone who is engaged in addressing the nursing crisis on a
Statewide level. Last fall, I was appointed by the Governor to
serve on the Commission on Crisis in Nursing created by the
Maryland General Assembly to investigate and find ways to deal
with this urgent issue.
Today, nurses in hospitals and related facilities are
caring for more and sicker patients than we did a decade ago.
The result is that hospitals are truly having increased
difficulties filling vacancies for RN's. The hospital industry
cites difficulty in filling vacancies to point to a nationwide
nursing shortage, but a closer look at the data suggests that
the real problem is that there is a shortage of nurses who are
willing to work in hospitals under the current working
conditions.
We view this situation as a staffing crisis rather than
nursing shortage. It is systemic understaffing brought on by
the restructuring of the industry under managed care that has
led to dramatically deteriorating working conditions and
increased concern about the quality of care which causes nurses
to leave hospitals. Inadequate, unsafe assignments has given
rise to increased numbers of medical errors. As you said in
your opening statement, the Institute of Medicine found that
44,000 to 98,000 Americans die every year in hospitals due to
medical errors. While the IOM report exposed a national crisis,
it did not explore one of the primary causes for the crisis,
which is understaffing.
SEIU recently completed a national survey reported in this
document on the shortage of care. We find that the majority of
nurses identified understaffing as one of the leading causes of
medical errors.
In my State of Maryland, the nursing crisis and the
deteriorating conditions has compromised quality of care for
the people in our communities. According to the Maryland
Hospital Association, ``over half the hospitals throughout
Maryland report that they have had to close beds, delay or
cancel surgeries, disrupt scheduled procedures, and reroute
ambulances to other facilities for emergency patient care.''
The MHA says that it is increasingly common for patients
arriving in an emergency department ``to be held there until
adequate staffing becomes available on a patient unit.'' Your
loved ones deserve better, and so do mine.
A particularly devastating side effect of the understaffing
crisis is the abuse of mandatory overtime by many health care
employers. Nurses are often mandated to work extra hours, which
can mean back-to-back 8-hour shifts, or more hours on top of a
12-hour shift, to fill the gaps in staffing. Of course, this
threatens patient safety. There is no way an exhausted and
overworked nurse is as alert and accurate as a well-rested
nurse coming on fresh for her shift.
Mandatory overtime also places an incredible stress on
family life, particularly when last-minute changes have to be
made to find child care or care for elderly parents.
According to our survey, nurses in acute care hospitals
work an average of an additional 8\1/2\ weeks of overtime in a
year. Nurses are not only being increasingly required to work
excessive amounts of mandatory overtime, but are also required
to routinely ``float'' or be reassigned to units where they
lack expertise and training. Nurses are being stretched to the
limit, experiencing high levels of stress, chronic fatigue, and
work-related injuries.
These intolerable work practices lead to further burnout
and undermine a nurse's sense of professionalism and are
driving nurses from our hospitals, because we were never
trained to provide inadequate or poor care.
According to the SEIU survey, only 55 percent of acute care
nurses plan to stay in hospitals until they retire, and only 43
percent of nurses under age 35 plan to stay at the hospital
until they retire. But 68 percent of nurses say they would be
more likely to stay at their facilities if staffing levels in
their facilities were adequate.
These statistics show a little discussed fact about the
``shortage.'' In reality, the current supply of nurses far
exceeds the demand. According to the Health Resources and
Services Administration survey, there are approximately 500,000
nurses who have licenses but are not practicing in the field,
and the proportion of nurses employed in hospitals has
decreased substantially and consistently, from 68 percent in
1988 to 59 percent in the year 2000.
There is a brief window of opportunity and a fine line
between the staffing crisis and the nursing shortage.
Deteriorating staffing and working conditions have led many
nurses to leave the profession altogether, and fewer young
people are entering it. The nursing school enrollment has
declined in each of the last 6 years, and as a result, the
average age of RN's working has increased to the age of 45. As
these trends continue, there will likely be a severe nursing
shortage in the future.
I have focused my remarks principally on the hospital,
since that is where the nursing crisis is most severe. There
is, however, a related and equally serious problem in nursing
homes. While RN's make up a small proportion of the nursing
home work force and are largely in managerial positions, most
of the staff in nursing homes are certified nursing assistants,
L.V.N.s or LPN's. SEIU members include more than 120,000
nursing home employees, a vast majority of whom are C.N.A.s and
a large number of whom are LPN's.
Similar to administrators in the hospital industry, nursing
home owners have argued that they are facing a shortage of
nurses and nursing aides. For this reason, they have asked for
increased Medicare and Medicaid reimbursement and have resisted
setting the minimum staffing standards. But like most
hospitals, the real problem is not finding people to work in
nursing homes; it is keeping them there.
The turnover rate for direct care workers in nursing homes
is nearly 100 percent, causing a revolving door of caregivers
which renders continuity of care impossible. Workers are
leading due to heavy work load; they simply do not have enough
time to care for the number of residents they are assigned to,
which leads to stress, guilt, and burnout. Moreover, low wages,
lack of health care insurance, and high injury rates make
nursing home work unsustainable for many workers.
Nurses across the country are sounding the alarm because
staffing levels are too low to provide the quality of care for
the needs of their patients. In many States where we have
unions, we have turned to the bargaining table to change our
working conditions in order to ensure safe staffing and better
patient care.
Eliminating mandatory overtime, establishing safe staffing
standards, and improving recruitment and retention by
increasing pay have been primary issues of contract
negotiations from coast to coast.
At my hospital, we have worked very hard to ensure that the
past practice of not requiring mandatory overtime is followed,
and I can tell you that is very much an incentive for nurses to
stay.
Earlier this year, SEIU nurses at Aliquippa Community
Hospital became the first in their State to win an agreement in
their contract eliminating mandatory overtime, and their CEO,
Fred Hyde, recently joined the nurses in pressing for a State
law in Pennsylvania to protect patients and nurses from
mandatory overtime, calling it ``involuntary servitude.''
Increasingly, SEIU, along with other unions and the
American Nurses Association, have introduced legislation at the
State level to establish staffing standards, ban mandatory
overtime, provide whistleblower protection for nurses when they
speak out on understaffing that jeopardizes good care, and
provide for involvement of direct care nurses in the
development of staffing policies.
On the Federal level, legislation has been introduced that
is designed to attract new people into the nursing profession
by making it easier to access education and training resources.
While we applaud these efforts, this will not address the
fundamental problems facing our profession and our patients.
Forcing more overtime, or simply relying on nurse recruitment
programs will not solve the problem, either. Likewise, easing
immigration rules to attract more foreign nurses or expanding
the number of visas allowed for nurses and nursing home workers
will only push more caregivers through the revolving door of
our Nation's hospitals and nursing homes.
All these measures will only treat the symptoms, but will
not cure the disease. Unless and until we address the
understaffing and poor working and patient care conditions that
plague our nurses, we will never resolve this shortage.
Fundamentally, the solution to the nursing crisis lies in
the establishment of safe staffing standards in our hospitals.
Specifically, we must set enforceable minimum staffing
standards linked to the acuity of patients, quality of care,
skill of the staff, and the skill mix to ensure that in our
hospitals, emergency rooms and outpatient facilities, patients
receive the care they deserve.
We must make sure that the minimum levels do not become the
ceilings. We must make safe staffing a requirement for all
hospitals receiving Federal taxpayer dollars. We must make sure
the Federal Government provides adequate oversight of our
hospitals and that the industry's self-monitoring system under
the Joint Commission on Accreditation of Healthcare
Organizations be reformed. We must also protect the rights of
patients and the rights of health care workers who blow the
whistle on staffing problems that jeopardize quality of care
without fear of losing their jobs.
This problem did not happen overnight, and it is not going
to go away overnight. The first step we can take today to stop
the hemorrhaging by starting a concerted effort to ban
mandatory overtime. Limiting forced overtime will ease the
impact of the shrinking supply of nurses by encouraging more
nurses to stay in the profession. It will protect countless
patients in the same way that limits on mandatory overtime is
there for train engineers, air traffic controllers, truck
drivers, and other occupations where public safety is at risk.
At the same time, we cannot lose sight of the fact that the
system needs help. We must find a way to set meaningful
standards for staffing in the health care industry.
Understaffing in our hospitals is a serious problem. It is a
problem that will only be solved through the joint efforts of
public officials like you, nurses, and hospital administrators.
Mr. Chairman, we look forward to working with you on this
critical issue, and I am certainly happy to answer any of your
questions.
Senator Durbin. Thank you very much for your testimony.
In introducing my former colleague, Congresswoman Lynn
Martin, I forgot a very important part of her resume. She
served as Secretary of Labor under President Bush, and she
certainly has the background to address this issue.
Welcome, Lynn.
TESTIMONY OF HON. LYNN MARTIN,\1\ CHAIR, PANEL ON THE FUTURE OF
THE HEALTH CARE LABOR FORCE IN A GRAYING SOCIETY, ACCOMPANIED
BY MARY JO SNYDER, DIRECTOR, THE NURSING INSTITUTE, UNIVERSITY
OF ILLINOIS AT CHICAGO, COLLEGE OF NURSING
Ms. Martin. Thank you very much, Mr. Chairman, and
representatives of the other Members of your Subcommittee.
---------------------------------------------------------------------------
\1\ The prepared statement of Ms. Martin appears in the Appendix in
page 142.
---------------------------------------------------------------------------
The name of the panel that I chaired--not necessarily with
knowledge at the beginning, that is for sure--was ``The Future
of the Health Care Labor Force''--in all of its permutations--
``in a Graying Society.'' You will hear also from Mary Jo
Snyder, who is Director of The Nursing Institute and was also a
member of this panel.
Panel members represented public institutions, academia,
think tanks, private businesses, organized labor, and
professional groups. It crossed racial, gender, and political
lines. We have released our report and recommendations, so this
is a serendipitous time, I think, to come before this
Subcommittee for what is an extraordinarily necessary look at
the problem across the health care continuum.
I think it is a wake-up call. That crisis will strike with
full force by 2010, and it will continue for many years
thereafter. America will not have enough health care workers,
particularly nursing care workers, to care for the people who
will need it most--every senior citizen.
The health care labor shortage is not a short-term,
temporary decline in the supply of nursing care providers.
Instead, America, like the rest of the world, is facing a
systemic change in the population of those being served and in
the population of caregiving professionals.
How concerned should we be? Well, consider this. Between
2000 and 2030, the ratio of potential caregivers to people most
likely to need care will decrease by 40 percent.
The usual American solutions of money and technology will
not be enough; although they are part of the answer, they do
not provide the living human beings who are needed to care for
other real human beings.
In the past, we have had caregiving shortages. Today, we
use some of the same solutions--flextime, higher wages,
bonuses, immigration--all to increase in the short term the
number of health care workers.
But for the future, we are not just facing a temporary
shortage. We are facing a systemic change, not just in the
population of those being served, but in the professions
themselves.
The underlying problem has two dimensions--demographic
change and an insufficient supply of professional nurses, nurse
aides, and other health care workers in the work force. The
forces of demographic change are inescapable. We face a future
in which there will be many more older people in the
population, some of whom are sitting here right now; and at the
same time, relatively fewer younger people, both family members
and professionals, to care for them.
Between the years 2010 and 2030, the proportion of the
United States population aged 65 or older will increase from
approximately 13 percent to 20 percent. That means 30 million
people. And the number of people aged 85 or older will increase
by over 4 million.
At the same time, the United States will experience a more
than 6 percent decline in the proportion of people aged 18 to
64--the work force and the family members who have
traditionally cared for elderly members of our society.
These demographic changes will occur, moreover, within a
labor market in which the pool of potential health care
employees will be in high demand by other service sector
employers. You have heard talk about hospitals. This is a
concentrated look at specifically the full range of services
that people over the age of 65 will need.
Worse yet, many of the nursing care occupations today are
neither attractive nor financially competitive. You have seen
the report issued by the University of Pennsylvania School of
Nursing. They surveyed 44,000 nursing professionals, and a
shocking 40 percent said they intend to leave the nursing
profession for a different career within 1 year.
Let me turn to the implications and the effects of these
trends. Approximately 20 percent of all informal caregivers
employed while giving such care gave work, either temporarily
or permanently. These are people who work outside the health
care setting, this informal network of people who care,
temporarily or full-time, for aunts, mothers, and fathers.
Seven percent of informal caregivers went from full-time to
part-time work.
Thirty-three percent of full-time employees and 37 percent
of part-time employees have lost time from work due to these
informal caregiving responsibilities.
In other words, the effect on the rest of the economy as
these numbers increase is going to be real and negative. If our
country fails to build the required professional caregiver
infrastructure, the costs will come home to roost in other
ways. One way or another, we will have to care for our growing
elderly population. And because it is women who provide most of
the informal care, it will be women who will have to scale back
or even quit their jobs to take care of aging parents and
relatives.
We have a list of recommendations from the panel, some for
the private sector, some for the public sector, and some a
combination. It is a reform agenda.
It notes that more money by itself will not totally solve
the problem, but that no labor shortage has ever been solved
without a market-based set of economic reasons. In other words,
money still counts.
We recommend for the private sector that they have more
attractive wage and benefit packages; that they make the work
environment more desirable; and that they use best management
practices across a spectrum of health care facilities. We
believe there has to be ongoing training and continuing
education for all nursing care providers, with a focus on team-
oriented education.
For the public sector, we think there should be a Federal
commission established to investigate economic incentives
targeted to workers in geriatric nursing occupations. I can
only say that with all the difficulties, there is still a TV
show called ``Emergency Room'' where we can see doctors and
nurses and nursing care professionals in an exciting work
environment. There is never going to be that successful a show
titled, ``Nursing Home.'' And yet more of us are going to need
those services.
We want to see a public-private panel established to
examine education and training requirements for all nursing
care professions that would assist the State and employers in
professionalizing all nursing care occupations.
We want to see changes in Medicare rules and regulations so
that all entry-level nursing education and training programs
include training in geriatrics. We are finding that so few of
them do, it is actually shocking.
We want appropriate Federal agencies to require guidelines
of the States so that standardized entry criteria may be
developed for training.
And, as you have found out today, there is still not enough
data. We want Federal data collection agencies to be required
to provide more recent data so that you and your colleagues can
make appropriate decisions.
We want to see partnerships that can identify the most
successful recruitment and retention strategies. We want to
focus more on independent and informal caregivers and the
economic consequences of such caregiving.
In conclusion, Mr. Chairman, we have a challenge before us.
We need to start now, because change will take time, and we
cannot afford delay. In the end, I believe that America will
respond to this crisis. The profession of nursing can be
enhanced and respected.
America today cares for its elderly. I am confident that we
will find the solutions to make sure we do it for the future.
Thank you very much for having us and for beginning the
dialogue.
Senator Durbin. Thank you very much. Ms. Snyder.
Ms. Snyder. Actually, Senator, I will defer my comments at
this time. Secretary Martin did a wonderful job, and our
written testimony is part of it.
Senator Durbin. Thank you very much. Mr. Cox.
TESTIMONY OF J. DAVID COX, RN,\1\ VICE PRESIDENT, NATIONAL
VETERANS AFFAIRS COUNCIL, AMERICAN FEDERATION OF GOVERNMENT
EMPLOYEES, AFL-CIO
Mr. Cox. Chairman Durbin, Ranking Member Voinovich, and
Members of the Subcommittee, I am J. David Cox. I have worked
as a registered nurse at the Salisbury, North Carolina W.G.
Bill Hefner VA Medical Center for 17 years.
---------------------------------------------------------------------------
\1\ The prepared statement of Mr. Cox appears in the Appendix in
page 152.
---------------------------------------------------------------------------
Being a nurse at the VA 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 in the
VA, I applaud you for holding this hearing on the issue of
nursing shortages.
Thank you for giving AFGE the opportunity to tell you about
the causes and harmful effects of understaffing at VA medical
centers.
How bad is the nursing shortage at the VA? Since 1995, the
VA has cut RN staff by 10 percent, its LPN's by 13 percent, and
its nursing assistants by a whopping 30 percent.
The combination punch of these staffing cuts means one in
six nurses is no longer taking care of America's veterans.
These staffing cuts hurt patient safety and quality of
care. The constant stresses to the system created by
understaffing are creating serious fractures in the health care
system. For example, nursing assistants at the VA help patients
with activities of daily living. They help veterans eat, bathe,
take a walk, and, yes, go to the toilet.
The shortage of nursing assistants at the VA condemns
patients to the indignity, frustration, and anger associated
with waiting and waiting and waiting for someone to come and
help them.
Because the VA does not have enough nursing assistants, by
necessity LPN's and RN's must take on increased work loads and
help veterans with these basic nursing activities. Nurses on
wards are already understaffed, must juggle their extra duties.
While RN's and LPN's are spread so thin and must perform
more basic nursing functions, they are not able to keep an eye
on their patients who need adequate monitoring.
Research shows that registered nurse staffing levels were
the most important factor in predicting the success rates of
saving patients who have cardiac arrest or go into shock while
in the hospital. Unfortunately, this dire situation is in large
part due to the VA's reorganization and budget. It is not
wholly due to a tight labor market.
VA's response to its unsafe staffing levels has been to
force mandatory overtime on already overwhelmed nurses to work
the next shift day after day.
AFGE locals in Danville, Illinois and Cleveland, Ohio and
across the country have told me alarming stories about nurses
working 16-hour days with impossible patient work loads, trying
to care for too many acutely ill patients with too few staff.
To top it off, nurse pay has been stagnant.
These deteriorating conditions are driving more nurses to
leave the VA and the nursing profession. These difficult
working conditions are not just symptoms of staff shortages.
Forcing nurses to work two shifts in a row is a prescription
for medical errors and nurse burnout. Mandatory overtime
aggravates the problem and is driving more nurses to leave the
VA and the nursing profession.
The overall increase in the VA's overtime costs suggests
that the VA is using mandatory overtime to fill shifts on a
routine basis. In the past 3 years, VA's cost for overtime for
nurses has nearly doubled.
Stopping mandatory overtime is an immediate step that would
both improve working conditions for nurses and improve patient
safety.
Like other Federal employees, VA nursing staff are paid
less than their counterparts in the private sector. Private
hospitals typically pay staff premium pay to work on weekends.
This premium is not for overtime but for a regular shift.
Current law on Federal employee pay prohibits the VA from
paying its nursing assistants Saturday premium pay.
If VA is to compete for and retain high-quality nursing
staff, it must pay Saturday premium pay for nursing assistants.
Mr. Chairman, I need to tell you that many people who enter
the nursing profession nowadays enter it through the door of a
nursing assistant. I, myself, started as a food service worker
and went to nursing assistant to an LPN to an RN, because
somebody reached out a hand and encouraged me to go to school
because there were loans, because there was an employer who
stepped forward and cared, and I have been able every 2 weeks
to contribute back on a regular basis to the Federal and State
Governments that reached out that helping hand to me.
I encourage you to continue looking at how we can encourage
people to enter whatever door is necessary to become part of
the nursing profession and to be able to care for yourself and
many of our other friends in this room as we continue to grow
older each day, and we need nursing care.
Thank you for caring about the nursing shortage at the VA
and about America's veterans. I would be happy to answer any
questions, sir.
Senator Durbin. Thank you very much, and thanks to the
entire panel.
Mr. Mecklenburg, it seems like all roads lead back to us--
first, the Federal Government and its level of reimbursement to
the institutions that provide health care; our antiquated civil
service rules; perhaps our insensitivity to funding at the
Veterans Administration; and loans and scholarships--things
that we can do here on Capitol Hill.
And certainly, a lot of roads lead back to the
administrators of hospitals in terms of how their hospitals are
managed and how they treat the people who work there. I think
we have heard in the course of these two panels a lot of
questions raised about mandatory overtime, and I would like to
visit that first if I might.
Can you give me an indication--are there hospitals that
just categorically do not have mandatory overtime, that just do
not impose that as a policy on their employees?
Mr. Mecklenburg. Well, let me say that what we have heard
today is that the issue of nurse staffing and mandatory
overtime is a complicated issue, and the mandatory overtime
issue specifically is symptomatic of the larger issue that you
are exploring of nurse staffing and critical shortage of health
care workers.
You heard a lot from the first panel in terms of data. We
could use more data to understand this problem. So in the
absence of either a uniform definition of mandatory overtime or
collecting data on this, I have to tell you what I do know, and
let me tell you about my own organization.
Nurse staffing is a big issue. It has always been an issue.
We are a 24-hour-a-day, 7-day-a-week, 365-day-a-year
organization, and staffing is an issue on every shift. And you
use a lot of different techniques to get the appropriate
staffing for the number and acuity of patients that one has to
take care of.
We do not know every day what our needs are going to be. We
do not know how many patients are going to show up in the
emergency room. We do not know the acuity of patients post-
operatively. So it is a very complicated process.
Our clear preference is to use full-time staff, staff who
are employed, who are our employees, or permanent part-time
staff. I would point out to you that that is the most
economical way for us to run our organizations as well, and
when we are concerned about cost, moving to overtime, moving to
people on call, using very expensive private agencies that cost
us double the cost of an RN, and finally, mandatory overtime as
a last resort, are very expensive ways. But nevertheless, all
of those techniques are ones that we have to have available to
us.
In my institution, we do not use mandatory overtime very
often at all; it is a rare occurrence. In my role as chairman
of the American Hospital Association, part of what I am doing
this year is going around the country, meeting with colleagues,
and talking about current issues. And one of the hot topics for
us, in part because of the light that is being shone on this
issue, is to ask about their mandatory overtime practices. And
quite honestly, what I hear is very similar to what we do at
Northwestern Memorial, and that is that it is a technique to be
used as a last resort, for all of the reasons that I just
mentioned.
I think what we have to be careful of in addressing
mandatory overtime--and it is not our preferred way to solve
the nursing shortage; there are too many other techniques that
have to be used for both the short-term and the long-term--is
to recognize that we cannot not deal with the patients in the
hospital at any point in time.
Consider if you will for a moment a small rural hospital in
this country where a nursing unit perhaps has six or seven
patients on the evening or night shift. There is only one nurse
required plus support staff on the evening and night shift. The
evening shift ends. The night shift nurse who is supposed to
come in calls in and has a sick child or is sick himself or
herself. What do you do?
The institution as well as the professional nurse are
responsible for taking care of those patients. So as we look at
the dimensions of this and caring for our nurses and providing
a positive work environment, we need to recognize that our
patients come first, and we have to assure that there is
adequate and continuous staffing to deliver the quality that we
also talk about in this issue.
Senator Durbin. Have you linked any studies on medical
errors with mandatory overtime?
Mr. Mecklenburg. I am not aware of those. I have asked that
question. I think your staff asked a question in advance about
the Institute of Medicine report. We have had two reports, as
you know, in the last 18 months. I do not know of any direct
correlation in those two reports dealing with safety, dealing
with medical errors and nurse staffing.
I believe there was an Institute of Medicine report in 1996
that said the evidence did not support a linkage with staffing
ratios at that time.
As you heard from this morning's panel, these are things
that are----
Senator Durbin. Medical errors and staffing ratios.
Mr. Mecklenburg. There was no evidence for mandatory
staffing ratios at that time. I do not know of any link in that
study on medical errors. Maybe there is some research out there
that I am not familiar with.
But you heard this morning that those studies are occurring
because all of us are concerned about medical errors; all of us
are concerned about nurse staffing, and we have to find the
evidence to know if much of that is true or not.
Senator Durbin. Ms. O'Sullivan, how do we balance this? Put
yourself in Mr. Mecklenburg's position for a moment. You are
the administrator of a hospital, and the Federal Government and
your conscience tell you that you do not turn people away from
the emergency room. But you are in the midst of a complicated
surgery, and you complete the surgery even if it went 14 hours
instead of 4 hours, and the nurse who is supposed to show up
for the next shift just called in and said her car broke down
50 miles away, and she does not know if she is going to make
it.
How do you deal with the overtime issue in that
circumstance?
Ms. O'Sullivan. First of all, nurses agree that taking care
of the patients is the number one priority. We agree on that.
The issue to solve that particular problem, though, does
not start when the nurse called in sick or when the nurse's car
broke down. I have been in nursing for almost 30 years, and I
have worked numerous overtime shifts when things exactly like
that have happened. In an environment where I was respected and
valued for my contributions, where I was being paid adequately
for my work, and where I had not been doing it day after day
after day after week after week----
Senator Durbin. I see a lot of heads nodding out there.
Ms. O'Sullivan [continuing.] And saw very little attempt on
the part of my employer to do something more about it besides
require mandatory overtime.
So the solution does not start when the nurse calls in
sick. The solution starts--and it is multifaceted, absolutely.
Nurses are there to take care of the patients. That is the
number one priority. But the best way to take care of patients
also revolves around taking care of yourself and knowing that
you are there and capable of taking care of those patients.
Senator Durbin, I would like to comment a moment on the
medical error and staffing issue. You referred earlier to The
Chicago Tribune headlines, which we all so enjoyed. You know
that after that, Governor Ryan appointed a task force in the
State, and I have been privileged to serve on that task force
representing nursing. It has been an interdisciplinary task
force.
The first recommendation we made to the Governor in terms
of dealing with medical errors and patient safety had to do
with staffing, interdisciplinary staffing, as has been referred
to here by several of the speakers--pharmacists, respiratory
therapists, and nurses. If we do not have that kind of
staffing, it only stands to reason that errors will occur.
In all the reading I did--and believe me, there was a lot
of reading for that task force work of specific studies that
show medical errors related to staffing--but they do show, as
many panel members today have reported, improved outcomes, less
negative outcomes, with RN staffing and appropriate skill mix,
staff mix.
Senator Durbin. Let me ask you about another thing. You
talked about basic respect for nurses at the institution. If I
heard you correctly, if that is present, when you are asked to
fill in in an emergency situation, you have a much different
attitude toward that request, rather than being asked
repeatedly and not respecting your own life and your own
professional need.
Let me ask you about the issue of nurse injuries. This is
something that I was surprised to find out as we prepared for
this hearing. Nurses and nurse aides have some of the highest
workplace injuries. Nurse aids suffer 13 injuries per 100
employees annually compared to the construction industry rate
of 8 per 100 employees annually.
Is this a factor----
Ms. O'Sullivan. Yes, this is a huge factor. The nursing
profession is as dangerous as the coal mining profession in
terms of injuries sustained--back injuries and infections are
huge issues in terms of being able to care for patients and
having a profession that attracts people to it.
In my institution and among nurses that I talk with around
the State, that is only aggravating the nursing shortage. We
have so many nurses off work and nurse aides off work because
of back injuries. When there is less staff there, whether it be
nurses or assistive personnel, you try to lift a patient or
move a patient or get a patient into a chair by yourself. If
you do that once, you might get away with it; if you do it day
after day after day, with large numbers of patients, you are
going to sustain a back injury.
When you are tired, when you are overworked, you are going
to sustain injuries. So nursing is a very dangerous profession.
Senator Durbin. Ms. Bragg, did you run into that as well?
Ms. Bragg. Senator Durbin, I had the unfortunate experience
of having a patient fall on me as I attempted to get him out of
a chair. He convinced me and another nurse that he could stand
on his own, and we were going to transfer him out of the bed
into the chair, and he fell on me. It did not bother me at that
moment, but about 2 hours later, I was walking down the hall
and found myself lying on the floor, because my disc had come
totally out-of-joint, and I could hardly move.
It is very serious in terms that we have hospitals still
using unsafe needles; we suffer recurrence of needle-stick
injuries; we have equipment that is antiquated and old and
heavy. When I transfer one of my CCU patients to a test
downstairs, the heart monitor that I have to carry weighs 40
pounds. Well, I get to carry that in one hand while I am
pushing the stretcher with a 200- to 300-pound gentleman on it
with the other hand.
You go home at night, and the heating pad becomes your best
friend. We should not have to do that. The answer to the
question is that there is no ancillary support to help us in
hospitals' attempts to cut corners and to put people on the
line who can do the job. A nursing assistant cannot do my job,
so we cut them and their roles, and that leaves me in a CCU
with no ancillary support to even help me move these patients.
Senator Durbin. Mr. Cox, what about the Veterans
Administration?
Mr. Cox. Twenty percent of the VA's workers' comp claims
are for back injuries, most of which occur when trying to lift,
move, and transport patients by themselves when there is not
another person to call.
Mr. Chairman, if I could also comment on the overtime
issue. A nurse calling in sick this afternoon and making that
coverage because coverage has to be made is one issue. But the
VA puts out a time sheet every other Friday, and on that time
sheet, we know 3 weeks ahead of time--there are maybe 10
shifts--that there is no nurse available, that there is not
enough coverage, and then they say, ``Nurse 1, you will work 16
hours this day; Nurse 2, you will work 16 hours that day--and
by the way, you do not get a day off this week because you have
to work overtime to make basic coverage.'' It is not the
unplanned; it is planned to run on overtime.
Senator Durbin. That is an important distinction.
Let me stay with the injury issue for a moment. Mr.
Mecklenburg, it is clear that this is a big problem for nurses
and a big problem in hospitals, and yet the American Hospital
Association came out against the ergonomics rule. Can you
explain that to me?
Mr. Mecklenburg. The American Hospital Association does
support a workable ergonomics proposal. We did oppose the
proposal that was before us last year that was based on
manufacturing standards. The hospital environment has unique
aspects to it, and we are working right now with OSHA on
ergonomic standards for health care.
Hospital work is hard work. Nursing work is very hard work.
If you go across hospitals in the country, regardless of an
ergonomics proposal, there are lots of activities going on to
improve safety in hospitals. But when we get to a regulatory
piece, I think we have to be cognizant that different
workplaces need some different interpretations from time to
time, and that was the basis for our objections.
Senator Durbin. I do not disagree with that at all. It
clearly has to be tailormade to the workplace, but we have
really reached an impasse.
Madam Secretary, if I am not mistaken, your predecessor as
Secretary of Labor, Elizabeth Dole, was the first to announce
the ergonomics standard or at least identify it as a problem
that needed to be addressed. So as Secretary of Labor, you must
have gone through your own experience with the ergonomics. Can
you address the whole question of injuries and health
professionals and ergonomics? It is not the real focus of the
hearing, but we should address it since we have visited the
injury question.
Ms. Martin. To concentrate if I might on the area that this
particular panel looked at, you are quite correct. Although we
did not concentrate on injuries--and Mary Jo may wish to
comment since she directs the Nursing Institute--one of the
things that is quite clear is that the physical labor required
in a nursing home is stupendous. And let us again stay with the
obvious. Most nurses and nurse aides are women. Many people in
nursing homes cannot help at all with movement. There is almost
no thanks. Some of these people never have visitors, so their
only contact is this health care professionals. And when she or
he does not have adequate support, the answer is that the
person receives no help, or you can have the increase in
injuries.
Some of the changes that can occur are technological here.
We can make some differences. But the other part of the reality
is that these are human beings, and I would hope that the
impasse in this area could eventually be worked out in an
appropriate way, because you will not have people deliberately
choosing careers where their chance of being hurt is increased;
and as they get older, their ability to do some of these things
does become a factor. This is one of those things that keeps
going around.
Nurses and nurse aides are getting older. The requirement,
physically, is getting tougher in nursing homes because people
go at a later age, and they are more seriously ill. That is not
generally the place of choice, so the narrowing of the talent
pool is something, and the injury issue is real.
I would ask Mary Jo to comment.
Ms. Snyder. Thank you.
One of the things that we think is significant in relation
to injury but with this labor issue is that remember we are
speaking of the entire nursing care continuum, not just to the
RN The RN's dissatisfaction from our studies and issues of
working conditions and reasons for leaving the field has a lot
to do with their level of support, that support being at all
caregiver levels.
We would ask that as we look at solutions, we look at
solutions across the entire care continuum, specifically at the
nurse aide and the other caregiver levels.
We did look at the issue of technology, some of that being
ergonomic type of support, to support the nurses' role in this
hard labor--this is a difficult piece of labor--and we do not
believe that technology is really the solution here.
Senator Durbin. Well, I think technology can play a role in
making life a little easier. The Neon plant in Belvedere, which
you visited and I have visited, changed the workplace and saw a
dramatic decline in the number of accidents.
I would just say on this issue of ergonomics that we have
been debating this for over 20 years, and the people gathered
here who are in the nursing profession know that this is a
serious problem and part of the stress and difficulty of being
a nurse today. We have got to find a way to establish standards
that make the workplace safer for these employees.
Let me ask you this, Mr. Mecklenburg. On the question of
whistleblowers, this is painful for Senators and for Members of
Congress; it must be painful for hospital administrators to
protect, let alone reward, those who point out deficiencies in
their own management. Yet if you are going to deal with things
in an honest fashion, how do you think the American Hospital
Association would suggest that we deal with protecting
whistleblowers within hospitals who come forward and say, ``Let
me tell you, you are setting up an unsafe situation here for
the employees of this hospital and for the patients''?
Mr. Mecklenburg. Senator, if I could comment one last time
on the technology and the previous issue of ergonomics. There
are technological helps that can be there, and if I can, I
would link that with the questions you asked this morning about
Medicare reimbursement, because I think they are very
important.
As you know, we opened a marvelous new facility 2 years
ago.
Senator Durbin. Yes. It is beautiful.
Mr. Mecklenburg. When we did that, we were able to buy new
equipment for that facility. If you may recall, one of the
features is that every patient bed has a scale built into it.
One of the stresses for nurses is when they have to remove
a patient from the bed to weigh them--and for some patients,
that is multiple times every day. The technology exists to put
a scale in that bed and not have to move the patient. That
technology is expensive.
Senator Durbin. How expensive?
Mr. Mecklenburg. It is very expensive. These beds cost
thousands of dollars each and are far more than the simplest
bed available on the marketplace. But the cost of injuries, as
is implied in our conversation here, is also very high, and it
makes sense for that investment.
Hospitals are struggling with technologies like the beds,
but also when we talk about medical errors, the investment in
information technology that helps us get at that and also
simplifies the nurse and other professional work.
We have had hospital marketbasket calculations in the last
3 years of about 3 percent a year. We have gotten less than
full marketbasket. The investment in this technology requires
more than that.
You also asked a question about nursing salaries and what
has happened to them. If I may, I would like you to know what
is happening in our institution, and it gets right back to this
investment question.
In the last 3 years at Northwestern Memorial, our average
starting nursing salary has gone up 16.7 percent. The average
starting salary is at a 22.7 percent increase, plus increases
in benefits, plus an improved pension plan, plus a contribution
to their 401(k). The average nursing salary at Northwestern
Memorial is $50,500 a year, which is--I do not know that this
data is wrong, but it is looking at all nurses who may be
working in schools and so on.
For us to afford the technology for ergonomics, the
information technology, and deal with the issue of increasing
worker compensation, the Medicare program has got to recognize
that a marketbasket based on 1992 information just does not
make it anymore.
We are not making a lot of profit on Medicare. Oftentimes--
we just talked about inpatient--we are losing our shirt on home
care. We are losing our shirt on outpatient care. When you put
all of that together, the data that MedPAC looks at is very
different.
So I wanted to link those several things together if I may.
I think the issue of whistleblower is a very complicated
one, and it is difficult to give you the kind of response that
you want. But there is no question that the mechanisms have to
be provided within the institution for people to make their
criticisms, their concerns, and their suggestions well-known. I
think we have adequate laws that protect workers who are fired
for the wrong reasons, and I would not disagree with that
whatsoever. I must tell you that I am concerned about enhancing
the whistleblower protections for the obvious reasons.
Senator Durbin. Does anyone else involved in this want to
comment on the whistleblower issue? Ms. O'Sullivan.
Ms. O'Sullivan. Yes, I would like to comment. We agree that
there need to be systems within the facility. Nurses need to
make their concerns known where they can be solved, and that is
within the facility, within the organization. That requires
that nurses be a part of the decisionmaking process beforehand
as well as after issues get out-of-hand.
One of the problems that the crisis in staffing has caused
is that there is not the time to be as involved in these
decisionmaking meetings and decisionmaking times. So nurses
need to be involved ahead of time. They need to first report as
they go along and have issues within the system. We certainly
support that.
The issue is getting fired but also retributions occurring
within the work environment if nurses whistleblow outside. So
those are some of the protections for sure that we are looking
at.
We are not looking at enhancing the legal costs by any
stretch of the imagination, but nurses need to be protected if
they are reporting in their patient advocacy role concerns that
they have about health care in their institutions.
Senator Durbin. I have learned a lot this morning, and I
hope everybody has derived as much or more from the hearing as
I have. It has been a good experience.
We have talked a lot about retention and workplace
situations. I want to close by going back to the points that
were raised by Secretary Martin as well as by Mr. Cox about
recruitment and how to bring people into the profession.
I recall part of your testimony, Mr. Mecklenburg about the
Explorer Post at Northwestern Hospital and the fact that what
you are trying to do is introduce young people and others into
the opportunities in this profession. And I think for all the
negatives we have talked about today, we should never overlook
the positives that can come with good nursing experience. It
has to be a memory that you carry for a lifetime. My family and
I have been through this with great nurses and great doctors,
and we will never forget it, and I think that bears repeating.
But for a moment, if we could just reflect on this recruitment
question--what can we do to make sure that the food worker at
some hospital even considers the possibility of being an LPN or
an RN? What can we do to make sure that as tough as the nursing
job might be, Secretary Martin, that the idea of caring and
loving and providing that professional need is there and
interests a young person, and how can we reach out to bring
them in?
I have some ideas in the legislation that I am working on,
but if anyone would like to comment, I welcome it; and I also
hope that if you think about it on your way home and want to
jot me a note with some ideas, and anyone in the audience is
welcome to do the same.
Would anyone like to comment on that? I think Mr. Cox
really said it pretty well.
Ms. Bragg. Senator Durbin, I would like to make one
comment. I sat in a room with a think tank group, and there was
an economist there. After he heard everybody's testimony, he
said, ``Throw money, and throw a lot at it, but if you do not
fix the systems behind it, if I cannot provide good care, I am
not going to go there.''
When I listen to people talk about the inflated salaries--I
live in the Washington metropolitan area, and if you read the
newspaper want ads for nurses like I do, we are looking at
tremendous amounts of money being thrown out to get nurses in,
given them a bonus for a 1- or 2-year commitment, and then they
are gone. I think that is why you are seeing inflated salary,
because it is not coming to those of us at the bedside for our
stay at the hospital. I think that the recruitment process
aimed at the people in the younger generation come up behind us
is critical, because they have got to follow us. But they are
not going to be around for another 5 or 6 or 8 or 10 years, and
in that process, we have got to be able to retain the people
that we have.
In my facility, the people who have been in the hospital
system between 15 and 25 years make up over 50 percent of the
nursing staff. We cannot afford to lose one of those people,
and at the same time, we have got to be able to bring people
in. And it becomes so inherent with the scheduling practice,
with our mandatory overtime issues, with the workplace issues,
with the ergonomics issues, and every single one of those
pieces--and you said it very eloquently--this is not a problem
that has one solution, and it is not a problem to be solved
easily, because every one of those pieces is going to impact
the success of the other piece.
Senator Durbin. I think Secretary Martin made a point that
I want to close on. That is, we are not just dealing with the
nursing shortage in the future, we are dealing with a family
shortage. There will not be as many children around to care as
we might have today, and there will be a lot of us who are in a
position where we are going to need it.
I thank this panel very much and all who have gathered here
today. We are going to take your ideas and move them forward in
the legislation.
Thank you very much.
[Whereupon, at 12:37 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
[GRAPHIC] [TIFF OMITTED] T5471.001
[GRAPHIC] [TIFF OMITTED] T5471.002
[GRAPHIC] [TIFF OMITTED] T5471.003
[GRAPHIC] [TIFF OMITTED] T5471.004
[GRAPHIC] [TIFF OMITTED] T5471.005
[GRAPHIC] [TIFF OMITTED] T5471.006
[GRAPHIC] [TIFF OMITTED] T5471.007
[GRAPHIC] [TIFF OMITTED] T5471.008
[GRAPHIC] [TIFF OMITTED] T5471.009
[GRAPHIC] [TIFF OMITTED] T5471.010
[GRAPHIC] [TIFF OMITTED] T5471.011
[GRAPHIC] [TIFF OMITTED] T5471.012
[GRAPHIC] [TIFF OMITTED] T5471.013
[GRAPHIC] [TIFF OMITTED] T5471.014
[GRAPHIC] [TIFF OMITTED] T5471.015
[GRAPHIC] [TIFF OMITTED] T5471.016
[GRAPHIC] [TIFF OMITTED] T5471.017
[GRAPHIC] [TIFF OMITTED] T5471.018
[GRAPHIC] [TIFF OMITTED] T5471.019
[GRAPHIC] [TIFF OMITTED] T5471.020
[GRAPHIC] [TIFF OMITTED] T5471.021
[GRAPHIC] [TIFF OMITTED] T5471.022
[GRAPHIC] [TIFF OMITTED] T5471.023
[GRAPHIC] [TIFF OMITTED] T5471.024
[GRAPHIC] [TIFF OMITTED] T5471.025
[GRAPHIC] [TIFF OMITTED] T5471.026
[GRAPHIC] [TIFF OMITTED] T5471.027
[GRAPHIC] [TIFF OMITTED] T5471.028
[GRAPHIC] [TIFF OMITTED] T5471.029
[GRAPHIC] [TIFF OMITTED] T5471.030
[GRAPHIC] [TIFF OMITTED] T5471.031
[GRAPHIC] [TIFF OMITTED] T5471.032
[GRAPHIC] [TIFF OMITTED] T5471.033
[GRAPHIC] [TIFF OMITTED] T5471.034
[GRAPHIC] [TIFF OMITTED] T5471.035
[GRAPHIC] [TIFF OMITTED] T5471.036
[GRAPHIC] [TIFF OMITTED] T5471.037
[GRAPHIC] [TIFF OMITTED] T5471.038
[GRAPHIC] [TIFF OMITTED] T5471.039
[GRAPHIC] [TIFF OMITTED] T5471.040
[GRAPHIC] [TIFF OMITTED] T5471.041
[GRAPHIC] [TIFF OMITTED] T5471.042
[GRAPHIC] [TIFF OMITTED] T5471.043
[GRAPHIC] [TIFF OMITTED] T5471.044
[GRAPHIC] [TIFF OMITTED] T5471.045
[GRAPHIC] [TIFF OMITTED] T5471.046
[GRAPHIC] [TIFF OMITTED] T5471.047
[GRAPHIC] [TIFF OMITTED] T5471.048
[GRAPHIC] [TIFF OMITTED] T5471.049
[GRAPHIC] [TIFF OMITTED] T5471.050
[GRAPHIC] [TIFF OMITTED] T5471.051
[GRAPHIC] [TIFF OMITTED] T5471.052
[GRAPHIC] [TIFF OMITTED] T5471.053
[GRAPHIC] [TIFF OMITTED] T5471.054
[GRAPHIC] [TIFF OMITTED] T5471.055
[GRAPHIC] [TIFF OMITTED] T5471.056
[GRAPHIC] [TIFF OMITTED] T5471.057
[GRAPHIC] [TIFF OMITTED] T5471.058
[GRAPHIC] [TIFF OMITTED] T5471.059
[GRAPHIC] [TIFF OMITTED] T5471.060
[GRAPHIC] [TIFF OMITTED] T5471.061
[GRAPHIC] [TIFF OMITTED] T5471.062
[GRAPHIC] [TIFF OMITTED] T5471.063
[GRAPHIC] [TIFF OMITTED] T5471.064
[GRAPHIC] [TIFF OMITTED] T5471.065
[GRAPHIC] [TIFF OMITTED] T5471.066
[GRAPHIC] [TIFF OMITTED] T5471.067
[GRAPHIC] [TIFF OMITTED] T5471.068
[GRAPHIC] [TIFF OMITTED] T5471.069
[GRAPHIC] [TIFF OMITTED] T5471.070
[GRAPHIC] [TIFF OMITTED] T5471.071
[GRAPHIC] [TIFF OMITTED] T5471.072
[GRAPHIC] [TIFF OMITTED] T5471.073
[GRAPHIC] [TIFF OMITTED] T5471.074
[GRAPHIC] [TIFF OMITTED] T5471.075
[GRAPHIC] [TIFF OMITTED] T5471.076
[GRAPHIC] [TIFF OMITTED] T5471.077
[GRAPHIC] [TIFF OMITTED] T5471.078
[GRAPHIC] [TIFF OMITTED] T5471.079
[GRAPHIC] [TIFF OMITTED] T5471.080
[GRAPHIC] [TIFF OMITTED] T5471.081
[GRAPHIC] [TIFF OMITTED] T5471.082
[GRAPHIC] [TIFF OMITTED] T5471.083
[GRAPHIC] [TIFF OMITTED] T5471.084
[GRAPHIC] [TIFF OMITTED] T5471.085
[GRAPHIC] [TIFF OMITTED] T5471.086
[GRAPHIC] [TIFF OMITTED] T5471.087
[GRAPHIC] [TIFF OMITTED] T5471.088
[GRAPHIC] [TIFF OMITTED] T5471.089
[GRAPHIC] [TIFF OMITTED] T5471.090
[GRAPHIC] [TIFF OMITTED] T5471.091
[GRAPHIC] [TIFF OMITTED] T5471.092
[GRAPHIC] [TIFF OMITTED] T5471.093
[GRAPHIC] [TIFF OMITTED] T5471.094
[GRAPHIC] [TIFF OMITTED] T5471.095
[GRAPHIC] [TIFF OMITTED] T5471.096
[GRAPHIC] [TIFF OMITTED] T5471.097
[GRAPHIC] [TIFF OMITTED] T5471.098
[GRAPHIC] [TIFF OMITTED] T5471.099
[GRAPHIC] [TIFF OMITTED] T5471.100
[GRAPHIC] [TIFF OMITTED] T5471.101
[GRAPHIC] [TIFF OMITTED] T5471.102
[GRAPHIC] [TIFF OMITTED] T5471.103
[GRAPHIC] [TIFF OMITTED] T5471.104
[GRAPHIC] [TIFF OMITTED] T5471.105
[GRAPHIC] [TIFF OMITTED] T5471.106
[GRAPHIC] [TIFF OMITTED] T5471.107
[GRAPHIC] [TIFF OMITTED] T5471.108
[GRAPHIC] [TIFF OMITTED] T5471.109
[GRAPHIC] [TIFF OMITTED] T5471.110
[GRAPHIC] [TIFF OMITTED] T5471.111
[GRAPHIC] [TIFF OMITTED] T5471.112