[Senate Hearing 107-630]
[From the U.S. Government Publishing Office]

                                                        S. Hrg. 107-630


                               BEFORE THE

                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             FIRST SESSION


                             JUNE 14, 2001


      Printed for the use of the Committee on Veterans' Affairs 

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            JOHN D. ROCKEFELLER IV, West Virginia, Chairman

BOB GRAHAM, Florida                  ARLEN SPECTER, Pennsylvania
JAMES M. JEFFORDS (I), Vermont       STROM THURMOND, South Carolina
DANIEL K. AKAKA, Hawaii              FRANK H. MURKOWSKI, Alaska
PATTY MURRAY, Washington             LARRY E. CRAIG, Idaho
ZELL MILLER, Georgia                 TIM HUTCHINSON, Arkansas

                     William E. Brew, Chief Counsel

      William F. Tuerk, Minority Chief Counsel and Staff Director


                            C O N T E N T S


                             July 14, 2001


Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, 
  prepared statement.............................................     3
Cleland, Hon. Max, U.S. Senator from Georgia.....................     4
Rockefeller, Hon. John D. IV, U.S. Senator from West Virginia, 
  prepared statement.............................................     2
Specter, Hon. Arlen, U.S. Senator from Pennsylvania, prepared 
  statement......................................................    28


Cox, J. David, Vice President, National VA Council, American 
  Federation of Government Employees, AFL-CIO....................    17
    Prepared statement...........................................    18
Garthwaite, Thomas L., M.D., Under Secretary for Health, 
  Department of Veterans Affairs.................................    29
    Prepared statement...........................................    29
    Response to written questions submitted by:
        Hon. Arlen Specter.......................................    35
        Hon. Ben Nighthorse Campbell.............................    39
Janzen, Sandra K., Chief Nurse Executive, Tampa (James A. Haley) 
  VA Medical Center, Tampa, FL...................................    51
    Prepared statement...........................................    53
McMeans, Sandra, representative, American Nurses Association, 
  Martinsburg, WV................................................    11
    Prepared statement...........................................    12
Myers, Sarah, President, Nurses Organization of Veterans Affairs, 
  Atlanta, GA....................................................     6
    Prepared statement...........................................     7
Petzel, Robert, M.D., Director, VA Upper Midwest Health Care 
  Network, Department of Veterans Affairs, Minneapolis, MN.......    54
    Prepared statement...........................................    55
Raymer, Mary C., Associate Chief of Staff for Patient Care 
  Services, Department of Veterans Affairs Medical Center, Salem, 
  VA.............................................................    57
    Prepared statement...........................................    59


American Organization of Nurse Executives, prepared statement....    68
Lyons, Kenneth T., National President, National Association of 
  Government Employees, prepared statement.......................    67
Regan, Mark, National Field Service Supervisor, The American 
  Legion, prepared statement.....................................    65





                        THURSDAY, JUNE 14, 2001

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The committee met, pursuant to notice, at 10:01 a.m., in 
room SR-418, Russell Senate Office Building, Hon. John D. 
Rockefeller IV (chairman of the committee) presiding.
    Present: Senators Rockefeller, Wellstone, Nelson, Specter, 
and Campbell.
    Chairman Rockefeller. The meeting will come to order.
    We have some votes on the floor this morning beginning at 
10, but they have not yet begun. So we will start this hearing.
    We are going to talk about nursing, and my theory on 
working with the VA is that we do not play ``gotcha,'' which I 
think has been a committee instinct sometimes, but that we try 
to look out into the future and figure out in a positive, 
constructive way how we can prepare for the future, what is 
going to be happening, and what are we doing to fix the 
    So the quality of care issues, which dominate so much of 
the VA, obviously are tremendously important. The question of 
the nursing shortage and the shortage in the health care system 
in general, is a very, very serious one.
    Experts caution that we are on the brink of a very severe, 
complex, and longer-lasting personnel shortage. While it is bad 
now; it is going to be worse in the VA system and elsewhere.
    There have been a lot of changes in health care delivery 
and many providers are going to be retiring. That is true in 
teaching, it is true in nursing, and it is true in health care. 
It is the changeover in generations. So the huge demand for 
nurses will exceed supply for years to come unless significant 
steps are taken rather quickly.
    We have had some hearings on the nursing shortage, but, 
surprisingly, the Department of Veterans Affairs has not been 
included in these discussions. That is wrong. The VA is a 
health care system not unlike all other health care systems in 
this country, and I have said this before with regard to long-
term care and the patients' bill of rights. The nursing 
shortage only brings all of this home. Actually, the problem is 
magnified in the VA, and I expect we are going to hear about 
that this morning.
    So VA nurses are closer to retirement age than those in 
other parts of our health care system and we will talk about 
that--a fact that is huge. There is, however, a little bit of a 
silver lining, and that is, the VA enjoys a very loyal nursing 
staff where the turnover rate is lower than it is in the rest 
of the American health care system, which I find important and 
interesting. And part of that is because the VA nurses and 
managers have been able to carve out some new ideas and 
thoughts and have done some interesting things.
    So we have to do what we can to foster good working 
environments. We have to face the future about potential 
shortages. Veterans are getting older--more difficulties 
associated with that--and then we have to figure out what we 
can do for the short term. But, again, that will not be enough. 
The VA has shown real leadership in the past in making sure 
that nurses are valued and their potential is maximized.
    So we have a lot of good witnesses today, and I am finished 
my remarks.
    [The prepared statement of Chairman Rockefeller follows:]

 Prepared Statement of Hon. John D. Rockefeller IV, U.S. Senator From 
                             West Virginia

    Good morning. As I again assume the chairmanship of this 
committee, it is altogether fitting that the first hearing we 
are holding is on the nurse shortage and how it will affect VA 
patient care. Quality of care issues have always been important 
to this committee and to me, in particular, and the impending 
nurse shortage has the potential to be a serious quality of 
care issue for the Department of Veterans Affairs.
    We as a Nation have faced health care staffing shortages 
before. Experts, however, caution that we may be on the brink 
of an even more severe, complex, and longer lasting personnel 
shortage now. Among other factors, experts point to recent 
changes in health care delivery and the pending retirement of 
so many caregivers. By all accounts, the huge demand for nurses 
will exceed supply for years to come, unless significant steps 
are taken, and taken now.
    There have already been several hearings in this session of 
Congress on the nursing shortage, but surprisingly, the 
Department of Veterans Affairs has not been included in these 
discussions. The VA is a health care system not unlike all 
other health care systems in this country. I've said this 
before with regard to long-term care and the patients' bill of 
rights. The nursing shortage only brings this point home. 
Actually, the problem is magnified in the VA, as I suspect we 
will hear about this morning.
    While the VA's nurses are closer to retirement age than 
those in other health care systems--a fact that looms large in 
all our minds--there is a bit of a silver lining here. VA 
enjoys a lower turnover rate, and some VA nurses and managers 
have managed to carve out some innovative programs, albeit few 
and far between.
    We must do what we can to foster good working environments 
for our nurses, to recruit the best and brightest to VA, and to 
encourage more enrollment in nursing schools. These are tough 
issues. But we must start now to fix those things than can be 
fixed in the short-term.
    We should be able to agree upon and enact changes that can 
address the problem in the short term. But that won't be 
enough. VA has shown real leadership in the past to make sure 
that nurses are valued and that their potential is maximized. 
For the long term, I encourage a return to that leadership.
    Today, we have a broad-based group of witnesses who will 
lay out for us the problem and suggest some remedies. I welcome 
all the witnesses.

    Chairman Rockefeller. Senator Campbell?
    Senator Campbell. With two impending votes, Mr. Chairman, I 
think I will save the witnesses the pain of going through 
another opening statement and submit mine for the record.
    Chairman Rockefeller. Was that painful? [Laughter.]
    Senator Campbell. No, it was not.
    Chairman Rockefeller. I understand. Thank you.
    Senator Campbell. I will submit mine for the record.
    Chairman Rockefeller. OK.
    [The prepared statement of Senator Campbell follows:]

 Prepared Statement of Hon. Ben Nighthorse Campbell, U.S. Senator From 

    Mr. Chairman, thank you for holding this important hearing. 
First, I would like to welcome Mr. Gordon Mansfield, and I look 
forward to discussing his potential role as Assistant Secretary 
for Congressional Affairs. I would also like to welcome this 
panel of witness, each of whom will undoubtedly shed a personal 
light on the issue of America's nursing shortage. I am 
confident that our discussion today will yield positive results 
for folks not only in my home state of Colorado, but also for 
veterans throughout this country.
    As a veteran myself, I understand the importance of quality 
health care, and I know that nurses play a crucial role in 
caring for those brave men and women who have defended our 
    In 1997, the VA had the largest staff of any hospital 
system in the world. As the veteran population is aging, 
patient needs are changing: home health care, spinal cord 
therapies, psychiatric help, and disease treatment are just a 
few of the many needs of today's vets. Nurses not only have to 
be compassionate caregivers, but also experienced specialists.
    In Colorado, many nurses have been reluctant to fill 
positions because of their fear of managed care, or their 
reluctance to accept low wages. Fewer young people are choosing 
nursing as a profession, and the current nursing workforce is 
fast approaching the age for retirement. While we cannot 
predict that there will be an across-the-board shortage of 
nurses right now, I understand that many analysts predict that 
our nursing needs will not be met in the next 10 years.
    I do not believe that there is one specific reason for this 
potential shortage of nurses, nor do I think there is one 
simple solution. But I am glad we have this chance to address 
this issue, and to look at its impact on the Veterans' 
Administration. Again, I would like to thank the witnesses who 
have come here from all over the country, and I also welcome 
any Coloradans who are in the room. The issue of a potential 
nursing shortage is a serious one for all of us here; I hope we 
can work together.
    Thank you Mr. Chairman.

    Senator Wellstone. Mr. Chairman, I will just say a couple 
of quick things, and I thank Senator Cleland for being here. I 
do not think we could have anybody better talking about 
    I also want to thank the nurses for being here. Thank you 
for your work. Senator Rockefeller was so right. The way in 
which you sort of feel for your mission and take care of 
veterans is much, much appreciated, I think sometimes you 
probably think not backed up with the resources, and I think 
that is part of what this is about.
    I want to welcome Dr. Randy Petzel who is here and will be 
testifying later. He is the Director of VISN 13, and he has 
dedicated his life to serving veterans. We do a lot of work in 
our State on veterans' issues, and everybody--as I said to 
Randy, Mr. Chairman, in our office--has the utmost respect for 
the work that you do.
    In addition to the RN's, I also want to talk about the 
licensed practical nurses and nursing assistants who also are 
doing the work and deserve our support.
    I do not think it is a question about a nursing shortage in 
the future. It is now. We have got a great VA hospital in 
Minneapolis. You have heard it in West Virginia. Ben, you have 
heard it, I am sure, in Colorado, the same thing in Nebraska. I 
could talk about the overtime now and all the hours, and not 
enough people to do so much of what they need to do. And so my 
last point--and, boy, am I ever really rushing this--is I go 
back to the budget resolution. Money is not a sufficient 
condition, but it is a necessary condition. We all worked 
together. We looked at that independent budget. We had an 
additional $2.6 billion per year. We passed it. It got taken 
out in the conference report.
    We cannot do millennium, we cannot do Hepatitis C, we 
cannot do mental health, and we certainly cannot provide the 
care for people on what we have got in this budget. It is just 
absolutely true.
    And so I think we have got to stop trying to make the foot 
fit the shoe because it is not going to work, and we have got 
to get a bigger shoe. And I think we absolutely have to make 
that commitment, and I know we will under your leadership.
    Thank you, everybody.
    Chairman Rockefeller. Senator Nelson?
    Senator Nelson. Thank you, Mr. Chairman.
    As my colleague from Minnesota indicates, nursing shortages 
occur everywhere. We are short. I am very anxious and I hope 
that you will be able to help us figure out how we do this even 
when we have the money, because obviously there is some 
challenge involved in getting people to direct their vocation 
that way as opposed to heading into high-tech areas or other 
careers and other professions. So I am very anxious, and I hope 
that, in addition to learning that we will need to have more 
money, we will also have a plan of how we are going to be able 
to get there if and when we do have the money that is necessary 
to help promote the program.
    So I appreciate your being here, I respect your profession, 
and we are looking forward to learning more about it.
    Thank you, Mr. Chairman.
    Chairman Rockefeller. Thank you, Senator.
    Senator Cleland, we welcome you, sir, and I know that you 
are going to introduce Sarah Myers.


    Senator Cleland. Well, thank you very much, Mr. Chairman. 
This is, in Yogi Berra's great phrase, deja vu all over again 
for me, not only to be here with the wonderful employees of the 
Veterans Administration but to be in a room that I worked in as 
a staff member, actually a VA hospital investigator, right over 
there in that corner over there, where we are going to put a 
little memorial, a little brass plaque one day.
    I came out of this committee, and I am indebted to it for 
taking the offensive in this particular issue. I would say to 
you that I think that for those of us who have been patients in 
the VA system, we know how critical VA nurses really are, and 
it is a shame to see the nursing shortage bring our health care 
system and the VA to a critical condition.
    I would like to say it was the military and the VA nurses 
that nursed me back to health. These nurses were more than 
caregivers, they were also givers of hope. They gave me a 
reason for living.
    So we are delighted to be with some leaders in the VA today 
who are experts in the field. I want to thank the committee for 
getting involved in this issue quickly. Quality patient care is 
actually directly linked to nursing. When I meet with health 
care groups from Georgia and across the Nation, obviously the 
increasing need for registered nurses is always a part of the 
    Now, statistics from the National League of Nursing and the 
American Nursing Association demonstrate that the nursing work 
force is shrinking. The Federal health care sector, employing 
approximately 45,000 nurses, may be hardest hit in the near 
future with an estimated 47 percent of its nursing work force 
eligible for retirement just in about 3 years from now. That is 
about half of the nursing work force eligible retirement in 
about 3 years.
    The VA is the largest single employer of nurses. 
Anticipated nursing vacancies in the Federal health care 
agencies are particularly alarming with the increased nursing 
care needs of an aging America. That means me and you. So I am 
particularly more and more interested in quality health care in 
the VA since more and more I will probably have to use it more.
    Senator Rockefeller, thank you for your leadership on this 
committee. You and I, Senator, are working to develop 
legislative initiatives to help recruit and retain VA nurses to 
take proper care of our veterans.
    Now, the key to developing these initiatives and 
understanding this complex issue is the testimony we will be 
hearing today from our panelists. I am pleased to introduce Dr. 
Sarah Myers, president of the Nurses Organization of the VA, 
better known as NOVA. Dr. Myers brings an impressive 
understanding of the challenges facing VA nursing, representing 
approximately 3,000 NOVA members from across the Nation, and as 
a doctorally prepared registered nurse working at the Atlanta 
VA Medical Center, Dr. Myers received her Ph.D. in nursing from 
Georgia State. Dr. Myers is clinical coordinator for geriatric 
care at the Atlanta VA and was appointed by the former Under 
Secretary for Health, Dr. Ken Kizer, to serve on the Federal 
Advisory Committee to review VA long-term care programs.
    Mr. Chairman, members of the committee, it is an honor to 
be back here in the committee room with you and to present to 
you a distinguished lady in the field of nursing, Dr. Sarah 
    Thank you very much.
    Ms. Myers. Thank you, Senator Cleland.
    Mr. Chairman, I thank you for holding these hearings on the 
nursing shortage----
    Chairman Rockefeller. Dr. Myers, what I want to do is to 
introduce all three of you. Senator Cleland, thank you very, 
very much, and we will work on the plaque. [Laughter.]
    I want to introduce the other two also and then go right 
through so we have sort of a continuity of thought, and it is 
very brief. And I think also Senator Miller wanted to be here 
to introduce you, and he may pop in. So he will be able to do 
that when he comes.
    Our second witness is Sandra McMeans, who is a nurse from 
Martinsburg, WV. She will be representing the American Nurses 
Association, and we are obviously very honored that you are 
here and very happy about that.
    The third witness is David Cox, who is first vice president 
of the National VA Council of the American Federation of 
Government Employees. Because I want to spend as much time as 
possible--and this is why I really wanted to do all three at 
once--on conversation and questions, I hope and pray that you 
have been told that all of your statements are made a part of 
the record and that you will try to keep your thoughts 
delivered to about 5 minutes. It is hard to do, but if 
    Ms. Myers?


    Ms. Myers. Thank you, Mr. Chairman. I thank you for holding 
these hearings on the nursing shortage and its implications for 
the Department of Veterans Affairs. I am presenting testimony 
before this committee today on behalf of over 30,000 registered 
nurses employed by the DVA. NOVA is dedicated to providing 
quality care for our Nation's veterans, and nurses are the 
backbone of the DVA, providing care to veterans 24 hours a day, 
7 days a week. I am pleased to have the opportunity to testify 
today on the nursing shortage, an issue of grave concern to the 
DVA health care community, the veteran population, and the 
veterans' families.
    In April 2001, NOVA held its annual meeting in Crystal 
City, Virginia, with over 110 registered nurses from around the 
country in attendance. During the course of the meeting, 
several themes emerged including: retirement and retention; 
inconsistent application of the locality pay law; loss of the 
framework for nursing due to restructuring at headquarters, at 
the VISN level and at local facilities; and the environment in 
which care is currently being delivered. These themes will form 
the basis of this testimony as NOVA addresses this very 
critical issue.
    Consistent with the nursing shortage within the United 
States, staffing levels are cut to the point where nurses are 
unable to meet the needs of their patients, and they are 
beginning to leave the profession.
    NOVA believes this has also happened in the DVA with the 
flat-line budget and the inability of the budget to keep up 
with the rising health care costs. Health care providers in the 
DVA have the opportunity to assist in turning this trend 
around, and we look forward to working with this committee to 
explore solutions to the nursing shortage.
    The autonomy nursing has traditionally had in the DVA has 
made it an attractive place to work, but this, too, is 
changing. We would like to offer the Senate Veterans' Affairs 
Committee some strategies to deal with the nursing shortage.
    First, I would like to address workplace issues. DVA nurses 
are extraordinarily dedicated and pride themselves on providing 
quality care to veteran patients. They always go the extra 
mile, but this pace cannot be maintained indefinitely.
    Too few nurses are caring for too many patients. Due to 
restrictions on hospital admissions and length of stay, the 
patients in hospitals are more acutely ill and in need of 
greater care. This is magnified in the DVA because veteran 
patients are older with multiple, chronic problems.
    As the level of nursing staff has decreased, the demands on 
nursing staff have increased. Nurses from coast to coast have 
been informing NOVA that the implementation of bar code 
medication administration takes longer and requires additional 
staff. At a number of facilities, due to a lack of needed 
equipment, the nursing staff is forced to record information 
with pen and paper and then retranscribe the information into a 
centralized computer system.
    NOVA believes that it is critical that the DVA address 
these workplace issues immediately. Some of our 
recommendations--and they are included entirely in the 
testimony, but I will highlight some here. They include: 
allocating an appropriate level of funding to nurse staffing 
and technology; funding research patient care programs that 
would ease the physical work of the nurse and provide safer 
care for the patient.
    In regards to educational support, NOVA has several 
recommendations for the scholarship program which will make the 
DVA more competitive with the private sector. These include: 
reduce the requirement for continuous employment from 2 years 
to 1 year; remove the award limit of $10,000 per school year 
for a 3-year maximum to $30,000 by changing the provision to 
$30,000 per employee.
    Additionally, NOVA proposes the DVA consider implementing 
the following programs: implement a national program such as 
the VA Cadet program to recruit and provide incentives to high 
school students for choosing nursing as a profession; to 
support internship programs; and develop mentoring programs.
    In regards to nursing leadership, the Nursing Strategic 
Healthcare Group is one of the strategic health care groups 
that comprise the Patient Care Services in the DVA 
headquarters. NOVA proposes a senior advisory position be 
created, the Executive Assistant to the Secretary. This new 
position would be unprecedented in DVA history, but would be 
consistent with similar positions at the Department of Health 
and Human Services as well as the Office of the Surgeon 
    The appointment of this position would communicate that the 
role of nursing is valued within the DVA and that nursing is 
important enough to the mission of the DVA to make this 
positive change.
    I again thank you, Mr. Chairman, for holding this very 
important meeting. A committed and satisfied nursing work force 
for our Nation's veterans is necessary to sustain the high-
quality patient care. NOVA seeks the assistance of the Senate 
Veterans' Affairs Committee and urges quick action to address 
these issues, as the nursing shortage has reached crisis 
proportions. There is no relief on the horizon without the help 
of this committee.
    Thank you.
    [The prepared statement of Ms. Myers follows:]
 Prepared Statement of Sarah Myers, President, Nurses Organization of 
                     Veterans Affairs, Atlanta, GA
    Mr. Chairman, I am Sarah Myers, a doctorally-prepared, clinical 
nurse specialist in geriatrics at the Atlanta Veterans Affairs Medical 
Center and President of the Nurses Organization of Veterans Affairs 
(NOVA). I thank you for holding these hearings on the nursing shortage 
and its implications for the Department of Veterans Affairs (DVA).
    I am presenting testimony before this Committee today on behalf of 
the over 30,000 registered nurses employed by the DVA. NOVA is 
dedicated to providing quality care to our Nation's veterans, and 
nurses are the backbone of the DVA, providing care to veterans 24 hours 
a day, seven days a week. I am pleased to have the opportunity to 
testify today on the nursing shortage, an issue of grave concern to the 
DVA health care community, the veteran population, and veterans' 
    In April 2001 NOVA held its Annual Meeting in Crystal City, 
Virginia with registered nurses from around the country in attendance. 
During the course of the Meeting, several themes emerged, including: 
retention and recruitment; inconsistent application of the locality pay 
law; loss of the framework for nursing due to restructuring at 
headquarters, the VISN level and at local facilities; and the 
environment in which care is currently being delivered. These themes 
will form the basis of this testimony, as NOVA addresses this critical 
    The DVA is facing serious challenges in providing care of a 
consistently high quality, and the nursing shortage is a major 
challenge now and will be a greater challenge in the future. The 
following statistics reflect the DVA nursing workforce:
     The average age is currently 45.98 years.
     Only 23 percent of DVA nurses are under 40 years of age.
     Approximately 11 percent are under 35 years of age.
     The average age of new hires is 41.65 years of age.
     Registered nurse retirement eligibility through 2005 is 
projected at 35 percent.
     It is estimated 35 percent of new hires will not advance 
beyond entry level with the new Qualification Standards.
    Peter Buerhaus, RN, PhD, an internationally-renowned nurse 
researcher on the nursing shortage, predicts the total number of nurses 
per capita will probably peak by 2007 and decline steadily thereafter. 
By 2020, the registered nursing (RN) workforce is forecast to be 
roughly the same size as it is today, declining nearly 20 percent below 
the RN workforce requirements. This nursing shortage is unprecedented 
because it will be driven by a rapidly aging workforce that will not be 
replaced by younger professionals.
    Nursing has traditionally been a female profession, but women now 
have more career options and are no longer entering the profession of 
nursing. Enrollments in nursing schools have been declining by nearly 5 
percent annually for the past five years. While nursing enrollments are 
going down, women comprise nearly 50 percent of enrollments at medical, 
business and law schools, and they are also entering the technological 
fields in unprecedented numbers. In order to maintain a viable nursing 
workforce, the DVA will need to develop long-term strategies to recruit 
both women and men into the field of nursing.
    In the short-term, the DVA needs to develop strategies to retain 
the current nursing workforce. It is projected 35 percent of the RN 
workforce will be eligible for retirement by 2005. In order to retain 
nurses past the minimum retirement age, the DVA will need to address 
workplace issues such as work schedules, staffing levels, rotating 
shifts, mandatory overtime, and patient/staff safety.
    Initiatives to ease the nursing shortage by expanding tuition 
assistance and other recruitment programs need to be addressed. NOVA 
believes these programs are a step in the right direction, but putting 
resources into recruitment alone will only create a revolving door. As 
long as the nursing staff is overloaded and unable to provide quality 
care, nurses will continue to face high levels of stress, injuries and 
low morale. Nurses unable to meet the needs of their patients will quit 
or retire in order to find less demanding and more rewarding careers or 
    Most nurses and policy analysts believe the current shortage is 
largely due to workforce issues, as opposed to economic ones. Health 
care is not the attractive profession it has been historically, and 
nurses have entered the profession in order to make a contribution. In 
addition, it is widely believed the health care industry created the 
nursing shortage long before the supply shortage began to emerge. 
Staffing levels were cut to the point where nurses, unable to meet the 
needs of their patients, began to leave the profession. NOVA believes 
this has also happened in the DVA with the flat-line budget and the 
inability of the budget to keep up with rising health care costs.
    Health care providers in the DVA have the opportunity to assist in 
turning this trend around, and NOVA looks forward to working closely 
with this Committee to explore solutions to the nursing shortage in the 
DVA. DVA nurses are proud of the mission of the DVA and proud to care 
for our Nation's heros; it is an honorable mission. The autonomy 
nursing has traditionally had in the DVA has made it an attractive 
place to work, but this is changing. NOVA would like to offer the 
Senate Veterans Affairs Committee some strategies to deal with the 
nursing shortage.
                            workplace issues
    DVA nurses are extraordinarily dedicated and pride themselves on 
providing quality care to their veteran patients. They always go the 
extra mile, but this pace cannot be maintained indefinitely. Staffing 
has been cut to the bare bones, and DVA nurses are tired and 
frustrated. If nursing, the backbone of the DVA, breaks so does the 
entire system.
    Too few nurses are caring for too many patients. Nurses in 
hospitals and outpatient clinics are caring for many more patients or 
more seriously ill patients today than they did a decade ago. Due to 
restrictions on hospital admissions and lengths of stay, the patients 
in hospitals are more acutely ill and in need of greater care. This is 
magnified in the DVA because veteran patients are older with multiple, 
chronic illnesses. As a result, nurses throughout the system are 
sounding the alarm: staffing levels are too low to provide the quality 
of care their patients deserve.
    Medical and pharmaceutical costs continue to increase by double 
digits annually, and the dollars appropriated to provide health care to 
these aging veterans do not meet the demand. Nursing, the largest 
segment of the DVA workforce, has perceived a dramatic shift in 
staffing levels to the point quality care has become compromised and 
both patient and staff safety is an issue that must be addressed.
    As the level of nurse staffing has decreased, the demands on the 
nursing staff have increased. Support services such as clerical, 
housekeeping, transport and lab staffing have been declining. This has 
increased the workload of nurses because the tasks formerly handled by 
the support services staff still need to be taken care of. Nurses are 
having to pick up the slack by changing beds, emptying trash and doing 
a myriad of other tasks that should be provided by support services. 
This practice is not viable from an economic point of view, but also 
removes nurses from performing tasks related to their professional 
training. This leaves other patient care tasks undone with less time to 
spend with patients and their families.
    Other staffing issues such as rotating shifts and mandatory 
overtime also contribute to stress, frustration and low morale. The 
literature supports the detrimental physical outcomes of rotating hours 
of work, and there is data that demonstrates a higher level of back and 
neck injuries in nurses who rotate shifts or work overtime. For 
example, the nursing home setting has one of the highest rates of 
workplace injury; in 1999 there were 13/100 compared to the 
construction industry which experienced 8/100. Additionally, the level 
of workplace violence continues to rise which is due in large part to 
under staffing. In order to retain a nursing workforce, it is critical 
these staffing issues be addressed. As nurses reach retirement age and 
are coping with a stressful and unsafe work environment, their decision 
to retire or continue working becomes an obvious one.
    Technology is intended and has been designed to save patient's 
lives and reduce medical errors. It has created new demands on the 
nursing staff, and the need for the most efficient computerization has 
never been greater. Technology cannot achieve its mission unless there 
is adequate staff and equipment to implement the technology. Nurses 
from coast to coast have been informing NOVA that implementation of 
BCMA takes longer and requires additional staff. At a number of 
facilities due to the lack of needed equipment, the nursing staff is 
forced to record information with pen and paper and then retranscribe 
the information into a centralized computer system. It is imperative 
that adequate funding for equipment be allocated, as this double work 
stresses an already short-staffed nursing unit.
    With 35 percent of the nursing population reaching retirement 
eligibility by 2005 and fewer nurses entering the profession, NOVA 
believes it is critical the DVA address these workplace issues 
immediately. Some recommendations include:
     Allocating an appropriate level of funding to nurse 
staffing and technology.
     Funding patient care research programs that would ease the 
physical work of the nurse and provide safer care for the patient.
     Continuing to monitor, change and enhance the locality pay 
system to ensure nurses are paid equitably throughout the DVA, not 
merely in certain VISNs or facilities where directors currently possess 
discretionary authority.
     Removing the salary cap on nurse executive positions 
throughout the system to be more competitive with the private sector.
     Providing flexible work schedules, incentives for 
unpopular shifts, and premium pay for working peak times.
     Reducing shift rotation and mandatory overtime by 
providing sufficient nurse staffing.
     Providing adequate and reasonable support for technology 
    DVA nurses are dedicated to their veteran patients; they need to 
feel they have treated their patients with respect, compassion, 
empathy, knowledge and skill. Nurses are doing the nurturing, the 
caring, the reaching out to the whole family involved with a particular 
patient. In the end, the nurse makes the difference in terms of the 
experience of the patient, and nurses need to be given the time and the 
tools to make a difference and feel proud of their contribution.
                          educational support
    As recently noted by the President of the Student Nurses 
Association, nursing education is the single most important factor a 
graduate is seeking in a prospective employer. Graduates realize their 
education doesn't end at graduation but continues throughout their 
career. They are seeking employment with an employer dedicated to 
funding continuing education. As the DVA moved to the VISN structure 
and funding VISNs using the VERA model, educational support of nursing 
programs has dropped and varied dramatically from VISN-to-VISN. NOVA 
believes the DVA needs to develop a system-wide policy which addresses 
nursing education, tuition reimbursement, authorized absence for 
educational development and loan repayment/debt reduction.
    Several years ago, the National Nursing Education Initiative (NNEI) 
was implemented to address the BSN requirement, as a result of the 
implementation of the Qualification Standards. Additionally, $50 
million was allocated over a five-year period to fund nursing 
education. It is NOVA's understanding this office is experiencing 
challenges to their mission. This needs to be addressed immediately 
because nurses are experiencing difficulty in applying for and 
obtaining scholarships. Funding needs to be provided for additional 
staff to administer the program, counselors to assist nurses in the 
application process, and program coordinators to monitor credentialed 
programs. Currently, this is being handled at the facility level or by 
individual nurses, and the disarray of this program has negatively 
impacted these funds getting to the nurses who need them.
    NOVA also has several recommendations for the scholarship program 
which will make the DVA more competitive with the private sector:
     Reduce the requirement for continuous employment from two 
years to one year.
     Remove the award limit of $10,000 per school year for a 
three-year maximum of $30,000 by changing the provision to $30,000 per 
     Make the scholarship program permanent and fully implement 
a loan reduction program.
    Additionally, NOVA proposes the DVA consider implementing the 
following programs:
     Implement a national program such as the VA Cadette to 
recruit and provide incentives to high schools students for choosing 
nursing as a profession.
     Support nurse internship programs for new hires for 12 
weeks with preceptors.
     Develop mentoring programs.
    The development of a sound education policy will have a tremendous 
impact on the recruitment and retention of the nursing workforce in the 
years to come. There needs to be an adequate number of nurse educators 
to train new employees, develop mentorship programs and provide 
continuing education. Additionally, these nurse educators need to 
oversee the implementation of residency programs in specialty areas 
such as critical care and mental health to teach new and current 
employees these skills and knowledge base. Currently, at one VA 
facility if a nurse decides to become a critical care nurse, she/he 
must resign and find employment in the private sector in order to 
receive this training. By funding education and implementing a system-
wide policy, the DVA will: have a better trained and educated nursing 
workforce; recruitment and retention will be positively impacted; 
morale will increase; and the DVA's mission of quality health care for 
our Nation's veterans will be realized.
                           nursing leadership
    The nursing workforce comprises approximately one-third of the 
Veterans Health Administration (VHA), and nurses are at the veterans' 
bedside day and night. Nursing staff provides the greatest proportion 
of direct health care service to the veterans served by the DVA. 
Nursing care has a direct impact on quality of care as well as the 
satisfaction level of patients and their families. For these reasons, 
it is critical the voice of nurses be heard throughout the system, and 
it is also imperative nurses occupy leadership roles from the 
headquarters to facility levels.
    The Nursing Strategic Healthcare Group (NSHG), one of the strategic 
health care groups that comprise the Patient Care Services Office in 
DVA Headquarters, has evolved from a Nursing Service in 1993 to a 
consultation-focused resource that supports the nursing workforce. NOVA 
believes the NSHG is critical to maintaining visible and close 
communication with the nursing staff throughout VHA. The goal of the 
NSHG has been to serve as a resource for planning, practice, 
regulations, education and research activities that involve nurses.
    The NSHG serves a critical role focusing primarily on the strategic 
direction and administrative policies affecting VA nurses throughout 
the country. NOVA proposes a new senior nurse advisory position be 
created: Executive Assistant to the Secretary. The focus of this 
position would be broad in scope and focus on the specific interests of 
the Secretary and provide assistance on a wide variety of health-care 
areas related to the broader sphere of health care, women's issues, and 
other related topics.
    This new position would be unprecedented in DVA history but would 
be consistent with similar positions at the Department of Health and 
Human Services as well as in the Office of the Surgeon General. This 
advisory position would also send a positive message to all VA nurses 
in the field, as well as to those in the broader nursing community. It 
would communicate that the role of a nursing is valued within the DVA 
and that nursing is important enough to the mission of the DVA to make 
this positive change.
    I again thank you Mr. Chairman for holding this very important 
hearing. A committed and satisfied nursing workforce caring for our 
Nation's veterans is necessary to sustain the high quality care our 
veterans currently receive. NOVA seeks the assistance of the Senate 
Veterans Affairs Committee and urges quick action to address these 
issues, as the nursing shortage has reached crisis proportions. There 
is no relief on the horizon without the help of this Committee.

    Chairman Rockefeller. Thank you very much, and that was 
perfect timing.
    Ms. McMeans?


    Ms. McMeans. Good morning, Chairman Rockefeller and members 
of the committee----
    Chairman Rockefeller. Could you pull that a little closer, 
the microphone a little bit closer? Thank you very much.
    Ms. McMeans. Good morning, Chairman Rockefeller and members 
of the committee. I am Sandy McMeans, RN. I am a staff nurse at 
the Martinsburg, WV, VA Medical Center and president of the 
West Virginia Nurses Association Local 203 bargaining unit. I 
am pleased to be here today representing the American Nurses 
Association, ANA, and its union arm, the United American 
    I would like to begin by thanking the committee for the 
opportunity to testify on an issue of critical importance to 
the health of our Nation's veterans. Staff nurses like myself 
provide the vast majority of direct health care services to our 
Nation's veterans, and the Veterans Health Administration--or 
VA--employs the largest nursing work force in the world.
    America is experiencing a crisis in nurse staffing. Health 
care providers across the Nation are having difficulty finding 
experienced RN's that are willing to work in their facilities. 
Areas hardest hit include emergency room, critical care, labor 
and delivery, and long-term care. Projections show that the 
situation will only get worse.
    My written statement provides information on the expert-
panel-based methodology for nurse staffing and resource 
management. When properly implemented, this tool allows staff 
nurses to have meaningful input into staffing and other patient 
care decisions. ANA and I support this model, and we urge this 
committee and the VA to implement it or a comparable system 
across the 173 medical centers.
    Another problem that must be addressed is the use of 
mandatory overtime. ANA has been hearing from nurses across the 
Nation about the dramatic increase in the use of mandatory 
overtime as a staffing tool. Many nurses report that their 
employers insist that they stay on longer than their scheduled 
shift, regardless of the level of their fatigue. We are in a 
situation now where 40- and 50-year-old nurses are being forced 
to work 16- and 20-hour shifts.
    Nurses in particular are placed in a unique situation when 
confronted by demands for mandatory overtime. We are ethically 
bound to refuse to provide care when we are unable to do so 
safely. And we know that fatigue leads to poor performance. At 
the same time, we face the loss of our license--our careers and 
our livelihoods--when charged with patient abandonment. Without 
action on this matter, nurses will continue to confront this 
    For this reason, ANA supports legislative initiatives to 
ban the use of mandatory overtime.
    My written statement contains further recommendations on 
the need to fund replacement nurses to allow staff nurses to 
take the time they need to further their education and some 
concerns about the implementation of changes in the locality 
pay system.
    But I would like to use my remaining time to repeat what I 
think are the most important points. It is critical that the 
committee understands that no effort to address the nursing 
shortage will be a success unless we fix the problems in the 
work environment. Until we address issues such as inappropriate 
staffing and mandatory overtime, the health care providers 
across the Nation will continue to experience 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.
    ANA and I look forward to working with you and your 
partners in the VA system to make the current health care 
environment conducive to high-quality nursing care. Efforts in 
this direction will have a positive impact on the health care 
services that our Nation's veterans receive.
    Thank you for the opportunity to provide this testimony, 
and I will be happy to answer any questions that you may have.
    [The prepared statement of Ms. McMeans follows:]
 Prepared Statement of Sandra McMeans, Representative, American Nurses 
                      Association, Martinsburg, WV
    Good Morning, I am Sandra McMeans, RN. I am a staff nurse at the 
Martinsburg, West Virginia VA Medical Center and President of the West 
Virginia Nurses Association local 203 bargaining unit. I am pleased to 
be here today representing the American Nurses Association (ANA) and 
its union arm, United American Nurses (UAN). ANA is the only full-
service association representing the nation's registered nurses through 
its 53 state and territorial member nurse associations.
    As this Committee is aware, health care institutions across the 
nation are experiencing a crisis in nurse staffing, and we are standing 
on the precipice of an unprecedented nursing shortage. Certainly, the 
current and emerging shortage of registered nurses (RNs) poses a real 
threat to the nation's health care delivery system, and to its largest 
integrated health care system--the Veterans Health Administration 
(VHA). Registered nurses comprise the largest health care workforce in 
the nation, and the VA has the largest nursing workforce in the world. 
The concerns that we have all been hearing about the current nursing 
shortage underscore the fact that having a sufficient number of 
qualified nurses is critical to the nation's health.
    The emerging nursing shortage is very real and very different from 
any experienced in the past. Hospitals, long term care facilities and 
other health care providers across the nation are currently 
experiencing a nurse staffing shortage. Employers are having difficulty 
finding experienced nurses, especially in emergency departments, 
critical care, labor and delivery, and long term care who are willing 
to work in their facilities. Press reports about emergency department 
diversions and the cancellation of elective surgeries due to short 
staffing are becoming commonplace.
    In addition, workforce projections show that the current shortages 
are just a minor indication of the systemic shortages that will soon 
confront our health care delivery system. Today's staffing shortage is 
compounded by the lack of young people entering the nursing profession, 
the rapid aging of the RN workforce, and the impending health care 
needs of the baby boom generation.
    It is important to realize that the causes, and therefore the 
answers, to the new nursing shortage are complex and interrelated. It 
is critical to examine issues in the work environment, education, and 
health delivery systems. ANA maintains that the reasons for the current 
shortage, and the answers to the impending shortage are multifaceted. 
Unfortunately, there is no single cure to what ails nursing.
                   recent changes in nurse employment
    Current nurse satisfaction issues are inexorably tied to changes in 
nurse employment practices over the last decade. A quick review of 
nursing workforce data shows that we have been directly impacted by the 
turmoil that has typified the health care sector for the last decade. 
Throughout our entire health care system, innovative methods of cost 
containment were the hallmark of the 1990's. New models of health care 
delivery were implemented in our health care facilities, and highly-
trained, experienced--and therefore higher paid--personnel were often 
eliminated or redeployed. As RNs typically represent the largest single 
expenditure for hospitals (averaging 20 percent of the budget) we were 
some of the first to feel the pinch.
    Analysis of census data shows that between 1994 and 1997, RN wages 
across all employment settings dropped by an average of 1.5 percent per 
year (in constant 1997 dollars). Between 1993 and 1997, the average 
wage of an RN employed in a hospital dropped by roughly a dollar an 
hour (in real terms). RN employment, which had previously been growing 
in the hospital sector, reversed to the negative. In addition to 
reducing staff nurses, many providers eliminated positions for nursing 
middle managers and executive level staff.
    As you are aware, the VHA has also undergone major restructuring. 
Since 1995, its has downsized inpatient capacity and while adding 350 
additional care sites. Today, the VHA provides health care to more than 
500,000 additional veterans with 25,000 fewer employees that it did 
just six years ago. In addition, the amount spent per patient has been 
cut by 24 percent. Much like the rest of the private health care 
system, VA nurse have been directly impacted by these changes. For 
instance--in the five years between September 1995 and September 2000, 
the VA cut ten percent of its total RN positions.
                    the current employment situation
    It is increasingly evident that the changes in the RN employment 
environment over last decade have precipitated a downturn in the number 
of people choosing to work in the nursing profession and growing 
discontent among those who remain. Enrollments in four-year nursing 
schools have dropped by approximately 5 percent per year over the last 
6 consecutive years. As the image of professional nursing has changed 
from a field that offered many opportunities and high job security to 
one that holds great uncertainty, low starting wages, and difficult 
working conditions, students have shied away from nursing programs.
    A recent ANA survey of nurses revealed that nearly 55 percent of 
the nurses surveyed would not recommend the nursing profession as a 
career for their children or friends. In fact, 23 percent of the 
respondents indicated that they would actively discourage someone close 
to them from entering the nursing profession.
    At the same time, an alarming number of existing RNs are choosing 
not to work in nursing. The 2000 National Sample Survey of Registered 
Nurses shows that a disturbingly large number of nurses (500,000 
nurses--more than 18 percent of the national nurse workforce) who have 
active licenses are not working in nursing. Another national survey 
commissioned by the Federation of Nurses and Health Professionals 
reports that 50 percent of all currently employed nurses have recently 
considered leaving direct care positions for reasons other than 
retirement. Clearly, something in the practice setting is driving these 
people away.
                        the environment of care
    In an effort to ascertain the cause of nurse discontent, ANA 
recently conducted an on-line survey of nurses across the nation. 
Nearly 7,300 nurses took the opportunity to express their opinions 
about their working conditions. The majority (70 percent) of the 
respondents work in hospitals or acute care facilities, 50 percent were 
staff nurses. These nurses report that over the last two years they 
have experienced increased patient loads, increased floating between 
departments, decreased support services and increasing demands for 
mandatory overtime.
    This survey reveals that the recent reductions in the RN staffing 
have negatively impacted patient care, the work environment for nurses, 
the perception of nursing as a career, and the staffing flexibility 
needed to address temporary staffing shortages. Nurses in VA medical 
centers in particular are being confronted by staff downsizing, 
increased patient acuity, shorter hospital stays, bed closures, and 
flat-lined budgets. These changes have caused such a deterioration in 
the work environment that nurses are opting not to accept staff nurse 
positions. Hence the increasing staff vacancy rate being reported by 
the VHA as well as private health care providers. After all, how many 
of us would want to work in an environment where we have little to no 
control over the number of hours that we work, the quality of the work 
we produce, or the ability to change our work environment?
    ANA supports an integrated state and federal legislative campaign 
to address the current and impending nursing shortage. Many of these 
solutions are directly applicable to the VHA. Following are key federal 
initiatives we hope this Committee will consider.
    Nurses across the nation are expressing deep concerns about the 
dramatic increase in the use of mandatory overtime as a staffing tool. 
ANA hears that overtime is the most common method facilities are using 
to cover staffing insufficiencies. Employers may mandate that a nurse 
work an extra shift (or more) or face dismissal for insubordination, as 
well as being reported to the state board of nursing for patient 
abandonment. Concerns about the use of mandatory overtime are directly 
related to patient safety.
    We know that sleep loss influences several aspects of performance, 
leading to slowed reaction time, delayed responses, failure to respond 
when appropriate, false responses, slowed thinking, and diminished 
memory. In fact, 1997 research by Dawson and Reid at the University of 
Australia showed that work performance is more likely to be impaired by 
moderate fatigue than by alcohol consumption. Their research shows that 
significant safety risks are posed by workers staying awake for long 
periods. It only stands to reason that an exhausted nurse is more 
likely to commit an error that a nurse who is not being required to 
work a 16 hour shift.
    Nurses are placed in a unique situation when confronted by demands 
for overtime. Ethical nursing practice prohibits nurses from engaging 
in behavior that they know could harm patients. At the same time, RNs 
face the loss of their license--their careers and livelihoods--when 
charged with patient abandonment. Absent legislation, nurses will 
continue to confront this dilemma. For this reason, ANA supports 
legislative initiatives to ban the use of mandatory overtime. ANA is 
seeking relief from the use of mandatory overtime in the private sector 
through Medicare provider contracts.
    Currently, the VHA does not have a nationwide policy on mandatory 
overtime, nor does the VA collect nationwide statistics on the use of 
mandatory overtime. Recent increases in overtime costs, however, do 
substantiate what ANA and the UAN have been hearing--that mandatory 
overtime is being used regularly and routinely. Reports show that the 
VA nearly doubled its annual overtime costs in the three years between 
1997 and 2000. These reports are disturbing and they highlight the need 
to address the abuse of mandatory overtime in our VA medical centers. 
The practice could be halted by an executive order, through regulatory 
action within the VHA, or through federal legislation.
Adequate Staffing
    Of course the use of mandatory overtime is a symptom of a larger 
problem, inappropriately low nurse staffing. ANA has long held that the 
safety and quality of care provided in the nation's health care 
facilities is directly related to the number and mix of direct care 
nursing staff. More than a decade of research shows that nurse staffing 
levels and skill mix make a difference in the outcomes of patients. 
Studies show that where there are more nurses, there are lower 
mortality rates, shorter lengths of stay, better care plans, lower 
costs, and fewer complications. In fact, four HHS agencies--the Health 
Resources and Services Administration, Health Care Financing 
Administration, Agency for Healthcare Research and Quality, and the 
National Institute of Nursing Research of the National Institutes of 
Health--recently sponsored a study on this very topic. The resulting 
report (Nurse Staffing and Patient Outcomes in Hospitals, released on 
April 20, 2001) found strong and consistent evidence that increased RN 
staffing is directly related to the decreased incidence of urinary 
tract infections, pneumonia, shock, upper gastrointestinal bleeding, 
and shorter hospital length of stay.
    In addition to the important relationship between nurse staffing 
and patient care, several studies have shown that one of the primary 
factors for the increasing nurse turnover rate is dissatisfaction with 
workload/staffing. ANA's recent survey states that 75 percent of nurses 
surveyed feel that the quality of nursing care at the facility in which 
they work has declined over the past two years. Out of nearly 7,300 
respondents, over 5,000 nurses cited inadequate staffing as a major 
contributing factor to the decline in quality of care. More than half 
of the respondents believed that the time they have available for 
patient care has decreased. This survey reflects similar findings from 
a national survey taken by the Henry J. Kaiser Family Foundation (1999) 
that found that 69 percent of nurses reported that inadequate nurse 
staffing levels were a great concern. The public at large should be 
alarmed that more than 40 percent of the respondents to the ANA survey 
stated that they would not feel comfortable having a family member 
cared for in the facility in which they work.
    Adequate staffing levels allow nurses the time that they need to 
make patient assessments, complete nursing tasks, and respond to health 
care emergencies. It also increases nurse satisfaction and reduces 
turnover. The VHA, much like private health systems, continues to 
struggle with the development of valid, reliable and implementable 
nurse staffing guidelines. In 1985, the VA developed nurse staffing 
guidelines. These were then suspended in the mid-90's and a new 
methodology was developed. This new expert-panel based methodology for 
nurse staffing and resource management has been implemented to varying 
degrees of success across the 173 medical centers. In the best cases, 
expert panels consisting of shift supervisors, nurse administrators, 
staff nurses and union representatives meet on a regular basis to make 
recommendations on nurse staffing needs. These panels investigate 
variables ranging from nurse experience levels, patient acuity trends, 
census data, use of overtime, and changes in administrative workloads 
to determine nurse staffing needs. Recommendations are then made 
through the nurse executive.
    ANA supports this model, and we urge this committee and the VHA to 
urge all of the medical centers to implement the expert-panel 
methodology or a comparable system. As my colleague from Florida will 
attest, one of the main components of the magnet hospital designation, 
and one of the chief indicators of nurse satisfaction, is the ability 
of the staff nurse--the individual who provides direct patient care--to 
have meaningful input into staffing and other patient care 
determinations. When implemented properly, the expert panel methodology 
provides an excellent opportunity for this communication.
Education Support
    ANA applauds the VHA for its recent change in the nurse 
qualification standard. This new standard makes a BSN (bachelors of 
science in nursing) a criteria for promotion. The ANA supports efforts 
designed to make the BSN the standard for entry into nursing practice. 
The increasing acuity of today's patients, combined with shortened 
lengths of stay and decreased staffing requires all nurses to be as 
clinically prepared as possible. ANA is particularly pleased by the 
National Nursing Education Initiative (NNEI) which provides 
scholarships for RNs in the VHA who return to school to attain 
baccalaureate and advanced degrees. Nurses in the NNEI are eligible for 
a maximum of $20,000 in scholarship funds. In return, nurses in this 
program must meet a service obligation. For instance, a full-time 
student must agree to serve as a full-time VHA employee for a period of 
one calendar year for each year of school or part thereof for which a 
scholarship has been granted.
    To date, more than $50 million has been obligated under NNEI. There 
are a total of 1427 participants in the program; 67 percent are 
enrolled in baccalaureate programs and 30 percent are in advance degree 
programs. Six nurses in the Martinsburg facility have enrolled in RN to 
BSN program. In addition, our first application for enrollment in a 
Masters Program has just been approved. I am thrilled that these nurses 
are able to take this opportunity to further their education, and I 
urge this Committee to be vigilant in ensuring that the promise of 
continuing education is maintained.
    With that said, I would be remiss if I did not point out the few 
bugs in this new education initiative that need to be addressed. As 
current staff nurses are being evaluated and promoted on basis of their 
educational preparation, it is important that they be able to take the 
time needed to further their education. I am disturbed by reports that 
staff nurses who would like to continue their education are being told 
that their facility can not schedule the time off that they need to 
attend school. Certainly it was not the intent of this program to base 
nurse promotions on educational attainment, while at the same time 
placing barriers to their education.
    The NNEI does contain a provision that allows a medical center to 
pay a ``replacement salary'' to hire a new (typically temporary) staff 
nurse to carry out the duties of an employee who is unavailable while 
pursing full-time education or training. However, funding for these 
replacement salaries is conspicuously absent from the NNEI, and the 
responsibility to find funding has been left to the Facility Director. 
Nurses in facilities where the Director can not or does not locate 
funds needed for replacement workers will continue to be disadvantaged 
until this problem is remedied.
Locality Pay
    As this Committee is very well aware, the Veterans Benefits and 
Health Care Improvement Act (P.L. 106-419) was signed into law last 
year. ANA strongly supports this law which makes a number of 
significant changes to the old nurse locality pay system. The new 
system requires Facility Directors to use third-party industry wage 
surveys in making such adjustments and authorized the Department's 
Under Secretary for Health to modify any adjustment determination made 
by an individual Facility Director. It also requires the Secretary to 
report annually to this Committee on the staffing of covered positions 
and on pay adjustments.
    ANA urges this Committee to remain vigilant in your oversight of 
these programs. It is too early to evaluate the effectiveness of this 
new system, but a few potential problem areas have already emerged. For 
instance, it may be difficult to obtain accurate wage surveys because 
most private facilities deem this information proprietary. 
Additionally, the B.S.N. requirement discussed above makes the VA staff 
nurse population significantly different than those found in many 
private facilities.
    ANA is concerned that there may not be an appropriate mechanism for 
gathering the information needed to update VA nurse executive 
compensation. In addition, ANA maintains that nurse practitioners 
should qualify for the enhanced program of specialty pay that the VHA 
offers physicians and dentists (as authorized under Subchapter III of 
Chapter 74, 38 U.S.C.). We look forward to working with you on these 
important issues.
    In closing, I would like to reiterate the point that the problems 
that the Veterans Health Administration is experiencing with nursing 
recruitment and retention will remain and likely worsen if changes in 
the workplace are not addressed. In fact, the profession of nursing as 
a whole will be unable to compete with the myriad of other career 
opportunities available in today's economy unless we improve working 
conditions across the board. We must strive to make direct care an 
attractive vocation for our high-caliber RNs. Nurses, administrators, 
other health care providers, health system planners, and consumers must 
come together in a meaningful way to create a system that supports 
quality patient care and all health care providers. We will have to 
begin by improving the environment for nursing.
    ANA looks forward to working with you, and our health care provider 
and union partners to make the current health care environment 
conducive to high quality nursing care. Improvements in the environment 
of nursing care, combined with aggressive and innovative recruitment 
efforts will help avert the impending nursing shortage. The resulting 
stable supply of high quality nursing care will make great strides in 
your continuing efforts to address the health care needs of America's 

    Chairman Rockefeller. Thank you very, very much.
    What I have to do, Mr. Cox, if you will forgive me, because 
we have a few minutes to vote, so I have to leave now. And, 
unfortunately, there are two votes.
    So we are going to stand in recess for a few minutes while 
I cast my vote, wait impatiently for the second one to start, 
cast it immediately and out of order, and then rush back here, 
all with your hopeful forgiveness.
    Mr. Cox. That will be fine, Mr. Chairman. [Laughter.]
    Chairman Rockefeller. So we stand in recess for a few 
    Chairman Rockefeller. Mr. Cox?

                         WASHINGTON, DC

    Mr. Cox. Mr. Chairman, we were glad to give you a break to 
go vote, but we would also call to the committee's attention 
that very rarely do nurses in the VA get to take a break. 
    Chairman Rockefeller, members of the committee, my name is 
J. David Cox, and I proudly worked as a registered nurse at the 
Salisbury, NC, W.G. Bill Hefner VA Medical Center for 17 years. 
My stepfather and my father-in-law have both been treated at 
that facility. Caring for veterans and being an American 
Federation of Government Employees union activist are my life's 
    On behalf of the 135,000 caregivers our union represents, I 
thank you for giving AFGE the opportunity to tell you about the 
harmful effects of understaffing that front-line workers 
experience and see every day. AFGE applauds you for holding 
this hearing on the nursing shortage at the VA and urges you to 
be bold and innovative in addressing the crisis in health care. 
I ask that my written statement be included in the record.
    The nursing shortage at the VA is not impending. It is 
here, sir. Since 1995, VA has cut RN staff by 10 percent, its 
licensed practical nurses by 13 percent, its nursing assistants 
by a whopping 30 percent. The majority of these reductions 
occurred because the VA balanced its budget by not replacing 
nurses who left the VA.
    Because of our budget, my facility in Salisbury won't even 
be able or does not even try to replace the 50-plus RNs and 
LPNs and nursing assistants that have left within the last 
    Let me describe some of the effects that understaffing has 
on patient care and hospital staff. At our facility we have two 
long-term care wards that each have 30 beds. Previously there 
was an RN for each ward. Now there is a single RN for both 
wards. This change in staff-to-patient ratio was not done in 
accordance with patient needs or any rational standard of care 
but to meet the level of staff on duty. Because that nurse must 
now give care to twice as many veterans, research indicates 
that these veterans will be more at risk for urinary tract 
infections, they will be more likely to develop painful 
bedsores, and the infections of these sores can be an outcome 
of a life-threatening situation.
    Because of the increased workload for the nurse, those 
veterans will have a greater likelihood of falling down in the 
hospital. For a frail and elderly patient, a single fall has 
serious medical consequences. If these veterans experience a 
medical complication or go into shock, the success rate in 
saving them is much lower because of the reduced nurse-to-
veteran ratio.
    What happens when the lone night nurse quits or takes a 
vacation or has to take care of a sick child? More and more the 
VA is using mandatory overtime as a routine method of filling 
shifts. For the 60 patients on these two long-term care wards, 
this means their nurse is working a double shift for 16 hours. 
Forcing an already overloaded staff to work an extra shift is a 
prescription for medical errors. Even when medical errors are 
avoided, patients still suffer. Weary, exhausted nurses will 
lack the keen level of concentration and emotional stamina 
necessary to deliver high-quality and compassionate care. 
Medications, basic care, and other critical medical 
interventions will be delayed, forgotten, mixed up because the 
nurse is being spread too thin and is just bone tired.
    Mandatory overtime usually occurs on wards that are already 
operating at unsafe staffing levels. The use of mandatory 
overtime is a short-sighted response to inadequate staffing 
that is worsening the staffing problem.
    And, sir, I want to go ahead and raise to you two issues 
that we would like for you to explore in your legislative 
framework, and I would like to highlight those. The policy and 
practice of excessive mandatory overtime is risky and unsafe 
and must be limited. Senator Kennedy and Senator Kerry plan to 
introduce legislation that will curb mandatory overtime for 
licensed nurses. Chairman Rockefeller, AFGE asks that you 
support the Kennedy-Kerry legislation and ensure that VA nurses 
have the ability to stop the overtime clock unless there is a 
real emergency.
    VA must also use a rational process for setting safe 
staffing levels. Research shows that increasing the numbers of 
RN's and other nursing staff in a hospital makes a difference 
in patient outcomes and quality of care. Currently, VA only 
maintains staffing standards for intensive care units and 
operating rooms. Other wards arbitrarily set personnel ceilings 
on the number of staff on duty.
    AFGE urges you to include in your legislation a provision 
to begin to address the longer-term solution to the nursing 
shortage, setting meaningful standards for staffing, sir.
    Thank you very much.
    [The prepared statement of Mr. Cox follows:]
    Prepared Statement of J. David Cox, Vice President, National VA 
     Council, American Federation of Government Employees, AFL-CIO
    Chairman Rockefeller and members of the Committee: my name is J. 
David Cox. I am a Registered Nurse and I am testifying on behalf of the 
American Federation of Government Employees, AFL-CIO (AFGE). I am the 
1st Vice President of AFGE's National VA Council. I am also the 
President of the AFGE local at the Salisbury, NC, VAMC.
    AFGE applauds you for holding this hearing on the nursing shortage 
in the DVA and its impact on patient care. The lack of adequate 
staffing at the DVA is the primary concern for the 135,000 DVA 
employees AFGE represents who are struggling to do right by our 
veterans. AFGE looks forward to working with you and the Committee on 
legislation to improve working conditions for DVA nurses and the safety 
of their patients.
    The nursing shortage is not impending it is here. From September 
1995 to September 2000, DVA cut Registered Nurses (RNs) by 10 percent, 
Licensed Practical Nurses (LPNs) by 13 percent, and Nursing Assistants 
(NAs) by 30 percent. These cuts have meant a loss of 1 in 6 direct 
patient caregivers. These reductions are attributable to DVA's 
reorganizations and budgetary contraints. From 1995 to 1999, management 
either could not or did not try to replace a third of the 15,851 RNs 
who left DVA. At my facility in Salisbury, NC, we cannot even try to 
fill the 50 RN vacancies because of our budget.
    At every DVA Medical Center facility I have visited across the 
country from East Orange, NJ to San Francisco, CA, from Minneapolis to 
New Orleans the impact of the nursing shortage is devastating and broad 
in scope.
     Employees struggle to fulfill DVA's core mission of 
providing veterans high quality care because of the shortage in direct 
patient care staff. Veterans are being denied access to care at the DVA 
and veterans are being diverted to private sector hospitals at what we 
presume is a great expense to DVA facilities because DVA lacks 
sufficient numbers of RNs.
     Reductions in staff-to-patient ratios and excessive 
overtime is damaging quality of care and endangering patient safety.
     DVA's ability to conduct cutting-edge medical and clinical 
research is erroded because of the DVA nursing shortage and impending 
shortage of pharmacists.
     The training of medical and nursing students is suffering 
because current DVA nurses have no time or energy to provide them with 
the needed review and feedback that is crucial to their education as 
health care professionals.
     DVA's approach to its nursing shortage (stagnant wages, 
excessive overtime, unscheduled tours of duty, reliance on agency 
nurses and creating new qualification standards which in effect limit 
nurse promotions) has resulted in placing nurses in increasingly 
difficult and untenable working conditions, which in turn makes DVA a 
less desirable workplace for employee candidates.
         the nursing shortage at the dva is going to get worse
    DVA's staffing problem is likely to get worse as nurses and the 
veterans they care for grow older. DVA patients are already older, 
sicker and poorer than the non-DVA patient population treated in the 
private sector. Although the overall veteran population will decrease 
in the coming decades, the demand on the DVA for the most labor 
intensive medical care for elderly veterans with chronic and multiple 
illnesses, and disabling conditions will increase.
    The increase in demand will occur when DVA's workforce is 
approaching retirement at a faster rate then the nursing workforce in 
the private sector. According to the American Hospital Association, the 
average age of nurses providing inpatient care is 45; in the DVA the 
average age for a full time RN is 48. Within four years 35% of DVA's 
RNs will be eligible to retire. At the same time, 29% of the LPNs and 
34% of the NAs will be eligible to retire. DVA will not be able to 
provide care for the most vulnerable veterans--the poor, elderly and 
disabled--when they are most in need of DVA's care, unless we act 
               addressing the nursing shortage at the dva
    AFGE greatly appreciates that your draft legislation will mandate 
Saturday premium pay for Title 38-Title 5 hybrid employees, like LPNs 
and pharmacists. We ask that you also include DVA's Title 5 employees, 
such as Nursing Assistants and medical clerks. We also appreciate that 
you will address some problems with the pay of part-time RNs. We also 
support enhancing the current employee education initiatives to 
encourage and support current DVA staff to become RNs, LPNs, and NAs.
    AFGE is concerned, however, that the draft legislative framework 
does not address the core working conditions that are sending DVA 
nurses out the door and driving RN candidates away from the DVA.
    Chairman Rockefeller, it is essential that your legislation address 
the following working conditions at DVA which have negative effects on 
quality of care and patient safety:
    1. Excessive and dangerous use of overtime;
    2. Lack of safe staffing standards;
    3. Inadequately involving front-line nurses in key policy decisions 
affecting patient care;
    4. Stagnant wages and the failure to reward nurses for their years 
of experience in promotions to Nurse Level II and III;
    5. Lack of a systemic and focused upward mobility program for 
current staff to become RNs.
1. Excessive Mandatory Overtime Is Risky and Unsafe; It Must be Limited
    Working RNs 16 hours or more a day takes a toll on patient care. 
The cumulative impact of DVA's use of mandatory overtime is that RNs 
and other nursing staff are overworked, overwhelmed, and fatigued from 
working too many hours day after day. Under these working conditions 
RNs are more likely to make medical errors. Even when medical errors 
are avoided, patients still suffer. Weary and worn out nurses may not 
be as observant of the subtle changes in a patient's condition that 
signal a medical problem. Overwhelmed and overtired nurses may also 
lack the keen level of concentration and emotional stamina necessary to 
deliver high quality and compassionate care. Medications, basic care, 
and critical medical interventions are delayed, forgotten or mixed up 
because staff is spread too thin and exhausted.
    The DVA does not have a nationwide policy on mandatory overtime, 
nor does DVA take disciplinary actions against Medical Directors or 
nurse managers who rely upon mandatory overtime excessively in lieu of 
adequate staffing. Only the patient and the RN suffer the consequences 
when a bleary-eyed RN makes a medical error at the end of two 
consecutive tours of duty. AFGE regards DVA's failure to hold 
management accountable for excessive overtime as a disturbing 
indication of DVA's lack of commitment to patient safety and in 
becoming the employer of choice.
    DVA's use of mandatory overtime ignores the reality of what is 
required to deliver high quality care. Nurses are the quality and 
safety monitors of health care. They are responsible for providing the 
first warning and swift intervention for those too vulnerable and sick 
to help themselves. When nurses are exhausted from working 16 or more 
hours a day, day after day, how can we expect them to recognize an 
impending or actual complication and mobilize intervention from 
physicians and other staff to save a patient's life?
    The DVA should not be allowed to use mandatory overtime as a 
routine method of filling shifts instead of an emergency response to 
urgent circumstances. It is not an acceptable substitute for adequate 
nurse staffing levels. The use of mandatory overtime is a short-sighted 
response to inadequate staffing because it worsens the problem, places 
patients at risk and puts extraordinary burdens on direct patient care 
    For public safety, airline crews, air traffic controllers, train 
operators and truckers have limits on the maximum hours they can work. 
Isn't it time that we set similar public safety protections for 
patients and the workers who care for them?
    Senator Edward Kennedy (D-MA) and Senator John Kerry (D-MA) plan to 
introduce legislation that will curb mandatory overtime for licensed 
nurses. Chairman Rockefeller, AFGE asks that you support the Kennedy-
Kerry legislation and provide DVA nurses the ability to stop the 
overtime clock unless there is a real emergency, not a failure of 
management planning. Curbing mandatory overtime is an immediate step 
that would improve quality care, working conditions and protect 
patients at the DVA.
2. Rationalizing Safe Staffing Levels Would Improve the Quality of Care
    Research shows that increasing the numbers of RNs and other nursing 
staff in a hospital makes a difference in patient outcomes and quality 
of care.
     The 1998 study ``Nurse Staffing Levels And Adverse Events 
Following Surgery In U. S. Hospitals'' (Kovner and Gergen) showed that 
patients who have surgery done in hospitals with fewer registered 
nurses per patient than other hospitals run a higher risk of developing 
avoidable complications following their operations. The study found 
hospitals that provided one more hour of nursing care per patient day 
than the average nursing care hours per patient day had almost 10 
percent fewer patients with urinary tract infections and 8 percent 
fewer patients with pneumonia. One estimate is that an additional one 
hour per day of nursing care is about a seventeen percent increase in 
nurse staffing levels.
     A 1995 study, ``Comparing the Contributions of Groups of 
Predictors: Which Outcomes Vary with Hospital Rather than Patient 
Characteristics'' (Silber, Rosenbaum and Ross) found that RN-to-bed 
ratio was the most important factor in predicting the differences among 
hospitals' success rates in saving patients who experienced serious 
adverse events. Silber's research found that nurse staffing levels were 
even more significant than the board certification of physicians in 
rescuing a patient because nurses are the ones who first recognize a 
complication and call the physician.
     Studies have shown that even slight increases in nurse-to-
patient ratios reduce the likelihood of patient falls in nursing homes. 
For the elderly a single fall may have significant medical 
     This February the Department of Health and Human Services 
released a study on ``Nurse Staffing and Patient Outcomes in 
Hospitals'' that found facilities with more RNs on staff had a 3 to 12 
percent reduction in rates of unfavorable outcomes for patients, like 
urinary tract infections, pneumonia, and shock/cardiac arrest. The 
study also showed that a reduced rate of unfavorable outcomes for 
patients subsequently lowered hospital costs.
    Currently DVA only maintains staffing standards for Intensive Care 
Units (ICU) and the operating room. These standards have forced DVA to 
maintain minimal staffing ratios on these wards. In other wards, like 
psychiatric and medical, staffing standards are determined by the 
number of staff on duty, not the needs of the patients. In other words, 
staffing standards at the DVA are not consistent from facility to 
facility. Nor are the staffing levels adequately measured or rational. 
Moreover, there is no accountabiity for unsafe staffing levels.
    Chairman Rockefeller, AFGE urges you to include in your legislation 
a provision to begin to address the longer term solution to the nursing 
shortage setting meaningful standards for staffing. The problem of 
understaffing in DVA is serious. It can only be solved if we have all 
stakeholders at the table, including nurses and other front-line health 
care workers, and the unions which represent them. We urge you to 
require DVA to create a joint labor-management committee to develop 
factors for establishing safe staffing levels at all DVA facilities. 
These factors should then be used by a facility labor-management 
committee to establish ward and facility specific safe staffing 
standards. DVA should report to the Senate Veterans Affairs Committee 
on the development of these factors and standards, and whether 
facilities are meeting the safe staffing standards.
3. Increasing the Ability of Front-line Nursing Staff to Advocate for 
        Their Patients
    It's common sense that the staff most responsible for providing 
bedside care, for being the primary surveillance system of a patient's 
condition, and for communicating and coordinating medical treatment and 
interventions be involved in decisions about the delivery of patient 
care. AFGE urges this Committee to amend 38 U.S.C 7422 to permit AFGE 
the opportunity to sit down at the bargaining table with DVA to discuss 
working conditions that affect the quality of patient care.
    A study by the American Academy of Nursing in the early 1980's 
showed that hospitals where nurses have greater control over their 
practice environment and where there is a culture of respect for nurses 
were magnets for the recruitment of high quality nurses. Other studies 
suggest that patient outcomes improve when nurses are truly valued and 
respected and given the support they need to care for patients.
    Loosening the current restrictions on labor-management negotiations 
would give front-line nurses and other care givers a stronger voice to 
advocate for their patients.
4. Improving the DVA Nurse Pay and Promotion System Would Enhance 
        Recruitment and Retention
    If DVA wants to be the employer of choice its working conditions 
must improve. In addition to safe staffing, limiting the abuses of 
mandatory overtime and enhancing nurses' ability to advocate for 
patients, a key area in need of improvement is pay. AFGE greatly 
appreciates the hard work by Senators Rockefeller and Specter in 
reforming the nurse locality pay system last year. The guarantee of an 
annual nationwide raise was welcome relief to DVA nurses.
    Unfortunately, some medical directors continue to exercise their 
discretion to deny nurses a locality pay increase. For example, Medical 
directors at Clarksburg, WV, Altoona, PA, Erie, PA , Philadelphia, PA, 
Wilkes-Barre, PA, Dublin, GA, Gainsville, FL, Lake City, FL, Miami and 
West Palm Beach, FL, Spokane, WA, Honolulu, HI, and White River 
Junction, VT, all did not provide RNs with a locality pay increase 
(only the 2.7 percent nationwide increase). AFGE urges that the 
legislation to address the nursing shortage include correcting the 
continuing inequities in the nurse locality pay system.
    AFGE would also urge you to address the mounting of problem of 
nurses who are on pay retention and, therefore, do not even receive the 
full GS nationwide pay increase. Between 1994 and 1997 the wage growth 
for nurses fell by 1.5% annually, according to a 1999 Buerhaus and 
Staiger study. In order for DVA nurses to maintain a decent standard of 
living and for DVA to become an employer of choice, locality pay and 
full pay raises for nurses on pay retention must be addressed.
    DVA is implementing Nurse Qualifications Standards that would 
practically shut the door on promotions to a Nurse Level II unless a 
nurse has a Bachelor in Nursing Science (BSN). A licensed RN of 15 
years who does not possess this type of degree, but has an Associate 
Degree in Nursing, is expected to work at the DVA at the Nurse I level 
solely because of her or his educational degree. How can DVA expect to 
retain or recruit employees who are highly qualified, experienced, 
licensed RNs, who happened to choose a different course of education? 
DVA does permit a waiver for RNs who do not have their BSN degree, but 
we are concerned that this waiver is not being fully used. AFGE urges 
this Committee to encourage DVA to rethink these qualifications 
standards and the potentially punitive effect of the education 
5. DVA is in a powerful position to increase the number of qualified 
        nurse candidates
    Given the current nursing shortage, DVA must aggressively recruit 
new nurses in anticipation of the retirement of a significant portion 
of its nursing workforce. The DVA has a pool of qualified staff who 
with proper encouragement and support would become RNs, LPNs or NAs. 
AFGE strongly believes that DVA would benefit from a revitalized upward 
mobility program for current staff to encourage them to go into the 
field of nursing and other health care professions on the verge of 
shortages, such as pharmacy and social work. An upward mobility program 
could also enhance the diversity of DVA's RN staff.
    AFGE supports the following improvement to the Employee Incentive 
Program Scholarship program:
     Require each DVA facility to recruit and fund a minimum 
number of scholarships for current staff to become RNs, LPNs, or NAs.
     Link the the overall scholarship limit to increases in 
education cost inflation;
     Reduce the the scholarship requirement for continuous 
employment from 2 years to 1 year, provided that more senior employees 
receive preference when funds are limited;
     Make the scholarship and debt reduction programs 
    AFGE would also urge the Committee to direct the DVA to work with 
nursing schools and colleges to provide classes at the DVA facility 
either in person or through teleconference to facilitate greater 
participation in the scholarship program.
    In sum, AFGE recognizes that many approaches to the nursing 
shortage must occur to resolve a problem that has been years in the 
making. But addressing these adverse working conditions at DVA is a 
necessary and prudent course to improve quality of care and protect 
patients at the DVA .
    When DVA fails to create favorable working conditions by treating 
its staff with respect and dignity it sends a profound message to not 
only its workforce but to candidates for employment. Moreover, the way 
that DVA management treats its workforce ultimately redounds to DVA's 
genuine desire and capability to honor veterans with compassionate and 
high quality care.
    Thank you for considering AFGE's views.

    Chairman Rockefeller. Thank you, Mr. Cox.
    Ms. McMeans, you used the words ``ethically bound,'' and 
that interested me very much, and I would like to have each of 
you maybe comment on that, because it is true in teaching, half 
of all American teachers are retiring. It is true in nursing in 
the non-VA system as well. I want to get your comments on 
whether it is more true in the VA, in your judgment, than in 
non-VA health care.
    A shortage is defined as not enough people, and if you are 
ethically bound, on the one hand, but exhausted on the other, 
you have mandatory overtime. I just want to try and draw you 
out in a question here. What happens, let's say, if the OR is 
staffed but other departments are not because there is a 
shortage plus a reduction in hours because of legislation? And 
how does that, in your minds, work with the whole idea ethical 
responsibility. All patient care is important, and a nurse 
becomes not just a giver of care but a giver of hope, as 
Senator Cleland said, and of love or self-esteem.
    So how do we deal with this? One, is it worse out there in 
the non-VA system as you talk with your counterparts? Second, 
how do you square the phrase you used, ``ethically bound,'' if 
there is a mandatory reduction in hours, with what happens then 
to the patients if it is in effect and there is still a 
shortage of nurses? And I was looking at you, but I am 
directing these questions to everybody.
    Ms. McMeans. I see what you are saying. If the mandatory 
overtime is reduced, we can get more staff nurses to come to 
    Chairman Rockefeller. How do you do that?
    Ms. McMeans. We just put out the word that there is no more 
mandatory overtime. Right now in the community in Martinsburg, 
that is one of the things out there. Nurses have quit and left 
the VA, and the word is you do not want to go to work there 
because you do not know when you are going home. You can come 
into work at 7:30 in the morning, and you think you are 
supposed to get off at 4. Then you find out at 3:30 that you 
have to stay another 8 hours. Then you are obligated to come 
back in the next day. This is the word that is out in the 
community. So nurses will not come to the VA for those reasons.
    At the outside hospitals and other areas, they do not have 
this mandatory overtime, so nurses coming out of school, they 
are thinking, OK, well, I will go there and give it a try and 
see what it is like.
    Chairman Rockefeller. And do they also work shorter hours? 
So are these nurses available?
    Ms. McMeans. Yes, I believe, if the VA starts to be 
creative in their retention and how they are going to bring 
nurses in. Right now they are not really thinking part-time. We 
have no part-time in Martinsburg. There are nurses out there 
that are willing to come back part-time, work fee basis, some 
of the older nurses who have gone out and retired who are 
willing to come back and help. We do not have that at this 
moment. This would really help with, you know, the shortage 
right now, with the staffing shortage.
    Chairman Rockefeller. OK.
    Ms. Myers. I would like to also add to that the notion of 
looking at retired military nurses as a option for bringing 
more nurses into nursing. I would also like to respond to your 
comment about--I guess it was a question as to whether it is as 
bad on the outside, non-VA. Having had some recent personal 
experiences in several hospitals in Atlanta with family 
members, I do not believe that it is as bad as it is at the VA.
    Chairman Rockefeller. Because of the budget.
    Ms. Myers. Because of the budget. That is the main reason, 
because of the budget. I see traveling nurses. I see agency 
nurses. Even though the VA is using some agency nurses, I do 
not believe that the situation is as worse as it is at the VA.
    Chairman Rockefeller. So you must be really happy about the 
tax cut bill, aren't you? [Laughter.]
    Carefully taking a drink of water. [Laughter.]
    Mr. Cox?
    Mr. Cox. Mr. Chairman, I recently had a cardiac 
catheterization and a stent put in my heart in the private 
sector, and I can tell you, it was a medical center that I used 
to work at. I was never forced on mandatory overtime. I was 
asked if I wanted to work overtime. But, also, if the workload 
went up, they were able to offer whatever price it took to hire 
the staffing, and still yet that medical center does not force 
    We have mandatory overtime in the VA simply because there 
is not enough staff in the very beginning.
    Chairman Rockefeller. And there is not enough staff because 
there is not enough funding.
    Mr. Cox. That is exactly right.
    Chairman Rockefeller. And it is going to get worse.
    Mr. Cox. Yes, sir.
    Chairman Rockefeller. Because of this tax cut bill, right?
    Mr. Cox. Yes.
    Chairman Rockefeller. So how do we handle that?
    Ms. McMeans. I will give my money back, my little----
    Chairman Rockefeller. That will help, but it will not solve 
the whole problem.
    But I am serious. How do we handle it? Because that is the 
ultimate issue. You know, this is not political, but I did not 
agree with the tax cut bill. I think it was wrong for about 150 
reasons. But one of the ultimate casualties from that bill is 
going to be the VA system. And, therefore, we have to be very, 
very sure as we go through the appropriations process that we 
are very even and fair between hospitals so that each hospital 
has the most it possibly can for all purposes.
    But it is a budget-run system. It is a national health care 
system. It does not have the ability to rise above a budget. 
And so how do we do that? What can we do to make up? If you 
reduce the mandatory overtime, which if somebody told that to 
me that I had to work 18 hours or 20 hours a day, even if it 
did not bother me, the fact that I was being told that I had to 
would bother me. I might choose to do it because the need was 
there, but I would not want to be told to do it. But, on the 
other hand, with the shortage, will people be there for the 
non-critical type of care that patients in VA hospitals 
    Mr. Cox. I think they would, Mr. Chairman. When I reviewed 
the number of licensed nurses in many States, there is a large 
number of licensed nurses. But at the same token, when you 
review how many of them are actually in the work force 
practicing as registered nurses and licensed practical nurses, 
that number has shifted down. About 96 percent of the nurses in 
this country are women who have children, have family 
responsibilities and things. Forcing them over, telling them 
they have got to leave children at home alone, things like 
that, all those contribute to, they say, well, no, I just 
cannot do nursing anymore, I am going to choose another job.
    Chairman Rockefeller. All right. We all have responsibility 
with this. Obviously the main responsibility is ours because we 
have increased the budget.
    But AFGE is a very powerful and large organization. What 
are you all doing to try to work at this solution of the 
shortage of nurses?
    Mr. Cox. One of the things that I advocate continuously to 
our membership, those that are nursing assistants and LPNs, is 
to strive to go back to school to become registered nurses. We 
have worked with community colleges and universities and things 
to develop programs where people can actually work and go to 
school and do those type of innovative things. And that has 
helped and figured out ways that people can proceed to pursue 
an education to deliver better quality of care. Those are 
things that we have done.
    Also, many AFGE members go around to local hospitals, and 
now more than just hospitals, they are going into community 
groups because many nurses do not go into nursing right out of 
high school. Many of them are 20, 30 years old nowadays when 
they enter the nursing profession, and we are trying to work in 
that arena.
    Also, we are doing such things as talking to many of your 
colleagues over here on the Hill about the problems with 
nursing, and particularly about the VA.
    Chairman Rockefeller. OK. Other points on this subject?
    Ms. Myers. In terms of NOVA, we are looking at the VA Cadet 
Nurse Program, the model that is at the Salem, Virginia, VA. We 
are challenging our members to go out and assist in mentoring 
programs and recruiting nursing students who have not chosen a 
career to come into nursing.
    We are also monitoring the Nursing Education Initiative, 
which was put into place a couple of years ago, the $50 million 
that was allocated, and as you can see in the testimonies, 
recommendations are made there for ensuring monitoring by 
having someone hired at the specific VAs to implement that 
program and ongoing monitoring.
    Chairman Rockefeller. Maybe this will have to be the final 
question because we have two more panels, and this is terrible 
to do, to have three panels in such a short time, with two 
votes mixed in, and I apologize to all of you for that.
    I expressed myself and my views on the tax cut. It does not 
necessarily express your views. But I would like to have each 
of your views on the record as to what you think a flat-line VA 
budget will mean in terms of nursing shortage in the VA health 
care system? Starting with you, Dr. Myers.
    Ms. Myers. I believe that it will continue to jeopardize 
the safety of patients in terms of not having sufficient 
registered nurses or nurses in general to take care of 
patients. I believe that the morale of the current work force, 
nursing work force, will continue, and the availability in 
terms of the supply of nurses that are needed in terms of the 
demand, the gap is going to widen because the nurses who are 
not comfortable and unsatisfied being at the VA are going to 
    Chairman Rockefeller. And you hear that conversation 
    Ms. Myers. Yes.
    Chairman Rockefeller. And they say what kinds of things?
    Ms. Myers. It also jeopardizes the 50 percent of the work 
force who are eligible for retirement. Those nurses, it is 
possible that those nurses could leave at any time. So that 
will further complicate the problem.
    Chairman Rockefeller. Ms. McMeans?
    Ms. McMeans. I believe personally that you will see, I will 
say, a decrease in the patient load in the Martinsburg VA, 
because I look for the nurses to leave. I really do. And I do 
hear it. In fact, I lost a nurse practitioner just this week 
who has been in the system for like 5 years. She was an ICU 
nurse, and she left. She has a master's degree, and she left 
because she could not even get a Nurse 3. I am an associate 
degree nurse, and she makes like $2,000 more than what I do. 
And she could not because she was told that there was no money 
in the budget for it.
    I have seen nurses walking out the door. I see a lot of 
nurses that are eligible for retirement who are tired because 
of the mandatory overtime, because of having to stay late 
shifts, and working short, and they are afraid of the 
responsibility. I see them leaving and going to the private 
sector. I can go out now and get a job for $25 an hour and work 
8 hours any day I want of the week, any shift that I want. And 
all I have to worry about is the insurance benefits. So why 
would I come to the VA and work for you?
    I hear this all the time. And I look for nurses to really 
leave the work force.
    Chairman Rockefeller. So the statement that I made earlier 
about that the VA being blessed by an unusually low amount of 
turnover among nurses is now jeopardized?
    Ms. McMeans. Yes. And the nurses that are leaving are the 
ones with the 25 and 30 years of service.
    Chairman Rockefeller. If the ``mandatory'' overtime was 
eliminated, in legislation but the funding was not changed, 
would the result be the same--that is, nurses continuing to 
leave or leaving at a faster pace?
    Mr. Cox. I think taking the mandatory overtime off would 
certainly help curtail some of the nurses' leaving because we 
lose nurses who will say, ``I have worked other places, and no 
one forced me to work overtime. They asked me if I wanted to 
work it.'' And nurses are compassionate, caring people. They do 
not just walk off and leave patients of any type uncared for. 
They make arrangements. But to force them I think is what is 
causing some of them to leave and go other places.
    Chairman Rockefeller. Could you each--and this will be the 
final question--give me an example, a real-life example of what 
happens when a nurse is exhausted into his or her 15th hour? 
What is the fatigue factor? What kinds of things can happen or 
do happen as a result of that condition?
    Ms. Myers. As a charge nurse in a nursing home care unit 
working on the evening shift, a nurse is giving bar code 
medication administrations in a 32-bed unit with a census--
excuse me, a 32-bed unit with approximately six or seven 
nursing personnel. It is suppertime. Patients need to be 
toileted, fed. A patient falls out of the bed, and the nurse 
who was supposed to be monitoring that patient was down helping 
with another patient or has gone off the floor to have supper.
    Medication errors, forgetting to administer a medication, 
not being attentive to a patient's pain, need for pain control. 
A patient asks for pain medication, and the patient does not 
get the pain medication.
    Chairman Rockefeller. Because they push the button and 
there is no----
    Ms. Myers. The nurse is busy doing something else.
    Chairman Rockefeller [continuing]. Nurse at the other end?
    Ms. Myers. Correct.
    Chairman Rockefeller. Ms. McMeans?
    Ms. McMeans. I will agree with her on the medication 
errors. I have seen IV's not being hung, not getting hung. I 
see paperwork being left behind, important information and 
things that need to be passed on maybe to the next shift not 
being done because the nurses just totally forgot--not that she 
wanted to, but because she is exhausted and just really cannot 
    I will see a nurse the next day getting ready----
    Chairman Rockefeller. In other words, you mean they 
postpone it. They say they will do it in a half-hour, and then 
do three or four other things in between, and then the memory 
is a little less clear, because they are tired, of what it was 
that they wanted to write down.
    Ms. McMeans. If I am working on an admission and I am doing 
an admission paper right now on a patient, and then all of a 
sudden this patient goes into cardiac arrest over here, and I 
run over and take care of him, and then this patient is having 
a seizure, well, I have to run over there. Well, guess what got 
left behind? The paperwork.
    Chairman Rockefeller. Right.
    Ms. McMeans. And it is going to sit there because I do not 
have time. I am going to take care of my patients first.
    Now, what will be the final result, probably----
    Chairman Rockefeller. And that is part of your ethic, isn't 
    Ms. McMeans. Right.
    Chairman Rockefeller. That is a no-brainer, what you are 
going to do.
    Ms. McMeans. Right, exactly. So, therefore, important 
information is not passed on. Whatever I was typing or writing 
or doing at that time will not be passed on to the next shift. 
Maybe they will not get some information that they need to, you 
know, review or talk over with the doctor. And I see a nurse 
possibly calling in the next day sick because they are just too 
exhausted to make it back in.
    Chairman Rockefeller. Thank you.
    Mr. Cox?
    Mr. Cox. I guess I would give an example of when I was a 
child in school, we always had the hardest subjects first in 
the day. You usually had math first out in those first few 
years. And I also know that any time that we have had 
physicians who have had surgery and so forth in the hospital, 
they purposely want their cases scheduled first in the day. And 
I guess there has to be a reason because when people are 
starting fresh, they are relaxed, and there are less errors and 
less chances of things going wrong.
    Now, if we are doing those things for what is a normal 
maybe 8-hour day, think about what the end results can be at a 
16-hour day or maybe even sometimes longer. People are tired. 
They do not think as well. They get more frustrated. They do 
not feel as well at the end of a 16-hour day. Things happen. 
They are not as caring and compassionate either with how they 
treat and take care of people.
    So lots of things I think can go wrong. I could enumerate 
those medication errors and things of that nature, but I say 
look at what physicians themselves do if they have to have some 
medical procedures. They purposely make their colleagues 
schedule them first off in the day.
    Chairman Rockefeller. I thank all of you very, very much. I 
think again this underscores the brutality of what happens if 
you do not adequately fund nursing. So I really appreciate what 
you have said, and I apologize for making you wait, and I thank 
    Ms. Myers. Thank you.
    Ms. McMeans. Thank you.
    Mr. Cox. Thank you, sir.
    Chairman Rockefeller. Senator Specter has arrived, and we 
would welcome any comments you have, sir.
    Senator Specter. Thank you very much, Mr. Chairman.
    I regret not being here for the entire session. I have been 
working on a committee on reorganization, trying to get the 
Senate reorganized after the shift in majority control, and I 
commend Senator Rockefeller, Chairman Rockefeller, for 
convening this session.
    The problem with nurses is an enormous one. I hear about it 
wherever I travel. I was in Scranton this past Monday, and it 
is a major area of concern in the private sector as well as in 
the public sector as to how we persuade more professionals to 
become nurses. It is a matter of major concern in Scranton and 
    On the Appropriations Subcommittee, which has jurisdiction 
over the Department of Health and Human Services, we have 
looked into a very difficult issue--nurses performing 
anesthesiology. There has been quite a bit of controversy over 
whether a nurse ought to be able to do that, subject to a 
certain amount of supervision by a medical doctor. And after 
studying the issue, it is my view that rural areas are very 
different from cities based on the experience I had growing up 
in a rural area.
    Finally, we worked it out so that there would be State 
control over the issue with the Governors making the primary 
decision. I think that is going to encourage nurses to go into 
the profession if they have greater latitude in anesthesiology. 
That might be an illustration of giving more professional 
responsibility to nurses.
    The scholarship program is a good idea. Tax incentives are 
another idea. But there is no doubt that we have to be 
innovative to try to provide professionals in this very 
important line of endeavor.
    [The prepared statement of Senator Specter follows:]

      Prepared Statement of Hon. Arlen Specter, U.S. Senator From 

    Good Morning. Our purpose here today is two-fold: first, 
the Committee meets today to vote on--and, I hope, approve--the 
nomination of Mr. Gordon H. Mansfield to be VA's Assistant 
Secretary for Congressional Affairs. Second, we will receive 
testimony on a vexing issue--projected shortages of nurses to 
staff VA--and other--hospitals, clinics and long term care 
    This is a nomination that is of particular interest to the 
Members of this Committee since the nominee will coordinate VA 
activities on Capitol Hill--activities designed to communicate 
VA's message to us . . . and to transmit, from time to time, 
Congressional messages back to VA and to the Administration. 
The Assistant Secretary for Congressional Affairs also assists 
us in securing needed constituent services from VA--one of the 
most vital, to us, services that VA can perform.
    In short, the job of the Assistant Secretary for 
Congressional Affairs is an important one--and I think Gordon 
Mansfield is highly qualified to perform it. So I have--and I 
will--support his confirmation.
    The other issue we will address today is the issue of 
projected shortages of nurses to staff VA--and other--
hospitals, clinics and long term care facilities. Anyone who 
has ever been in a hospital--as I have--will confirm a point on 
which most already agree: that the nursing staff is the 
backbone of any health care facility. VA hospitals--any and all 
hospitals--simply could not operate without a full compliment 
of nursing staff. Surely, the physicians and health care 
executives could not run the place without nurses; they would 
be the first to agree to that point. So we must assure that VA 
is thinking ahead to prevent, or minimize, the impact of 
shortages that most experts seem to agree are just over the 
    I am pleased to note that--at least in VISN IV 
(Pennsylvania)--there does not appear to be a insurmountable 
problem. If I am informed correctly, VISN IV employs 
approximately 2600 nurses and it currently has approximately 
160 vacancies. That is not good news--particularly when three 
VA medical centers in Pennsylvania (in Coatesville, Erie, and 
Philadelphia) have unfilled vacancy rates of over 10%. But it 
does not appear to me to be a extraordinary problem.
    Obviously, however, VA needs to assure that it prevents 
nurse shortages. It needs to assure that it remains competitive 
in the hiring environment--both by offering competitive 
salaries and, perhaps more importantly, by addressing the 
intangible issues that nurses advise need attention. VA needs 
to cut back on mandatory overtime. VA needs to offer cutting-
edge training opportunities--and child care assistance and time 
away from work to put these opportunities within reach of real 
world employees. And VA needs to offer to nurses the respect 
and empowerment to which they are entitled. I am most troubled 
by a University of Pennsylvania study which found that:
     only 39% of surveyed nurses thought hospital 
administration listened and responded to nursing staff's 
     only 40% thought nurses had an adequate 
opportunity to participate in policy decisions; and
     only 39% thought that nurses' contributions to 
patient care were publicly acknowledged.
    This cannot be the environment within which VA nurses 
work--not if VA is to continue to attract and retain the 
quality staff it has now.
    We will be looking to our witnesses this morning for 
tangible, specific ideas on what VA must do to get--and 
remain--competitive in the future marketplace for nurses. 
Perhaps VA cannot solve the overall national nursing shortage 
issue--though I am anxious to hear how it might contribute to 
solving a broader national problem. But it can--and it must--
position itself to compete successfully in the environment of 
staffing scarcity caused by that broader national problem. VA's 
survival--and the care of the Nation's veterans requires it.

    Chairman Rockefeller. Thank you, Senator.
    Could Dr. Garthwaite and Cathy Rick please come forward? 
Again, I would note that your full statement is in the record, 
and the 5-minute limit is actually becoming increasingly 
important, and I know you both understand that.
    Dr. Garthwaite, we welcome you.


    Dr. Garthwaite. Thank you, Mr. Chairman, Senator Specter. I 
appreciate the committee's interest in nursing issues in VA and 
in society in general and for holding this hearing and for 
legislation passed last year, Public Law 106-419, that allowed 
us to pay additional salaries to nurses.
    I would just make three points so we can get on with the 
    First, I think today VA is largely meeting the needs of 
veterans with 35,000 skilled and dedicated registered nurses 
throughout our system. There is no question that in some areas, 
in some nursing specialties, we have significant difficulties 
in recruiting nurses.
    Second, we are worried about tomorrow. We are worried 
because of the age of our nursing work force. We are worried 
about the projections of a shortage in nursing. And we are 
worried by the demographics which basically show that as baby 
boomers age and need nursing care, they leave the work force 
and leave a much smaller total work force in which fewer people 
are going into nursing. So we are, too, concerned about 
tomorrow in nursing.
    Finally, I would just say that we have numerous strategies, 
and we look to work with this committee in trying to develop 
others that induce people to go into nursing, and especially to 
get nurses to want to come into the VA and stay with us for a 
long time.
    With that, I will stop and entertain your questions.
    [The prepared statement of Dr. Garthwaite follows:]
 Prepared Statement of Thomas L. Garthwaite, M.D., Under Secretary for 
                 Health, Department of Veterans Affairs
    Mr. Chairman and Members of the Committee:
    I am pleased to appear before the committee to discuss VA's nurse 
staffing situation and the looming crisis in nursing.
                nursing shortage: a national perspective
    VA is able to provide quality care to veterans, and meet most of 
the demands for nursing staff. However, there are increasing 
difficulties in filling positions in some locations, and extreme 
difficulty filling some specialty assignments. We recognize that if 
national nursing workforce projections are accurate, a shortage of 
nurses could adversely affect our ability to provide health care for 
    The future supply of registered nurses is not assured given the 
current aging of the registered nurse workforce and the decreasing 
number of students who choose nursing as a career. National nursing 
leaders and health care organizations are projecting a shortage of 
registered nurses that will be unlike any experienced in the past. 
Additionally, the demand for registered nurses is expected to increase 
as baby boomers age and require more health care services.
    Noted nursing economist Dr. Peter Buerhaus has predicted that the 
total number of nurses per capita will likely peak in 2007 and decline 
steadily thereafter. The number of nurses in the workforce is projected 
to fall nearly 20% below requirements by the year 2020. One-half of the 
2.1 million nurses currently in the United States workforce will reach 
retirement age in the next 15 years. (Buerhaus; DHHS). At the same 
time, changes in the way health care is delivered will require larger 
numbers of well-educated nurses who perform increasingly complex 
functions. These changes are projected for health care delivery in all 
settings, whether in hospitals or in community settings. Based on 
current trends, the demand for nurses will grow 23% between 1999 and 
    The projected shortage will result in part from a number of 
substantial changes that continue to take place in the profession. 
Factors identified that will intensify the nursing shortage include:
     A decline in enrollment in schools of nursing \2\
     Aging of the nursing workforce \1\, \3\
    \1\ Buerhaus, P.I.; Staiger, D.O.; Auerbach, D.I. Implications of 
an Aging Registered Nurse Workforce. Journal of the American Medical 
Association, 2000, 283:2948-2954.
     Average age of a new graduate in nursing has climbed to 
30.5 in 1995-2000 versus 24.3 in 1985 or earlier \2\
    \2\ Bednash, G. Nursing Schools' Enrollments Decline as Demand for 
RNs Continued to Climb. American Association of Colleges of Nursing, 
February 2000
     Poor image of nursing as a career choice and more career 
choices for women \1\, \2\
    \3\ The Registered Nurse Population: Findings from the National 
Sample Survey of Registered Nurses. U.S. Department of Health & Human 
Services, March 1996.
     Pay stagnation, after inflation adjustment \1\
    \4\ Searching for Trust: America's Message to Hospitals and Health 
Systems. Reality III, National Focus Group Research, American Hospital 
Association, 1998-1999
     Perceived negative work environment \5\
    \5\ Aiken, L. et al. Nurses' Reports on Hospital Care in Five 
Countries. Health Affairs, May-June 2001:43-53
     Inadequate numbers of qualified faculty to educate the 
numbers of nurses needed \2\
                         rn staffing within va
    Registered nurses comprise the largest segment of health care 
workers within the Veterans Health Administration (VHA). Currently, VHA 
employs over 35,000 registered nurses and nurse anesthetists. VA nurse 
employment is stable at this time. VA enjoys a lower turnover rate (9.5 
percent in 2000) than the national average of 15%. However, VA is 
experiencing difficulty in recruiting nurses with certain special 
qualifications such as intensive care, nurse practitioners or nurse 
anesthetists. While the difficulties are occurring nationwide, the 
types of nurses for which there are shortages vary by geographical 
region. Certain VA medical centers also report difficulties recruiting 
Licensed Practical Nurses (LPNs) and nursing assistants (NAs).
    Based on the new reporting requirement established in Public Law 
106-419, after September 30, 2001 we will have a more complete picture 
of the RN staffing levels and recruitment and retention difficulties at 
each VHA facility, as well as throughout the system.
    VA is more successful than the rest of the healthcare industry at 
retaining nurses. VA's nurse turnover rate is 9.5% vs.15% for the U.S. 
This means that when nurses take positions with VA, they are more 
likely to continue their careers in VA. However, the age of a new nurse 
hire in VA is 41.65 years. If younger nurses were attracted to VA, they 
would be more likely to stay with VA, and VA would be less exposed to 
the looming nurse supply shortage in future years.
    Today, 12 percent of the VA nursing population is eligible to 
retire. Each year, an additional 3.7 to 5.3% of VA nurses become 
eligible to retire. By 2005, 35% of the current VA nursing workforce 
will be retirement eligible. Based on past experience, we predict that 
about two-thirds of these nurses will actually retire by that date. 
That means that over 1 in 5 VA nurses today will be gone by 2005. VA 
has been able to successfully recruit to fill these vacancies as they 
occur. However, as the labor market tightens considerably, recruitment 
difficulties can be expected.
    The retirement eligibility projections for allied nursing 
occupations are similarly high with 29% of LPNs and 34% of NAs will be 
retirement eligible by 2005.
              changing skills for future nursing workforce
    The current trends in health care delivery increased focus on 
outpatient settings delivering comprehensive wellness and health care, 
with patients experiencing shorter hospital stays for acute illness 
episodes will continue to force changes in the nursing profession.
    Nurses must possess clinical decision-making and critical thinking 
skills, with preparation in community health, patient education and 
nursing management/leadership. They will require a breadth and depth of 
knowledge to make rapid patient assessments during critical stages of 
an acute illness, as well as to assist patients in making the 
transition from one care setting to another.
    Based on this intense and complex care environment, the National 
Advisory Council on Nursing Education and Practice has proposed that by 
the year 2010 two-thirds of all practicing nurses must possess a 
baccalaureate degree if optimal care is to be provided. VA's new Nurse 
Qualification Standard, with its emphasis on educational achievement, 
and VA's commitment to funding academic education for nurses completing 
baccalaureate and higher education are positioning VA to attain this 
desired mix of educational attainment.
    VA is taking steps to ensure that our workforce is ready to meet 
the challenges by offering career tuition assistance to nurses. VA has 
implemented two educational assistance programs to enhance recruitment 
and retention of health professionals such as nurses--the Employee 
Incentive Scholarship Program (EISP) and the National Nursing Education 
Initiative (NNEI). The EISP provides scholarships of up to $10,000 per 
year for up to three years for employees to pursue degrees or education 
in health care occupations for which VA is experiencing staffing 
problems. In return for VA's tuition and expenses support, employees 
agree to serve a period of obligated service. As of this month, VHA has 
awarded 189 scholarships amounting to over $1.7 million, primarily for 
nursing and pharmacist degrees.
    In addition, VA has implemented the NNEI to help ensure that we are 
able to meet our staffing needs for registered nurses. The NNEI 
functions like the EISP, but awards scholarships solely to nurses to 
obtain baccalaureate or post-graduate degrees and training. Already, 
1,639 VHA nurses have been awarded more than $18.5 million support for 
tuition and expenses. The investment that we are making in educating 
our nurses and other health care professionals, coupled with the 
requirement that scholarship recipients serve a period of obligated 
service, will help VA retain quality health care staff, even during 
times of shortages. It is also noteworthy that the implementation of 
the EISP and the NNEI has stimulated interest in working for VA.
             va strategies to address the nursing shortage
    VA is actively addressing the projected future nurse supply 
shortage through several initiatives. First, I appointed a VHA Staff 
Focus Group to develop a comprehensive plan aimed at increasing 
employee job satisfaction that enables VHA employees to fully develop 
and use their talents. I have just received this Group's 
recommendations and am reviewing them now.
    Second, the VHA Office of Patient Care Services, Nursing Strategic 
Healthcare Group (NSHG) has implemented a Future Nursing Workforce 
Planning Group to advise the Chief Consultant on issues that impact 
VA's future supply and utilization of registered nurses. This group 
will make recommendations before the end of this fiscal year for 
specific actions to address the impending shortage of registered nurses 
and other nursing staff.
    In addition to the work of the national VA groups noted above, a 
number of VA facilities are initiating programs to combat an impending 
nursing shortage. Facilities are actively recruiting through the media. 
Relocation, recruitment and referral bonuses are being used. New youth 
programs are being developed in several facilities. Structured programs 
for new hires are in place in many facilities. Facilities report 
partnerships and special programs for students in middle school and 
high schools.
    Recruitment and retention efforts include the EISP and NNEI 
described above. These programs provide great benefit to VHA and our 
nurses. In addition, the Education Debt Reduction Program (EDRP), being 
readied for implementation this summer will provide an additional 
recruitment and retention tool. The EDRP will provide tax-free payments 
to newly hired employees to help pay the costs of obtaining their 
training or degrees. This program enables VA to pay up to $24,000 over 
three years to employees enrolled in the program.
    I have attached to my prepared statement a comprehensive listing of 
all the strategies VA is using to recruit and retain nurses. I will 
continue to encourage all facilities to use these authorities to the 
extent necessary to assure quality nursing care for veterans.
    We appreciate the opportunity to comment on the committee's draft 
legislative framework to address nursing shortages in VA. However, we 
have not yet had the opportunity to develop a departmental position on 
it, but will do so expeditiously and submit it in writing.
    VA will continue to devote talent and resources to averting the 
impending national shortage of nurses and minimize any impact on the 
care we deliver. Interventions will be designed and implemented that 
will ensure the health care system's ability to maintain a highly 
qualified workforce to provide care for the Nation's veterans.
      Attachment--Recruitment and Retention Strategies for Nurses
    The following is an overview of the numerous authorities available 
to enhance VA's ability to recruit and retain highly qualified nurses:
     flexibilities in the nurse locality pay system survey process
Deviations to Periodic Step Increase (PSI) Waiting Periods
    The normal waiting period for a PSI to advance to the second, third 
or fourth step of a level in Nurse I is 52 weeks of creditable service. 
The waiting period to advance to all other steps in Nurse I and all 
steps in grades II through V is 104 weeks. Facility directors may 
request deviations to these waiting periods if necessary to enhance 
recruitment and retention. This would typically be requested to mirror 
the advancement and promotion patterns in the community and should be 
supported by evidence of staffing difficulties related to those 
Exceptions to the 133 Percent Rate Range
    The rate range under the Locality Pay System (LPS) is normally 133 
percent of the beginning rate of the grade (12 steps). Facility 
directors may request extension of the rate range for a grade, up to 
175 percent (26 steps), if such an extension is necessary to recruit or 
retain well qualified nurses. Facilities submitting requests must 
exhibit staffing problems specific to the grade for which the extension 
is requested, and show that the problems are related to higher maximum 
rates in the community. This authority is particularly useful for 
retention as it gives on-board employees greater earning potential.
Expanding the Local Labor Market Area (LLMA)
    Facility directors may expand the survey area for any covered nurse 
occupation or specialty if the survey area does not adequately 
represent the LLMA for an occupation or specialty or if there are less 
than 3 job matches per grade. LLMAs may be expanded differently for 
different occupations or specialties. LLMAs may be expanded as far as 
necessary to obtain the required survey data.
Higher Rates of Pay for Specialized Skills
    When a nurse is appointed above the minimum step rate of the grade 
because they possess specialized skills, particularly specialized 
skills that are difficult or in demand, the facility director may 
adjust the salary rates of other nurses in assignments requiring the 
same specialized skills up to the same number of steps. For instance, 
if a critical care nurse is hired at Step 5 based on specialized skills 
related to critical care, the director may authorize an increase of up 
to 4 steps for all on-board critical care nurses.
Pay Retention Upon Transfer
    Nurses who transfer between VA facilities normally receive the rate 
of pay at the gaining facility applicable to their existing grade and 
step. This may result in a salary decrease if the employee transfers to 
a facility with lower rates of pay. Facility directors may authorize 
the individual to receive pay retention or an intervening rate of pay 
(a rate which is above the rate of pay for the corresponding grade and 
step but less than pay retention) based on a special recruitment need 
or solicitation of an employee to fill an assignment requiring special 
qualifications. Use of this authority enhances recruitment abilities by 
attracting experienced VA nurses who are seeking to relocate.
Scheduling Salary Surveys
    Facilities are required to conduct LPS surveys within 120 days of 
any GS adjustment in order to determine if an adjustment to LPS rates 
should be made coincident to the GS adjustment. Facility directors may 
also order salary surveys at any other time it may be deemed 
appropriate. For instance, facility directors may wish to conduct 
additional surveys simultaneous to scheduled salary increases in the 
community or if evidence, such as increased turnover or difficulty 
recruiting, suggests that the facility's rates are no longer 
competitive in the community.
Setting Beginning Rates of Pay
    Passing on Amount of GS Adjustment. Every LPS schedule receives the 
full amount of the nationwide General Schedule (GS) adjustment each 
January. If appropriate, facilities may grant larger adjustments. This 
automatic increase is in addition to any other adjustments granted 
throughout the year.
    Setting Beginning Rate up to Community Maximum. The beginning rate 
for any grade for which survey data was collected may be set equivalent 
to, but not exceed, the highest beginning rate for corresponding non-VA 
positions in the LLMA. Facility directors should consider all factors 
that affect the facility's staffing abilities when choosing the 
beginning rates of pay, including the geographic relationship of their 
facility to major non-VA health care facilities in the LLMA, the rates 
paid by the facility's major competitors, and benefit packages offered 
by competing establishments.
    Setting Beginning Rate up to 7th Step of Next Lower Grade. When 
data is not available for a grade and an adjustment is necessary to 
recruit or retain well-qualified employees, the facility director may 
increase the beginning rate of Nurse II, III, IV, or V up to the 7th 
step of the next lower grade. The beginning rate for Nurse I may be 
adjusted so that that the beginning rate for Nurse II falls in the 
range from the 4th through 7th step of Nurse I. The beginning rate for 
the levels with Nurse I may be adjusted to provide a 3-step 
differential between them.
Special Salary Rates
    When differences in local pay interferes with VA's ability to 
recruit and retain health care personnel, special salary rates may be 
authorized to achieve adequate staffing or to recruit personnel with 
specialized skills. These rates may be competitive with, but not 
exceed, pay for comparable positions at non-Federal facilities in the 
same local labor market. This authority has not been widely used for 
nurses because pay comparability is normally achieved through the LPS.
Specialty Schedule
    A separate LPS salary schedule may be established for any clinical 
nursing category by conducting a survey of pay rates for the 
corresponding specialty in the local labor market. This allows the 
facility to pay higher rates for assignments that are typically 
difficult to fill, such as critical care nurse, operating room nurse 
and nurse practitioner.
Third Party Survey Data
    Recent legislative changes expand the sources of salary information 
that can be used to set salary rates. In addition, that legislation 
provides for collection of various salary data, including average 
rates, rate ranges, bonuses, and the value of benefits. These new 
flexibilities will enhance VA's ability to accurately measure and set 
salaries for nurses.
         additional recruitment and retention tools for nurses
Advances in Pay
    VA has the flexibility to grant nurses an advance in pay of up to 4 
week's salary. This is particularly beneficial for new hires 
particularly those who incur extraordinary expenses in relocating or 
setting up separate households with their first jobs.
    In VA, new employees have to wait three weeks to receive their 
first paycheck. This advance in pay serves as an interest-free loan 
that the nurse repays from regular allotments from future paychecks. 
This is a no-cost feature to VA that can serve as a beneficial 
recruitment tool to new hires.
Appointments Above the Minimum Rate of the Grade
    Individuals with superior qualifications, candidates for hard-to-
fill specialties, and those with specialized skills may be appointed at 
a rate above the minimum of the grade. This flexibility permits the 
employing agency to offer pay rates up to 30 percent higher than the 
established minimum.
    For individuals with years of experience or high qualifications, a 
higher entry rate is appropriate and necessary to offer a competitive 
Higher Rates of Additional (Premium) Pay
    Facility directors may authorize higher rates of premium pay (tour 
differential, Sunday pay, Saturday pay, holiday pay, overtime and on-
call) for nurses when necessary to address recruitment or retention 
problems being caused by higher non-Federal rates of premium pay in the 
community. For instance, VA may have difficulty staffing positions 
because VA's tour differential rate is 10 percent and other 
establishments in the community pay 15 percent for similar tours. This 
gives facilities a mechanism to ensure all areas of pay are competitive 
to meet staffing needs.
Exemplary Job Performance and Exemplary Job Achievement
    A cash award of up to $2,000 may be granted to nurses who 
demonstrate both exemplary job performance and exemplary job 
Special Advancement for Achievement (SAA)
    Advancements of up to 5 steps within the grade may be granted to 
recognize professional achievement provided the individual has 
demonstrated excellence in performance above that expected for the 
grade level or assignment and potential for assumption of greater 
Special Advancement for Performance (SAP)
    Advancements of 1 step within the grade may be granted when there 
has been a demonstrated high level of performance and ability over and 
above that normally expected of nurses in the particular grade.
Employee Recognition and Incentive Awards Programs
    Recognition and awards programs motivate employees to make 
contributions that support and enhance organizational goals and 
objectives. The types of awards available to recognize nurses include 
special contribution awards (e.g., time-off awards and on-the-spot 
awards), suggestion awards, gainsharing awards, honor awards, and non-
monetary awards.
    Managers also are encouraged to consider non-traditional forms of 
recognition, such as products or services in lieu of a cash payment.
Payment of Education Expenses
    VA has the flexibility to pay for training that leads to an 
academic degree. VA has a long tradition of offering career tuition 
assistance to nurses.
    VA has implemented two new educational assistance programs to 
enhance recruitment and retention of health professionals such as 
nurses--the Employee Incentive Scholarship Program (EISP) and the 
National Nursing Education Initiative (NNEI). The EISP allows VA to 
provide its employees, who agree to serve a period of obligated 
service, substantial scholarships to pursue education in selected 
healthcare disciplines. The NNEI is a targeted scholarship program for 
employees pursuing degrees in nursing.
    The EISP and NNEI provide scholarships to pursue higher level 
education. The scholarships range up to $10,000 per year, with a 
maximum award of $30,000 over three years.
    VA is implementing the Education Debt Reduction Program (EDRP), 
which will help VA recruit health professionals with educational loan 
obligations. The program will allow VA to make payments to new 
appointees in certain healthcare positions (including nurses) over a 
specified period of time to help them reduce or pay off the balances on 
loans used for healthcare education. The EDRP policy is in the final 
concurrence process.
Recruitment Bonuses, Relocation Bonuses, and Retention Allowances (3 
    Nurses may receive payments of up to 25 percent of basic pay for 
accepting positions with VA.
          Recruitment Bonuses: Lump sum payments to new hires or former 
        employees following a break in service of at least one year.
          Relocation Bonuses: Lump sum payments to nurses currently 
        employed with the Federal Government who physically relocate to 
        a position in a different commuting area.
          Retention Allowances: Biweekly payments included in regular 
        paychecks to retain employees for critical work, who are likely 
        to leave Federal employment.
Reemployment of Civilian Retirees
    VA may request that the Office of Personnel Management waive the 
dual compensation restrictions in those instances where we need to hire 
retired nurses due to special circumstances.
    These needs might be temporary, as VA encountered in Operation 
Desert Storm. In that instance, VA was given delegated authority to 
grant waivers to fill behind critical healthcare personnel in the 
reserves who were activated for military duty. Additionally, the 
authority can be used to reemploy nurses who elect to retire, but whose 
services are critical to the completion of ongoing projects.
Specialty Certification
    A cash award of up to $2,000 must be granted to nurses who become 
certified, while employed by VA, in a specialty related to the 
accomplishment of VA's health care mission.
Travel Expenses for Interviews and New Appointments
    VA may pay the travel expenses of a nurse to travel to a pre-
employment interview. Additionally, we may pay the moving expenses for 
newly hired nurses' relocation to their first post of duty.
    This flexibility permits VA to supplement pre-employment evaluation 
activities with a face-to-face interview, if desired. Additionally, the 
payment of moving expenses enables VA to recruit new employees from 
outside the local area. In instances where the available skills are 
distant from the facility, the payment of moving expenses can serve as 
an incentive to a nurse to relocate.
                             non-cash tools
    There are a variety of things that managers can do to attract and 
retain employees with critical skills. They include:
Family-Friendly Policies
    A number of initiatives in this area include flexible leave 
policies for family care, including the Family and Medical Leave Act 
and Family Friendly Leave Act, leave sharing programs, paid time off 
for adoption, bereavement leave, on-site day care, subsidized day care, 
Flexible Work Arrangements
    In some situations, nurses can be given flexible work hours, 
compressed work schedules, and variable work hours/days to accommodate 
employees' personal preferences. In addition, nurses may be able to 
work from home or a satellite location, improving productivity, morale, 
and productivity.
Non-Cash Perquisites
    These incentives can include such items as a close-in parking 
place, a computer upgrade, or special work-related software. For some 
individuals, occasionally providing support staff to assist in work 
tasks will help the critical employee be more productive. It also sends 
the message that the nurse is appreciated.
Response to Written Questions Submitted by Hon. Arlen Specter to Thomas 
                          L. Garthwaite, M.D.
    Question 1. The collaboration between medical schools and VA in 
educating the Nation's doctors is well known. Does VA have affiliations 
or similar arrangements with the Nation's nursing schools? Would 
nursing schools with which VA has such affiliations not be fertile 
sites for recruiting VA nurses--just as they are for VA physicians? 
What efforts are being made to better establish such relationships with 
the schools that train nurses and, therefore, with nursing students 
    Answer. VA maintains academic affiliations with more than 546 
schools and colleges of nursing. In FY 2000, there were at least 20,182 
unpaid undergraduate (associate and baccalaureate degree) and 458 paid 
graduate and post-graduate nursing students who received all or part of 
their clinical education at any one of the more than 1,300 sites of 
care in VA. The total funding for the 458 paid trainees in FY 2000 was 
$1.3 million. Funding is projected to be $1.1 million in FY 2001 (421 
trainees), and $1.4 million dollars in FY 2002 (492 trainees).
    VA's nursing affiliations are somewhat different than it's medical 
affiliations, in that VA nurses are not as strongly aligned in paid 
teaching and faculty roles and the preponderance of nursing 
affiliations are not funded. Schools of nursing do, nonetheless, 
provide fertile sites for recruitment. Positive student experiences 
influence new graduates' employment decisions. VA facilities utilize a 
variety of approaches to recruit affiliated nursing students.
    VA has initiated Memoranda of Understanding with both the American 
Association of Colleges of Nursing (AACN) and the American Association 
of Community Colleges (ANCC) and meets with representatives of these 
organizations regularly to discuss issues that impact on the 
recruitment and retention of nurses. In addition, VA is involved in a 
collaborative effort with the University Health Services Consortium and 
AACN to develop a Post Baccalaureate Residency Program for new 
graduates that, when implemented, will provide an organized transition 
for new BSN graduates into the work setting and will contribute to VA's 
ability to recruit new graduates.
    VA is the sponsor of the nationally acclaimed Veterans Affairs 
Learning Opportunities Residency Program (VALOR). Administered by local 
VA facilities, VALOR is an honors program that provides specialized 
summer educational and clinical experiences to nursing students with 
GPA's of 3.0 or higher. VALOR participants are paid 80 percent of RN 
pay, and if they elect VA employment after graduation, they are given 
special salary consideration. Currently there are 267 VALOR students 
being supported in 77 VA medical centers. VA also hires nursing 
students for summer employment and part-time employment during the 
    Question 2. The VA patient population tends to be older--and more 
seriously and/or chronically ill--than its private sector counterpart. 
Thus, demands placed on the VA nurse are--I believe--more difficult 
than those of private hospitals. In order to compete for the highest 
quality nursing staff, it would seem appropriate to offer more benefits 
and higher salaries than those of the private institutions. Will this 
be a possibility given the probable financial constraints of the 
medical care budget? If salary increases are not--or cannot be--the 
solution, what other mechanisms exist to reward VA nurses 
    Answer. VA is committed to offering a competitive pay and benefits 
package to nurses and other health care providers. VA can offer to 
nurses a variety of recruitment and retention incentives, as well as 
forms of recognition and reward for exceptional performance and 
achievement. These flexibilities are described in the Attachment to 
these responses.*
    * The information referred to can be found on page 32.
    VA has responded to the issue of patient acuity and mix of 
veterans' health conditions through the enhanced qualifications 
standard for nurses, which emphasizes additional education and 
preparation for a more diverse and demanding clinical care environment. 
Another mechanism that VA has used to respond to any unique clinical 
demands in a patient care environment is through the mix of clinical 
skills in staff assigned to a unit.
    Question 3a. There are numerous hospitals across the country which 
go into high schools to attract and recruit students who might be 
interested in nursing--and offer them scholarships to nursing school in 
exchange for a commitment to work in that hospital after training is 
complete. Such programs, it seems to me, are no different than the 
military services going into high schools and recruiting students for 
ROTC in exchange for service commitments. Does VA have any programs 
like this? Does it have authority to do this? If not, has it ever asked 
for such authority?
    Answer. VA does have authority to implement outreach programs to 
interest elementary and high school students in nursing and health care 
    Question 3b. What programs are being developed by VA to target and 
attract high school students into nursing--particularly minority 
students and young men who may not have considered nursing in the past?
    Answer. VA medical centers across the country are developing 
outreach programs to interest students and adults in nursing as a 
    The Salem VA Medical Center has implemented a Nurse Cadet Program 
for high school students. This Nurse Cadet Program provides basic 
health care education and exposure to health careers through an 
organized volunteer experience. The Greater Los Angeles Healthcare 
System, holds a youth day in collaboration with the Health and 
Biotechnology Consortium of the local school system. Teens are given 
tours of that tertiary care facility, have formal presentations by 
health care providers, receive handouts and have the opportunity for 
one-on-one discussions with health care providers. In the Western New 
York Healthcare System, the Buffalo VAMC sponsors a number of 
activities among which is an Explorer Troop that enables youth to 
become familiar with health occupations.
    Question 4. I am told that it is common knowledge within the 
nursing profession that if you go to work at a VA hospital, you can 
expect greater responsibilities--and less support in executing those 
responsibilities. Does a bias against working for VA exist within the 
nursing profession--particularly among young people? Is VA viewed as a 
place where you will work harder than elsewhere--and get less 
compensation and prestige in return for your effort? What sort of 
efforts have been discussed to end the stigma--if it exists--of working 
at VA?
    Answer. VA has no data to corroborate the contention that any 
stigma attaches to employment by VA. We believe that because the 
turnover rate for VA nurses is well below that of the private sector, 
this is an indication that VA nurses understand and embrace the mission 
of care for veterans. When newly hired RNs are asked why they chose to 
work at VA, typical answers include ``I've heard such good things about 
VA.'', or ``When I was a student at VA, I had a great experience.''
    VA is acknowledged as a leader in quality care and patient safety 
in the health care industry, as demonstrated by the frequency with 
which VA nurse leaders are invited participants in local, state and 
national professional conferences to share success stories and 
    VA is committed to being an Employer of Choice. We will continue to 
address any areas of concern and dissatisfaction that employees may 
    Question 5. In my visits to VA hospitals, I have observed that the 
nursing staff is fiercely loyal and, in many cases, is long-tenured. 
This surely is a good thing--but I sometimes do not see many young 
nurses in place to replace long-tenured nurses who are approaching 
retirement age. Are VA nurses older, on average, than nurses elsewhere? 
Has VA in the past failed to target what are now mid career nurses? Can 
VA now reestablish itself within the population of nurses in the 35-45 
age range? How?
    Answer. VA nurses are only marginally older, on average, than the 
general population of nurses (VA 46, Nation 45.2). In addition, 23 
percent of VA nurses are under the age of 40, as compared to 31.7 
percent in the general U.S. nurse population. VA has, in fact, already 
established itself within the population of nurses age 35-45, since the 
average age of a newly hired VA nurse during FY 2000 was 41.65. 
However, we agree that it is important that VA focus recruitment 
strategies and resources on attracting nurses from all age groups into 
VA careers.
    Question 6a. Three VA Medical Centers in Pennsylvania--at 
Coatesville, Erie and Philadelphia--currently have at least 10% of 
their ``authorized'' nursing slots unfilled. When a VA Medical Center 
says it has a certain number of ``authorized'' nursing slots, what does 
that number mean? Is it the number of nurses needed to meet existing 
demand for services? Or is a number one which an official in 
Washington--or in the hospital's executive suite--figures the VA ought 
to be able to afford to hire?
    Answer. This number is usually termed the ``authorized ceiling,'' 
which refers to the number of nurses authorized for the nursing 
service. The authorized ceiling is the number negotiated at least 
yearly on the basis of suggested staffing as determined by each 
facility's staffing methodology (which takes into consideration patient 
acuity and workload) and budget. In most cases, recruitment and hiring 
can occur to fill up to the authorized ceiling. Sometimes, however, in 
very tight budget situations, secondary approval may be required to 
hire, or hiring may be frozen or delayed.
    Question 6b. When a VA Medical Center is operating on less than the 
full compliment of ``authorized'' nurses, does that mean the medical 
center has the money to hire nurses--but it cannot find them? Or does 
it mean that the medical center lacks funds to hire the full compliment 
of staff?
    Answer. This generally means that the medical center has the money 
to hire nurses, but cannot find them. However, as mentioned above, in 
very tight budget situations secondary approval may be required to hire 
or hiring may be frozen or delayed, resulting in staffing being under 
    Question 6c. If I am told that the Philadelphia VA, for example, is 
``authorized'' to have 550 nurses on staff but it has 55 vacancies, 
what should I infer about care being provided there? Are 10% of 
patients who seek services turned away because of a 10% nurse staff 
shortfall? Are nurses asked to work 10% more hours to make up for that 
shortfall? Or does the medical center just cut corners and somehow 
muddle through?
    Answer. A variety of scenarios could be presumed if a facility has 
55 vacancies. In the event of staffing variances, nursing and 
administration staff review overall patient care and staffing 
requirements to consider which options would be best to ensure safe and 
adequate patient care. Possible options that would be considered and 
utilized include:
     changing patient mix;
     coordinating shared staff resources among units;
     obtaining better support services and/or adding additional 
support services;
     decreasing bed capacity per unit;
     changing staff mix;
     increasing use of overtime and/or use of `registry' or fee 
basis nurses;
     modifying the role/function on care providers;
     increasing float personnel;
     changing practice patterns; and
     developing new programs to alter staff needed (i.e., same-
day surgery, telephone triage, etc.).
    A facility may also experience difficulties meeting all its patient 
care demands. For example, clinic appointments may take a longer time 
to complete, and time required for scheduled procedures or surgeries 
may be lengthened. The many interrelated factors in the health care 
environment make creative problem solving and organizational redesign a 
critical and essential requirement for a successful nursing and medical 
center management team.
    Question 7. It is suggested that the root cause of projected 
nursing shortages is the fact that young women today have more career 
choices than in earlier generations, and that even higher salaries will 
not entice today's young woman into this traditionally woman-dominated 
profession. Is there truth to this assertion? If so, what will it take 
to again interest young women in nursing? Can money solve the problem? 
Would salary increases draw more people into nursing jobs at VA--or 
would it just better reward those who are already there?
    Answer. It is true that one cause of the nursing shortage is seen 
to be the wider variety of career options available to women. The 
projected shortage however, will result in part from a number of 
substantial changes that continue to take place in the profession. 
Factors identified that will intensify a nursing shortage are:
     a decline in enrollment in schools of nursing;
     aging of the nursing workforce (average age nationally, 
45.2 years; VA, 46 years);
     increased average age of a new graduate in nursing (30.5 
in 1995-2000 vs. 24.3 in 1985 or earlier);
     poor image of nursing as a career choice and more career 
choices for women;
     pay stagnation after inflation adjustment;
     perceived negative work environments; and
     inadequate numbers of qualified faculty to educate the 
numbers of nurses needed.
    We believe that salary increases alone will not prevent the 
impending nursing shortage. While competitive salaries are absolutely 
necessary, other actions as well are necessary. More men and minorities 
must be attracted to nursing as a career choice; and, more work must be 
done to address the concerns of current and prospective nurses over 
workplace issues.
    It is important to be able to attract new and more diverse people 
to the career, but we must also be able to retain the current 
workforce. Therefore, increased salaries, along with improved career 
image and work environments, would certainly help.
    Question 8. As you may know, the University of Pennsylvania 
recently completed a survey of 43,000 nurses practicing in more than 
700 hospitals in five countries (and 13,000 nurses in PA alone). It 
found that:
     only 39% of surveyed nurses thought hospital 
administration listened and responded to nursing staff's concerns;
     only 40% thought nurses had an adequate opportunity to 
participate in policy decisions; and
     only 39% thought that nurses' contributions to patient 
care were publicly acknowledged.
    Are these findings consistent with your experience? Is the solution 
to VA's problems to be found in rectifying the alienation that many 
nurses, apparently, experience?
    Answer. A recent ``ONE-VA'' Employee Survey asked similar 
questions. Approximately 22,500 licensed nurses gave the following 
     37 percent agreed or strongly agreed that ``Sufficient 
effort is made to get the opinions and thinking of people who work 
     35 percent agreed or strongly agreed that ``Supervisors/
team leaders ask for employee ideas and opinions before making 
important work decisions.''
     43 percent agreed or strongly agreed that ``Supervisors 
personally recognize the contributions of individuals and teams.''
    This survey will be repeated in upcoming months. The questions from 
the One-VA survey do not allow for an exact comparison to the questions 
in the University of Pennsylvania survey, since wording and survey 
methodology are not the same. However, they do quantify the experiences 
of VA nurses and provide an indication of how VA nurses opinions 
compare to the private sector on very similar issues.
    VA recognizes that the retention of a qualified nursing workforce 
must be a priority. Providing nurses greater recognition of 
professional contributions, involvement in decision-making, and 
opportunities for self-governance are strategies that will enhance 
    Question 9. If I am not mistaken, in the armed services, men occupy 
health care professional and support slots in proportions higher than 
in the civilian sector. Why do you think that is? Is it more acceptable 
somehow for a man to perform nursing, or nursing-related, duties in the 
military than in a civilian hospital? Whatever the whys and wherefores 
of that point, does VA recruit nurses and related staff in the 
    Answer. VA does have an active outreach effort to recruit members 
of the armed services when they muster out. Two indicators of VA's 
success in recruiting former military members are the number of 
veterans in VA's workforce and the number of men working as nurses in 
VA. As of September 30, 2000, 61,628 individuals in VA's workforce 
(28.1 percent) were veterans. The number of VA nurses who are veterans 
is 3,249, or 9.3 percent. Men constitute 13.8 percent of the VA nurse 
workforce, compared to only 5.4 percent of the nursing workforce in the 
United States generally.
Response to Written Questions Submitted by Hon. Ben Nighthorse Campbell 
                     to Thomas L. Garthwaite, M.D.
    Question 1. What types of incentives could the VA offer to young 
nursing students about to enter the workforce?
    Answer. VA can offer a variety of incentives. A comprehensive list 
of these recruitment and retention incentives, as well as rewards, is 
attached to these questions.*
    * The information referred to can be found on page 32.
    In addition, VA is the sponsor of the nationally acclaimed Veterans 
Affairs Learning Opportunities Residency Program (VALOR). Administered 
by local VA facilities, VALOR is an honors program that provides 
specialized summer educational and clinical experiences to nursing 
students with GPA's of 3.0 or higher. VALOR participants are paid 80% 
of RN pay and if they elect VA employment after graduation they are 
given special salary consideration. Currently there are 267 VALOR 
students being supported in 77 VA medical centers. VA also hires 
nursing students for summer employment and part-time employment during 
the school year.
    VA also offers tuition assistance for support of academic 
education, debt reduction assistance for graduates, and continuing 
education support for employees to maintain and enhance their clinical 
    Question 2. Nurses from the Denver Medical Center have been in to 
talk about the nursing shortage. They are concerned that the new 
regional restructuring of the VA health care system is downgrading the 
nursing profession. Their nursing executives are taking a backseat to 
administrators--this lowers morale. They believe that the nurses are 
the only advocates for the patients' total needs. If nursing is 
downgraded, they are afraid that no one will really care for the VA 
patients. In your experience, is this something that is happening 
throughout the VA health care system? And, how would you address it?
    Answer. A variety of reorganization models are being considered or 
implemented at VA medical centers. While there is a trend toward the 
product line philosophy, no particular model has been mandated. Nurse 
involvement in decision-making is identified as an element that impacts 
the retention of nurses. VA recognizes the significant contributions 
made by nurse executives and nurses at all levels of the organization. 
The Joint Commission on Accreditation of Healthcare Organizations, as 
well as Sec. 201 of Public Law 106-419, mandates the involvement of 
nurses in decision making. VA fully endorses and is a proponent of such 
involvement, because VA recognizes that providing nurses greater 
recognition of professional contributions, involvement in decision-
making, and opportunities for self-governance are strategies that will 
enhance retention of a qualified nursing workforce.
    Question 3. A recent article in the Washington Post discusses how 
local hospitals are hiring nurses from overseas to fill their vacant 
slots. While many hospitals are focusing their efforts on retaining 
current nurses and on hiring American nurses, there are still a number 
of foreign-born nurses being hired in our hospital systems. How do you 
think hospitals can best address the differences between foreign and 
American nurses to make sure that all nurses work at the same standards 
and are fully acclimated to their jobs?
    Answer. To date, VA has no plans to recruit significant numbers of 
foreign?educated nurses. VA regulations require that all nurses hired 
have passed the National Council Licensure Examination (NCLEX) and be 
licensed in a state or territory. NCLEX serves as the ``gate keeper'' 
to ensure competency to practice nursing. Further, in order to be 
eligible to take NCLEX, foreign applicants must have successfully 
passed a standardized language test and have their course of study 
evaluated using standard American curricular criteria.
    Notwithstanding this rigorous review and testing, all hospitals 
hiring foreign nurses should initiate on-site clinical evaluations and 
education, similar to the structured orientation programs commonly 
implemented in VA medical centers for all newly employed nurses.
    Question 4. Within the VA nursing workforce, what is the ratio of 
nurses who are veterans to those who are not? Could the difference 
between vets and non-vets be a cause for concern, and how could the VA 
best address this issue?
    Answer. As of September 30, 2000, there were 3,249 veterans 
employed as nurses with VA (9.3 percent of the VA nurse population).
    VA has no data, nor is there any subjective evidence, to suggest 
that there is any difference between nurses who are veterans and those 
who are not. The veteran status of VA nurses does not appear to be a 
cause for concern. We are extremely proud of the dedication shown by 
all our nurses in meeting the health care needs of our veteran 

    Chairman Rockefeller. Cathy Rick is VA's highest-ranking 
nurse. We welcome you.
    Ms. Rick. Good morning and thank you, Mr. Chairman. I do 
not have prepared testimony, but I would like to make just two 
brief points: that is, to recognize the individuals who are 
leading our Nursing Workforce Work Group that I chartered in 
September of last year, Rebecca Williams and Cynthia McCormack, 
two nurse execs in the field, who are co-chairing that group; 
and a special recognition to Dr. Charlotte Beason from my 
office, taking a leadership role in pulling issues related to 
priorities and recommendations to my office through that work 
force. Dr. Beason and Rebecca Williams are in the audience as 
    The other point I would just like to make is in my past 
year, my first year in this position, it has been clear to me 
that we have a very caring and committed nursing work force in 
VA. And when I ask nurses in our system what they like about 
their job, what I hear most often is caring for veterans, and 
that I think is a strong commitment to our mission and to what 
we are all about.
    I just offer my continued support with my passion for both 
nursing and veterans in working with the nursing staff, nursing 
leaders in the field, our professional nursing organizations, 
VHA nursing leadership, and our union partners as we work 
toward continued efforts to address our nursing work force 
    And I will leave it at that so we can have time for 
    Chairman Rockefeller. Thank you very, very much.
    To both of you, Dr. Garthwaite, you wrote me a letter in 
which you said you felt that the nursing employment is 
basically stable at this time. And I do not want to try to draw 
controversy here. It is not my purpose to draw controversy. I 
want to draw out things that are useful so that we could do a 
better job in the future.
    There is a little bit of difference between your letter, 
your testimony, and what the previous panelists said. There was 
the implication that nurses are leaving already; they are 
planning to leave; they are getting out because of fatigue and 
exhaustion. But comment on that for me, could you, both of you?
    Dr. Garthwaite. Mr. Cox is correct in terms of the total 
nursing staffing over the last 5 years, largely because we have 
moved from an inpatient setting to an outpatient setting where 
we need fewer nurses total to deliver care. As you know, we 
have significantly decreased the amount of care provided for 
patients in the hospital. So a significant part of a decrease 
in total nurse staffing across VA has been that change in the 
locus of care.
    Over the last 2 years, we are up 606 nurses, which is, you 
know, essentially stable to slightly increased. So I think that 
was really the point I was trying to make. But I would say that 
within certain nursing specialties we see significant problems 
in ICU nurses and nurse practitioners and others.
    So, overall, we are up 606 nurses in the last 2 years. That 
does not mean we are not experiencing difficulties.
    Chairman Rockefeller. Systemwide?
    Dr. Garthwaite. Yes. But that does not imply that 
everywhere we can hire every nurse that we want or that if 
nurses walked in the door in several of our facilities we would 
hire them instantaneously. So because we are operating in every 
State in the Union, there are significant differences in our 
needs and our ability to recruit in those different areas.
    Chairman Rockefeller. Ms. Rick?
    Ms. Rick. It is the big picture that makes it look like it 
is stable at this point. So when you look at the whole system, 
the impact is not as significant as you get to a point of care 
in a particular unit or particular patient care area or a 
facility. There are targeted areas that there is significant 
difficulty, as Dr. Garthwaite mentioned. And I think the areas 
that were referred to in the earlier testimony are on target, 
those areas that are those with less attractive schedules to 
work, so those are the acute-care areas with days, evenings, 
nights, and weekends that are more difficult to recruit to. And 
there is more competition because of the increasing 
opportunities in the outpatient, ambulatory, health promotion, 
and disease prevention opportunities for nurses. Those roles 
typically fall in a more attractive working schedule that 
nurses find in ambulatory care. So there are competing forces.
    But when you look at the overall picture of our nursing 
work force at this point in time, when we look at our paid 
system and how many nurses were paid in a previous time period 
to this time period, we are actually up about 2 percent.
    I do not think that that should imply that there is lack of 
recognition or insensitivity to the significant struggles with 
recruitment in many facilities.
    Chairman Rockefeller. There was a very obvious and clear 
point made about the use of mandatory overtime. How would you 
respond to that?
    Ms. Rick. I think your impression is accurate. Anytime 
someone mandates anything of us as human beings, it is not the 
same as volunteering, and it is not the same as doing something 
out of compassion.
    We do have a very slight increase in use of overtime over 
the past 3 years, and anticipating needing to have a better 
understanding of where we are with mandated overtime in our 
system, I have asked for information from the field, surveying 
the field, asking for how much mandatory overtime is being 
used, is it becoming an increasing problem, and I am starting 
to get some of those responses back.
    There are very few areas that have responded that it has 
been a significant problem, but it is increasing because the 
demand is there.
    Dr. Garthwaite. I think it is clear that we also desire not 
to use mandatory overtime. That is not our intention. But we 
also have patients in beds with certain needs, and nurses are 
required to meet those needs. We fully recognize the safety 
issues that people who are fatigued are not going to perform as 
well as those who are not. And so we just need to get more 
aggressive and creative, I think, about good, innovative 
practice in different parts of our system that have avoided 
using mandatory overtime and see if we can replicate those 
practices in other areas.
    Chairman Rockefeller. Senator Specter?
    Senator Specter. A nursing survey by the University of 
Pennsylvania--a very expansive survey, 43,000 nurses and more 
than 700 hospitals, five countries, 13,000 in Pennsylvania 
alone--disclosed that some 40 percent of nurses are 
dissatisfied with their present job, 22 percent are planning to 
leave within the next year, and 33 percent of those under 30 
plan to leave within the next year. So it appears that younger 
nurses are disproportionately unhappy.
    Ms. Rick, how would you account for that, the overall 
dissatisfaction of nurses and the differential with respect to 
younger nurses?
    Ms. Rick. Dr. Aiken's study points to several factors, the 
study that you are referring to, that influence people's 
decisions about whether they like their workplace or not. And a 
lot of it has to do with career progression, advancement 
opportunities, supporting environment with working 
relationships. Those are the kinds of things that are 
articulated in that study, and I think those are significant 
    Senator Specter. Career opportunities? What is meant by 
    Ms. Rick. Career advancement, a learning environment, 
continuing education not only being offered but supported by 
time and money. Those are the kinds of things that were 
articulated in that article, and I do think they are 
    Senator Specter. Dr. Garthwaite, to what extent has the 
Veterans Administration been concerned about the shortage of 
    Dr. Garthwaite. Significantly. I have three groups working 
on work force issues from slightly different perspectives. 
Cathy has her own specific group looking very specifically at 
nursing issues. There are some more generic issues in work 
force planning, retention, recruitment, and development that 
John Gardner's committee has been examining.
    Senator Specter. When did the Veterans Administration first 
begin to focus on the problem with nurses?
    Dr. Garthwaite. Well, I think we have always been concerned 
about our nursing work force. I personally chartered these 
committees shortly after I was confirmed by the Senate. So I 
have taken a personal interest because I really do believe that 
work force development is the way to improve the VA health care 
    Senator Specter. Has there been any focus of attention 
prior to the activities which you initiated?
    Dr. Garthwaite. Absolutely. We have had nursing education 
initiatives. We previously had scholarship initiatives. We have 
taken steps to improve the educational basis of nursing with 
the nurse qual standards. That has had some controversy 
surrounding it, I think largely because of communication issues 
and implementation issues. We are still trying to work through 
    We've had a nursing innovations program and a nursing 
research program to attract nurses to the VA. We certainly 
supported local initiatives like the Cadet program that we will 
hear about in a few minutes.
    So there are a series of things that we have done and 
supported to try to improve nursing throughout VA.
    Senator Specter. How big a factor has compensation been?
    Dr. Garthwaite. I think it is significant but not the total 
picture. I think you have to be competitive. You cannot lag 
behind. But you also have to pay attention to other work force 
issues or workplace issues.
    Senator Specter. Ms. Rick, is there any issue within the 
Veterans Administration medical care system analogous to the 
nurse anesthetist issue which I discussed a few moments ago?
    Ms. Rick. Which issue? The study that Dr. Aiken did?
    Senator Specter. Well, no, the----
    Ms. Rick. Oh, nurse anesthetist. I did not hear what you 
    Senator Specter. About wanting more professional standing.
    Ms. Rick. I am sorry.
    Senator Specter. More comparability with medical doctors.
    Ms. Rick. Yes, yes. I think that is a good analogy, and it 
does apply to the professional nurses as well.
    Having respect and opportunity to have--some of it is the 
career progression and the clinical advancement and clinical 
partnership that I mentioned earlier. I do think it has a 
significant impact on nurses' feeling good about their work, 
feeling respected for their work, and being a full partner at 
the table and making not only clinical decisions but resource 
decisions and innovative designs.
    Senator Specter. What action would each of you like this 
committee to take to assist in the problem?
    Dr. Garthwaite. My sense today is that with better salary 
rates, many of the things are in our control, and we are 
aggressively pursuing those. I think looking more broadly, 
though, I think that anything that Congress is already taking 
up that will promote people going into the nursing profession 
more broadly would be helpful.
    Senator Specter. What is that? Can you be specific? You are 
much closer to the problem than we are. Tell us what you would 
like us to do.
    Ms. Rick. I think----
    Senator Specter. Let's let Dr. Garthwaite finish the 
specific terms, and then we will turn to you, Ms. Rick.
    Dr. Garthwaite. I had the opportunity to deliver a 
commencement address at Miami-Dade County Community College 
where people were getting associate nursing degrees, and we are 
trying to work with community colleges to bring in associate 
degree nurses and then through our national education 
initiative to allow them to go on to get their bachelor degree 
and hopefully go on to become advanced practice nurses or 
clinical nurse specialists, and so forth.
    Senator Specter. How would that relate to what this 
committee can do?
    Dr. Garthwaite. Well, I think that continued support of 
basic education for entry level education as was evident in 
this group of people in this community college is important. 
This is a clear way up for them, and they seem to be very 
dedicated and interested in nursing as a profession. I would 
think that if there are ways that we can work through providing 
the financial support to get them started, the VA might bring 
them in and help further develop their careers. I think that is 
something we could work on.
    Senator Specter. Ms. Rick, what would you suggest the 
committee do to help alleviate this problem?
    Ms. Rick. I think working together to continue to address 
flexibility in work force hiring and benefits. I think the 
salary and benefits issue is always going to be an issue, and I 
think that continuing to work together on that is important. 
And anything that we can do to stay in the game with all of the 
other competitive forces that are going to be out there related 
to other initiatives that VA will need to compete with, and 
some of that has to do with that same learning environment 
opportunities and the scholarship options that Dr. Garthwaite 
    I think that there will be many specific things that will 
come out of the recommendations of the Nursing Workforce Work 
Group that I look forward to working with you on.
    Senator Specter. Thank you very much, Ms. Rick, Dr. 
    Thank you, Mr. Chairman.
    Chairman Rockefeller. Thank you, Senator Specter.
    I think the scholarship program is incredibly important and 
is part of a legislative proposal. I have a whole bunch of 
letters which I am going to put in the record from people who 
have benefited from the scholarships because they get education 
in return for service, and incentives of any kind are obviously 
desperately important.
    [The information referred to follows:]

                                                      June 8, 2001.
    After being an LPN for 18 yrs I decided to go back to school to 
further my education. My husband is unemployed and now has several 
medical problems that prevents him from being able to get a job. I have 
a daughter who is turning 16 next month and she has plans on going to 
college. In my present position financially this would be impossible 
for her to attend college.
    I decided I would get student loans and go back to school to get my 
BSN. Then I heard about the EISP and applied for it. Now that I have 
this scholarship I do not have to worry about paying back student loans 
and can concentrate on school work. I can also concentrate on my 
daughters future.
    I will continue working at the VA after graduation. I presently 
work with restraints and restraint alternatives and give inservice to 
employees. I feel this scholarship is a great opportunity and the VA 
can only benefit by making it available to new employees and easier to 
                                        Jennifer King, LPN.
    When I graduated with my Bachelor's of Science in Nursing (BSN) in 
1995, and came to work at the Beckley, Veterans Affairs Medical Center 
(VAMC), I knew I wanted to obtain a Master's of Science of Nursing 
(MSN). Being a single mother of two children, the extra money and time 
needed away from work to go to class often made this dream seem 
hopeless. Many scholarships provide full or partial tuition but no 
guarantee of being able to get off work to go to class or any assurance 
of a job in your area after graduation.
    As soon as I heard of the availability of the NNEI scholarship 
program,* I knew this was the answer. I applied to WVU FNP program and 
the NNEI scholarship last spring. I was accepted at WVU for fall 
enrollment. The NNEI scholarship has been a godsend. I could not have 
returned to school without it. Although it is still difficult to work 
full time, raise two teenagers, and go to school. I don't have to worry 
about how I'm going to pay for school or how I'm going to get off work 
for class. I will graduate in May of 2003 with my MSN and will be 
eligible to sit for the Advanced Practice Certification. After 
graduation, I plan to continue working for the Beckley VAMC. I am 
interested in pain management and am currently the team leader of a 
process improvement team working to develop a comprehensive, 
interdisciplinary pain management policy for our hospital. I would, in 
the future like to help establish a nurse managed pain management 
clinic at the Beckley VAMC.
    * Editors Note: The NNEI (National Nursing Education Initiative) is 
administered by VA under the authority of the Employee Incentive 
Scholarship Program. As a component of the EISP, the NNEI is targeted 
to VA employees who are registered nurses and seeking additional 
education to enhance their capability to provide high quality care to 
    The VA would benefit from this scholarship program being available 
to new employees. We are in the middle of a nursing shortage. The VA 
must be able to recruit and retain quality-nursing staff. These 
motivated individuals will provide a secure long term return on the 
financial investment of this scholarship program.
                                         Teresa Hanft, BSN.
                                                     June 10, 2001.
    To Whom It May Concern: My name is Margie Drake. I have worked for 
the Federal Government for the past 27 years; the last eight with the 
Department of Veterans Affairs. In my last assignment, I worked as a 
Program Assistant in the Public Relations Office at the Baltimore VAMC 
but always had the desire to become a Registered Nurse. During the fall 
of 1995, I entered the Nursing Baccalaureate Degree program at Villa 
Julie College because it offered a part-time, weekend-evenings program. 
I was able to obtain some limited funding through the Tuition 
Reimbursement program to assist with the hefty tuition bills and for 
that I was grateful. The thought of where money will come from to pay 
for education is always stressful. Then I saw a new program that the VA 
was offering. It was called the Employee Incentive Scholarship Program 
(EISP) and was available to VA employees who were seeking degrees in 
Title 38 positions. Hoping I would be eligible, I applied for and was 
accepted into the program. The EISP paid for not only my tuition but 
for books, fees and other related expenses. I was extremely pleased to 
have received this award. Having received my degree in December 2000, I 
am now working as a staff nurse at the Baltimore VAMC. I guess you can 
say it's my dream come true.
    The EISP is an extremely worthwhile program It allows VA employees 
the opportunity to pursue their education without the financial burden. 
However, participants need to be aware that hard work and motivation 
must be present in the pursuit of their education. There is a service 
obligation connected with this scholarship (anywhere between 1 and 3 
years). I have a desire to work for the VA for many, many more years so 
the service obligation is merely a ``thank you'' in return for their 
financial support. And as a new nurse, I hope to serve the veterans of 
our nation in a knowledgeable, compassionate and competent manner. It 
is common knowledge that a severe nursing shortage exists nationwide. 
Scholarship programs such as EISP are desperately needed to retain our 
seasoned nurses. It would be great to offer scholarship programs to 
recruit nurses into the VA.
    I am sincerely grateful for being selected as a recipient of the 
EISP funds and the opportunity to serve as VA registered nurse. 
Hopefully many more VA employees will be able to benefit from the EISP.
                                          Margie Drake, RN,
                                         VAMC, Baltimore, Maryland.
                                                      June 8, 2001.
    To whom it may concern, I would like to take this time to show my 
gratitude for the scholarship funds I received to complete the studies 
required for my BSN (Baccalaureate of Science in Nursing). While 
completing my studies, I continued my full-time employment at the 
McGuire VAMC in Richmond, VA. With other financial obligations, it was 
indeed a great help to receive extra reimbursement for my education. I 
was able to afford the tuition and books without having to take out 
another loan.
    With the education I received, I have a wider knowledge base to 
care for the women veterans I serve in the Women's Health Center.
    I plan to attend graduate school next fall to receive my Masters 
Degree as a Nurse Practitioner. I hope that this program will continue, 
not, only to be of assistance to me next year, but to all others who 
choose to further their careers in order to help those who have fought 
and continue to fight in defense of our country.
            Thankfully yours,
                                       Shaun M. Miller, RN,
                                        Hunter Holmes McGuire VAMC,
                                             Women's Health Center.
                                               June 8, 2001
    To Wbom It May Concern, My name is Cheryl Winston, I work at 
McGuire VA Medical Center Hospital in Richmond, Va. I would like to 
express my sincere appreciation for the scholarship I received toward 
obtaining my Bachelors Degree in Nursing. I am looking forward towards 
my fall semester, which ends in December at Old Dominion University. I 
am anxiously preparing towards graduation. I would like to reinforce 
the need to continue with this education program toward tuition 
reimbursement as it has benefited me through my educational experience. 
The scholarship has indeed helped me financially. in December 2001 I 
will be graduating from Old Dominion University with Honors in Nursing. 
With my degree I will be able to share my knowledge with my patients 
and to provide a more theoretical approach towards patient care.
            With much appreciation,
                                        Ms. Cheryl Winston.
                                                      June 8, 2001.
    To Whom it May Concern: I have benefited from the EISP Scholarship. 
I feel fortunate that I'm a single mother with 3 children, trying to 
advance my career in Nursing (BSN). I will be able to work at home 
while enrolled with Excelsior College, University of the State of New 
York. My children and myself are blessed to benefit from this 
scholarship by supplying the scholarship money to continue my education 
and study at home and be with them.
                                          Mary Conley, LPN.
                                                      June 8, 2001.
    To Whom it May Concern: It is a tremendous relief to have the EISP 
Scholarship. For years I have struggled to raise two children as a 
single parent, obtain a General Educational Development Certificate and 
to gain a BSN degree at a snail's pace. My tedious journey has been 
fuelled with less than enough money and insufficient time to attend 
classes on full-time bases. Now thanks to the VA for awarding me an 
EISP Scholarship and granting me the opportunity to work only 32 hours 
every two weeks. So since January 1, 2001, I have been attending NC A&T 
State University full-time. During the years of journey, I could have 
settled for less than my dream, but I held out. Because, I think I can 
better serve those who suffer mental illness with a BSN for a couple of 
years then advance to get my Masters. Thanks VA! Thanks! Thanks!
                                        Theresia McGee, NA.
                                                      June 8, 2001.
    To Whom it May Concern: I have been a VA nurse for 17 years and am 
grateful everyday for the many opportunities the VA has provided, 
especially the NNEI program. When I made the decision to return to 
school for a graduate degree, I was specifically interested in a school 
with an oncology CNS/NP program (there are only about 36 in the 
country), in a city where there was also a VA. I chose Duke University 
and the Durham VA. Duke was challenging and expensive, but I earned a 
great education. The Durham VA was flexible in accommodating my class 
and clinical schedule. The Kansas City VA was supportive and helpful 
with my transfer. I borrowed $18,000 from the college foundation for my 
education. . . . When the NNEI came through with $10,000 to reimburse 
my 1999 tuition I was extremely grateful, and the money helped me pay 
down my student loans. I have been a loyal and dedicated VA nurse for 
my entire career . . . and will remain that way until I retire. The 
NNEI program rewards and assists VA nurses and I have no doubt that the 
VA will get a return on their investment from all the NNEI scholarship 
recipients . . . you can count on it from me.
                                    Susan Diamond, RN, MSN.
                                                      June 8, 2001.
    To Whom it May Concern: Since I earned my ADN in 1987, I have 
wanted to return to school to increase my knowledge and skills in 
nursing. It was financially impossible for me to do so at that time. 
Now, 14 years later, and the single mother of 4 children, it is not 
only financially impossible to fund my own further education, but also 
impossible to find the time to go to classes. I had resigned myself to 
waiting until my last child was grown (2008) before attempting to take 
classes toward my BSN and eventually towards a Nurse Practitioner 
degree. However, I knew that someday I would do that, and just kept 
working and saving. When I heard about the scholarship program, I was 
excited, but also knew that none of the local programs would suit my 
needs, as I would have to take too much time away from my children to 
attend classes according to their requirements. Very soon after I heard 
of the NNEI program. I also got a tip about the University of 
Wisconsin-Green Bay distance learning program for RN-BSN. After 
completing all the necessary paperwork and having all the necessary 
forms submitted, I was pleased to have been awarded the NNEI 
scholarship and to have been accepted into Green Bay's program. I am 
taking one class a semester (3 per year) and am working from home. The 
VA has been very supportive of me and many advance practice nurses have 
been generous with their knowledge and mentoring support. Without this 
scholarship program, it would not have been possible to further my 
education at this time of my life, confining me to the same educational 
and professional level for many years to come.
                                        Suzanne Hixson, RN.
                                                      June 8, 2001.
    To Whom it May Concern: I want to extend my very personal and 
heartfelt thanks to the VA for making the National Nurses Educational 
Initiative (NNEI) available. Obtaining my master's degree in nursing 
has always been a goal for me. More important was an advanced degree in 
a specialty field of my interest. I have been in research for 10 years 
and thoroughly enjoy the field. January 1999, I learned of a master's 
program offered at Duke University School of Nursing in Clinical 
Research Management. I enrolled with great concern but no idea how I 
would fund a Duke education. Being awarded the NNEI has afforded me the 
opportunity to complete my degree without worry of tuition and to 
realize my goal. I am most grateful for the support of the NNEI. I know 
of no other program of its magnitude offered to nurses through their 
employer, I feel very fortunate to be a nurse in the Veteran's Health 
Administration. The NNEI has given me a sense of pride in knowing the 
VA considers the level of education of the VA nurse to be an important 
factor in the delivery of quality health care to the veteran patient. I 
have been a VA nurse for 18 years. I love working with veterans and 
consider veterans a very special and unique population.
    ``Nurses are the mainstay of VA healthcare.''--Hershel Gober.

                                           Ailein Ward, RN.
                                                      June 8, 2001.
    To Whom it May Concern: It was always in my plans to return to 
school to receive a BSN degree. However, trying to budget the cost of 
attending a university while everyday life was a challenge, but thanks 
to the NNEI, I was able to attend school and not worry about my other 
life expenses. The NNFI scholarship has provided me with an unlimited 
amount of college tuition to complete my degree. Words can't explain, 
but this scholarship was a big help and it came just in the knick of 
time! Thanks NNEI!
                                   Jodi Johnson-Thomas, RN.
                                                      June 8, 2001.
    To Whom it May Concern: I am truly grateful to the VA/NNEI for 
allowing me the opportunity to return to school. I am presently doing 
an internship involved with my pursuit to get my masters in Health 
Education/Health Promotion. Upon returning to the school scene after 20 
years, I really did not think that I could do it. With the incentive 
(NNEI), it has encouraged me to realize my unlimited potential. My 
success in this endeavor is truly measured by the collaborative 
decisions of all involved. I encourage nurses nationally to consider 
the opportunity that the NNEI has given me.
                                       Pauletta Fuller, RN.
                                                      June 8, 2001.
    To Whom it May Concern: I am very thankful to the VA because I have 
earned my BSN and now I am working on my HSA. Both times have been 
financially challenged events for me, The scholarships came as 
blessings for me. I am able to serve those who serve me in the military 
times and I can return my service to them.

                                             Anne Zipp, RN.

    Chairman Rockefeller. The burnout factor would strike me as 
very important, even on an 8-hour shift much less a more 
intensive shift. Does the VA have a way of monitoring that? I 
think just this week, VA asked its network directors to provide 
a report on the nursing situation, which in my opinion, would 
be a little late.
    So how do you monitor the fatigue factor? How do you watch 
this, if you do?
    Ms. Rick. We do not have a systematic, systemwide structure 
or mechanism to do that. It is----
    Chairman Rockefeller. Wouldn't that be important to have?
    Ms. Rick. Well, it is incumbent on each point of care 
manager and facility director to make staffing decisions and 
assignment decisions based on those factors. But we do not 
currently have a systemwide structure to monitor them.
    Chairman Rockefeller. Well, I will state I think it is 
important to have a system, and we need to pursue it. But then 
if it is not there, how do you monitor staffing decisions? You 
have heard testimony--I did not have to hear that testimony 
because I had heard it before in my own visits to hospitals. As 
the VA head nurse, how do you deal with that question, because 
it has to weigh on you, about people who are overworked and 
underpaid? And I am going to ask you one more question about 
pay, but please go ahead.
    Ms. Rick. Well, the process that is in place to keep me 
informed and to help me help the field, since I work for the--
    Chairman Rockefeller. Who keeps you informed?
    Ms. Rick. That is what I was getting to. We have a national 
Nursing Executive Council. There is a nurse exec from each 
network who represents nursing from that network. That council 
was put in place as I started in my position. We had our first 
meeting last November. So that council was put in place to 
develop a national nursing strategic plan. Nursing work force 
is one of the six goals identified in that plan. And that group 
is in place to look to develop realistic strategies and actions 
to address each of the six goals. And it is my job to then take 
those initiatives forward and look at a systemwide approach.
    So that is the process that I have put in place in the time 
that I have been there.
    Chairman Rockefeller. OK. I would be interested in pursuing 
what you get back, but I cannot do it here because of time 
    My final question would be on the question of funding. It 
was interesting, Dr. Garthwaite, when Senator Specter asked 
what you want us to do. I would have thought you would have 
jumped right across the table and grabbed us both by the throat 
and said, ``Get us some more darn money.''
    Dr. Garthwaite. I am trained not to do that, sir. 
    Chairman Rockefeller. No, but, you see, that is bad 
training. That is bad training, because your first obligation 
is not to the second largest agency in the Federal Government 
but to those patients. I mean, I read it that way. I think that 
is the oath you took.
    Dr. Garthwaite. I agree.
    Chairman Rockefeller. Isn't the basis of a lot of this the 
lack of money?
    Dr. Garthwaite. Well, certainly decisions to----
    Chairman Rockefeller. You cannot hedge on that.
    Dr. Garthwaite [continuing]. Staff are related to money.
    Chairman Rockefeller. You cannot hedge on that.
    Dr. Garthwaite. Yes. The only point I would make is that we 
get a certain amount of money from the Congress and through the 
President, and we have a set of priorities, priority veterans 
to see based on resources available. The tough bind that we get 
put in is that we attempt to see as many as possible, and that 
takes us to the edge of staffing, and I think that is probably 
what you heard from the previous panel. We obviously try to 
stay inside the staffing ratios that are good for patient care.
    But the alternative, unless more money comes forward, is 
for us to see fewer veterans, and then they do not get any 
care, often. Maybe they get alternative care in other health 
systems, but some do not get any as opposed to getting care 
from us. So I think that is the bind I feel that we are in.
    Would we like more money and would life be a lot easier? 
    Chairman Rockefeller. Well, that is the first thing. If you 
had another $2.7 billion, would the nursing shortage be 
relieved and the overtime question become less of an issue?
    Dr. Garthwaite. Yes, certainly. I mean, I think it would 
make it a lot easier.
    Chairman Rockefeller. I just want you to say that.
    OK. My final point, and this, again, for the record, to be 
explored later. It is my understanding that there is no staff 
at VA headquarters who monitors the problems involved with 
mandatory overtime. Network directors are also not judged by 
their abilities to keep nurses working in safe shifts.
    I just sort of posit that at you, and you can respond if 
you wish.
    Dr. Garthwaite. I have to say that, to the extent that we 
can develop meaningful monitors that allow us to improve the 
working conditions for nurses and a variety of our other 
professionals, I would favor that, and we will go back and look 
at that. I think that could be helpful.
    Chairman Rockefeller. But there are not people in VA now 
who are assigned to that type of monitoring?
    Dr. Garthwaite. Well, we have a significant number of folks 
in H.R. who look at our ability to recruit and retain and track 
the overall general trends. We have not specifically targeted 
mandatory overtime. In a way, you know, mandatory overtime, 
when you say you must stay, but if your boss asks you to stay 
over in a voluntary fashion and your boss is the one who rates 
you, it is not quite as non-mandatory as it would appear. So 
that the whole use of overtime is something that we try to 
minimize, and the fact that it is creeping up suggests that we 
have some staffing challenges. We are needing to use overtime 
more often. It is not in our employees' best interest. It is 
certainly more expensive for us to use overtime. So it is our 
goal to minimize the use of overtime.
    Chairman Rockefeller. OK. I appreciate both of you coming. 
I have other questions. How can you compete with the private 
sector, or can you, based upon salaries that you now offer to 
    Ms. Rick. The process for competing with local market pay 
scales is a survey process, so we survey the local market and 
look to come up with a competitive pay scale related to that 
survey process.
    Chairman Rockefeller. I honestly did not understand the 
    Ms. Rick. OK. Sorry. How do we compete? How do we determine 
our pay so that we are competitive with the local market is 
your question?
    Chairman Rockefeller. Yes. Can you compete? Do you pay as 
much as they do? Do they pay more than you do?
    Ms. Rick. We are not the pay leader in any market. We do 
compete with the market. It is a local decision how much 
additional pay is offered to the nursing staff based on the 
survey data that is collected.
    With the new public law that was passed, there is the 
annual increase, and then each facility needs to determine what 
additional increases, if any, are necessary in order to be 
competitive in the local market, and that decision is based on 
surveys, salary surveys.
    Dr. Garthwaite. One of the problems with the survey 
process, just to amplify a little bit, it is relatively easy to 
survey other hospitals and find out the starting salary. But 
how quickly people get advanced is not quite so simple. Staff 
salaries are a competitive advantage to the other hospitals so 
that they do not readily want to tell you how much they pay 
because they do not want you to just go a little bit higher and 
recruit away their staff. So there is no incentive for telling 
us their complete pay range.
    Chairman Rockefeller. A non-VA hospital can give bonuses 
for signing and you can't? Am I right on that?
    Dr. Garthwaite. We can.
    Ms. Rick. We have the authority for sign-on----
    Chairman Rockefeller. You do have the authority to give 
    Ms. Rick. And many facilities are using that authority.
    Chairman Rockefeller. Do you have the money to give 
bonuses, signing bonuses?
    Ms. Rick. Balancing our checkbook is always difficult.
    Chairman Rockefeller. All right. I thank you both very, 
very much. I will not even get into long-term care. I will 
probe that issue by post-hearing questions and expect a prompt 
answer. I really do want those long-term care rules and 
regulations done. I think OMB is going to try and make that 
very hard, but I want you to do that.
    Dr. Garthwaite. I think we are making progress.
    Chairman Rockefeller. I know. It is the regulations that I 
want, not the progress.
    Dr. Garthwaite. I meant on the regulations.
    Chairman Rockefeller. In any event, I appreciate both of 
you being here very, very much.
    Ms. Rick. Thank you. We appreciate the opportunity.
    Dr. Garthwaite. Thank you.
    Chairman Rockefeller. Thanks an awful lot.
    Very promptly, our third panel--will Sandra Janzen please 
come forward? Sandra is the chief nurse executive at the Tampa 
VA Medical Center, and Dr. Robert Petzel, who is a network 
director who oversees health care delivery in the Dakotas and 
Minnesota. Within your network, Doctor, you have established 
nurse-managed clinics that provide very good care to veterans 
and great working environments for nurses, and you are 
accompanied by Karen Robinson and also Mary Raymer. Or are you 
here on your own, Mary?
    Ms. Raymer. I am here on my own behalf.
    Chairman Rockefeller. OK. You are here on your own. Mary 
Raymer is associate chief of staff for patient care services of 
the Salem, VA, hospital.
    Sandy, perhaps you could lead off?


    Ms. Janzen. Yes, I would be pleased to. Mr. Chairman and 
members of the committee, I am honored to be here to present 
the Tampa VA Hospital and Clinics' journey for nursing 
excellence and to describe our environmental characteristics 
that support professional nursing. In March, we became the 
first VA organization to achieve the prestigious Magnet 
designation--recognition by the American Nurses Credentialing 
Center for excellence in nursing services.
    Chairman Rockefeller. Sandy--I should not say ``Sandy.'' I 
should say ``Ms. Janzen.'' I apologize for that.
    Ms. Janzen. ``Sandy'' is fine.
    Chairman Rockefeller. But we have got a little bit of a 
time problem, and so what I would like you to do is--I want to 
know about your awards, but I also want to know about what you 
are doing to make things better.
    Ms. Janzen. OK. Well, we use the process of the Magnet 
designation to address our environment, and that is part of the 
award and recognition that looks at the milieu that supports 
professional nursing practice. That is one of the objectives of 
the Magnet recognition that relates to our discussion.
    Because Magnet recognition requires strong organizational 
support for professional nursing practice, it requires a 
positive work environment that recognizes the nursing 
contribution to the organization, a culture of excellence, and 
nursing input into the organizational decisionmaking process. A 
Magnet culture needs to be real because you are site-visited, 
and it depends almost entirely on the nursing staff at the 
bedside to validate the written application and the working 
    Hospital leaders at our organization provide organizational 
support with an adequate staff mix and strong educational 
support for new and existing staff. Nurses are highly 
integrated into all clinical programs, are leaders in our 
organization, and they are allowed clinical autonomy. The nurse 
executive has the ability to pilot programs within existing 
resources to enhance clinical practice. In my paper I give you 
an example of evening and night nursing supervisor positions 
were eliminated several years ago to augment clinical nursing 
staffing and to empower nurses to make clinical and 
administrative decisions on those shifts.
    A positive work environment is recognized individually and 
for team contributions within our organization. We have a Gold 
Star program that recognizes exceptional customer service. 
Thank-you letters for outstanding patient care performance are 
sent from hospital leadership. Nurses receive peer recognition 
in nursing recognition ceremonies. Nurses are respected for 
their knowledge, evidenced by their leadership and membership 
in clinical teams.
    As a result of our self-assessment, using the Magnet 
criteria we enhanced our opportunities for nurse managers 
because they are the ones who really make a difference at the 
unit level, whether or not nurses stay in your organization. We 
are also systematically addressing nurse satisfaction issues. 
There is a commitment of our organization to really become an 
employer of choice.
    Magnet criteria also addresses the quality of clinical 
care. The organizational expectation at our facility is 
clinical excellence and veteran-focused care. We have a 
longstanding record of measuring nursing quality, and we 
participated in a national quality indicator project to really 
improve our practice and our nurse satisfaction.
    The Magnet criteria also emphasizes a positive work 
environment for our nurses. Our VA Patient Safety Center is 
systematically using ergonomic analysis to identify ways to 
ease patient care burdens on an aging nursing staff.
    The nurse executive is involved in decisions regarding 
allocation of facility resources. Our Facility Quality Council 
ensures nursing membership on quality improvement teams. 
Nursing staff decisions regarding patient care are respected. 
Nurse managers make critical bypass decisions based on patient 
needs and staff availability, and that decision is respected.
    One outcome of nursing involvement in decisionmaking is the 
installation of ceiling-mounted patient lifts in patient care 
rooms in our new Spinal Cord Injury Center. This is a direct 
result of nursing research and nursing input.
    I think Magnet recognition is not a quick fix for the 
recruitment and retention problems for the VA, but I do think 
that the Magnet criteria can be used to measure progress toward 
creation of a Magnet culture that supports professional nursing 
practice and respects the voice of nursing in organizational 
decisionmaking. We must really listen and hear what nurses' 
concerns are if we are to improve the environment for nursing 
practice and address the nursing shortage.
    We do have a Magnet culture at the Tampa VA not only for 
nursing staff but for all members of the organization. Magnet 
designation has raised the bar for employees in terms of higher 
standards for performance.
    Chairman Rockefeller. Ms. Janzen, I have to ask you to wind 
    Ms. Janzen. OK. Nurses are proud to work at the Tampa VA.
    Chairman Rockefeller. That is good. That is a good way to 
do it.
    [The prepared statement of Ms. Janzen follows:]

 Prepared Statement of Sandra K. Janzen, Chief Nurse Executive, Tampa 
             (James A. Haley) VA Medical Center, Tampa, FL

    Mr. Chairman and members of the Committee, I am honored to 
be here to present the Tampa VA Hospital and Clinics' journey 
for nursing excellence and to describe our environmental 
characteristics that support professional nursing. In March, we 
became the first VA organization to achieve the prestigious 
Magnet designation recognition by the American Nurses 
Credentialing Center (ANCC) for excellence in nursing services. 
We were the 30th of only 34 facilities nationally to achieve 
this designation since the program's inception in 1994.
    Magnet recognition is an organizational certification 
process based on quality indicators and standards of nursing 
practice defined by the American Nurses Association for nurse 
administrators and nursing services. The primary objective of 
Magnet recognition relating to this discussion is ``to promote 
quality in a milieu that supports professional nursing 
    Achieving Magnet recognition requires strong organizational 
support for professional nursing practice, a positive work 
environment recognizing the nursing contribution, a culture of 
excellence, and nursing input into organizational decision-
making. A Magnet culture must be real the site visit depends 
almost entirely upon the front line nursing staff to validate 
the written application and working environment.
    The Tampa VA set its goal for Magnet recognition to 
acknowledge the nursing contribution to the organization's 
quality journey. The Magnet criteria would serve as a guide for 
self-evaluation. The nursing shortage was beginning and I knew 
Magnet organizations had less difficulty with recruitment and 
retention. Lastly, I wanted public validation of our already 
strong reputation and for VA nursing.
    Organizational support for professional nursing practice. 
Hospital leaders provide strong organizational support for 
nursing at the Tampa facility with an adequate staff mix and 
strong educational support for new and existing staff. Nurses 
are highly integrated in all clinical programs, are leaders 
within the organization, and are allowed clinical autonomy. The 
nurse executive has the ability to pilot programs within 
existing resources to enhance practice. For example, evening 
and night nursing supervisory positions were eliminated to 
augment clinical staffing thus empowering nurses to make 
clinical and administrative decisions.
    Positive work environment that recognizes the nursing 
contribution. Nurses are recognized individually and for team 
contributions. A Gold Star Program honors employees for 
exceptional customer service. Thank you letters for outstanding 
patient care performance are sent from hospital leadership. 
Nurses receive peer recognition in semi-annual nursing 
ceremonies. Nurses are respected for their knowledge evidenced 
by their leadership and membership in clinical teams. As a 
result of the self-assessment process, enhanced educational 
opportunities for nurse managers are now provided and a work 
plan to address nurse satisfaction issues is in place. There is 
a real commitment to become an Employer of Choice.
    Culture of excellence. Magnet criteria address the quality 
of clinical care. Our organizational expectation for patient 
care is clinical excellence and veteran-focused. And, our 
record of measuring nursing quality prepared us for 
participation in a national quality indicator project to 
improve nursing practice and satisfaction. Magnet also 
emphasizes a positive work environment for nurses. Our VA 
Patient Safety Center is systematically using ergonomic 
analysis to identify ways to ease the patient care burdens on 
an aging nursing staff.
    Organizational decision-making. The nurse executive is 
involved in decisions regarding allocation of facility 
resources. The Facility Quality Council assures nurses are on 
all Quality Improvement Teams. Nursing staff decisions 
regarding patient care are respected--nurse managers make 
critical care bypass decisions based on patient needs and staff 
availability. One outcome of nursing involvement in decision-
making is the installation of ceiling mounted patient lifts in 
patient care rooms for the new Spinal Cord Injury Center--a 
direct result of nursing research and input.
    Achieving Magnet recognition is not a quick fix for the 
recruitment and retention problems facing the VA. But the 
criteria should be used to measure progress toward creation of 
a Magnet culture that supports professional nursing practice 
and respects the voice of nursing in organizational decision-
making. Really hearing and understanding nurses' concerns are 
critical if we are to improve the environment for nursing 
practice and maintain a high quality VA nursing workforce.
    The creation of a Magnet culture at Tampa is evident, not 
only for nursing staff but also all members of the 
organization. Magnet designation raises the bar for employees 
by establishing higher standards for performance. As a result, 
Tampa nurses recognize the increased expectation for providing 
exceptional care and customer service. They face many workload 
challenges due to an unrelenting and growing demand, yet remain 
optimistic. Nurses are proud to work at the Tampa VA.
    This concludes my statement. I will be happy to respond to 
the Committee's questions.

    Chairman Rockefeller. Doctor?


    Dr. Petzel. Mr. Chairman, members of the committee, we 
appreciate the opportunity to participate in this hearing on 
work force strategies. I want to acknowledge my colleague to my 
right, Dr. Karen Robinson, who is a nurse executive at the 
Fargo VA Medical Center and is the individual responsible for 
establishing the program I am about to describe in our network.
    I want to discuss primary care clinics run by nurse 
practitioners in the VA's Upper Midwest Network. In an effort 
to improve access, nurse-managed primary care delivery clinics 
were established in 1999 across our Upper Midwest Network. 
These community-based outpatient clinics use nurse 
practitioners as independent practitioners with prescriptive 
authority. To qualify as a nurse-managed clinic in our network, 
the following criteria need to be met: We need a master's 
prepared advanced practice nurse with national certification as 
a primary care provider; that individual must be credentialed 
and privileged at the institution that sponsors the clinic. In 
the case of one of the sites, it is the Fargo VA Medical 
Center. So they have credentials and privileges that are very 
similar to other members of the medical staff, such as 
physicians. In addition to that, there is ancillary help 
provided, a registered nurse is a part of the program, and in 
place needs to be a program to evaluate outcomes in 
relationship to the practice of the clinic.
    Four clinic sites include the Chippewa Valley clinic in 
Wisconsin; Grafton, ND; and Fergus Falls and Maplewood, MN. The 
average staffing at these clinics is from 4 to 6.5 FTE, and on 
average, these advanced practice nurses carry a panel of 
approximately 1,000 patients.
    Patient satisfaction survey results are excellent. The 
patients appreciate the availability of these clinics in their 
communities and are particularly complimentary of the style of 
care that they receive in a nurse-managed care clinic.
    Our measures of quality, the prevention----
    Chairman Rockefeller. Could you explain what you mean by 
    Dr. Petzel. They particularly enjoy the sense of connection 
and--it is difficult to put into words, but the relationship 
that a nursing individual in that role provides to the patient.
    Our measures of quality, prevention, and chronic disease 
index and the implementation of clinical practice guidelines in 
these nurse-managed clinics are consistent with all of our 
other primary care clinics in their host hospitals.
    In terms of cost, the cost per visit is less expensive, it 
is less costly per episode of care in these clinics than it is 
in our host medical centers, which logically makes sense.
    In summary, the world of health care is in the state of 
transformation and change. There are demands for high quality, 
greater accountability, and lower cost which are driving the 
way we do business presently. Nurse practitioners are effective 
providers of safe, high-quality, cost-effective primary care 
which results in a high degree of patient satisfaction. We plan 
on extending the program within our network, and we plan on 
specific research-based outcome studies to be certain that the 
outcomes in these patients are similar to or better than the 
outcomes of patients being treated in other clinics.
    We also think this provides an excellent opportunity for 
professional growth for nurses, and we believe it is something 
that will and should attract nurses and nurse practitioners to 
the Veterans Health Administration.
    [The prepared statement of Dr. Petzel follows:]

 Prepared Statement of Robert Petzel, M.D., Director, VA Upper Midwest 
  Health Care Network, Department of Veterans Affairs, Minneapolis, MN

    Mr. Chairman and members of the Committee:
    I appreciate the Committee's invitation to participate in 
this very timely hearing on nursing workforce strategies.
    For today's hearing, I am going to discuss primary care 
clinics run by nurse practitioners in the U.S. Department of 
Veterans Affairs Upper Midwest Health Care Network, in the 
states of Minnesota, North Dakota, and South Dakota.
    Health care presently is an ever-changing environment for 
all Americans, including the veteran population. New and 
innovative approaches to health care must include goals that 
maximize quality care, improve access and cost effectiveness, 
facilitate patient satisfaction, and optimize the functional 
status of patients. Recognizing the opportunities in this 
challenging environment, nurse practitioners are being 
effectively utilized as competent primary care providers who 
can meet these goals.
    In an effort to improve access, nurse-managed primary care 
delivery clinics were established in 1999 across the VA Upper 
Midwest Health Care Network. These community-based outpatient 
clinics (CBOCs) use nurse practitioners as independent 
practitioners with prescriptive authority. To qualify as a 
nurse-managed clinic in our Network, the following criteria 
must be met: (1) a Masters degree-prepared advanced practice 
nurse with national certification as a primary care provider; 
(2) a qualified registered nurse as a case manager on site; (3) 
credentialing and privileging in place that includes 
prescribing authority; (4) provisions in place for ancillary 
help and access to medical records, laboratory, pharmacy, and 
radiology services; (5) establish outcomes research in the 
future; (6) establish academic partnerships.
    The four clinic sites include Chippewa Valley, WI; Grafton, 
ND; Fergus Falls and Maplewood, MN. Staff at each site includes 
a nurse practitioner, a registered nurse, and a clerk with 
total FTE ranging from 4-6.5 FTE. Some sites also have a 
licensed practical nurse. Panel sizes for the nurse 
practitioners range from 600 to 1,100 patients.
    Evaluation of the program outcomes includes market 
penetration, patient satisfaction, financial analysis, clinical 
indicators, and workload analysis. These clinics have enrolled 
and are providing primary care to an average of 1,000 veterans, 
most of whom are new to the VA system. Patient satisfaction 
survey results are excellent; patients appreciate the 
availability of these clinics in their communities and are 
complimentary of the care they receive. For example, when a 
nurse practitioner from the Minneapolis VA Medical Center 
transferred to the Maplewood clinic, a number of her patients 
requested to move with her; this certainly demonstrates a high 
level of satisfaction when a patient changes their site of care 
to remain with their provider. It is also important to note 
availability of appointments. Even though the nurse 
practitioner at the Grafton clinic has a panel size of 1,100, a 
patient can be seen within 48 hours of a requested appointment.
    Prevention and chronic disease index ratings and clinical 
practice guideline implementation in these nurse managed 
primary care delivery clinics are consistent with the other 
primary care clinics at the host VA medical centers in VISN 13. 
In fact, the nurse practitioners strive to meet the indicators 
and place greater emphasis on patient education.
    Cost per visit at the clinics range from $98.00 (Chippewa 
Valley) to $140.00 (Maplewood) as compared to $137.00 per visit 
at the host Minneapolis VA Medical Center and $102.00 (Fergus 
Falls) to $108.00 (Grafton) as compared to $162.00 per visit at 
the host Fargo VA Medical Center.
    The following case is just one example of the care 
individuals receive when they come to a nurse managed clinic in 
our Network. Mr. K. is a 87-year-old veteran who has been 
receiving care at the Fergus Falls Clinic since April, 1999. He 
has a history of chronic obstructive pulmonary disease, 
prostatic carcinoma, valvular heart disease, and congestive 
heart failure. He cares for his wife who has been blind for 
many years. Initially he came to the clinic for daily dressing 
changes to a leg ulcer. The nurse at the clinic arranged for a 
community health nurse to change his dressings on the weekends. 
However, during his visits to the clinic for the dressing 
changes, he was noted to be more short of breath with activity, 
ankle swelling, and have a hemoglobin of 7.7. He was given a 
blood transfusion and medications were adjusted. As stated by 
Donna Hendel, R.N., nurse at the clinic, ``I am convinced Peggy 
(the Nurse Practitioner at the Clinic) has been responsible for 
preventing at least one hospitalization so far.'' As a result 
of the interventions of the staff at the Clinic, Mr. K. is able 
to remain in his home, caring for his wife, and is able to 
travel to Fergus Falls rather than having to come to Fargo, a 
distance of 65 miles, for his care.
    In summary, the world of health care is in transformation. 
Demands for higher quality, greater accountability, and lower 
costs are currently driving the system. Nurse practitioners are 
effective as providers of safe, high-quality, cost-effective 
primary care, which results in high patient satisfaction. 
Additionally, patients generally select a provider whom they 
feel will listen and address their needs; nurse practitioners 
have a history of providing patient-focused care. Therefore, it 
made sense to move forward with the establishment of nurse 
managed primary care delivery clinics throughout our Network. 
However, our work is not done. We must now demonstrate in terms 
of outcomes-based research the services that nurse 
practitioners provide and their positive impact on client 
    This concludes my remarks. I will be pleased to respond to 
any questions you may have.

    Chairman Rockefeller. Thank you, sir.
    Ms. Robinson?
    Ms. Robinson. Thank you for inviting us today to this 
hearing and----
    Chairman Rockefeller. You came a long way.
    Ms. Robinson. I have. And I think Dr. Petzel explained the 
program very well, and I am open to any questions.
    Chairman Rockefeller. You have got to say something else 
about why what you do, in your judgment, works?
    Ms. Robinson. OK. With these nurse-managed clinics, this 
came about from Dr. Kenneth Kizer, who felt that we needed to 
utilize advanced practice nurses, nurse practitioners, to their 
fullest capacity. And so Dr. Petzel, our network director, 
charged me with looking at this, and I had a fantastic 
committee to work with. We looked at how could we enhance the 
role of nurse practitioners, and we did have several nurse 
practitioners on the committee. And we came up with this 
concept, and we find that it is working very well.
    For example, we had a nurse practitioner at the VA Medical 
Center in Minneapolis who transferred her practice to 
Maplewood, one of the nurse-managed clinics. A majority of her 
patients in her panel transferred with her. And so we think 
that really says it all. The nurse practitioners are excellent 
practitioners as well as educators, researchers, and managers, 
and we feel with these clinics we have the best of both worlds.
    Chairman Rockefeller. Thank you.
    Ms. Raymer?

                       CENTER, SALEM, VA

    Ms. Raymer. Thank you, Chairman Rockefeller.
    It is a pleasure to be here, and my focus of my 
presentation is going to be to tell you about the VA Cadet 
program, which you have actually heard mentioned a few times by 
my colleagues on former panels.
    We implemented this program in Salem, VA, at our medical 
center this year, and basically it was implemented due to my 
growing concern about the shortage of nursing, the decline in 
school enrollments, and what could I personally do about that 
as a nurse executive.
    You have heard statistics, of course, earlier about what 
the average age of the VA nurse is and so forth, and I am kind 
of a typical profile of that person. I have been in the VA for 
27 years, graduated from the University of Nebraska, and I am 
one of those people that, by 2005, the 35 percent of us, that 
are eligible for retirement. And I looked with growing concern 
at the decline in school enrollments. Who is going to take our 
    When I went to the Internet to see what kind of youth 
programs were in place, I found a great void. I personally had 
my first experience in a health care environment as a Candy 
Striper. This was a youth volunteer program that was sponsored 
by the American Red Cross many years ago. It was interesting as 
I talked to my colleagues last evening. All four of us of 
approximately the same generation had been a Candy Striper. Yet 
when I looked for those kind of programs today, there were 
    So it occurred to me, well, it really doesn't take a mental 
giant to figure out that if you have no programs to give a 
positive message to the youth, then how can you possibly expect 
that children are going to enter into the work force in a 
nursing career.
    Chairman Rockefeller. I am interrupting, but that is an 
extraordinarily interesting and important point. I would never 
have guessed that those do not exist.
    Ms. Raymer. Actually, I did not either when I first----
    Chairman Rockefeller. Why?
    Ms. Raymer. Well, I think due to a variety of issues, the 
first being that, as has been said, nursing is still a 96 
percent female profession, 95, 96 percent. So as that started 
to change in the 1970's and 1980's for women, women were 
presented with many other options for careers.
    When I was growing up in the 1950's and 1960's, women 
primarily chose to be nurses, teachers, or secretaries. And all 
of that changed, of course, to the good for women that they had 
all these other choices. But, unfortunately, that work force--
those choices were not replaced by other people, i.e., men. The 
profession did not really address that decline and how can we 
then encourage young men to go into the field or remain 
competitive in workplace practices, which is some of the things 
that you have heard earlier, so that women continue to choose 
    And I think the youth volunteer program kind of went by the 
wayside at that time because it was not considered--it was not 
really considered good to want to be a nurse there for a while. 
You ought to want to do other things if you were a young woman. 
And so those programs just pretty much went by the wayside.
    Over the last 5 years, I have also chaired the Nurse 
Qualification Standards Implementation Committee for the new 
standards for the VA, and I have been very appreciative of the 
VA's commitment to the funding for that program. You have heard 
a little bit about that already as well. So that was addressing 
some of our needs at Salem in educating the current nurses that 
we had to go back and get degrees. It still did nothing to 
answer the induction of new people.
    So, ultimately, what I came up with was a program that was 
geared to a youth volunteer program specifically for nursing, 
and we called that the VA Cadet. We did mass mailings to the 
local community, private and public high schools, to the home-
school organization, to specialty interest groups such as the 
pregnant teens, to the organizations, the civic organizations 
like Girl Scouts, Boy Scouts, and so on. That is how we did our 
marketing, basically.
    We designed a program that consists of a 5-hour orientation 
for the youth. The faculty for that come from myself and my 
nurse leaders volunteer to do that, and we bring them in and we 
give them didactic information so that they are safe in the 
workplace: how to do infection control, how to wash your hands, 
how to make beds for the patients, how to answer a patient call 
light, how to communicate with patients, how to maintain 
patient confidentiality. We cover all of those things. And then 
we do a little skills lab, and they get to do return 
demonstrations, and then we take them on a tour of the facility 
and kind of target where we are going to have them work.
    I think there are two really key components of success for 
the program. The first is you have to have a dedicated cadre of 
nurses that are willing to mentor these young people. You 
cannot just turn them loose in a hospital setting, obviously. 
But along with that, you cannot make that mentor be the already 
overworked staff nurse on the unit. They are already dealing 
with patients, and so that has been a central point that we 
have consolidated that with other people other than the staff 
    Second, you have to be very responsive to the student. You 
have to be flexible. These children--they are marvelous, by the 
way, just marvelous children to work with, but they are very 
busy. They have very demanding schedules, the youth of today. 
And so you cannot just say, well, you can only come from 10 to 
12 on Wednesday. That is not going to work. You have to look at 
their school schedules and individualize their experience so 
that it meets their needs as well.
    So, basically, we have had at this point two orientation 
classes, and we have inducted 11 new cadets. We have ten young 
women and one young man. They come from five different schools 
in the Roanoke-Salem area and range in age from 14 to 17. And 
they have given us in a period of 4 months 140 volunteer hours, 
which translates to approximately an hour a week that they have 
served at the VA.
    We developed as part of our marketing strategy a badge, 
which is here on this coat, and this is the coat that they wear 
so they have a sense of identity and people respond to that.
    There have been some other outcomes other than direct 
patient outcomes that we actually did not anticipate, and the 
first one of those was the very positive influence they had on 
the nursing staff, on the current nursing staff. They are 
delightful to work with, and they give a real morale booster to 
the nursing staff on the units, as well as us as faculty who 
have the joy of teaching them.
    The Girl Scout Council endorsed the program for a merit 
badge, so that gave added incentive for them to come. The 
scholarship program from the Disabled American Veterans that 
they sponsor for youth scholarships, that has been a powerful 
incentive. And in order to qualify for that, they have to serve 
100 hours in the year that they are applying.
    Chairman Rockefeller. You are going to have to wind up.
    Ms. Raymer. OK. I am just about finished. I got so carried 
away, I forgot my notes here.
    In summary, then, I would only say that I would highly 
recommend that the Cadet program be expanded across the system 
and used by other people, and I would close with a comment from 
one of the VA Cadets. She was from our charter class, and she 
was talking to a fellow student who was considering enrolling 
in the program. And she said to that student, ``You will love 
it. The nurses are awesome and the patients are great. It 
really makes you feel good to come here.'' And I believe that 
that is a youth that we want in nursing, and we definitely want 
that person taking care of our veterans.
    Thank you.
    [The prepared statement of Ms. Raymer follows:]
  Prepared Statement of Mary C. Raymer, Associate Chief of Staff for 
 Patient Care Services, Department of Veterans Affairs Medical Center, 
                               Salem, VA
    Mr. Chairman and Members of the Committee:
    I am pleased to be here today to discuss a program we have 
implemented at the VA Medical Center in Salem, Virginia, to address the 
nursing workforce shortage.
    The VA Cadet Program was initiated in response to my growing 
concern for future recruitment of youth into nursing careers. As a 
child of the 1950's with 27 years of VA experience, I represent the 
typical profile of the registered nurse of 2001 in the Department of 
Veterans Affairs. The average age of the VA nurse is 46 with 77% of all 
VA nurses over 40. Sixty percent of us have a bachelors or higher 
degree. In addition, I am one of the 35% of VA Nurses who are eligible 
to retire by 2005.\1\ Many of my generation had their first experience 
in a health care setting through programs such as the Candystriper 
Program sponsored by the American Red Cross. Yet, when I looked for 
such programs today, I found a great void for structured mentoring 
programs to provide incentives for the youth of today to choose nursing 
as a career. As reflected in the 2000 National Sample Survey of 
Registered Nurses (NSSRN),\2\ conducted by the Division of Nursing at 
the Federal Health Resources and Services Administration, nursing is 
primarily (94%) a female profession and the young women of today are 
presented many choices for careers. Nursing must compete with the 
workplace practices of all other disciplines. The factors that will 
induce young people to choose a nursing career are the same as those 
cited for retention of the current nursing work force. As recently 
stated by Aiken et al in the Nurses Reports On Hospital Care In Five 
Countries, ``hospitals will have to develop personnel policies and 
benefits comparable to those in other lines of work and businesses, 
including opportunities for career advancement, lifelong learning, 
flexible work schedules, and policies that promote institutional 
loyalty and retention. Popular short-term strategies such as signing 
bonuses and use of temporary personnel do not address the issues at 
their core.'' \3\ However, with no formal mentoring programs and 
frequent media attention to the problems and hazards of the nurses' 
work environment, there are few positive messages to choose nursing. 
Interventions to correct workplace issues must be made in concert with 
developing and expanding mentoring programs, such as the VA Cadet, that 
provide the youth opportunities for positive experiences in the health 
care setting. The NSSRN also reported a 5.4% increase from 1996 to 2000 
in the number of registered nurses. This is the lowest increase ever 
reported by the survey, which has been conducted every four years since 
1975. The increase from 1992 to 1996 was 14.2%. Enrollments in all 
types of entry level programs have continued to decline for several 
    \1\ Cournoyer, Paulette, VA Nursing Data Trends--FY 2000. 
    \2\ Health Resources and Services Administration, Bureau of Health 
Professions, Division of Nursing National Sample Survey of Registered 
Nurses--March 2000. website. Available at: http//www.HRSA.gov. Accessed 
June 10, 2001.
    \3\ Aiken, Linda et al., ``Nurses' Report On Hospital Care In Five 
Countries'' Health Affairs, Vol 20, No. 3 (2001), pp. 43-53.
    \4\ Bednash, Geraldine, ``The Decreasing Supply of Registered 
Nurses--Inevitable Future or Call to Action?'' JAMA, Vol 283, No 22 
(2000), pp.2985-2987
    Having served as the Chairperson of the Nurse Qualification 
Standards Implementation Committee, I am appreciative of the commitment 
the Department of Veterans Affairs has made for supporting nursing 
education for current staff. This support for nurses to acquire a 
bachelors and higher degree will make major strides in meeting the 
needs for these nurses in the future. The need remains for a formal 
mentoring program to promote nursing as a career.
    The VA Cadet Program provides a structured volunteer experience 
designed to give the student, age 14 or older, a sampling of the 
nursing care environment and interest them in choosing nursing as their 
life's work. I will briefly describe the program and the marketing 
strategies we have implemented.
                     va cadet--program overview \5\
    \5\ Raymer, Mary, VA Cadette--A Nursing Youth Volunteer Program 
(2000), Unpublished.
    A detailed position description and orientation curriculum was 
developed and processed through the nurse leadership and clinical 
practice forums for review, revision and ratification. This is a 
critical element as it achieved endorsement of the concept by these 
nursing leadership groups and assured that the youth were engaged in 
activities that were appropriate. The orientation includes general 
safety and work environment topics and focused nursing skills lab for 
eleven different functions. Some of the tasks include handwashing, 
making beds, and distributing fresh drinking water to patients. 
Conceptual skills include communication with the patients, infection 
control, and confidentiality issues. The Cadet is presented a 
Certificate of Achievement on completing the five-hour orientation 
session. A key component in the program is flexibility for the student. 
We conduct the orientation sessions on Saturday and design their 
volunteer experiences to mesh with the very demanding schedules of 
today's youth. The next crucial component is a cadre of dedicated 
nurses willing to mentor the Cadets. In today's health care 
environment, it is not realistic to expect the staff nurse who is 
already stressed with a myriad of patient care demands, to also be 
responsible for the Cadet. Thus, we have centered the supervision and 
mentoring role with medical center nursing supervisors. They, as well 
as other nurse leaders at the medical center, also volunteer as faculty 
for the orientation.
    The program is designed to progress from the Junior Cadet to the 
Senior Cadet after 60 hours of service. The position description for 
the Senior Cadet includes additional tasks, which are more complex. The 
rationale for the progression is to keep the young person interested 
and to expose them to more types of nursing care tasks.
    A marketing plan includes mailings to all area public and private 
high schools; youth volunteer organizations, PTA groups, home school 
organizations, special interest groups such as the teen mother group, 
and regional church newsletters. Additionally, we utilized the 
excellent video produced by the National Student Nurses' Association 
entitled, Nursing: The Ultimate Adventure,\6\ which is targeted at 
junior and senior high school students. The marketing plan also 
included the development and production of a logo and badge worn on the 
Cadets' lab coat and a lapel pin.
    \6\ National Student Nurses' Association, Inc. Nursing: The 
Ultimate Adventure (Produced by Envision, Nashville, TN 2000)
    To date, the program has had two orientation sessions and has 
inducted eleven VA Cadets. The students and faculty rated the program 
at the exceptional level on the post orientation evaluation. The ten 
young women and one young man represent five different schools in the 
community and range in age from 14 to 17. Thus far, the Cadets have 
volunteered a total of 140 hours in four months, averaging one hour per 
week per student. Orientation is scheduled quarterly with the next 
session on July 14.
    Other direct outcomes from the project have been RN recruitment as 
a result of the extensive media coverage of the Program and positive 
exposure to the volunteer and school community. The Girl Scout Council 
has endorsed the VA Cadet for badge work and the program has been 
featured at several civic organization meetings. The Cadets contribute 
to a positive working environment for the nursing staff and the faculty 
providing the orientation.
    The scholarship program sponsored by the Disabled American Veterans 
for youth volunteers \7\ has been a significant drawing point for the 
students and their parents. We also provide other information on 
funding available and nursing schools in the local area and surrounding 
    \7\ Disabled American Veterans National Commander's Youth Volunteer 
Scholarship (2001).
    I highly recommend that programs such as the VA Cadets be included 
as one of the strategies for addressing the nursing workforce issue. I 
will close with a comment from a VA Cadet of our Charter Class. In 
discussing the program with another student the Cadet said--``you'll 
love it--the nurses are awesome and the patients are great--it really 
makes you feel good to come here''--this is surely a young person we 
want in nursing and providing health care to our veterans.
    Thank you again for this opportunity to discuss the Salem VA 
Medical Center's VA Cadet Program. I will be happy to respond to the 
committee's questions.

    Chairman Rockefeller. Thank you very much.
    Ms. Janzen, I would think that there would be a direct 
relationship between a nurse's satisfaction and his or her 
ability to act with as much autonomy as can be possible.
    Ms. Janzen. Absolutely.
    Chairman Rockefeller. And so we agree on that. But then 
going back to the first panel and the question of being 
overworked and tired. How much autonomy is there in the VA for 
nurses? And how does it compare to non-VA facilities?
    Ms. Janzen. I think it is probably stronger in VA 
facilities than in some non-VA facilities. I do believe that 
Magnet organizations in the country have figured out a way to 
increase the clinical autonomy of nurses and increase the 
respect for nurses' decisionmaking.
    Chairman Rockefeller. Can you give me some examples of 
    Ms. Janzen. Many of the Magnet facilities in the country 
have a shared governance model. They are very well represented 
at all levels of the organization in terms of designing new 
places for people to work, not just having the architects look 
at it, really having nursing involvement, really listening to 
what is going to make the nurses' lives easier; listening when 
they say, you know, I do not want the equipment room way down 
at the end of the hall, it needs to be close by; buying nurse-
friendly equipment that eases the workload of nurses; listening 
to those kinds of things. They are more than happy to work with 
patients. That is why they are there. But we need to make it 
easier for nurses to really work with patients.
    Chairman Rockefeller. And can that be done more broadly--
assuming the funding level for VA hospitals. VA hospitals are 
90 percent Government funded, and VA cannot spend more than 
they have. So, again, I believe that VA is going to suffer more 
the huge tax cut than any other group that I can currently 
think of.
    Does the autonomy help?
    Ms. Janzen. Of course it helps with that because, you know, 
if the decisions are made at the unit level, you are not 
wasting time going up the hierarchy. You can really make 
decisions based on the clinical unit. You have to listen to the 
nurses when they say they have too much to do, and then you 
need to pull back in terms of the demands of patient care and 
respect that.
    Chairman Rockefeller. Now, how can you do that information?
    Ms. Janzen. Well, we----
    Chairman Rockefeller. How do you do it?
    Ms. Janzen. We have had to divert patients and go on 
critical care bypass when we have no more beds and our ICUs are 
plumb full. We have had to delay surgery. I mean, that is the 
direct result. We delay surgery. We ask nurses to take care of 
patients they do not normally take care of.
    We have been relatively successful at Tampa because we have 
really listened to the nurses, but it is a very fragile edge 
that we walk. And any, you know, future budget cuts that impact 
the number of nurses who can be at the front line will be 
serious because the VA will not be able to provide the care. 
And nurses will not stay in an environment that they do not 
perceive is supportive of their work because there might be 
another organization down the street that is doing it a bit 
better. And I think that that is a risk that the VA runs.
    Chairman Rockefeller. Let me ask something I was not 
intending to ask. If we are going into a period of recession--
and the news from the Federal Reserve this morning is that we 
are just flat as--is Fargo flat? [Laughter.]
    Dr. Petzel. Quite.
    Ms. Robinson. It is really flat.
    Chairman Rockefeller. As flat as Fargo. And that is not 
good news. But what it also means is that the various choices 
that women now have or that men now have will become fewer. But 
do you think that a downturn in the economy could spark more 
interest in people coming to work with you in nursing?
    Ms. Janzen. Well, no. Peter Buerhaus in his study said that 
one of the reasons for the current shortage is the very good 
economy. So that many nurses who are nurses do not have to work 
because they can elect not to work. So that is one of the 
issues for the general nursing shortage.
    That may indeed have a factor, but we have to look at the 
fact that we are not looking at people with value systems that, 
you know, Mary and Karen and I came with, you know, from the 
Candy Striper days and, you know, we will give all--these 
people want a life other than just nursing and other than just 
VA. And they will not select a career that does not give them a 
balanced life.
    Chairman Rockefeller. Yes. So that is a big, big problem, 
isn't it? Young people want time for all sorts of things in 
their life.
    Ms. Janzen. They want a balanced life. They want an 
exciting career, and they want a balanced life. Nursing can be 
an exciting career, and I really believe that. And the options 
to work in all different kinds of nursing settings, change your 
career several times, and still, you know, end up with a 
retirement in the VA, these are very attractive things. But it 
needs to be an exciting environment. We need to be very 
responsive to what they want, and that goes back to an 
organizational culture that supports saying, OK, we are going 
to try that.
    Chairman Rockefeller. So it makes it so much more important 
to do what you are all talking about?
    Ms. Janzen. That is right.
    Chairman Rockefeller. Because just speaking personally--and 
none of you have reached my generation yet, but you will 
someday. But I understand exactly what you are all saying 
because if I had to criticize myself, which I frequently have 
to do, it would be that the amount of time that I spent, for 
example, with my children when they were growing up because I 
was a Governor was seriously reduced because I had to take care 
of the State.
    Ms. Raymer. You have to have that environment to induce 
them to come into that kind of career field. I think that is 
what many people today have said, that there is not really a 
quick fix. I mean, you cannot go out and implement a Candy 
Striper or a Cadet program if then when the young person comes 
into the setting they see this, you know, terrible situation. 
They are obviously not going to want to come to work there. And 
so you have to create an environment like Sandy is talking 
about in order to promote those kind of people to come into 
    Ms. Robinson. I would echo those comments. When you 
interview an individual for a position, you have to listen very 
carefully to what they are wanting and describe to them the 
setting that they will be working in. And I use as an example 
our nurse-managed clinic in Grafton, ND. We were recruiting for 
a nurse practitioner, and we had an interview with just an 
excellent young man who was a nurse practitioner, had been in 
the role for about 5 years, and his resume was just 
outstanding. And he was very interested in this concept. But he 
lived in a community about 30 miles away, and he was all set to 
sign up with us, and he went back to his community, and they 
said, ``How can you leave us? How can you leave us?'' And so he 
called me, and he said, ``I just cannot do it.'' He had a sense 
of community.
    So there is still that out there, and we were able to match 
his salary, et cetera. He liked the idea of the nurse-managed 
clinics, but it was a sense of community.
    Chairman Rockefeller. Nurse clinics are famous for spending 
more time with patients. One, if you agree with that, why is 
that so? And what can we do with that?
    Ms. Robinson. That is true. There are some nurse-managed 
clinics that do that. When we developed the model, we looked at 
the Columbia University model in New York. We looked at 
Vanderbilt in Tennessee, and we also looked at Rutgers in New 
Jersey. And we found that not to be the case in all of those 
    With our particular nurse-managed clinics, we utilized the 
same guidelines as we do in our host medical centers for 
appointments. If it is a first-time appointment, you know, they 
have X amount of time. If it is a return appointment--so it is 
the same as it is at our host medical centers. But I know that 
that is not the case nationwide.
    Dr. Petzel. There is a perception, however, in the nurse-
managed clinics that the provider is spending more time with 
the patient on the patient's part. We are not sure what that is 
about, but there is that perception.
    Chairman Rockefeller. That is interesting.
    Well, to be honest with you, if the perception is there, 
you are going to have happier health professionals.
    Dr. Petzel. It is important. You are absolutely right.
    Ms. Robinson. And I think it is developing that rapport. I 
think nurse practitioners are more comfortable in the area of 
patient education, teaching, working with family.
    Chairman Rockefeller. OK. Well I have to wind this up. This 
is an enormous problem. It is a problem throughout America.
    If we do have a recession, one of the things that is going 
to happen is that a whole lot of people, not just in the 
veterans community, but a whole lot of people out there are 
going to lose health insurance. And so, the whole sort of 
urgency about the health care system will come back. The 
outrage is that we still have so many who have no health 
insurance at all.
    So if you add that concern with some of the frustrations 
that we have heard this morning and some of the positive 
solutions that we have heard this morning health care delivery 
could benefit. But the need to deliver good health care to 
veterans and to non-veterans alike could focus more of a public 
    Do you agree? You do not have to.
    Dr. Petzel. It is certainly possible, absolutely possible.
    Chairman Rockefeller. It is a good way to end a hearing, 
    Dr. Petzel. Yes. [Laughter.]
    Chairman Rockefeller. OK. Thank you all very, very much.
    The hearing is in recess. And Senator Specter's statement 
goes in the record.
    [Whereupon, at 12:35 p.m., the committee was adjourned.]
                            A P P E N D I X


 Prepared Statement of Mark Regan, National Field Service Supervisor, 
                          The American Legion
    Mr. Chairman and Members of the Committee:
    The American Legion appreciates the opportunity to submit this 
statement addressing a problem that continues to grow each day--a 
shortage of nurses within the Department of Veterans Affairs (VA) and 
its potential to decrease the Veterans health Administration's (VHA's) 
ability to deliver quality health care to America's veterans. Clearly, 
sufficient and high quality nursing care is one of the most important 
and necessary components of VHA's healthcare delivery system or any 
healthcare delivery system.
    In fact, nurses continue to serve as the backbone of direct patient 
care. Quality nursing care is synonymous with quality patient care. One 
aspect of ensuring quality nursing care is ensuring there is sufficient 
coverage for the range and complexity of medical issues. This is 
essential if VHA is to meet its obligations and keep the promise of 
quality medical care to veterans.
    Articles appearing in nursing publications argue that the nurse 
shortage is evident by rising nursing vacancy rates, which have 
resulted in closed beds, non-urgent surgery cancellations, and the 
diversion of patients from emergency rooms. Moreover the nursing 
shortage can be attributed to the diminishing supply of new talent 
entering the profession coupled with a growing demand for health care 
    Preliminary results of the latest National Sample Survey of 
Registered Nurses showed a 5.4 percent increase in the total RN 
population, but it was the lowest increase in the previous national 
surveys, which dates back to 1977. The latest numbers from the American 
Association of Colleges of Nursing indicate that enrollments in five 
year baccalaureate nursing schools dropped 16.6 percent during the past 
five years. Furthermore, the supply of nurses, reported as 
insufficient, will slow even further. In addition, the registered nurse 
(RN) workforce is getting older. As those RNs retire, the supply of 
working RNs is projected to be 20 percent below requirements. 
Consequently, this is not just a cyclical nursing shortage, but a 
significant issue that could impact the delivery of health care for 
some time.
    Overall, VA nurse staffing was relatively stable in 2000. The 
turnover rate was 9.5 percent, while the percentage of new nurses 
brought on board was 9 percent. VHA's turnover rate of 9.5 percent 
compares very favorably to the US turnover rate of 15 percent. 
Nevertheless, VHA is still experiencing nursing shortages. This often 
involves positions with special qualifications that vary by region. 
However, The American Legion has seen several long-term care programs, 
for example, the nursing homes in Tuskeegee, AL; Augusta, GA, and 
Amarillo, TX, that are not at capacity due to the lack of nursing 
    Additionally, The American Legion has seen large voids in the 
nursing staff positions, for example, 40 RN vacancies in Richmond, VA. 
There is also a significant nursing shortage at the Albuquerque VA 
Medical Center (VAMC), which threatens its ability to provide quality 
care and treatment to veterans. Inpatient beds in medicine, surgery and 
psychiatry have been closed since May 2000, and elective surgeries are 
being delayed because the facility must limit its operations to ensure 
quality care and to maintain a safe patient environment. Referral 
facilities have looked elsewhere because a VAMC can not accommodate 
their workload. The facility has taken aggressive measures and 
conducted nation wide recruitment.
    Salary surveys were conducted. Consequently, salaries were 
increased on several occasions. Recruiting bonuses were also used as an 
incentive to attract qualified candidates. Yet, despite these efforts, 
many vacancies still exist with no apparent light at the end of the 
tunnel. There are simply not enough nurses in the geographic area to 
meet the demands, and the situation has been compounded by a reduction 
in the number of slots for students at the university's nursing school. 
The facility has stemmed the net loss of personnel, but it has not 
substantially increased the number of nurses on board to offset the 
previous losses.
    The American Legion's strongly believes that what happens at VAMCs 
often reflect the general state of affairs within the health care 
community as a whole. Therefore, when there are difficulties recruiting 
Intensive Care Unit (ICU) nurses at a VHA facility, there are often 
difficulties in finding ICU nurses in the surrounding community 
facilities. When VHA is diverting veterans from the emergency room, 
community facilities are often doing the same.
    The American Legion commends Congress for passing Public Law 106-
419, because it provided the framework to help revitalize VHA salaries 
in a number of disciplines, including nursing. While there are reports 
that some stations still have work to do to resolve significant salary 
discrepancies between VHA and the community and VHA must remain 
competitive in its benefits package, this is only one component of the 
equation of retention and recruitment.
    A study by the Center for Health Economics and Policy at the 
University of Texas Health Science Center in San Antonio Texas 
identified three essential factors that affect the retention of nurses:
          1. Work environment practices that may contribute to stress 
        and burnout,
          2. The aging of the RN workforce combined with the shrinking 
        applicant pool for nursing schools, and
          3. The availability of other career choices that makes the 
        nursing profession less attractive.
    Other factors cited most frequently for leaving nursing included:
     lack of time with patients,
     concern with personal safety in the healthcare setting,
     better hours outside of nursing, and
    It should also be noted that 63 percent of those surveyed said that 
RN staffing is inadequate and that current working conditions 
jeopardize their ability to deliver safe patient care.
    Other studies reinforce and expound these themes and factors. A 
study, which included five Countries, found that nurses in Countries 
with different health systems reported similar problems in their work 
environment. Less than half of the nurses surveyed said that the 
administration listens and responds to their concerns. Less than 38 
percent said that there is enough staff to get the job done. Nurses 
also commented that staffing shortages forced many RNs to perform non-
nursing duties. Finally, the results suggest a large number of young 
nurses plan to leave their jobs.
    Health care institutions are struggling with and searching for 
solutions. ``Experts'' say that improving the work place and polishing 
the image of nursing are among the steps that must be taken. The 
National Association of Government Employees (NAGE) has been on record 
saying that VHA must embrace staffing practices that are favorable to 
employee and family needs, such as hiring staff for permanent tours 
instead of rotating shifts, and providing alternative work schedules. 
NAGE also noted that rewards and recognition for employees in the field 
must improve, and advocates VHA increasing its educational resources to 
allow VHA nurses to pursue a Bachelor of Science in Nursing (BSN) or 
Masters Degrees.
    It is clear the nursing profession faces significant challenges 
imposed by an aging workforce (the average age of VHA nurses is 46 
years), the increasing medical care demands of an aging population, a 
declining interest in the profession, prompted by more preferable 
career alternatives for women, and a perceived lack of appreciation and 
respect for the profession. In a survey released in February 2001 by 
the American Nurses Association, 56 percent of those surveyed said they 
would not recommend their profession to their children or their 
    VHA has two committees looking at the nurse shortage and they will 
provide proposals to address the needs and issues within VHA. However, 
VHA should have the capabilities to aggregate data relative to its 
nursing coverage to include the number of vacant positions in the 
system. Data would also be useful regarding the associated consequence 
of those vacancies - bed closures, delayed delivery of care, etc. This 
would help to clarify and define VHA's needs. VHA is currently working 
to improve in this area.
    VHA should continue to explore ways to enhance the work 
environment. Morale among nurses is deeply impacted by the amount of 
non-nursing functions they are required to perform. Therefore, it is 
imperative VHA make sure there is sufficient clinical and ancillary 
support to maximize the nursing skills of nurse providers. Similarly, 
local facilities have a number of practices to facilitate hiring, but 
their use varies across the country reflecting local decisions on the 
use of limited resources. The ability to provide recognition rewards, 
likewise, can be affected by the local budget. Thus, adequate funding 
is imperative.
    VHA must draw upon its models of collaborative efforts to use the 
talent among its clinical staff to help address the issues that 
surround the availability of teachers for nursing programs. VHA 
continues to be a leader in the fields of the electronic medical record 
and patient safety initiatives. Finally, VHA must ensure that such 
efforts are widely recognized because this will enhance its ability to 
attract those looking to be part of the cutting edge of nursing 
    VA's Chiefs of Nursing have said that one of the most effective 
recruitment tools is to capture student nurses while they are in 
training or as they graduate. One state has considered legislation 
providing starting bonuses, while a private sector facility has 
established programs for new nurses that involve preceptorships, 
mentoring and financial incentives to stay. VHA must not only stay 
abreast of these initiatives, but it must be placed in a position to 
excel in these initiatives.
    The American Legion is appreciative of the many contributions of 
VHA nursing personnel and recognizes their dedication to veterans who 
rely on VHA health care. Every effort must be made to recognize, reward 
and maximize their contributions to the VHA healthcare system because 
veterans deserve nothing less.
    Mr. Chairman and members of the Committee, The American Legion 
sincerely appreciates the opportunity to submit testimony and looks 
forward to working with you and your colleagues to resolve this 
critical issue. Thank you for your continued leadership on behalf of 
America's veterans.
 Prepared Statement of Kenneth T. Lyons, National President, National 
                  Association of Government Employees
    Mr. Chairman and Members of the Committee:
    The National Association of Government Employees (NAGE) represents 
150,000 public sector employees throughout the United States, including 
15,000 at VA facilities nationwide. On behalf of these dedicated 
employees, NAGE would like to thank the committee for this opportunity 
to submit this written testimony for the record.
    An alarming trend is occurring throughout the United States health 
care system, and more specifically within these Department of Veterans 
Affairs (VA) hospitals, nursing homes, and clinics. This trend is the 
nursing shortage that is creating a crisis for quality patient care and 
the overall future of the nursing profession. Registered nurses make up 
the largest health care workforce in the nation, and the VA has the 
largest nursing workforce in the world, but even with these 
distinctions, the ever-dwindling supply of nurses continues its trend. 
In the 2000 National Sample Survey of Registered Nurses it was found 
that a disturbing 18% of nurses who have active licenses are not 
working in the field, and from another survey, 55% would not recommend 
the profession as a career choice to those interested. Why is it that 
these dedicated nurses who sacrifice themselves day in and day out for 
the good of the patient are turning their backs on the profession?
    Numerous factors combine together to bring about the state of 
today's VA hospitals. One such reason is the fact that the profession 
primarily consists of women, as 94% of nurses are female, and women 
today are offered countless more career choices than they were even a 
few years ago. Suddenly becoming a nurse does not hold the same appeal 
as it once did and one reason for that is a lack of mentoring programs 
and successful recruiting. At this time the average age of new 
graduates from nursing school is 30.5, and the average age for active 
nurses is about 46 years old. Twelve percent of the VA nursing staff is 
eligible for retirement at this time, and every year another 3.7 to 
5.3% become eligible as well. This shows that the majority of active VA 
nurses have been in the profession for some time, while they are not 
getting the younger, fresher recruits who are needed for the next 
generation of nursing professionals. And with enrollment in all types 
of entry level programs declining, it is evident that something must be 
done to stimulate interest and growth in the field. Programs such as 
the VA Cadet Program offer firsthand volunteer nursing experience to 
students 14 and older, where hands on nursing skills are learned. So 
far, several sessions of the program have been held, with the 
curriculum receiving an ``exceptional'' review from those involved, and 
the program plans on an in-depth marketing campaign to increase 
awareness and interest to a more youthful demographic. This is a much-
needed step in the positive direction, but many other issues must be 
resolved within the profession to retain those that are recruited.
    It is increasingly evident that changes in nursing circumstances 
have created a strained working environment. Staffing shortages, 
stagnant pay, and career advancement opportunities are some problems 
facing nurses. As opposed to six years ago, VA hospitals have increased 
care to more than 500,000 veterans with 25,000 less employees. Common 
sense tells anyone that with such a disproportionate change in 
quantity, the quality of care is going to decrease drastically. In a 
recent ANA survey, over 40% of the nurses surveyed stated they would 
not feel comfortable having a loved one cared for in the facility they 
worked in. Because of the understaffing at veterans' hospitals nurses 
are forced to work mandatory overtime to compensate the 
insufficiencies. It is common for a nurse to go into work thinking he 
or she will be leaving at their scheduled time, yet, once there find 
that he or she is required to work an extra shift to cover gaps in the 
staffing. Nurses may log on 15 to 16 hour shifts for several days a 
week, and this kind of exertion is mentally and physically taxing, 
draining the caregiver of focus, patience, and motivation, all leading 
to impaired performance and decreased patient care and safety. At this 
time there is no nationwide policy for mandatory overtime nor are 
statistics collected. Until legislation is passed, nurses will face the 
problem of being forced to work beyond their limit, potentially putting 
their patients in harm's way, or suffering the repercussions of being 
charged with patient abandonment, it is a catch twenty-two.
    To further accentuate the problems caused by these long, tedious 
hours is the pay. Census data from 1994 to 1997 shows a decrease in 
average wages every year, with, for instance, a Registered Nurses' 
salary dropping by more than a dollar an hour. Numerous strategies are 
being proposed to reverse this situation. Waiting periods between 
Periodic Step Increases (PSI) in pay can be deviated at the request of 
facility directors, shortening the time it would take a hardworking 
nurse to receive increased compensation, and offering incentive to a 
prospective nurse. A four-week salary advance could also be offered, 
which is attractive to newly hired staff who tally large expenses 
relocating and training. Also advancements in steps could be awarded 
for excellence in achievement and performance beyond what is expected 
for the grade level. Such recognition boosts self-confidence and 
morale, easing some of the mounting pressures constantly placed on 
these nurses. It also creates a workplace atmosphere where hard work is 
actually recognized and rewarded, a very positive aspect in the 
recruitment of new nurses. Several changes can also be made in the 
Locality Pay System such as using third-party industry wage surveys to 
make adjustments in salaries, and expanding the Local Labor Market Area 
(LLMA) as needed to adequately obtain these surveys. Changes such as 
these promote much needed opportunities for career advancement.
    In accord to these opportunities are two new educational assistance 
programs the VA has to offer. The Employee Incentive Scholarship 
Program (EISP) is available to employees who want to seek further 
education in various healthcare disciplines. In return the employee is 
obligated to a period of service. The National Nursing Education 
Initiative (NNEI) is a scholarship offered to nurses who want to return 
to school and receive their baccalaureate or advanced degrees. This 
coincides with the new nurse qualification standard that makes a 
bachelors of science in nursing (BSN) mandatory for a promotion. 
However, a large number of nurses, especially minority populations, 
only have an associate degree, and limiting promotions to strictly 
educational criteria, as opposed to performance, discriminates against 
those who have not attained that level yet. This is complicated by the 
fact that while these scholarships, especially the NNEI, are available, 
funding to hire temporary staff to cover while the nurse pursues his or 
her education is missing. So some employees are disadvantaged in their 
career advancement opportunities, a fact that does not help in 
attracting new and potential nurses.
    Mounting pressures including mandatory overtime, increased volumes 
of patients with decreased numbers in staff, and flat-line pay are 
enough to steer away new nurses, while also driving away the current, 
dedicated nurse force, more of whom are eligible for retirement every 
year. There is an unbalance of both numbers and rewards between direct 
patient care staff and administration, where directors in the ever-
increasing management are making up to $20,000 bonuses a year while 
those on the ``frontline'' are told there is not enough in the budget. 
When will they be recognized? Something must be done to curb the 
downward spiral of the nursing profession because the problem will not 
correct itself. NAGE urges that measures be taken and supports 
legislation capping overtime and adding to the budget to allow for the 
necessary staff and pay increases. The Department of Veterans Affairs 
has been historically viewed as a stable, secure, and desirable 
workplace, and with changes such as these we can once again make the VA 
the number one employer of choice.
  Prepared Statement of the American Organization of Nurse Executives
    The American Organization of Nurse Executives (AONE) welcomes the 
opportunity to provide testimony on the critical issue of the nursing 
shortage and its impact on all aspects on the health care system.
    AONE represents over 3800 nurse executives, managers, consultants, 
and educators dedicated to providing leadership, professional 
development, advocacy, and research in order to advance nursing 
practice and patient care, promote excellence in nursing leadership, 
and shape healthcare policy. Many of AONE members are current and 
former Department of Veterans Affairs nurse executives and some have 
served in leadership positions within AONE.
    For nurses in management positions and the over 2 million 
registered professional nurses licensed in the United States, the 
nursing shortage is a critical problem that has serious implications 
for all of health care, both today and in the future. Over the years, 
hospitals and health systems including the VA have repeatedly 
experienced temporary shortages of personnel, such as the nursing 
shortages of the 1960s, 1970s, and the late 1980s. These shortages 
responded to quick fix solutions of higher salaries and the importation 
of foreign-trained nurses. Unfortunately the demographics of today's 
shortage as outlined in AONE's October 2000 monograph Perspectives on 
the Nursing Shortage: A Blueprint for Action, reveals a looming health 
care situation crisis that, if not reversed, will find Americans 
critically short of the registered professional nurses needed to 
address the health needs of an aging American society.
    As America ages so does the nursing workforce. The average age of 
the 2.1 million US registered nurses is 45.2 years, for VA nurses it is 
48 years, and for those is academia it is over 52 years of age. In 
2000, only 9.1 percent of nurses were under the age of 30. This figure 
signals significant erosion in the nursing pipeline showing the 
reluctance of younger individuals to enter the nursing profession. In 
fact, the traditional source of nursing students (white, females) has 
seen a significant decline as new and varied career opportunities have 
been opened to women.
    Over the last five years, enrollments in baccalaureate nursing 
programs have declined by 20 percent and all RN education programs have 
declined by 50,000 students or 22 percent since 1993. The drop in 
enrollment is attributed to declining interest, program cuts and 
inability to attack sufficient faculty.
    Most regions of the United States are currently experiencing a 
major nursing shortage. A June 2001 survey by the American Hospital 
Association of their member hospitals revealed that currently 125,000 
nursing positions are unfilled. This translates to a nationwide vacancy 
rate of 11 percent. The shortages are particularly acute in such 
specialty areas as the emergency room, labor and delivery, the 
operating room and critical care units. Recruitment in these areas 
especially difficult because programs to produce such skilled 
clinicians have been reduced or terminated in many US hospitals, and 
the cohort of younger nurses from which to recruit has been greatly 
reduced. The seminal work of Dr. Peter Buerhaus in his groundbreaking 
research published in the June 2000 edition of the Journal of the 
American Medical Association has drawn national attention to the 
nursing shortage as a problem of unparalleled proportions. Dr. Buerhaus 
and his colleagues estimate that by the year 2020 the US, under the 
current nurse workforce scenario, will be short over 400,000 nurses.
    In the view of AONE, the solution to the nursing shortage lies in a 
multipronged approach that addresses the short-term supply problem but 
also stimulates long?term solutions that address all facets of the 
nursing workforce issue. Solutions can be found in three nursing bills 
that have been introduced in the House and Senate. They are S. 706/H.R. 
1436 the Capps-Kerry Nurse Reinvestment Act and S. 721 the Hutchinson-
Mikulski Nursing Employment and Education Development Act.
    These bills in whole or part address the AONE agenda for nursing 
shortage relief through:
     Increased funding of the Nurse Education Act.
     Increased funding for loans and scholarships for nursing 
students who agree to work in shortage areas.
     Increased funding for nursing research.
     Support for faculty development and mentoring to ensure 
that nursing programs are fully operational.
     Funding for specialty nurse internship and residency 
     Support to make educational expenses tax-deductible and 
loan forgiveness programs.
     Support for collaborative models to provide career ladders 
within the nursing profession.
     Enhanced recruitment of minorities into the nursing 
     Development of private-public partnerships to assist in 
the marketing of the nursing profession.
     Establishment a nurse corps.
    AONE is supportive of Senator Rockefeller's draft legislative 
framework to address nursing shortage as it affects the Department of 
Veterans Affairs. In particular AONE welcomes the elevation of the 
nurse consultant position, the expansion of education initiatives, and 
the encouragement of pilot programs to expand nurse-directed health 
    AONE is hopeful that Congress will act quickly to implement 
legislation to solve the nursing shortage. It welcomes the opportunity 
to support the over 34,000 nurses of the Department of Veterans Affairs 
who tirelessly care for our Nation's veterans and looks forward to 
continued cooperation with the Committee and the VA to support the 
nursing profession.