[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
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                   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.
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    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\
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    \1\ The information provided by Dr. Geolot appears in the Appendix 
on page 00.
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    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.
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    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.
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    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

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