[Senate Hearing 118-207]
[From the U.S. Government Publishing Office]


                                                      S. Hrg. 118-207

                      OVERWORKED AND UNDERVALUED:
                    IS THE SEVERE HOSPITAL STAFFING
                    CRISIS ENDANGERING THE WELL-BEING
                        OF PATIENTS AND NURSES?

=======================================================================

                             FIELD HEARING

                              [before the]

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               ----------                              

                            OCTOBER 27, 2023

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                       Printed for the use of the
          Committee on Health, Education, Labor, and Pensions
          
          
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                   U.S. GOVERNMENT PUBLISHING OFFICE                    
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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                 BERNIE SANDERS (I), Vermont, Chairman
PATTY MURRAY, Washington             BILL CASSIDY, M.D., Louisiana, 
ROBERT P. CASEY, JR., Pennsylvania       Ranking Member
TAMMY BALDWIN, Wisconsin             RAND PAUL, Kentucky
CHRISTOPHER S. MURPHY, Connecticut   SUSAN M. COLLINS, Maine
TIM KAINE, Virginia                  LISA MURKOWSKI, Alaska
MAGGIE HASSAN, New Hampshire         MIKE BRAUN, Indiana
TINA SMITH, Minnesota                ROGER MARSHALL, M.D., Kansas
BEN RAY LUJAN, New Mexico            MITT ROMNEY, Utah
JOHN HICKENLOOPER, Colorado          TOMMY TUBERVILLE, Alabama
ED MARKEY, Massachusetts             MARKWAYNE MULLIN, Oklahoma
                                     TED BUDD, North Carolina

                Warren Gunnels, Majority Staff Director
              Bill Dauster, Majority Deputy Staff Director
                Amanda Lincoln, Minority Staff Director
           Danielle Janowski, Minority Deputy Staff Director
                            
                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                        FRIDAY, OCTOBER 27, 2023

                                                                   Page

                           Committee Members

Sanders, Hon. Bernie, Chairman, Committee on Health, Education, 
  Labor, and Pensions, Opening statement.........................     1

                               Witnesses

Danella, Judith, RN, Staff Nurse, RWJ Barnabas Health, President, 
  United Steelworkers Local 4-200, Piscataway, NJ................     4
    Prepared statement...........................................     6

Tanzi, Carol, RN, BSN, Pediatric Recovery Room Nurse, RWJ 
  Barnabas Health, Edison, NJ....................................     8
    Prepared statement...........................................    10

Hagans, Nancy, RN, President of National Nurses United, President 
  of New York State Nurses Association, Brooklyn, NY.............    12
    Prepared statement...........................................    14
    Summary statement............................................    19

White, Debbie, RN, President, Health Professionals and Allied 
  Employees, Marlton, NJ.........................................    20
    Prepared statement...........................................    22
    Summary statement............................................    23

Pittman, Patricia, Ph.D., Fitzhugh Mullan Professor of Health 
  Workforce Equity, Director, Mullan Institute for Health 
  Workforce Equity, Dept. of Health Policy and Management Milken 
  Institute School of Public Health, The George Washington 
  University Washington, DC......................................    24
    Prepared statement...........................................    26

                          ADDITIONAL MATERIAL

Sanders, Hon. Bernie:
    Various statements and testimonials from stakeholder groups 
      and individuals, submitted for the Record..................    40
Booker, Hon. Cory A., U.S. Senator from the State of New Jersey:
    Prepared Statement submitted for the Record..................   147
Manigan, Mark E., President and CEO, RWJ Barnabas Health, West 
  Orange, NJ (invited)
    Written Statement for the Record.............................   147
    Written Summary Statement for the Record.....................   150
Alan Lee, President, Robert Wood Johnson University Hospital, New 
  Brunswick, NJ (invited)
    Written Statement for the Record.............................   151
    Written Summary Statement for the Record.....................   154
    RWJUH United Steel Workers Negotiation Timeline, Addendum....   155
    Setting the Record Straight, Proposed Adult Care Nursing 
      Guidelines, Addendum.......................................   158
Hagans, Nancy:
    National Nurses United, Letter of Support of the Nurse 
      Staffing Standards for Hospital Patient Safety and Quality 
      Care Act, H.R. 2530........................................   160
    National Nurses United, Proposed Congressional Actions to End 
      the Industry-Created Nurse Staffing Crisis.................   164
    National Nurses United, ``Examining Health Care Workforce 
      Shortages: Where Do We Go from Here?''.....................   176
    National Nurses United, Protecting Our Front Line: Ending the 
      Shortage of Good Nursing Jobs and the Industry-created 
      Unsafe Staffing Crisis.....................................   180
    National Nurses United, RN Staffing Ratios: A Necessary 
      Solution to the Patient Safety Crisis in U.S. Hospitals....   236
    National Nurses United, Deadly Shame: Redressing the 
      Devaluation of Registered Nurse Labor Through Pandemic 
      Equity.....................................................   243
White, Debbie:
    Code Red: Understaffed. Overworked. Unsafe for everyone, HPAE 
      Position Paper, March 2023.................................   335

 
                      OVERWORKED AND UNDERVALUED:
                    IS THE SEVERE HOSPITAL STAFFING
                   CRISIS ENDANGERING THE WELL-BEING
                        OF PATIENTS AND NURSES?

                              ----------                              


                        Friday, October 27, 2023

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                 New Brunswick, NJ.

    The Committee met, pursuant to notice, at 9:02 a.m., in 
Nicholas Music Center, Rutgers University, 85 George St., New 
Brunswick, New Jersey, Hon. Bernard Sanders, Chairman of the 
Committee, presiding.

    Present: Senators Sanders [presiding].

                  OPENING STATEMENT OF SENATOR SANDERS

    The Chair. I have been on the Senate Health, Education and 
Labor Pension Committee for 18 years, and you know what, we 
have never had a larger meeting than this. So, thank you all 
very much.

    [Applause.]

    The Chair. This is an amazing turnout and I thank you all 
very much. And let me officially call the Senate Committee on 
Health, Education, Labor, and Pensions to order.

    This is a hearing designed to discuss the working 
conditions that nurses at the Robert Wood Johnson University 
Hospital are facing and why they have been on strike for almost 
3 months. That is what this hearing is about. I want to thank 
all of the panelists who are here with us today.

    But before we get to the issue of why we are here, I wanted 
to thank all of the nurses who are in this room, the nurses who 
are watching this event on livestream, and the many, many 
nurses all over this country who put their lives on the line 
during COVID. You can remember, and you lived through it, and I 
can remember, 3,000 people a day dying during the worst public 
health crisis in 100 years.

    We can all remember hospitals overflowing with patients. 
And remember, we remember nurses and doctors and other health 
care professionals going to work without the personal 
protective equipment that they needed. They don't have the 
gloves, they didn't have the masks, they didn't have the gowns.

    They went to work every day to save us, and we owe them a 
debt of gratitude that can never be repaid. In my view, there 
are very few professions in America that are more important 
than nursing. But we all know doctors and others play an 
enormously important role in our health care system, but nurses 
are there when our babies are born.

    You are there taking care of mothers who suddenly find 
themselves with the baby. You are there in the emergency rooms 
when we are injured. You are there when we are dealing with 
very serious illnesses. And you are there providing the humane 
and compassionate care that every human being needs at the end 
of their lives.

    You are there and we thank you. And all of that and much 
more is why nursing is the most trusted profession in America. 
That is why nurses are the backbone of our health care system 
and why it is way past time for hospital executives to treat 
you with the respect and dignity you need.

    Now, I don't want to divert too much from the purpose of 
the hearing today, but I don't have to tell anybody in this 
room, or I think anybody in America, that we have a health care 
system, whether it is New Jersey, Vermont, or any place else in 
America, that is dysfunctional and is broken.

    I just want to say a word on this because it ties into what 
we will be discussing in a minute. I want everybody here to 
know that in the United States of America, we spend almost 
twice as much per capita as any other major country. Do you all 
know that? We are spending $13,000 for every man, woman, and 
child in this country.

    We should have the best health care system in the world. 
But, not only do we not have the best health care system, we 
are far behind many, many other countries. Despite our huge 
expenditure, 85 million Americans are uninsured or 
underinsured, and you deal with those folks every day. 
Unbelievable, and it is not talked about at all.

    Some 60,000 Americans die every single year because they 
don't get the medical help they need when they--help it, right? 
You have seen it. They are sick, and the doctor nurses, why 
don't you come in? Why didn't you come in 6 months ago when you 
had your symptoms? And the answer is, I was uninsured. I 
couldn't afford the deductible.

    The function of a humane and civilized health care system 
is to provide quality care to all, not to make huge profits for 
the insurance companies, the drug companies. And another issue 
that is not talked about is our life expectancy, how long we 
live is much lower than other countries and is actually in 
decline.

    For working class people, lower income people, the gap in 
their life expectancy with the rich is about 10 years in 
America. That is unacceptable. And on top of all of that, our 
broken health care system is one in which we do not have enough 
doctors, we don't have enough dentists, we don't have enough 
mental health practitioners, we don't have enough pharmacists.

    Perhaps most disturbingly, we have a major and growing 
shortage of nurses. And that, in my view, is because of two 
basic reasons. First, our nursing schools are unable to educate 
the large numbers of young people who want to become nurses 
because we are not investing in nurse educators.

    Young people understand how important and what a wonderful 
profession nursing is. They apply for nursing schools. They 
can't even get in because we don't pay the educators the kind 
of salaries they should be paid. I should tell you that is an 
issue the Committee that I Chair is attempting to address.

    But the second reason, and what this hearing is about 
today, is that there are over 1 million Americans who are 
licensed to be nurses but are no longer doing the jobs that 
they want to do and that they love because the working 
conditions in hospitals are often deplorable.

    How sad it is, how tragic it is that these nurses want to 
do their jobs, compelled to do their jobs, no longer feel 
comfortable in doing that work. And that brings us to why we 
are here today in New Brunswick.

    For nearly 90 days, some 1,700 nurses at the Robert Wood 
Johnson University Hospital have been on strike. What is this 
strike about? Yes, nurses at Robert Wood Johnson and workers 
all over this country want better wages and better benefits, 
but that is not the primary reason for this strike.

    What the nurses have told me, and I have had the 
opportunity on several occasions to sit down and talk with 
these nurses, is that what this strike has everything to do 
with is the safety of their patients. With tears in their eyes, 
and I have been in the room, and I have seen the tears in their 
eyes, nurses have told me that they are simply unable to 
provide the quality of care they want to provide and the care 
their patients deserve.

    The reason for that is the totally inadequate nurse, 
patient ratios that they are forced to deal with. What nurses 
in New Jersey, Vermont, and all over this country have told me 
is they have been stretched to the breaking point.

    They tell me that they are stressed out. They are burnt out 
and are leaving the profession they love in droves because they 
are overworked, undervalued, and are forced each and every day 
to do more work with less resources.

    In a moment, we are going to be hearing from the nurses and 
experts on this panel about this crisis and what Congress can 
and should do about it. I also want everybody here to know that 
the Committee did not just invite nurses and union 
representatives to this hearing. I very much wanted to hear 
both sides of the story. I think it is important to hear what 
the hospital has to say.

    We invited Mr. Mark Manigan, the President of RWJ Barnabas 
Health, which owns the hospital, and Alan Lee, the CEO of the 
Robert Wood Johnson University Hospital to give us their views. 
We invited them.

    We have been discussing their coming here for many, many 
weeks. Unfortunately, while Robert Wood Johnson told the media 
that their executives would be attending this hearing and were 
eager to set the record straight--that is what they told in the 
Jersey media. They have both declined.

    They have both declined to be here today. So, let me, in 
their absence tell them what I would have asked them, some of 
the questions I would have asked them if they were here. I 
would have asked them why they have some 1,700 nurses out on 
strike for nearly 90 days to improve safety at a hospital 
system that made over $4 billion in revenue in the first 6 
months of this year.

    I would have asked them how their health care system could 
afford to spend over $100 million on traveling nurses since the 
strike began, but somehow cannot afford to mandate safe 
staffing ratios to improve the lives of patients and nurses at 
the hospital. I was also very curious to know how this 
nonprofit hospital could provide some $17 million in CEO 
compensation for one person in 2021.

    Those were a few of the questions we had in mind. Let's be 
clear, what the nurses at Robert Wood Johnson are asking for, 
and it is important to make this clear, is not a radical idea. 
All they are asking for is for this very large, nonprofit 
hospital chain to mandate the same nurse, patient ratios that 
the State of California mandated some 20 years ago, and nurses 
in New York City won as a result of a strike some 10 months 
ago.

    The research, and we are going to hear more about this from 
people who know more than I do, but the research on this issue 
is clear. After California mandated adequate staffing ratios at 
hospitals, patient safety went up, unnecessary deaths went 
down, the retention of nurses went up, and medical errors went 
down. In other words, the safe staffing law in California has 
not only saved lives, it has saved hospitals money.

    When hospitals are adequately staffed, they are safer, they 
are more effective, and they are more cost efficient. As the 
Chairman of the Committee, I am working hard in a bipartisan 
way to increase the number of nurses in this country and to 
retain the nursing workforce that we have. But at the end of 
the day, the people who are going to bring about the change are 
the people in the system themselves.

    For better or worse, nurses are much more respected than 
politicians. And you are the driving force behind change. I 
just want to conclude by simply saying it is rather 
extraordinary. I know going out on strike is not something that 
you do every day. You have never done it in your lives.

    The idea that you are willing to go without paychecks to 
deal with--to walk on picket lines, to deal with all of the 
stuff out there in order to protect your patients is rather 
extraordinary.

    On behalf of the American people, thank you. The first 
hear--the first panelists that we are going to hear from is 
Judy Danella. Judy has, as I understand it, worked at Robert 
Wood Johnson for 28 years, and is President of the United 
Steelworkers Local 4-200. Judy, the mic is yours.

  STATEMENT OF JUDITH DANELLA, RN, STAFF NURSE, RWJ BARNABAS 
HEALTH, PRESIDENT, UNITED STEELWORKERS LOCAL 4-200, PISCATAWAY, 
                               NJ

    Ms. Danella. Thank you, Chairman Sanders. Good morning, 
Chairman Sanders and every party participating here. Thank you 
for the opportunity to speak on this important issue of safe 
staffing. Again, my name is Judith Danella.

    I am first and foremost a staff nurse on Seven Tower in 
Robert Wood Johnson and President of Local 4-200, which 
represents 1,700 nurses at the Robert Wood Johnson facility in 
New Brunswick. As many people have noted, we are in the midst 
of a genuine crisis in the nursing profession.

    An estimate from the National Council of State Boards of 
Nursing suggest that roughly 100,000 nurses have left the 
profession since 2020, and New Jersey is estimated to be one of 
the top three states that will be understaffed in this Nation. 
Worse yet, the crisis was not limited to the COVID-19 pandemic.

    Rather, we are in dire straits. That same study also found 
that about 20 percent of current nurses were considering 
quitting their jobs. As frontline caregivers and nurses, we 
know that safe staffing is crucial to the health and well-being 
of our patients and our ability to provide quality, safe 
patient care.

    It is crucial to our patient satisfaction rates, nursing 
retention, safety, and the future of nursing. One of the main 
reasons we find ourselves in this situation is because of the 
chronic understaffing by hospitals, which has made the nursing 
profession increasingly unsafe, both for nurses and for 
patients.

    This dynamic creates a vicious cycle. Hospitals understaff 
their floors, which puts nurses in difficult, if not outright 
impossible situations, which can leave them spread too thin or 
at risk of getting hurt on the job, causing many nurses to 
quit, which only exacerbates our understaffing issues. In 
addition to making it more difficult to retain our existing 
workforce, this vicious cycle makes it harder to recruit new 
nurses.

    I have seen firsthand how the hospital prefers to hire 
younger nurses, often cheaper nurses to replace the experienced 
nurses who have quit because of burnout and injury. The results 
have been in to bring new nurses directly out of college, with 
no prior clinical experience, and put them directly on the 
hospital floor with five to six patients.

    Being a nurse is not an easy job. It requires a significant 
amount of training both for technical and emotional skills for 
the job. By throwing younger, inexperienced nurses straight 
into the deep end and providing them with minimal training and 
patients to cover, the hospital is setting them up for failure, 
only exacerbating the retention problem we face.

    According to the American Nurses Association, nearly one in 
five nurses, newly licensed nurses, quit within the first year, 
often citing stressful working conditions, lack of leadership 
and supervision, and understaffing in the facilities they 
leave.

    Let's be real clear, this issue of chronic understaffing is 
not the result of larger labor market forces, but it is a 
purposeful business decision by the hospitals. Cruelly, the 
hospital know this job is a vocation for us.

    We do this job because we love it, and we love our patients 
and our profession. The hospital knows we as nurses will do 
whatever it takes to provide the type of care our patients need 
and that the dedication that we have, and they use their 
dedication against us. Nurses go into the job for the patients, 
not for the money.

    We love our patients. We are there to serve our patients 
and take care of our patients and the families. 85 days ago, 
over 1,700 nurses said enough is enough. We made the painful 
decision to go out on an unfair labor practice strike for safe 
staffing.

    We are no longer willing to be compliant to a broken system 
where management puts profits over patients. These so-called 
nonprofit hospitals have more than enough money to invest in 
their workforce to ensure that we have safe staffing.

    Instead, again, they line their pockets with the excess 
profits that come from chronic understaffing. According to an 
analysis conducted by the Senate HELP Committee earlier this 
month, Robert Wood Johnson Barnabas paid their CEO more than 
$17 million compensation in 2021.

    Barnabas itself has already paid over $102 million on 
replacing--replacement nurses, paying them well in excess of 
what we earn on our job, and giving them better staffing ratios 
than we even ask for today. Clearly, the money is there to hire 
nurses, as well as investments that would work--the hospital a 
safer workplace, which would address the long term recruitment 
and retention issues. In closing, I want to emphasize this 
point.

    Safe staffing is not just some abstract concept. It 
literally improves patient care, keeps more nurses in the 
profession, and most importantly, saves lives. I want to thank 
you, Chairman Sanders, for your leadership in bringing this to 
the front and foremost attention.

    I appreciate the opportunity to speak at today's hearing, 
and I look forward to answering any questions you may have. 
Thank you very much.

    [The prepared statement of Ms. Danella follows.]
                  prepared statement of judith danella
    Chairman Sanders, thank you for the opportunity to speak on this 
important issue of safe staffing. My name is Judy Danella, and I'm the 
President of USW Local 4-200, which represents over 1700 nurses at 
Robert Wood Johnson University Hospital in here New Brunswick, NJ. I am 
also a full-time registered nurse at the hospital and have worked there 
for more than 28 years.

    As many people have noted, we are in the midst of a genuine crisis 
in the nursing profession. An estimate from the National Council of 
State Boards of Nursing suggested that roughly 100,000 nurses have left 
the profession since 2020. \1\ And New Jersey is estimated to be one of 
the top 3 states in the Nation with a nursing shortage.
---------------------------------------------------------------------------
    \1\  https://www.ncsbn.org/news/ncsbn-research-projects-
significant-nursing-workforce-shortages-and-crisis

    Worse yet, this crisis was not limited to the COVID-19 pandemic. 
Rather, we are still in dire straits: the National Council of State 
Boards of Nursing also found that about 20 percent of current nurses 
were considering quitting their jobs. \2\ As frontline caregivers and 
nurses, we know that safe staffing is crucial to the health and well-
being of our patients and our ability to provide quality, professional 
care. It is crucial to our patients' satisfaction rates, nursing 
retention, safety, and the future of nursing.
---------------------------------------------------------------------------
    \2\  Ibid.
---------------------------------------------------------------------------
         Chronic Understaffing Drives our Health Care Shortage
    One of the main reasons we find ourselves in this situation is 
because of chronic understaffing by hospitals, which has made the 
nursing profession increasingly unsafe--both for nurses and their 
patients.

    This dynamic creates a vicious cycle: hospitals understaff their 
floors, which puts nurses in difficult--if not, outright impossible--
situations, which can leave them spread too thin or at risk of getting 
hurt on the job, causing many nurses to quit, which only exacerbates 
the understaffing issue.

    In addition to making it more difficult to retain our existing 
workforce, this vicious cycle also makes it harder to recruit new 
nurses. I have seen it firsthand that hospitals now prefer to hire 
younger--often cheaper--nurses to replace the experienced professionals 
who have quit their jobs due to burnout or injury.

    The result has been to bring in young nurses directly out of 
college--many with no prior clinical training--and to put them directly 
on the hospital floor, with as many as 5 or 6 patients at a time. Being 
a nurse is not easy, and it requires a significant amount of training, 
both for the technical and emotional skills required to do the job.

    By throwing younger, inexperienced nurses straight into the deep 
end and providing them with minimal training and too many patients to 
cover at once, hospitals are setting them up for failure--only 
worsening the retention issues we face.

    According to the American Nurses Association, nearly 1 out of 5 of 
newly licensed nurses quit within their first year--often citing 
stressful working conditions, lack of leadership and supervision, and 
understaffed facilities as key reasons for leaving. \3\
---------------------------------------------------------------------------
    \3\  https://www.nursingworld.org/practice-policy/nurse-staffing/
why-nurses-quit/
---------------------------------------------------------------------------
              Chronic Understaffing is a Deliberate Choice
    Let's be clear: this issue of chronic understaffing is not the 
result of larger labor market factors, but is a purposeful business 
decision by the hospitals. Cruelly, the hospitals know this job is a 
vocation for many of us.

    Nurses go into the job for patients. It's not for money. We love 
our patients and the hospital knows whatever challenges we face on a 
daily basis, we will do what it takes to care for the patient and their 
families. Nurses wear many hats through the day and each and every day 
we serve the patient. And hospitals use that dedication against us.

    87 days ago, our 1700 nurses said enough is enough, and made the 
painful decision to go on strike here for safe staffing. We were no 
longer willing to be complicit in a broken system where management puts 
profits over patients. These so-called ``non-profit'' hospitals have 
more than enough money to invest in their workforce to ensure that they 
have sufficient staffing for their patients.

    Instead, they line their pockets with the excess profits generated 
from chronic understaffing. According to analysis conducted by the 
Senate HELP Committee earlier this month, RWJBarnabas paid its CEO more 
than $17 million in compensation in 2021. Also, RWJBarnabas themselves 
have announced that they've already paid more than $90 million to 
replacement travel nurses during the strike--paying them well in excess 
of what we earn on the job and giving them even better staffing ratios 
than we have. \4\
---------------------------------------------------------------------------
    \4\  https://www.rwjbh.org/landing-pages/rwjuh-community-letter/

    Clearly, the money is there to hire more nurses as well as other 
investments that would make hospitals safer workplaces, which would 
address the long-term recruitment and retention issues.
                         Policy Recommendations
    That is why we need Federal legislation to address the issues that 
nurses like myself and the other 1700 nurses in my local face every 
day. With that in mind, I want to call attention to two very important 
pieces of legislation.

    First, the Nurse Staffing Standards for Hospital Patient Safety and 
Quality Care Act introduced by Sen. Brown (D-OH) and Rep. Schakowksy 
(D-IL-09) would,

    among other things, set minimum nurse-to-patient staffing 
requirements. With a Federal floor for safe staffing, such legislation 
would free us up from having to bargain--or in our situation, go on 
strike--over safe staffing, allowing us to focus on what we do best: 
caring for our patients.

    Second is the Workplace Violence Prevention for Health Care and 
Social Service Worker Act that has been spearheaded by Sen. Baldwin (D-
WI) and Rep. Courtney (D-CT-02). This bill would provide a path for the 
Occupational Safety and Health Administration (OSHA) to design 
regulations so that hospitals are held accountable to ensure safe 
workplaces for all parties, including their nurses. When hospitals are 
understaffed, patients and their relatives can become agitated and lash 
out at nurses. We need the combination of safe staffing legislation 
with protections around workplace violence in order to fully address 
the challenges facing nurses today.

    The United Steelworkers (USW) has strongly supported both of these 
bills and hopes that today's hearing will renew a national conversation 
on each of them. Together, these two pieces of legislation would 
represent a significant step forward in fight to ensure dignity, 
safety, and compassion for nurses.
                               Conclusion
    In closing, I want to emphasize this point: safe staffing is not 
just some abstract concept: it literally improves patient care, keeps 
more nurses in the profession, and most importantly, saves lives. I 
want to thank you Chairman Sanders for your leadership and for bringing 
attention to this important issue.
                                 ______
                                 
    The Chair. Thank you, Ms. Danella. Our next witness is 
Carol Tanzi. Ms. Tanzi is a pediatric recovery room nurse at 
Robert Wood Johnson and a member of United Steelworkers Local 
4-200. Ms. Tanzi.

  STATEMENT OF CAROL TANZI, RN, BSN, PEDIATRIC RECOVERY ROOM 
             NURSE, RWJ BARNABAS HEALTH, EDISON, NJ

    Ms. Tanzi. Thank you, Chairman Sanders. My name is Carol 
Tanzi, and I want to thank you for holding this hearing. I am a 
nurse at Robert Wood Johnson, and I have been there for 25 
years, all of which have been understaffed.

    As Judith mentioned, it is not an easy job or very 
glamorous. It is a calling. It is important because I know 
these children and their families want to get back to living 
their lives, celebrating birthdays and playing with friends.

    My job is challenging, but I accept that and give my heart 
and soul every day. Being a nurse, there are moral, ethical, 
and legal obligations. I am bound by my New Jersey State 
license to uphold the highest standard of care for these human 
beings that are placed in my care. I am legally obligated to 
question anything that doesn't align with that very high 
standard.

    Furthermore, to stop anything that could potentially harm 
my patient, which includes standing up to physicians and 
executive leadership, both considered positions of power. 
Patients don't come to the hospital unless they are very sick 
and very vulnerable.

    Being a level one trauma center, one of three in New 
Jersey, these children are often the sickest of the sick, 
suffering from highly complex health conditions and all of that 
complexity can be very scary and confusing for patients and 
families.

    The only way to administer excellent care is by building a 
relationship forged in trust. I must make a connection with 
each patient and family to get them to trust that I will give 
the best care. Until that trust is established, I am a 
stranger.

    Every patient deserves and expects my full energy and 
attention. At that moment, their child is the most important 
thing in the world. My ability to devote the required time to 
each patient allows them to relax and know they are my 
priority.

    It also helps me to properly assess the child. We had a 
child who was in the maintenance phase of chemotherapy. He 
suffered with the same childhood cancer that his father 
survived. The anxiety that his family had over the child's 
condition was amplified times a million.

    The child was going for an MRI to monitor disease 
progression. While I was prepping him, his parents mentioned he 
had vomited twice. Not normal, but they assumed it was because 
of a long car ride and not eating or drinking. He was never 
very interactive with the staff because he was traumatized from 
so many hospital experiences.

    This morning he was just quiet for them. I asked a few more 
questions, last food or drink? Not sure. Any recent sick 
contacts? Well, he was at grandma's house the day before until 
8.30 p.m., fell asleep in the car, so they just put him to bed. 
Despite sleeping nine and a half hours, he was still quiet.

    I called the doctor to get an order for a blood sugar check 
and start an IV. This takes time. The blood sugar was 39, 
dangerously low. After calling the doctor back with results, 
starting an IV, and giving him a sugar solution, he started to 
behave more like himself. But during this time, my full energy 
and attention had to be here, explaining each step and 
answering questions.

    With an already skeleton crew, my other two patients were 
not ready to go for their procedures. I was now under attack by 
the operating room manager and surgical team because of the 
delay. It is a horrible ripple effect, and it is the status 
quo. The pressure to be everywhere at once while keeping 
everyone safe is enormous.

    This is physically and emotionally exhausting. I can't say 
no to any of the responsibilities, so I literally run ragged 
daily, still feeling like I haven't done enough. Nurses never 
turn their back on their patients. Never. This is our 
community, and we carry a huge amount of trauma and guilt 
because of it.

    All nurses know that the people making decisions are not 
the people providing care. They are often not even health care 
professionals. If these execs have a loved one in the hospital, 
they will have a dedicated nurse, or what is called a 1 to 1 
ratio. Not even close to what the rest of the public will get.

    While the hospital is pushing a narrative of the importance 
of family and community, their actions clearly say otherwise. 
Nurses are not about propaganda. Looking good on paper is not 
the goal. Delivering quality care is.

    Education is another extremely vital part of my job. I must 
be able to give the patient--the parents all of the information 
they need to be confidently taking care of their recovering 
child. Again, this takes time and should not be rushed or 
interpreted--I mean, interrupted. When you are short staffed, 
something is likely to be missed. If you are interrupted and 
can't get back quickly, stress levels rise.

    In the hospital environment, everything is good until it 
isn't. Every nurse has many stories, and they stay with us, our 
personal traumas. We know it can be better if we had more 
staff. It is common sense. It is not enough--it is not having 
enough nurses, nursing assistants, unit secretaries, 
environmental staff, transporters, patient monitors, and 
equipment is a recipe for disaster, and the consequences are 
being paid in human terms.

    This is an unfair labor practice strike, and it is about 
dignity and respect--where am I--for patients and workers. It 
is about the fundamental right to quality health care for 
everyone. We walked out in the ultimate demonstration of 
patient advocacy.

    We are sacrificing a salary because we could no longer be 
complicit with the Robert Wood Johnson toxic culture of 
understaffing and gaslighting when we do confront them. We know 
our patients deserve better, and so do we. The COVID health 
care heroes have been cast to the street.

    We no longer accept the weight of the guilt that comes with 
unsafe staffing. It is morally and ethically wrong, and we want 
to get back to the bedside but refuse to return with the status 
quo. Spending $100 million on replacement workers is not the 
answer. These scams are money driven just by the nature of what 
they do. We are invested in seeing this hospital be the best in 
the states.

    That is why we fight. It is mind boggling anyone could not 
want safe staffing, especially since money is no issue for this 
hospital. We demand robust and enforceable staffing provisions. 
We need strong recruitment and retention to be a priority, not 
leaving the nurses outside for 85 days and removing our health 
care benefits.

    We need real accountability by the hospital so that this 
health care crisis can be corrected. This hearing is so 
important. It is so overdue for us to have a serious national 
conversation about safe staffing in our largely failing health 
care system.

    Thank you, Chairman Sanders, for calling this hearing and 
giving me the chance to provide my testimony. Thank you for 
your fierce advocacy for all workers.

    [Technical problems]--I look forward to your questions.

    [The prepared statement of Ms. Tanzi follows.]
                   prepared statement of carol tanzi
    Chairman Sanders, my name is Carol Tanzi, and I want to thank you 
for holding this hearing. I am a proud member of USW Local 4-200 and a 
registered nurse in the Pediatric Recovery Room at Robert Wood Johnson 
University Hospital--where I have worked for the past 25 years.
                         Nursing is a Vocation
    During that time, there is one thing that keeps me coming back to 
work every single day--and that's the patient. Nursing is more than 
just a job for us: it's a calling. We do this work because we want to 
see our patients live the fullest, happiest versions of their lives 
possible. Being in the Pediatric Recovery Room, I care for the kids in 
the hospital. Kids who just want to go back to school and play with 
their friends.

    More than just working with the kids, my job as a nurse also 
involves me regularly attending to the needs of their parents, 
siblings, and relatives by meeting them on an individual level.

    Robert Wood Johnson University Hospital is 1 of 3 Level I Trauma 
Centers in the state. That means that these kids in my unit--as well as 
other patients in the hospital--are often the sickest of the sick, 
suffering from complex health problems.

    All of that complexity can be very confusing and scary for both the 
patient and their loved ones. The only way to administer excellent care 
is by building a relationship, forged in trust. I have to make a 
connection with each patient and family to get them to trust that I 
will take great care of them. This takes time and must not be rushed.

    This is why the job of a nurse often takes multiple forms. There is 
the literal, physical caring for these patients: checking their vitals, 
giving them medication, helping them move around the hospital, and 
coordinating all of their care.

    But there is also the emotional care we provide. As I said, given 
the complexity of health issues among our patient population, there are 
a lot of basic, human-level needs that patients and their families 
require: understanding the diagnosis they just received, cheering them 
up after a particularly brutal day of treatment, or dealing with the 
sadness that can come from having to miss birthdays, holidays, or 
anniversaries because they're in the hospital. Everyone deserves and 
expects my full energy and attention. At that moment, their child is 
the most important thing in the world.
           The Physical and Emotional Tolls of Understaffing
    All of this care takes a toll on us: being a nurse is physically 
and mentally exhausting, and it can often be a thankless job since 
we're dealing with people on their worst days. However, we know how 
important the care we provide is, and that is we continue to show up 
for our community every single day.

    I always like to remind people: everyone in this room either has 
been a patient, will be a patient, or has a loved one who has been a 
patient at some point in their life. If you have a good experience or a 
bad experience, it will very likely depend on how many other patients 
your nurse has to cover at that time.

    As nurses, we see members of our own community in this hospital 
every day: our family, our friends, our kid's elementary school 
teacher, a member of our church, and so on. It is for this reason that 
we see ourselves as an integral part of the greater New Brunswick 
community, and we take that responsibility to our community very 
seriously.

    It is reasonable to expect the highest level of care and attention 
for your own family member, and we as nurses strive to give the most 
dedicated, compassionate, and holistic care as possible to all of our 
patients. All nurses know that the people making decisions are not the 
people doing the patient care.

    If these hospital executives do have a loved one in the hospital, 
they will be sure to have one dedicated nurse for them, or a 1:1--not 
what the rest of the public gets. What we are asking for is really 
common-sense staffing: enough qualified nurses to care for the very 
sick patients we serve.

    Unfortunately, chronic understaffing significantly limits our 
ability to provide this level of care. That physical and emotional care 
we provide takes time. But when you are in charge of 5, 6, or 7 
patients at once, you sometimes literally do not have enough time to 
attend to all of the physical needs--let alone their emotional needs. 
That is not okay.
                        Caring for Our Community
    Remember: we did not go out on strike for higher wages or better 
benefits. Rather, we felt we could no longer participate in Robert Wood 
Johnson's toxic culture of understaffing that prevented us from 
providing the high level of care that our community deserves. We no 
longer want to accept the weight of the guilt that comes with unsafe 
staffing. We morally and ethically know it is wrong.

    I also want to highlight another point Judy made: she said the 
decision to go on strike was painful. It was painful. As I said, the 
patients in this hospital are a part of our own community.

    While the hospital talks about the importance of ``being a family'' 
and ``a community'', their actions clearly say otherwise. Instead of 
listening to us and investing in their own, they choose to pay millions 
of dollars to literally fly in travel replacement nurses from all over 
the country who probably could not place New

    Brunswick on a map before arriving here--let alone feel the 
personal connections that we do to our patients.

    It is literally in their name: travel nurses. They fly in from all 
over the country, look for a strike, and try to make a profit from it 
by being paid sometimes double what we were making. That is not a 
recipe for loyalty and integrity.

    Let me be clear: We want to be back in that hospital, taking care 
of our community in the expert and personal ways that only we know how.

    But we cannot do that without robust and enforceable staffing 
provisions. We need sustainable ratios and real accountability on the 
part of the hospital.
                         Policy Recommendations
    That is why we need Federal legislation to address the issues that 
nurses like myself and the other 1700 sisters in my local face every 
day. With that in mind, I want to call attention to two very important 
pieces of legislation.

    First, the Nurse Staffing Standards for Hospital Patient Safety and 
Quality Care Act introduced by Sen. Brown (D-OH) and Rep. Schakowksy 
(D-IL-09) would, among other things, set minimum nurse-to-patient 
staffing requirements. With a Federal floor for safe staffing, such 
legislation would free us up from having to bargain--or in our 
situation, go on strike--over safe staffing, allowing us to focus on 
what we do best: caring for our patients.

    Second is the Workplace Violence Prevention for Health Care and 
Social Service Worker Act that has been spearheaded by Sen. Baldwin (D-
WI) and Rep. Courtney (D-CT-02). This bill would provide a path for the 
Occupational Safety and Health Administration (OSHA) to design 
regulations so that hospitals ensure safe workplaces for all parties, 
including their nurses. When hospitals are understaffed, patients and 
their relatives can become agitated and lash out at nurses. We need the 
combination of safe staffing legislation with protections around 
workplace violence in order to fully address the issues facing nurses 
today.

    The United Steelworkers (USW) has strongly supported both of these 
bills and hopes that today's hearing will renew a national conversation 
on each of them. Together, these two pieces of legislation would 
represent a significant step in fight to ensure dignity, safety, and 
compassion for nurses.
                               Conclusion
    That is why this hearing is so important. It is long overdue for us 
to have a serious, national conversation about safe staffing in our 
health care system. Thank you Chairman Sanders for calling this hearing 
and giving me the chance to provide my testimony.
                                 ______
                                 
    The Chair. Thank you, thank you, Ms. Tanzi. Our next 
witness is Nancy Hagans, President of the National Nurses 
United and President of the New York State Nurses Association. 
Ms. Hagans.

  STATEMENT OF NANCY HAGANS, RN, PRESIDENT OF NATIONAL NURSES 
    UNITED, PRESIDENT OF NEW YORK STATE NURSES ASSOCIATION, 
                          BROOKLYN, NY

    Ms. Hagans. Good morning and thank you for giving me the 
opportunity to testify here today. Good morning, Senator 
Sanders.

    [Technical problems]--hey, good morning. And thank you for 
giving me the opportunity to testify here today.

    My name is Nancy Hagans, and I am the President of the New 
York State Nurses Association and the National Nurses United, 
the largest union and professional association of registered 
nurses in the country.

    The nursing workforce is in crisis. An increasing number of 
nurses don't work in hospitals anymore because their employers 
have made this job unsafe for patients and for us. We are 
exhausted. We are overwhelmed.

    We are suffering moral distress. The leading cause of this 
crisis is that hospital industry refuses to hire enough nurses 
to staff a unit safely. As President of NNU, I am constantly 
hearing from nurses who are severely short staffed. I know 
firsthand. I work in a surgical floor where our staffing ratios 
was 1 nurse to 18 patients. It was insane.

    That is more than four times what is scientifically safe. 
When nurses are understaffed, we don't have time to give our 
patients the care they need and the way they need it. As a 
result, our patients are on a high--on higher risk of 
preventable medical errors, avoidable complications, and even 
death. I have been in a situation where I know if I had fewer 
patients, I might have been able to save a patient's life. It 
is the worst feeling you can imagine.

    Those experiences lead to moral distress. The hospital will 
claim there is a nursing shortage. There aren't enough nurses 
to hire to provide safe staffing levels. That is a lie. There 
were approximately--there are approximately 1.2 million 
licensed registered nurses who were not employed in 2022.

    Here in New Jersey, they are over 56,000 active licensed 
registered nurses who are not employed as RN. There is no 
nursing shortage. There is a staffing crisis. If we want to 
solve the Nation's staffing in crisis, then we must increase 
nurse retention. To do that, the Government must mandate 
minimum nurse to patient ratio.

    California has proven that rations work. Since 2004, the 
ratio law in California has improved patient care and increased 
nurse retention. A 2010 study found that if California's ratio 
and medical surgical units were implemented in New Jersey, they 
would have seen 13.9 percent fewer deaths in the state.

    Hospital planned ratios would close them and are impossible 
to--[technical problems]--but California hospitals all came 
into compliance within 2 years. Despite all the evidence that 
shows the success of ratios, most employers will refuse to 
staff safely, which is why we are organizing to win staffing 
ratios.

    This past January, after extensive negotiation at the 
bargaining table about staffing rations, nearly 7,000 nurses in 
New York City went on strike. After 3 days, we won a historic 
contract that included enforceable nurse to patient ratios.

    Nurses here in New Jersey and many other states are taking 
similar actions, but we should not have to strike to win common 
sense solutions to put back our patients in our communities. It 
is the responsibility of the Government to enact the policies 
that will protect us.

    On behalf of the 225,000 nurses represented by NNU, I 
strongly urge this Committee to pass the 11--the S. 1113, the 
Nurse Staffing Standard for Hospital Patient Safety and Quality 
Care Act sponsored by Senator Sherrod Brown.

    This bill will establish mandatory minimum nurse to patient 
ratios modeled after the successful ratios in California. Every 
nurse and every patient across this country deserves the 
protection that staffing ratios provide.

    If we want to solve the crisis and improve patient care in 
our Nation's hospitals, nurse staffing ratios must be 
implemented. Thank you. Thank you, Senator.

    [The prepared statement of Ms. Hagans follows.]
                   prepared statement of nancy hagans
    Good morning and thank you, Chairman Sanders, Ranking Member 
Cassidy, and Members of the Committee, for giving me the opportunity to 
testify here today. My name is Nancy Hagans, and I am President of the 
New York State Nurses Association (NYSNA) and President of National 
Nurses United (NNU), the largest union and professional association of 
registered nurses (RNs) in the United States, representing nearly 
225,000 nurses across the country.

    The nursing workforce is in crisis. Years of industry neglect at 
the hands of our hospital employers, exacerbated by unsafe conditions 
during the ongoing pandemic, have left registered nurses feeling 
abandoned, morally distressed, and physically and emotionally 
exhausted.

    I have worked for almost 30 years at Maimonides Medical Center in 
Brooklyn, New York. Over the course of my career, the staffing 
situation in our hospitals has gotten worse, and in recent years, it 
has become completely unbearable.

    In my testimony today, I will be illustrating the impacts of 
understaffing on nurses and on patients, and the role that hospital 
management plays in perpetuating this crisis. Across the country, 
nurses have been taking collective action through their unions, both at 
the bargaining table and through legislative advocacy, to improve 
staffing levels in their hospitals. But RNs should not have to spend 
this amount of time and energy fighting for the scientifically proven, 
common sense solution to our staffing crisis. Congress must take action 
to establish mandatory minimum nurse-to-patient staffing ratios at all 
hospitals across the country.
 I. Short-staffing of registered nurses in acute-care hospitals harms 
                    both nurses and their patients.
    Every nurse in the United States has horror stories from being 
understaffed in their hospital units. When I began working on the 
surgical floor at Maimonides hospital, our staffing ratio was one nurse 
to 18 patients--it was an impossible situation. To put this in context, 
the recommended safe ratio in a medical surgical unit is one nurse to 
four patients. We were caring for more than four times the number of 
patients than scientific evidence demonstrates is safe.

    I moved to work in the ICU at my hospital, where I was caring for 
three critically ill patients at one time. The safe staffing ratio for 
the ICU is one nurse to two or fewer patients.

    As President of the largest nurses' union in the country, I 
regularly hear from nurses across the country who are dealing with the 
same situation I was.

    These short-staffing levels are dangerous for both patients and 
nurses.

    As a nurse, when you're severely understaffed, you do not have the 
amount of time with each patient that you need to provide quality 
patient care. You can't give patients their medications on time; you 
can't turn them to prevent bedsores at regular intervals; you can't 
answer their calls promptly when needed because you have multiple other 
patients calling you at the same time. As a result, there are injuries, 
illnesses, and deaths that occur because a nurse is unable to give a 
patient the care they need.

    I've been in situations where I know that if I had fewer patients, 
I might have been able to save a patient's life. It is the worst 
feeling you could imagine.

    To do my job as a nurse well, I need to have enough time with my 
patients. Registered nurses have extensive education and clinical 
experience that enables us to provide safe, effective, and therapeutic 
patient care. These standards of nursing care can only be accomplished 
through continuous in-person assessments of a patient by a qualified 
licensed registered nurse. Every time an RN interacts with a patient, 
we perform skilled assessment and evaluations of the patient's overall 
condition. These assessments are fundamental to ensuring that the 
patient receives optimal care. Subtle changes in a patient, for example 
in skin tone, respiratory rate, demeanor, or affect, can provide 
critical information about their health and well-being. When RNs are 
understaffed, this information can be easily overlooked or 
misinterpreted by those without an RN's education and clinical 
experience.

    Studies show that when RNs are forced to care for too many patients 
at one time, patients are at higher risk of preventable medical errors, 
avoidable complications, falls and injuries, \1\ pressure ulcers, \2\ 
increased length of hospital stay, higher numbers of hospital re-
admissions, and death. \3\ Numerous studies have documented disparities 
in care in hospitals that serve communities of color. \4\ Studies have 
also found that registered nurse staffing levels in hospitals that 
serve communities of color are often lower, contributing to these 
disparities in care. \5\
---------------------------------------------------------------------------
    \1\  Kim J, Lee E, Jung Y, Kwon H, Lee S. Patient-level and 
organizational-level factors influencing in-hospital falls. J Adv Nurs. 
2022 Nov;78(11):3641-3651. doi: 10.1111/jan.15254. Epub 2022 Apr 20. 
PMID: 35441709; PMCID: PMC9790490.
    \2\  Kim J, Lee JY, Lee E. Risk factors for newly acquired pressure 
ulcer and the impact of nurse staffing on pressure ulcer incidence. J 
Nurs Manag. 2022 Jul;30(5):O1-O9. doi: 10.1111/jonm.12928. Epub 2020 
Feb 25. PMID: 31811735; PMCID: PMC9545092.
    \3\  Aiken, L., et al. ``Hospital nurse staffing and patient 
mortality, nurse burnout, and job dissatisfaction.'' Journal of the 
American Medical Association. 2002; 288(16): 1987-93, 1990. (43 percent 
of RNs surveyed had high burnout scores, and a similar proportion were 
dissatisfied with their current job. Both burnout and job 
dissatisfaction are indicators of turnover.) Increased LOS, Mortality 
and Readmission: Dierkes, A. M., Aiken, L. H., Sloane, D. M., Cimiotti, 
J. P., Riman, K. A., & McHugh, M. D. (2022). Hospital nurse staffing 
and sepsis protocol compliance and outcomes among patients with sepsis 
in the USA: a multi-state cross-sectional analysis. BMJ Open, 12(3), 
e056802. https://doi.org/10.1136/bmjopen
    \4\  Carthon, J. M. B., Brom, H., McHugh, M., Daus, M., French, R., 
Sloane, D. M., Berg, R., Merchant, R., & Aiken, L. H. (2022). Racial 
Disparities in Stroke Readmissions Reduced in Hospitals With Better 
Nurse Staffing. Nurs Res, 71(1), 33-42. https://doi.org/10.1097/
    \5\  Lake, E. T., Staiger, D., Edwards, E. M., Smith, J. G., & 
Rogowski, J. A. (2017). Nursing Care Disparities in Neonatal Intensive 
Care Units. Health Serv Res. https://doi.org/10.1111/1475--6773.12762.

    In addition to the harm that short-staffing causes to our patients, 
it also harms nurses. The failure by hospital employers to staff 
appropriately and provide the needed resources make it impossible for 
registered nurses to meet their ethical and professional obligations to 
provide safe, effective, and therapeutic nursing care. \6\ These 
conditions have led nurses to experience severe moral distress and 
injury (often incorrectly labeled ``burnout''); mental health issues, 
such as stress, anxiety, depression, and post-traumatic stress 
disorder; and physical exhaustion. Unsafe staffing levels leave nurses 
with the burden of having to decide who gets their care, and who 
doesn't. When your patient is harmed because you did not have the time 
to care for them, it is devastating.
---------------------------------------------------------------------------
    \6\  National Nurses United. 2020. ``Deadly Shame: Redressing the 
Devaluation of Registered Nurse Labor Through Pandemic Equity.'' 
National Nurses United. https://www.nationalnursesunited.org/sites/
default/files/nnu/graphics/documents/1220--Covid19--DeadlyShame--
PandemicEquity--WhitePaper

    When nurses are understaffed, we often do not have time to go to 
the bathroom, or to take a lunch or coffee break, because we have too 
many patients to care for at one time. We are literally running around 
for 12 hours, trying to provide the best care we can to far too many 
patients. It is exhausting and deeply stressful. Patient care suffers 
when nurses do not have adequate rest and meal breaks-it's dangerous 
for a nurse to be working when exhausted. As nurses, our state licenses 
hold us responsible for the nursing patient assignment. When we are 
working in unsafe staffing levels, we are constantly worried that our 
---------------------------------------------------------------------------
license is at risk because we cannot possibly do our jobs well enough.

    Chronic short-staffing also increases the risks of workplace 
violence \7\ and musculoskeletal injuries. \8\ Workplace violence has 
become an epidemic in U.S. hospitals, with employees in health care and 
social service industries facing the highest rates of injuries caused 
by workplace violence of any industry. The delays in care caused by 
short-staffing can add increased stress and frustration for patients 
and families which can contribute to increased risk of violent 
incidents, while at the same time, nurses don't have enough staff to 
adequately respond to or help prevent violent incidents from occurring. 
\9\ We're also at a higher risk of incurring musculoskeletal injuries 
because there may not be the staff needed to help with patient lifting, 
which often forces the RN to unsafely lift a patient by themselves.
---------------------------------------------------------------------------
    \7\  Lipscomb J et al. 2004. ``Health Care System Changes and 
Reported Musculoskeletal Disorders Among Registered Nurses.'' Am J 
Public Health. 94(8):1431--36. https://www.ncbi.nlm.nih.gov/pmc/
articles/PMC1448467/.
    \8\  Lee S et al. 1999. ``Work-related Assault Injuries Among 
Nurses.'' Epidemiology. 10(6):685-91. https://pubmed.ncbi.nlm.nih.gov/
10535781/.
    \9\  Fernandes, C. et al. The Effect of an Education Program on 
Violence in the Emergency Department. Annals of Emerg. Medicine. 2002; 
39(1):47-55. A 2002 study found that interactive, hands-on workplace 
violence recognition and intervention training can be effective in 
reducing violence incident rates and, importantly, that refresher 
trainings are needed to maintain those effects.
---------------------------------------------------------------------------
   II. The hospital industry intentionally implements short-staffing 
       levels to reduce labor costs and increase profit margins.
    At the heart of the horrific working conditions we experience are 
the hospital industry's intentional policies of short-staffing, a cost-
cutting measure that has allowed hospital employers to save money on 
labor costs at the expense of quality patient care and nurse health and 
safety. The utter disregard for RNs health, safety, and lives by 
hospital employers became apparent early in the Covid-19 pandemic. It 
was clear then as it remains now that hospital employers will 
prioritize their profit margins over the health and safety of nurses 
and patients.

    Labor is the largest cost in any hospital. To increase profit 
margins, hospital employers deliberately refuse to staff our Nation's 
hospitals with enough nurses to provide quality patient care. Hospitals 
often refuse to hire nurses (even during a pandemic), call nurses off a 
shift after they've already come in to work, and knowingly ask for 
fewer nurses than necessary to care for patients. In NNU's most recent 
survey of more than 2,800 nurses from Sept. 22 through Nov. 28, 2022, 
56.8 percent of hospital nurses reported that staffing has gotten 
slightly or much worse recently and nearly half of hospital nurses 
reported that their facility is using excessive overtime to staff 
units.

    For several decades, the hospital industry has attempted to deskill 
the nursing profession by inappropriately pushing care to the lowest-
cost and least-regulated setting, including displacing RNs with 
unlicensed or lower-licensed staff. Further, the industry has been 
replacing RN professional judgment with health information technology, 
automation, remote monitoring tools, and ``acute-care hospital-at-
home'' programs where patients are forced to rely on family members or 
themselves to provide complex clinical care that they have no training 
or licensing to provide. The hospital industry's attempts to break down 
registered nursing practice into tasks (often called 
``routinization''), and shift the tasks to unlicensed and lower-
licensed staff (i.e., deskilling) to reduce labor costs, undermines 
safe patient care.
   III. The impacts of unsafe staffing levels are causing registered 
  nurses to leave bedside nursing in acute-care hospitals, creating a 
                       national staffing crisis.
    Hospital employers have been perpetuating the false narrative that 
there is a ``shortage ``of registered nurses in the United States. They 
claim that they cannot hire enough nurses to staff appropriately and 
safely. First and foremost, it is imperative that we clarify that there 
is not a national shortage of registered nurses in the U.S., and we can 
prove this by looking at national employment and licensure data.

    According to statistics from the National Council of State Boards 
of Nursing and the U.S. Bureau of Labor Statistics, there were 
approximately 1.2 million licensed registered nurses who were not 
employed as RNs in 2022. The trend continues when you look at state 
specific data as well. Here in New Jersey, there are over 56,000 
actively licensed registered nurses who were not employed as RNs in 
2022. In New York, more than 175,000 actively licensed registered 
nurses are not currently working. In a 2022, NNU survey, more than half 
of nurses (55.5 percent) surveyed reported that they have considered 
leaving nursing.

    We know that while the nursing workforce pipeline can and should be 
strengthened, in particular to diversify the nursing workforce and 
increase the number and diversity of preceptors and nursing school 
faculty, the key problem in our staffing crisis is not the number of 
graduating RNs. Every year the United States continues to graduate more 
new nurses out of nursing school than ever before. \10\ Experts project 
that over the next decade, the national RN workforce will not only 
replace the expected 500,000 retiring RNs but expand the workforce by 
almost one million registered nurses. \11\ At the same time, data from 
2019 to 2022 shows that the entirety of growth in RN employment during 
that period has occurred outside of hospitals and instead into other 
settings like outpatient clinics and doctors' offices. \12\
---------------------------------------------------------------------------
    \10\  National Council of State Boards of Nursing. 2009-20. ``NCLEX 
Pass Rates.'' National Council of State Boards of Nursing. https://
www.ncsbn.org/exams/exam-statistics-and-publications/nclex-pass-
rates.page.
    \11\  Buerhaus, P. I., Staiger, D. O., Auerbach, D. I., Yates, M. 
C., & Donelan, K. (2022). Nurse Employment During The First Fifteen 
Months Of The COVID-19 Pandemic. Health Affairs, 41(1), 79-85. https://
doi.org/10.1377/hlthaff.2021.01289.
    \12\  Ibid.

    As demonstrated by national data, we don't have a ``nurse 
shortage,'' but we do have a staffing crisis in our hospitals, brought 
on by the lack of good nursing jobs where RNs are valued for their 
work, have strong health and safety protections, and are not required 
to care for more patients at any given time than is safe for optimal, 
---------------------------------------------------------------------------
therapeutic care.

    Hospital employers can hire enough RNs to safely care for our 
patients, but for decades they have refused to do so. Instead, they 
continue to ask nurses to do more with less, putting our patients in 
danger. As a result, many nurses are leaving the hospital bedside.
   IV. Mandatory minimum nurse-to-patient ratios will increase nurse 
                  retention and improve patient care.
    There are decades of scientific evidence that demonstrates mandated 
minimum nurse-to-patient ratios save lives. California is the only 
state in the country that has an RN-to-patient ratios statute that 
covers every acute-care hospital unit and department. The fight to win 
legislation in California was a decade-long fight that was successful 
in 1999 because of an extensive grassroots campaign led by union nurses 
at the California Nurses Association, an NNU affiliate. Despite 
opposition from the hospital industry, the nurses in California won the 
ratios law, which established the gold-standard for mandatory minimum 
nurse staffing ratios, and regulations were implemented in 2004.

    Now, nineteen years after implementing minimum nurse-to-patient 
ratios in California, a multitude of studies confirm the significant 
impact that mandatory, minimum staffing ratios have had on improving 
patient outcomes. A seminal study from 2010 compared California 
hospitals' post-implementation of the ratios law to hospitals in other 
states, including the state of New Jersey where this hearing is being 
held. The study found that if California's ratios in medical surgical 
units were implemented, New Jersey would have 13.9 percent fewer 
patient deaths. \13\ A more recent study found that last year, patients 
in California hospitals received on average three more hours of nursing 
care than hospitalized patients in other states. \14\ If the ratios 
mandate was implemented nationally, research estimates that thousands 
of lives would be saved each year. The California ratios mandate has 
proven to reduce costs for hospitals by improving nurse safety and job 
satisfaction, \15\ reducing spending on temporary RNs, \16\ overtime 
costs, \17\ and staff turnover. \18\ Nurses from other states flock to 
California because the working conditions are so much better than the 
rest of the country.
---------------------------------------------------------------------------
    \13\  Aiken L et al. 2010. ``Implications of the California Nurse 
Staffing Mandate for Other States.'' Health Services Research. 
45(4):204-21. https://onlinelibrary.wiley.com/doi/10.1111/
    \14\  Dierkes, A., Do, D., Morin, H., Rochman, M., Sloane, D.M., 
McHugh, M.D. (2021). The impact of California's staffing mandate and 
the economic recession on registered nurse staffing levels: A 
longitudinal analysis. Nursing Outlook, 70(2):219-227
    \15\  Spetz J. 2008. ``Nurse Satisfaction and the Implementation of 
Minimum Nurse Staffing Regulations.'' Policy Polit Nurs Pract. 9(1):15-
21. https://pubmed.ncbi.nlm.nih.gov/18390479/.
    \16\  Schmit, J. ``Nursing shortage drums up demand for happy 
nomads.'' USA Today. June 9, 2005. (Quoting Tenet Health System Chief 
Nursing Officer. Travel nurses cost hospitals at least 20 percent more 
than a nurse employee even when benefits are factored in. Full-time 
employees are paid at least 1.5 times their regular salary for overtime 
hours worked.)
    \17\  Ibid.
    \18\  Bland-Jones, Cheryl. ``Revisiting Nurse Turnover Costs, 
Adjusting For Inflation.'' Journal of Nursing Administration. 2008; 
38(1): 11-18, 12. (Finding that the total RN turnover costs for fiscal 
year 2017 were between $7,875,000 and $8,449,000, and estimating an RN 
annual turnover rate at 18.5 percent.) Aiken. 2010. supra, note 5 at 
913. (Finding that California RNs, after the implementation of the 
mandated nurse-to-patient ratios, experienced burnout at significantly 
less rates than those in New Jersey and Pennsylvania. 20 percent 
California RNs reported being dissatisfied with their job, compared to 
26 percent in New Jersey, and 29 percent in Pennsylvania. Both burnout 
and job dissatisfaction are precursors of voluntary turnover.)

    Nurses in other parts of the world are also taking up the fight for 
safe staffing ratios. The Center for Health Outcomes and Policy 
Research in Queensland, Australia conducted one of the most prominent 
studies on nurse-to-patient-ratios legislation and it's impacts on 
health outcomes that was funded by the government of Queensland. 
Considered the ``gold standard'' in scientific literature regarding 
nurse staffing, the study evaluated health outcomes before and 2 years 
after the implementation of the state staffing ratios law. Published by 
The Lancet, the study found that mandated minimum RN-to--patient ratios 
prevented thousands of hospital deaths annually, and saved hospitals 
millions of dollars by reducing average length of stay and rates of 
readmissions within thirty days of leaving the hospital. \19\
---------------------------------------------------------------------------
    \19\  McHugh MD, Aiken LH, Sloane DM, Windsor C, Yates P. 2021. 
Nurse staffing and patient mortality, readmissions, and length of stay: 
a prospective study of the effects of nurse-to-patient ratio 
legislation in a panel of hospitals. The Lancet. May 11, 2021: https://
doi.org/10.1016/S0140--6736(21)00768--6

    Despite the abundance of evidence that shows the success of minimum 
nurse staffing ratios, most hospital employers continue to refuse to 
implement safe staffing levels. The hospital industry continues to use 
the same arguments against nurse staffing ratios that they used before 
the California ratios law was passed. However, these arguments are 
---------------------------------------------------------------------------
easily dispelled by the success of the California law.

    Hospital employers often claim that ratios laws would force 
hospitals to close, and that nurse ``shortages'' would prevent 
hospitals from being able to meet ratio mandates. These criticisms 
proved false in the implementation of the ratios law in California. 
Just 2 years after the California law went into effect, California 
hospitals were in compliance with the ratios a super-majority of the 
time. The majority of safety-net hospitals, including rural hospitals 
with generally lower patient levels, were also in compliance. \20\ Of 
the 69 hospitals defined as rural acute-care facilities in California 
by the Department of Health Services, only 16 applied for an exemption 
to the law in 2004, and just 11 exemptions were granted. \21\ In the 
years since, these hospitals have been in compliance.
---------------------------------------------------------------------------
    \20\  Aiken, L. H. (2010). The California nurse staffing mandate: 
implications for other states. LDI Issue Brief, 15(4), 904-921.
    \21\  Lauer, G. ``Reaction To Nurse Staffing Rules Generally 
Favorable.'' California Healthline. October 25, 2004.
---------------------------------------------------------------------------
 V. In the absence of Federal regulation, Registered Nurses across the 
    country are organizing collectively to win safe staffing ratios.
    Across the country, registered nurses are sick and tired of being 
undervalued by our hospital employers. We want the best care for our 
patients, and to deliver that care, we need safe and healthy 
workplaces. So, we are organizing collectively to win safe staffing 
ratios.

    That is why nearly 7,000 New York nurses with the New York State 
Nurses Association went on strike this past January. Nurses at 
Montefiore Bronx and Mount Sinai Hospital in Manhattan went on strike 
to win staffing ratios.

    The strike came after a years-long legislative battle at the state 
level. In 2021, we passed laws that established a process for setting 
and enforcing staffing standards at every hospital and nursing home--no 
matter if the facility is public or private, union or non-union. This 
law laid the groundwork for us to more effectively fight for numerical 
staffing ratios in our contracts.

    After extensive negotiations at the bargaining table about staffing 
ratios and enforcement, we ended up going on strike.

    It takes a lot for nurses to decide to strike. If nurses are going 
on strike, then you know something is really wrong inside the hospital. 
We went on strike because it was our only option to fight for safe 
nurse-to-patient staffing ratios.

    We went on strike for 3 days in New York City. We had incredible 
support not only from New Yorkers, but from people all over the country 
and the world. After 3 days on strike, we won historic contracts that 
include enforceable nurse-to-patient staffing ratios with expedited 
arbitration and potential financial penalties payable to nurses when 
employers fail to uphold contractual safe staffing standards. It was a 
significant win for nurses in New York and we're going to continue to 
use our contract negotiations to win safe patient ratios and strong 
staffing enforcement at other hospitals in New York.

    We're not the only nurses taking strike action to make this happen. 
Nurses in Kansas, Texas, Minnesota, and many other states have been 
taking similar actions to win staffing ratios.
   VI. Congress must pass Federal legislation to establish mandatory 
   minimum nurse--to-patient ratios in order to improve the staffing 
                                crisis.
    Nurses should not have to go on strike to win common sense policy 
solutions that will improve patient care for everyone in our 
communities. We should be focusing on our patients and on health care. 
But the greed of our employers and the negligence of our elected 
officials has left us with no other choice.

    Instead, Congress must step up and take action to give nurses and 
patients basic protections. We strongly urge this Committee to swiftly 
pass S. 1113, the Nurse Staffing Standards for Hospital Patient Safety 
and Quality Care Act of 2023 sponsored by Senator Sherrod Brown. The 
bill would establish mandatory minimum staffing ratios based on the 
successful ratios that have been implemented in California. It would 
require hospitals to develop annual safe staffing plans that meet the 
bill's minimum staffing ratios, and it would require hospitals to 
provide additional staffing based on individual patient care needs. 
Hospitals would be required to post notices on minimum ratios and 
maintain records on RN staffing. The bill provides whistleblower 
protections for nurses who speak out against assignments that are 
unsafe for the patient or the nurse, and it authorizes the Secretary of 
Health and Human Services to enforce the minimum RN staffing ratios 
through administrative complaints and civil penalties.

    On behalf of the 225,000 registered nurses represented by National 
Nurses United, I strongly urge the Committee to work to improve patient 
care, protect our nurses, and solve the nurse staffing crisis in this 
country, by implementing safe staffing nurse-to-patient ratios in every 
hospital in this country.
                              ATTACHMENTS
          1. National Nurses United, Letter of Support of the Nurse 
        Staffing Standards for Hospital Patient Safety and Quality Care 
        Act, H.R. 2530

          2. National Nurses United, Proposed Congressional Actions to 
        End the Industry-Created Nurse Staffing Crisis

          3. National Nurses United, Written Testimony to Senate 
        Health, Education, Labor, and Pensions Committee in advance of 
        hearing titled, ``Examining Health Care Workforce Shortages: 
        Where Do We Go from Here?''

          4. National Nurses United, Protecting Our Front Line: Ending 
        the Shortage of Good Nursing Jobs and the Industry-created 
        Unsafe Staffing Crisis. Available at https://
        www.nationalnursesunited.org/sites/default/files/nnu/documents/
        1121--StaffingCr isis--ProtectingOurFrontLine--Report--
        FINAL.pdf

          5. National Nurses United, RN Staffing Ratios: A Necessary 
        Solution to the Patient Safety Crisis in U.S. Hospitals. 
        Available at https://www.nationalnursesunited.org/sites/
        default/files/nnu/graphics/documents/NNU--Ratios--White--
        Paper.pdf

          6. National Nurses United, Deadly Shame: Redressing the 
        Devaluation of Registered Nurse Labor Through Pandemic Equity. 
        Available at https://www.nationalnursesunited.org/sites/
        default/files/nnu/graphics/documents/1220--Covid19--
        DeadlyShame--PandemicEquity--WhitePaper

                                 ______
                                 
                  [summary statement of nancy hagans]
    The nursing workforce is in crisis. Years of industry neglect at 
the hands of our hospital employers, exacerbated by unsafe conditions 
during the ongoing pandemic, have left registered nurses feeling 
abandoned, morally distressed, and physically and emotionally 
exhausted. Intentional short-staffing in hospitals has been the leading 
cause of this nurse staffing crisis. In my testimony, I will illustrate 
the following:

          I. Short-staffing of registered nurses in acute-care 
        hospitals harms both nurses and their patients. As a nurse, 
        when you're severely understaffed, you do not have the amount 
        of time with each patient that you need to provide quality 
        patient care. As a result, there are injuries, illnesses and 
        deaths that occur because a nurse is unable to give a patient 
        the care they need. These conditions have led nurses to 
        experience severe moral distress and injury, and put them at 
        higher risk for workplace violence and musculoskeletal 
        injuries.

          II. The hospital industry intentionally implements short-
        staffing levels to reduce labor costs and increase profit 
        margins. Labor is the largest cost in any hospital. To increase 
        profit margins, hospital employers deliberately refuse to staff 
        our Nation's hospitals with enough nurses to provide quality 
        patient care.

          III. The impacts of unsafe staffing levels are causing 
        registered nurses to leave bedside nursing in acute-care 
        hospitals, creating a national staffing crisis. According to 
        national employment and licensure data, there were 
        approximately 1.2 million licensed registered nurses who were 
        not employed as RNs in 2022. While the nursing workforce 
        pipeline can and should be strengthened, the key problem in our 
        staffing crisis is not the number of graduating RNs. Hospital 
        employers can hire enough RNs to safely care for our patients, 
        but for decades they have refused to do so. Instead, they 
        continue to ask nurses to do more with less, putting our 
        patients in danger. As a result, many nurses are leaving the 
        hospital bedside.

          IV. Mandatory minimum nurse-to-patient ratios will increase 
        nurse retention and improve patient care. There are decades of 
        scientific evidence that demonstrates mandated minimum nurse-
        to-patient ratios save lives. California is the only state in 
        the country that has an RN-to-patient ratios statute that 
        covers every hospital unit. These regulations were implemented 
        in 2004 after an extensive grassroots campaign led by union 
        nurses in California. The California regulations are the gold-
        standard for mandatory minimum nurse staffing ratios. In the 
        years since, numerous studies have shown that the staffing 
        ratios have improved patient outcomes and nurse retention 
        rates.

          V. In the absence of Federal regulation, Registered Nurses 
        across the country are organizing collectively to win safe 
        staffing ratios. Across the country, registered nurses are sick 
        and tired of being undervalued by our hospital employers. We 
        want the best care for our patients, and to deliver that care, 
        we need safe and healthy workplaces. So, we are organizing 
        collectively through collective bargaining and strikes to win 
        safe staffing ratios in my State of New York, and in countless 
        other states across the country.

          VI. Congress must pass Federal legislation to establish 
        mandatory minimum nurse to patient ratios in order to improve 
        the staffing crisis. Nurses should not have to go on strike to 
        win common sense policy solutions that will improve patient 
        care for everyone in our communities. We should be focusing on 
        delivering care to our patients. Congress must pass S. 1113, 
        the Nurse Staffing Standards for Hospital Patient Safety and 
        Quality Care Act, to establish mandatory minimum nurse staffing 
        ratios at all hospitals across the country.

    The Chair. Thank you, Ms. Hagans. Our next witness is 
Debbie White, President of the Health Professionals and Allied 
Employees Union.

STATEMENT OF DEBBIE WHITE, RN, PRESIDENT, HEALTH PROFESSIONALS 
               AND ALLIED EMPLOYEES, MARLTON, NJ

    Ms. White. Thank you, Chairman Sanders, for organizing this 
crucial hearing. I am Debbie White. I have been a nurse for 35 
years. I am also President of HPAE, the largest health care 
union in the State of New Jersey.

    We represent 14,000 health care professionals across the 
state. First, I want to say, steelworkers, you are my heroes, 
and we stand in support. I am also an AFT vice president, and 
Randy says, hi, Chairman, and greetings on behalf of AFT's 
200,000 health care professionals. My colleagues here mirror 
the experiences of our HPAE members.

    I have also talked in detail to my colleagues across the 
country. I have heard the same exact stories in Alaska, Oregon, 
Montana, Ohio, Connecticut, Pennsylvania, and many others where 
we are represented. Hospitals are in crisis.

    Why? Because nurses aren't going to stay at the bedside. We 
have 140,000 licenses, nursing licenses in the state, and only 
a small percentage, 70,000, are willing to work in the 
hospitals. Not simply because of the pandemic, and we all know 
the pandemic was horrific. But it is the straw that broke the 
camel's back, but it goes much further back than this. It goes 
back to the corporatization of health care.

    Whether for profit or nonprofit, health care has become big 
business. What is the goal of big business? Make money. We make 
money off your sickness in this country. In New Jersey, most of 
our hospitals have made tremendous profits even during the 
pandemic.

    One would think then the primary focus for spending those 
profits would be on staffing. Instead, and this has gone on for 
decades, nursing care, in fact all hospital health care is a 
line item budget cut to its lowest number in order to maximize 
profits to spend elsewhere.

    Hospital management and corporations that run hospitals are 
too often focused on adding a new fountain in the lobby and 
other esthetics or paying for glossy advertisements and million 
dollar Super Bowl ads, rather than building up staff. Oh, and 
have I mentioned they are also spending a lot on anti-union 
firms.

    [Technical problems]--lobbying efforts against safe 
staffing laws and replacement costs during strikes. And by the 
way, this employer should be embarrassed to tell the public 
what they have spent on replacement costs. They should be a 
shame.

    Last year, HPAE contracted with Change Research to survey 
nurses in the State of New Jersey who work in hospitals and 
here is what we found. 30 percent of the nurses that we 
surveyed are no longer--they have left hospitals.

    They are no longer a hospital nurses. Of the 70 percent 
that remain, 72 percent have recently considered leaving. Most 
troubling is this. Of those with 0 to 5 years? experience, 95, 
95 say they are likely to leave soon. The No. 1 reason, poor 
staffing. The second is burnout related to poor staffing.

    We can't retain nurses in hospitals because of 
understaffing. Yes, we need to recruit nurses into the 
profession. Of course, we do, and we need to recruit educators 
as well. But without addressing retention, that is, stopping 
the migration out of hospitals, it is as if we are trying to 
fill a bucket full of holes with water.

    Those holes are the working conditions of our nurses. So, 
we are laser focused on staffing--on this staffing crisis and 
the solution. The AFT staffing campaign is called Code Red and 
has resulted in safe staffing laws in Oregon and Connecticut, 
among other states. The Pennsylvania bill for safe staffing is 
likely to pass in the second House.

    All of these bills will result in enforceable staffing 
ratios for nursing. Health care unions, we are leading the way, 
make no mistake about it. By now, we have all heard the slogan, 
safe staffing saves lives. It is true, though. We have 20 
years? worth of data since California adopted safe staffing 
legislation.

    The data is clear. The staffing law California did 
increase--did decrease, excuse me, patient deaths, did decrease 
negative outcomes for patients like hospital acquired 
infections, bedsores, and medical errors. It did decrease 
injuries both for patients and nurses. And it did increase 
retention of nurses at the bedside.

    All of this saved hospitals millions. So safe staffing 
saves money. However, we have seen that hospitals will not be 
good actors. They will never, as you can see by my colleagues 
here who are missing, never agree to safe staffing on their 
own. It is why we need legislation. We need laws to force 
hospitals to staff safely.

    We have our own bill here in New Jersey, supported by 
steelworkers, and all other unions in the State of New Jersey. 
It is S304 and 84536. We are encouraged by the success of other 
states.

    We are encouraged by the attendance in this room. Chairman, 
with your help, we will be able to save first California, then 
Oregon, now New Jersey. Thank you.

    [The prepared statement of Ms. White follows.]
                   prepared statement of debbie white
    Good morning,

    Thank you, Chairman Sanders, for organizing this crucial hearing. I 
am Debbie White; I have been a nurse for 35 years. I am also president 
of the Health Professionals and Allied Employees, which is the largest 
healthcare union in New Jersey, representing 14,000 healthcare 
professionals across the state. I am also a vice president of the 
American Federation of Teachers.

    HPAE is an affiliate of the AFT, the fastest-growing healthcare 
union in the country and second to our sister union, National Nurses 
United, in the number of nurses represented. AFT President Randi 
Weingarten sends her greetings and thanks you on behalf of the AFT's 
200,000 healthcare professionals.

    Over the past few months, HPAE has stood with our heroes, the 
United Steelworker nurses of Robert Wood Johnson University Hospital, 
because we know that the experiences of those on this panel are also 
the stories of HPAE nurses throughout New Jersey and nationwide. As an 
AFT vice president, I have talked in detail to my colleagues across the 
country and have heard the same stories in Alaska, Connecticut, 
Montana, Ohio, Oregon, Pennsylvania and others.

    Healthcare is in crisis. Not simply because of the pandemic, 
although that was the proverbial straw that broke the camel's back. No, 
it goes much further back to the corporatization of healthcare. In 
other words, healthcare corporations have become big business, and the 
goal of big business is to make a profit.

    Whether for-profit or nonprofit, hospitals are all in the business 
of making money. And in New Jersey, most of our hospitals have made 
tremendous profits--even during the pandemic. One would think the 
primary focus for spending those profits would be staffing. Instead--
and this has gone on for decades--nursing care, in fact all bedside 
care, is a line item in a budget cut to its lowest number to maximize 
profits. Hospital management, and the corporations that run hospitals, 
are too often focused on adding a new fountain in the lobby or paying 
for glossy advertisements instead of building up staff. They also spend 
millions on anti-union firms and lobbying efforts against safe staffing 
laws. Nurses know what safe staffing looks like, because they live it. 
But pleas for more staff go unmet because, and I'm quoting, ``it's not 
in the budget.''

    Nurses and all healthcare workers were burned out and stressed out 
prior to the pandemic. Thus, when they were met with the deadly and 
horrific working conditions during and after the pandemic, they left 
hospitals in droves.

    Last year HPAE contracted with Change Research to survey nurses in 
New Jersey who work in hospitals, and here is what we found:

          30 percent are no longer hospital bedside nurses.

          Of the 70 percent who remain in our hospitals, 72 
        percent have recently considered leaving.

          And most troubling, of those with 0-5 years' 
        experience, 95 percent report that they are likely to leave.

    The No. 1 reason nurses leave is poor staffing. The second reason 
is burnout and stress, also mostly due to poor staffing.

    I would assert that understaffing has driven our healthcare system 
to the brink of collapse. Frontline healthcare workers are leaving the 
bedside at an alarming rate because of untenable working conditions. In 
the HPAE 2022 survey:

          83 percent of nurses said staffing levels put their 
        license at risk.

          77 percent said quality of care is getting 
        progressively worse.

    Every patient, every citizen, every legislator should be alarmed at 
these statistics.

    Along with many other AFT affiliates and other healthcare unions, 
we decided to put our primary focus on this staffing crisis. The AFT 
staffing campaign is called Code Red and has resulted in legislation in 
Connecticut and Oregon, among other states. Legislation in 
Pennsylvania, which mirrors the Oregon law and was championed by the 
Pennsylvania Association of Staff Nurses and Allied Professionals and 
the Service Employees International Union, has passed through the House 
and is making its way through the Senate. Healthcare unions are leading 
the way. We want to be next in New Jersey.

    Why? Because we cannot retain nurses, and they will continue to 
migrate out of hospitals because staffing is poor. We do need to 
recruit into the profession, of course. But without addressing 
retention (that is, stopping the migration out of our hospitals), it's 
as if we are trying to fill a bucket full of holes with water. Without 
addressing the reasons for the migration, we will never stem the tide.

    By now, we've all heard ``Safe staffing saves lives.'' It is the 
mantra of every nurse in the country. But it is also truth. We have 20 
years' worth of data, since California adopted a safe staffing law, 
that shows the benefits of adequate nurse-to-patient ratios. The data 
is clear: The staffing law in California decreased patient deaths; 
decreased negative outcomes for patients, like hospital-acquired 
infections, bed sores and medical errors; decreased injuries for nurses 
and patients; increased retention of nurses (saving hospitals millions 
in orientations); and was cost-effective for hospitals.

    However, we have seen that hospitals will not be good actors on 
their own and agree to ratios--as you can see by the willingness of 
Robert Wood Johnson University Hospital to spend millions to refuse to 
settle this contract with its nurses. It has advertised the millions it 
has spent fighting the people it has referred to as ``healthcare 
heroes.'' The hospital should be ashamed to reveal this to the public. 
But it does highlight the lengths our healthcare corporations are 
willing to go to fight against safe staffing. It also highlights why we 
need staffing laws.

    Lobbying groups for corporations that own hospitals--both for-
profit and nonprofit--continue to work hard to beat back legislative 
solutions to the staffing crisis. Lobbyist groups like the American 
Hospital Association and the New Jersey Hospital Association, as well 
as the hospitals themselves, spend millions in profits to fight back 
against safe staffing bills. It is the healthcare unions (that is, the 
frontline healthcare workers) across the country that are speaking up 
for nurses. And when we speak up for nurses, we speak up for patients.

    We need laws to force hospitals and other healthcare institutions 
to staff safely. This strike is a test case for all hospitals. In my 
opinion, Robert Wood Johnson has failed the test. Ultimately, we can 
avoid more strikes like this one by passing legislation that mandates 
safe staffing. It is why HPAE, the Steelworker Union nurses, and every 
New Jersey union have been pushing the State Legislature to pass NJ-
S304 in Trenton to mandate enforceable staffing ratios. It is the 
solution.

    We are encouraged by the success of other states. We are encouraged 
by the crowd in this room. Chairman, with your help we will be able to 
say first California, then Oregon, now New Jersey.

    Thank you, sir.
                                 ______
                                 
                  [summary statement of debbie white]
    I am Debbie White; I have been a nurse for 35 years. I am also 
president of Health Professionals and Allied Employees, which is the 
largest healthcare union in New Jersey, representing 14,000 healthcare 
professionals. HPAE is an affiliate of the AFT, the fastest-growing 
healthcare union in the country representing 200,000 healthcare 
professionals.

    ``Safe staffing saves lives.'' It is the mantra of every nurse in 
the country. But it is also the truth. We have 20 years' worth of data, 
since California adopted a safe staffing law, that shows the benefits 
of adequate nurse-to-patient ratios. The data is clear: The staffing 
law in California decreased patient deaths; decreased negative outcomes 
for patients, like hospital-acquired infections and bed sores; 
decreased injuries for nurses and patients; increased retention of 
nurses (saving hospitals millions in orientations); and was cost-
effective for hospitals.

    As an AFT vice president, I have talked in detail to my colleagues 
across the country and have heard the same concerns about staffing in 
Alaska, Connecticut, Montana, Ohio, Oregon, Pennsylvania and others. So 
along with many other AFT affiliates and other healthcare unions, we 
decided to put our primary focus on this staffing crisis. The AFT 
staffing campaign is called Code Red and has resulted in legislation in 
Connecticut and Oregon, among other states. Legislation in 
Pennsylvania, which mirrors the Oregon law and was championed by the 
Pennsylvania Association of Staff Nurses and Allied Professionals and 
the Service Employees International Union, has passed through the House 
and is making its way through the Senate. Healthcare unions are leading 
the way. We want to be next in New Jersey.

    Hospital management, and the corporations that run hospitals, are 
too often focused on adding a new fountain in the lobby or paying for 
glossy advertisements instead of building up staff. They also spend 
millions on anti-union firms and lobbying efforts against safe staffing 
laws. It is the healthcare unions (that is, the frontline healthcare 
workers) across the country that are speaking up for nurses. And when 
we speak up for nurses, we speak up for patients.

    Over the past few months, HPAE has stood with our heroes, the 
United Steelworker nurses of Robert Wood Johnson University Hospital, 
because we know that the experiences of those on this panel are also 
the stories of nurses throughout New Jersey and the Nation. We are 
encouraged by the success of other states. We are encouraged by the 
crowd in this room. Chairman, with your help we will be able to say 
first California, then Oregon, now New Jersey.

    The Chair. Thank you, Ms. White. Our final witness is Dr. 
Patricia Pittman, Fitzhugh Mullan Professor of Health Workforce 
Equity and Director of the Mullan Institute for Health 
Workforce Equity at George Washington University. Dr. Pittman, 
thank you.

 STATEMENT OF PATRICIA PITTMAN, PHD, FITZHUGH MULLAN PROFESSOR 
  OF HEALTH WORKFORCE EQUITY, DIRECTOR, MULLAN INSTITUTE FOR 
HEALTH WORKFORCE EQUITY, DEPT. OF HEALTH POLICY AND MANAGEMENT 
MILKEN INSTITUTE SCHOOL OF PUBLIC HEALTH, THE GEORGE WASHINGTON 
                   UNIVERSITY WASHINGTON, DC

    Dr. Pittman. Thank you, Chairman Sanders. I, in addition to 
directing the Mullan Institute for Health Workforce Equity at 
George Washington University, I also lead one of the nine HRSA 
supported health workforce research centers, and some of the 
research I will discuss was funded through this mechanism. 
Views expressed today, however, are entirely my own.

    As other witnesses have indicated, there is growing 
recognition that the nursing crisis has been largely caused by 
attrition. Surveys and our own qualitative research identify 
the main reasons for these departures as understaffing, poor 
working conditions, and the corresponding fear of harming 
patients.

    The experience of fearing and of witnessing this harm is 
resulting in moral injury, a form of trauma caused by not being 
able to provide the care they believe patients need and feeling 
that they are powerless to make change. Among the outcomes of 
this distress are depression and suicide.

    Nurses commit suicide at twice the rate of the general 
population. Nurses' concerns about staffing have been borne out 
in over 20 years of research. Outcomes shown to be associated 
with low staffing levels include patient mortality, failure to 
rescue, hospital acquired pneumonia, respiratory failure, 
ulcers, falls, urinary tract infections, and patient 
satisfaction.

    Our team has also showed that nursing assisted personnel 
staffing levels impact outcomes, specifically patient 
satisfaction. This is in part because without sufficient 
support, nurses workloads increase.

    In other studies, we are looking at the effect on outcomes 
of overtime hours and agency nurse hours, as compared to 
regular staff nursing hours. We find that these two management 
strategies for handling shortages do improve outcomes, 
specifically in this case, pressure--preventing pressure ulcers 
up to a point. But beyond that point, they get worse.

    Over the past 5 years, we find over time ours were 178 
percent above the estimated safe threshold in our sample. For 
agency hours, the mean was 211 percent beyond the threshold, 
corresponding to a 3.5 increase in pressure ulcers attributable 
to excess reliance on agency nurses.

    This study can't tell us why this occurs, but we know from 
qualitative interviews that we have conducted, the travel 
nurses feel less empowered to speak up than regular staff when 
they experience unsafe staffing or dangerous assignments.

    Why aren't hospitals hiring more regular nurses to 
stabilize the workforce? One might assume that hospitals with 
more resources would use some of that money to attract more 
nurses to regular positions, perhaps by paying them more.

    Indeed, that was likely the assumption that policymakers 
made during the pandemic when they allocated provider relief 
funds to help hospitals make up for revenue losses and address 
the staffing crisis. Our research suggests this is not the 
case. In the year prior to the COVID pandemic, we found no 
relationship between hospital finance levels and staffing 
levels, either positive or negative.

    We then looked at the four waves of COVID and we found that 
in wave two and three, there was actually an inverse 
relationship. This means that not only our hospitals that are 
traditionally better resourced, not using those funds for 
increased staffing, but additionally hospitals that had a 
higher influx of cash during the pandemic had lower staffing.

    Our findings support the idea that something is amiss in 
the current hospital payments system. So how do we fix this? 
Research shows that mandatory thresholds will help ensure 
minimum levels.

    We find that among the three state strategies used, 
mandating nurse to patient ratios, requiring that staffing 
committees include bedside nurses, and requiring public 
reporting of staffing levels, only the minimum ratio law was 
associated with increased staffing. The other two had no 
effect. The other approach is to enhance incentives for 
hospitals to hire more nurses.

    Neither the hospital based--hospital value based program, 
or the hospital acquired conditions program, which include 
nurse sensitive patient safety measures, have been enough to 
offset the urge to cut costs by constraining staffing. But they 
could be reformed and combined with a mandatory approach.

    One idea is to include both nurse staffing hours per 
patient day and nurse turnover rates in hospital compare. This 
could subsequently lead to the inclusion of these measures in 
the hospital value based payment program. Long term, the way we 
pay hospitals for nurses and support staff may need to change.

    Rather than hiding labor in room and board, experts have 
been interested in exploring whether the actual nurses? hours 
per patient day could be an explicit component of the DRGs 
without driving prices up.

    In closing, while other elements of the nurse practice 
environments also matter, fixing unsafe staffing in U.S. 
hospitals is an essential first step, one that would not only 
improve patient outcomes, but would contribute to the health 
and the retention of hundreds of thousands of nurses. Thank 
you.

    [The prepared statement of Dr. Pittman follows.]
                 prepared statement of patricia pittman
    As Director of the Mullan Institute for Health Workforce Equity at 
the George Washington University School of Public Health, I appreciate 
the opportunity to speak with you today and share some of our research 
findings relating to nurse staffing and well-being. I will (1) review 
some of the background on nurse attrition and the so-called nursing 
shortage; (2) examine the evidence on why staffing is so important to 
both nursing and patient outcomes; (3) reflect on what may be driving 
unsafe staffing; and (4) discuss various policy approaches to 
addressing the problem of understaffing and moral injury.

    Some of the research I will discuss was funded under a Health 
Workforce Research Center collaborative agreement with the Health 
Services Research Administration (HRSA), although the views expressed 
here are entirely my own.
The shortfall has been largely caused by attrition, not an insufficient 
                                pipeline
    Registered nursing (RN) projections conducted by the Federal 
Government suggest that the current national nursing shortage is 
largely a result of licensed nurses dropping out of healthcare, rather 
than a problem of production. Some describe this as a shortage of 
nursing care, rather than of nurses (Trang 2023).

    Nationally, the HRSA estimates that while they expect a shortage of 
about 79,000 full time nurses in 2025, by 2035 there could be a surplus 
of 16,000 nurses (2022). Projection methodologies are always 
controversial, and certainly national numbers obscure geographic 
variation. However, we do know that the pipeline is robust. Currently 
we graduate about 185,000 new nurses a year, close to the 195,000 we 
are estimated to need in the future, and that rate is expected to 
increase each year, as it has in the past.

    The unanticipated problem in nurse supply has been the massive 
attrition of early career nurses. Bureau of Labor Statistics data show 
that more than 100,000 FTE left nursing in 2021 alone, the largest 
exodus of nurses in forty years of tracking the profession. Even more 
concerning, the majority of those leaving were under the age of 35 
(Auerbach et.al. 2022). We know that most of the problem is 
concentrated in hospitals, where there was a 3.9 percent drop in 
employed nurses that year, while in other settings there was a slight 
increase (1.6 percent).

    In 2022, some nurses returned to the bedside, but according 
surveys, RN hospital turnover is still above 22 percent (NSI 2023). 
Forty percent of all new hires left within a year of hiring in 2022, 
and almost 60 percent of those quitting had less than 2 years of 
service.

    The primary reason for these departures, as reported by nurses, is 
that understaffing and poor working conditions are resulting in patient 
harm (Medvec et al.. 2023). The experience of witnessing this harm is 
resulting in moral injury, a form of trauma associated with being 
unable to provide the care they believe patients deserve, and the 
feeling that they are powerless to make changes (Pittman 2021). Among 
the effects of this phenomenon are depression and suicide. Nurses 
commit suicide at twice the rate of the general population (Davis et 
al.., 2021).
 There is robust evidence that staffing levels affect patient outcomes
    Nurses' concern that understaffing results in poor patient outcomes 
has been born out in over 20 years of rigorous research in the U.S. and 
around the world (Pittman 2021). Outcomes associated with low staffing 
levels include patient mortality and failure to rescue, hospital 
acquired pneumonia, unplanned extubation, respiratory failure and 
cardiac arrest in ICUs, ulcers, falls, urinary tract and surgical site 
infection, as well as longer restraint application duration, more 
medication errors, and longer times to diagnosis in the emergency room. 
Studies also reveal a significant association with longer lengths of 
stay, higher rates of 30-day patient readmission and lower patient 
satisfaction.

    In a recent study, our team showed that nursing assistive personnel 
staffing levels also affect patient satisfaction, in part, no doubt, 
because without sufficient support staff, nurses must also do their 
jobs (Delhy, Dor, Pittman 2020).

    Additionally, the configuration of nurse staffing matters. In a 
study we are just completing, we find the two most common hospital 
management strategies for handling short staff--increasing overtime 
hours and agency nurses--can help improve outcomes (in this case 
pressure ulcers) up to a point, but beyond a certain level, actually 
worsen outcomes. Pressure ulcers are entirely preventable, yet there is 
a prevalence of 2.5 million cases in the U.S., and about 60,000 of 
these patients die annually, as a result (Afzali Borojeny et al 2020). 
In our study, the mean overtime nurse hours per patient day was 178 
percent over the estimated safe threshold for pressure ulcers, and for 
agency nurse hours it was 211 percent over the estimated safe 
threshold. This corresponded to a 3.5 percent increase in pressure 
ulcers during the last 5 years. Interviews we have conducted with 
travel nurses suggest that this may be a result feeling disempowered to 
speak up when they see unsafe or unethical practices, precisely because 
they are temporary.
         Current incentives for safe staffing are insufficient
    Labor economists have long identified the counter cyclical 
relationship of nurse attrition and unemployment (Buerhaus, Auerbach, 
Staiger 2009). Historically, poor working conditions and wages have led 
nurses to leave their jobs when their families are fully employed, 
401Ks are flush, or maybe they can find work elsewhere. During 
recessions, however, many licensed nurses return to healthcare jobs. 
With the average cost of turnover for a bedside RN an estimated $52,35 
today, hospitals understand the importance of improving retention (NSI 
2022). The question then becomes, what can hospitals do to stabilize 
the workforce?

    One might assume that hospitals with more financial resources would 
use some of that money to increase staffing, so fewer nurses would 
leave. Indeed, that is likely the assumption that policymakers made 
during the pandemic when they allocated provider relief funds to help 
hospitals make up for revenue losses and address the staffing crisis.

    In a forthcoming study, however, my team found that not to be the 
case. We found that in the year prior to the Covid-19 pandemic there 
was no relationship between hospital finance levels, measured as days 
cash on hand, and nurse hours per patient day, either positive or 
negative. We then looked at the four waves of Covid-19 and found that 
in wave 2 and 3 there was an inverse relationship. In other words, an 
increase in days cash on hand was associated with a decline in nurse 
staffing. We were surprised by that, and so we applied a lag time 
analysis to account for the time needed to use new resources to hire, 
but found that our results still held. This means that not only are 
hospitals that are traditionally better resourced not using those funds 
for increased staffing, but that, even with an influx of cash, there is 
no evidence is was used for staffing.

    This finding suggests that labor market dynamics do not entirely 
explain the problem of nurse attrition; it seems likely that the 
current hospital payment system has created a perverse incentive to 
understaff. Nurse and support staff labor are a significant portion of 
hospital budgets, and because their hours are not billed this has been 
the easiest place to control expenses. And despite the proven 
relationship with patient outcomes, value-based payment incentives tied 
to patient safety do not appear to be high enough to change the 
predominate financial calculations on staffing.
        Combining mandatory and incentive-based policy solutions
    Fixing the problem of unsafe staffing in this country may require a 
multi-tiered approach. Policy options will likely require both a 
mandatory component, for minimum thresholds, as well as economic 
incentives that reward those that go beyond that minimum.

    Among the mandatory strategies, three general approaches have been 
used: (1) directly mandating nurse to patient ratios, (2) requiring 
that staffing committees include bedside nurses (in the hopes that 
their perspectives will be considered by hospital administrators), and 
(3) public reporting of staffing levels, (in the hopes that consumers 
will ``vote with their feet'' and put market pressure on hospitals). 
Just three states have used nurse to patient minimum ratios, 
California, Massachusetts in their intensive care units, and just 
recently Oregon. We conducted a national study comparing these 
approaches over time and found that only the minimum ratios laws were 
associated with increased staffing (Han, Barnow, Pittman, 2021).

    Another mandatory approach that has gained attention recently, but 
has yet to be attempted, would be to require hospitals paid by Medicare 
to adhere to minimum nurse to patient ratios as a condition of 
participation (Aiken, Faigin 2022).

    Incentive-based approaches may also have an important role in 
addressing unsafe staffing. While they are unlikely to solve the 
problem alone, in conjunction with mandatory thresholds they could 
motivate hospitals to go beyond the minimum. At the Federal level, this 
could begin with required public reporting of nurse staffing hours per 
patient day and turnover rates, and the inclusion of these measures in 
Hospital Compare (CMS a, 2023). Currently, Hospital Compare includes 
nurse sensitive patient outcome measures, but no process measures 
tracking nurse staffing or turnover. Requiring standardized reporting 
of staffing and turnover could also lead to their inclusion in the 
Hospital Value Based Payment Program (CMS b, 2023), a voluntary reward 
program. Long term, the main payment structure could be reformed. 
Scholars have been interested in exploring whether nurse labor hours 
could be incorporated into Diagnostic Related Groups (DRGs), hopefully 
without driving up costs to payers or consumers (Pittman et al 2021; 
Yakusheva & Rambur 2023).

    In closing, I do want to acknowledge that while safe staffing will 
help reduce nurse turnover, other factors relating to nurse practice 
environments are also important. Studies show that improvements in team 
dynamics and greater trust in management are also key to reducing 
departures (Lasater et al 2021). A reduction of violence and harassment 
of health care workers is also imperative (CDC 2023).

    From a policy perspective, however, fixing unsafe staffing in U.S. 
hospitals is both feasible and an essential first step. If achieved, it 
would not only improve patient outcomes, but also contribute to the 
retention of the hundreds of thousands of nurses that drop out of the 
workforce due to moral injury.
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                                 ______
                                 
    The Chair. Let me begin the questioning with Ms. Danella. 
What I would appreciate is if you could put into human terms 
the fact that you have been a nurse for 28 years and you have 
seen a lot.

    What are you and your fellow nurses experiencing because of 
the kind of inadequate nurse--patient ratios that we have in 
terms of what it does to nurses and what it does for your 
patients.

    Talk about the emotional--we heard some discussion about 
what it means emotionally to see things happen that you feel 
badly about. So, from a human point of view, as a nurse for 28 
years, chat about that for a moment, please.

    Ms. Danella. I think what we look at is, No. 1, our 
colleagues, that support. When you go in and you look at the 
board and you see your patient assignment and it says you have 
six patients under your name, or four patients that are heavy 
patients, you look and you say, oh my god, what is my day going 
to be like? Am I going to be able to give that patient the care 
they need? I personally work on a stroke floor.

    Many of our patients are unable to get out of bed, unable 
to speak, unable to feed themselves. They are full care 
patients. You say, what is my priority that day? Do I feed the 
patient with a peg tube that cannot feed themselves? Do I feed 
the patient that has--flaccid on one arm and cannot feed 
themselves?

    You look, and you say, then do I have enough staff that is 
going to help me turn and reposition that patient as in our 
techs? No, wait, I have to go answer the phone because there is 
no unit clerk.

    Where does my priority lie? That is what we have to look 
at. And the priority is not answering that phone, it is taking 
care of that patient that is at the bed so that they don't get 
into cube, they don't get respiratory because we haven't been 
able to turn and reposition them.

    That they lay with a pressure ulcer because we haven't been 
able to change them.

    You look, and you say, let me make my day. I can do it, and 
it is a struggle for me as a 28 year nurse. Imagine the new 
people that are coming in, and we are saying, go. Because I 
want to help them, but sometimes I can't because I might have a 
cluster, but I got to go off the floor because my patient needs 
a stat CAT scan and there is nobody to watch my other patients.

    That is why I think safe staffing is being brought to the 
forefront. We work in a level one comprehensive stroke center, 
comprehensive cancer center. We work in, no offense to the 
other unions in the hospital or other staff, we work on one of 
the highest acuity populations in the hospital.

    We deserve staffing. We deserve nurse ratios. We deserve 
ancillary staff. We deserve what we are asking for. It is not 
money. It is staffing. I hope I answered your question.

    The Chair. You did. But let me just take that question down 
the line. Ms. Tanzi, did you want to respond on it? On a human 
level, what does the lack of adequate staffing mean to nurses 
personally, the quality care you want to provide, and how you 
feel about not being able in some cases to provide that care? 
Ms. Tanzi.

    Ms. Tanzi. I think the word that comes to mind for me, just 
as you were speaking, is anguish. Like you always have that 
feeling. It starts the night before your shift where you are 
just wondering what you are going to walk into.

    If you are lucky enough to have a full set of nurses, your 
unit clerk and your nursing assistant may have pulled out or 
been pulled to another floor that needs them more. You know, 
you are in a one patient's area taking care of somebody, but 
somebody else is calling out for you. It is the juggling, the 
constant juggling.

    Then you need a supply, and you go to the storeroom, and 
they don't have your supply. Now you have to call somebody. 
This is all time consuming stuff that you can't pawn off on 
somebody else. So, the anguish you feel, the dread, the anxiety 
that this causes every single day. You can't turn left without 
having something you need to do. Can't turn right without it. 
And there is no one to help. You ask your directors for help.

    I am sorry, there is nobody to send you as an extra pair of 
hands. You can't ask your director because they are never on 
the floor. They are always at some type of very important 
meeting. There is never a person you can actually turn to for 
real help. So, we try to support each other.

    We can't even go home and talk to our families because they 
don't even understand what we are talking about. This is very, 
very specific. This kind of trauma is specific to us because we 
know what we suffer.

    To this point, nurses have been afraid to talk about this 
to the general public because we don't want to alarm anybody 
that it is scary in the hospital. We don't want to raise fears 
to people that they might not be taking care of properly but 
have somebody whose mother get a bed sore, and it is a nurse's 
fault.

    Have somebody have a heart attack or like Judith is talking 
about, somebody who can't feed themselves--you have to take 
your time. If they had a stroke, you have to be careful, you 
have to take your time. You don't want to rush them. They 
deserve to get their whole meal. But instead, you feel like you 
are shoving food in.

    When you change somebody in the bed, you need two people. 
There is often not two people. So, you are doing it yourself. 
Rushing on one side of the bed, running to the other side of 
the bed. Having the patient try to hold themselves over on the 
bed so you can do their back.

    Things that need to be done are not getting done. And we 
have not agreed to that. That is not what we signed up for. Try 
telling a new nurse--try telling a new nurse, hey, here is this 
great profession. Get a lot of debt when you go to college, 
then go someplace and work your ass off and not be appreciated. 
In fact, you can actually be abused.

    How are we selling this? How are we potentiating more 
people coming into the field? With this culture, I can't 
imagine.

    The Chair. Ms. Hagans, this obviously is a national issue. 
It is not a New Jersey or Vermont issue. You have been a nurse 
for many years. Why don't you give us your experience as well?

    Ms. Hagans. Well, first, you all know, more nurses means 
better patient care, okay. As a nurse, you walk in into that 
hospital from 6.45 a.m.. If you didn't have a cup of coffee 
from home, that was your first and last meal for the day, to 
beginning. And then, you are coming in to take a report.

    Then you have to see your patients. I go in there knowing 
that I should be spending at least 5 minutes with the patient, 
but all I am doing is giving them the medication and run again. 
And we all need to know, every patient deserves that human 
touch where we have a conversation, newly diagnosis.

    You walk in there, but you are being called in 50 million 
directions. Then now you start doing the blood pressure and you 
have to give the medication. It is 9.00 a.m., and then now you 
are being called to come into round because the doctors are 
saying where are you to make round, but you are in the room 
with the patients.

    Then it is already 11.00 a.m., 12.00 p.m.. It is time to 
give your 2--[technical problems]--medication and 12.00 p.m. 
medication. You are yet as a nurse to sit there and take a 
break. We are talking about quality of care.

    How do you expect me to deliver safe patient quality care 
when I don't even have a minute to run to the bathroom? Then, 
it is 2.00 p.m., then now you need to give your 2.00 p.m. 
medications.

    Then we continuously--that is the reason we need safe 
staffing ratios in our Country. Imagine, in New York, we have 
the law, but the state has failed us. They have not 
acknowledged and helped us. The only reason we have staffing 
ratios is through our contractual agreement.

    What about the other hospital where they have no staff and 
no union to fight? What about those hospitals? 75 percent of 
nurses are not unionized in this country. So, let's do that 
math. How do we care for patients?

    How do we expect to deliver quality care to our patients 
when we don't have enough nurse, patients to care for those 
patients? That is the reason we are here asking that we need to 
have the minimum safe staffing ratios in the country, across 
this Nation.

    The Chair. Ms. White, you have been a nurse for many years 
as well. Why don't you jump in on that discussion.

    [Technical problems.]

    The Chair. Could you get that mic close to you and tell us 
what----

    Ms. White. I have been a nurse, a med surge nurse for 35 
years. Who stays a med surge for 35 years? As such, I saw a lot 
of new nurses.

    I was pretty much the mentor and the mama to everybody on 
the unit, as well as the union president and my local. But I 
have to say this, what does it look like in human terms?

    My patients would say to me, I hate to bother you. I see 
you running up and down the hallway. Can I just ask you for one 
thing? And they try, they try to be patient, but I mean, how 
long can you be patient when a nurse says, I will be right 
back.

    By the way, don't we all say that? I will be right back. 
How many hours later do we get back there because something 
else hijacks our time. Simple needs go unmet. Simple toileting 
needs, care, self-care needs. Patients don't get it. They don't 
get their meds in time. They don't get their dressing changes 
in time.

    They don't get their teaching. I mean, how many times have 
I thought, I am going to teach this patient? I said to myself, 
that is a new diabetic. They have to know about diabetes. They 
have to understand what it is like to inject insulin.

    I couldn't. I just didn't have the time because my time ran 
out. But the worst part about this is watching the new nurses 
that I have precepted and mentored start practice and every 
hour or so have to duck into the bathroom to cry because they 
never expected to be so overwhelmed in school, but this is the 
reality of our work.

    Unless--hospitals are forced to staff--now, they will tell 
you they know what is appropriate to staff. They will. But they 
don't want to ask their staff, what do you think is 
appropriate? Because we could tell you. And the science shows 
that there is a certain nurse to patient ratio that is safe.

    With these new nurses, we will retain them. We will keep 
them at the bedside. They won't be in the bathrooms crying. 
They will have mentors because the senior nurses who have the 
experience won't have exited the profession.

    That is another problem. And honestly, the doctor walks in 
for 5 minutes, spouts some jargon, and leaves, and the patients 
look at the nurse and says, I am not sure what he just said, 
can you explain it? And what do we say? I will be right back. 
It is necessary.

    The Chair. Dr. Pittman, you have done studies on these 
issues. What does the lack of adequate staffing ratios mean to 
the health of the nurses, the well-being of nurses?

    Dr. Pittman. Well, I think in qualitative terms we have 
been hearing it, obviously, but we do know that it is directly 
linked to depression.

    Depression is directly linked to suicide. As I said before, 
nurses commit suicide at twice the rate of the general 
population. It leads to attrition, not just from the hospital 
job and churn, and we know that costs hospitals, I think this 
year they are saying $52,000 per turnover of nurses.

    It is tremendous impact on the hospital itself. And as 
these things happen, even for those nurses who remain, 
unfortunately when you experience moral injury or burnout, for 
those who remain, it is--it becomes deactivating. You lose your 
compassion. You lose your ability to have hope for change.

    That has a direct effect on patients who are looking to 
nurses as their sole source of care in hospitals. So, and that 
is why we are seeing I think the figures are actually way 
higher than one in five nurses leaving.

    In hospitals, where most of the problem is, we are seeing 
40 percent of nurses leave in their first year, and by the 
second year, 60 percent of nurses have left. It is a huge waste 
of human capital. And it is a tragedy for patients who are 
receiving services.

    The Chair. You know, it is a funny thing. If we were in 
some poor country, didn't have money for health care, we might 
understand inadequate staffing. We are spending twice as much 
per capita on health care as any other nation on Earth.

    I wanted to ask the panelists, what is your reaction, your 
emotional reaction, if would you like, to a hospital that 
apparently has $100 million available for traveling nurses, who 
are paid significantly higher wages than you are, who have 
nurse, patient ratios--better than what you are asking for, I 
gather.

    A hospital chain that can provide its CEO with $17 million 
in compensation. What does that do to nurses morale when you 
hear those things? Ms. Danella, you want to start that off?

    Ms. Danella. I believe, as nurses of an institution, many 
of us feel demoralized. As Carol had said, there was no respect 
for us as nurses. For what they have done for us for 85 days, 
they could have taken that money.

    They are afraid if we win safe staffing, they would have to 
set the standard for all their other sites. We have taken that 
challenge on. We know that. Instead of saying we care about our 
nurses, they chose to make the travel nurses their priority, 
which is not right, as well as break our union.

    I believe in the end that is the goal. They are willing to 
pay much, much money rather than respect our union, and all we 
are asking for, again, is a deal on safe staffing. I would ask 
them to come back to the table. If they called me right now, we 
would go back to the table, make a proposal, answer our 
proposal, and get us back to work.

    I think that is what we want. And again, this is a fight 
that we have taken on. We will continue and we need safe 
staffing, and the executives need to look at us as human beings 
and as the employees that built that hospital the way it is. It 
wasn't the travel nurses. We did it, and we deserve to go back 
in there with a fair contract.

    The Chair. Hop in on that, Ms. Tanzi. What's the nurses? 
reaction? Apparently, there is enough money available, easily--
$100 million bucks. What do you think?

    Ms. Tanzi. Well, disgusting comes to mind. Enraged comes to 
mind. The narrative at the very beginning, every time we would 
bring up something is, you are the highest paid nurses in New 
Jersey. Not true. Not even true.

    They wanted to shame us and make us feel embarrassed that--
as if we were asking for more money. That was never the case. 
They are so terrified of us being organized that they literally 
were taking pages out of union busting 101 and trying it, with 
the intimidation, with the fear, with the harassment.

    That is the culture at Robert Wood Johnson. They are doing 
it to the people who are in there now. Our environmental 
service people, our technicians, saying that if you support 
these nurses, you will be fired.

    That is a threat they make good on. That is a threat they 
make good. Our siblings at Clara Maass are trying to get a 
contract--[technical problems]--directions for staff and 
organizing. Congratulations, because together is what the 
hospitals is afraid of. We have how many unions in New Jersey. 
We need every hospital to be unionized. Somerset is getting 
ready to be next.

    They literally are threatening them over there. Threatening 
them that if they participate with us, they communicate with 
us, that they will be penalized. That is a terrible way to go 
about business. That is saying you do not care about these 
people as people, you just want--shut up and go back to work.

    That is the attitude they have with us. Shut up and go back 
to work. And that is not what we are doing. We are going to 
stand up and fight for what this is. We are not losing steam 
because this is too important. We didn't come out here to go 
back to a terrible contract.

    If they come back with some stuff that isn't a good 
contract, it is going to get voted down again.

    The Chair. Ms. Hagans, did you want to add something that 
discussion?

    Ms. Hagans. Clearly union busting. What they are doing is 
purely union busting. You have a CEO that makes over $17 
million. Is putting profit over patients. And the reason they 
are doing it is union busting.

    Management do not want the unions there because if they 
have enough money to have replacement workers, this is not 
about what is good for the patient, it is not about what is 
good for the community, it is purely union busting, putting 
profit over patient.

    It is time that we have a law that will tell them, this 
cannot happen. We need to have the minimum safe staff 
integration across the country, so this doesn't ever happen 
again.

    The Chair. Ms. White.

    Ms. White. I would say that any hospital--[technical 
problems]--need to go public with the statement that we spend 
the $102 million on replacement nurses while their nursing 
staff is walking a picket line should be ashamed of themselves.

    Do they think--do they think this is a good look for the 
hospital? I can tell, I mean, I think it is a horrible look for 
the hospital and it shows what hospitals are willing to spend 
their profits on.

    But I also think this is a test case in New Jersey. I think 
every hospital system is backing Barnabas in their actions 
right now because they are terrified. They know nurses aren't 
going to take this anymore.

    They know this, and they see that these nurses, that all of 
you are not willing to stand for the status quo. That you want 
to see real change. I would pose this, if we had safe staffing 
laws, we wouldn't have nurses out on strike.

    The Chair. The evidence--the purpose of this hearing is 
not, as some of our critics think, for me to get involved in 
labor management relations. It is to deal with the issue that 
we have been talking about.

    We need strong staffing ratios so that we retain our 
nurses. That is what this is about. And of course, if nurses 
feel overworked, you correct me if I am wrong, because of 
understaffing, there is demoralization and people are leaving 
the profession.

    We have the insane situation, and I want people to jump in 
and criticize me. I mean, disagree with me or not. But we have 
a nursing crisis. We desperately need more nurses, and nurses 
are walking out the door, all right.

    At the end of the day, when you have nurses who have the 
time to take care of their patients, who feel good about their 
jobs, who are not going to leave the profession, at the end of 
the day everybody benefits, the hospital, the nurse, and the 
patient. All right, maybe I am going to go to Dr. Pittman again 
for this issue.

    We are here to talk about retention. We are here to talk 
about a nursing crisis where hospitals don't have the nursing 
they need, and nurses are walking out the door. What will all 
of this do to make sure that we retain nurses, that we have 
good nurse, patient ratios? What impact will that have?

    Dr. Pittman. Well, as I said before, I think it is an 
essential first step.

    It is also important to recognize that there is more work 
to be done, even if you were to attain it, because there are 
issues around trust and management, issues around violence and 
harassment of nurses, issues around employee voice that also 
have to be addressed in conjunction. But I think that it is 
really difficult in the case of nursing to do anything until 
you resolve the issue of the short staffing.

    I think one of the things that I think would be really 
important, and the reason that it is so important to understand 
the relationship between staffing and patient safety, is that 
consumers should be--the general population should be very 
concerned about this problem and physicians should be very 
concerned about this problem.

    The organizations that express the voice of those, in 
particular those two sectors, but others as well, really do 
need to--bridges need to be constructed with them, so they 
understand the implications for them.

    In particular, I think for this hospital that is on--been 
with so much labor distress now, it is really important to 
track the patient safety outcomes. See what is happening with 
the agency nurses and the outcomes.

    The Chair. All right. Let me ask you this, and this is--I 
have got a hard time dealing with this one. I get involved as 
Chairman of the Committee and based on what I do with a lot of 
labor issues and we have been involved in many strikes, and 
most of the issues are pretty clear cut.

    You have large multinational corporations, and they want to 
make zillions of profits. They want to pay their workers as 
little as possible. Workers are standing up with seeing that. 
The UAW, Teamsters, all of that is pretty understandable. 
Companies want more profits. Workers want more money. I 
understand that.

    This is different. What is different about this is the 
function of a hospital is not to make huge sums of money. The 
function of a hospital, I assume, every American assumes, is to 
provide the best quality care it can to its patients, right?

    I want you to help me on this one, because you have been 
sitting down and negotiating with the company--with the 
management. How--what is the management's explanation when you 
have 1,700 nurses, people who work with patients every single 
day, who are fighting primarily in order to do a better job to 
provide better care for their patients, which is presumably 
what the goal of the hospital is.

    All right. What is their response? We don't want good 
quality care at the hospital? Is that their response? We think 
you who do all the work every day don't know what is going on 
the floor? Is that the response?

    Help me out here because I really don't get it. If you are 
General Motors, if you are Stellantis, I get it. They want more 
money for their shareholders. I get that. But this one I don't 
get. What is their explanation as to why they don't want better 
quality care for their patients?

    Ms. Hagans. There is profit over patients. Look at the 
CEOs. Look at how much money they make. When you--when we have 
come in, when work short, the hospital still benefits on our 
back as nurses because they charge the same amount for the 
patients, if not more.

    Therefore, if they could continue to use us with less in 
order to make more money, they will continue to do it. That is 
the reason we are here today testifying asking to have that 
minimum staffing across this country. To have health equity for 
our communities. To continue to provide safe, patient care.

    The Chair. Ms. Danella, Ms. Tanzi, you have been sitting, 
you have been negotiating for a very, very long time. What does 
the management say in response?

    Ms. Danella. I was remaining silent for a reason. I was 
pretending I was the hospital at the table. You have to forgive 
me on that. It was purposely done. We have sat in the room 
hours and hours and hours with no response. It is a very simple 
concept. Enforceable safe staffing. There is not a lot on the 
table.

    We get told we will get back to you. Sunday night, it is 
now Friday. They haven't gotten back to us yet. So again, we go 
back and forth over very--it is a very simple idea that has 
been complicated to the max. I, as the president of the 
hospital--not the hospital. Oh my god, pardon me.

    I am sorry, president of the union can't even explain some 
of the concepts they want us to explain to our members. So 
therefore, it is simple terms, enforceable, safe staffing 
without sick call penalties.

    A cushion, yes, but not a core deficit that is 18 percent. 
We need to get a contract. We need to get to work. First and 
foremost, we need a response from the hospital. And if we get a 
response, maybe we can work with something. We are not getting 
that response.

    Ms. Tanzi.

    [Technical problems]--that this is really about dignity and 
respect for us and for our patients. The fact that we are 
asking for something that is scientifically proven, 
fundamentally important, that they are choosing to confuse it, 
do back moves, just to make it so that it is so untenable.

    That the things that they are promoting--not promoting, 
proposing would make it impossible to be enforceable. So that 
is what arguing is not standing for. They are saying, cut that 
out and we will have a deal. They are gaslighting. That is a 
term I just learned during the strike.

    Ms. Danella. I still don't understand it.

    Ms. Tanzi. It is unfathomable to me that they could still 
be saying we give--we have offered them safe staffing, but they 
just won't take it. Because that is a lie. That is a lie. And 
for them to just keep putting that same narrative out, it is, 
it is--I don't know but disgusting keeps coming to mind.

    But it is just--it is--to us, it is insulting. Treat us 
with respect. Our union shows up every single time, stays as 
long as they need them to do, whatever crackhead hours they 
want to put them up to. Come in 5.00 p.m., stay till 2.00 a.m. 
They are there. They show up.

    The disrespect is that they don't come with anything 
reasonable. It is not fair. And it is--and every contract that 
languishes on for over a year, what are we talking about here? 
Where is the respect? These are people who want to call us 
families in the next breath, but treat you like this while we 
are waiting.

    The Chair. All right.

    [Technical problems.]

    Ms. Tanzi. Some disgusting behaviors. We were told by our 
HR, the top of our H.R. to get over our COVID hangover. Manny 
Gonzalez had the nerve to say that while he worked from home. 
He was not where we were. So, these people who are hiding, 
hiding, can't look us in the eyes. They are negotiating in two 
separate rooms so that they don't have to look us in the eye. 
It is shameful.

    The Chair. All right. We have covered a lot of ground. Are 
there any questions that I should have asked you that I did not 
ask you? Dr. Pittman.

    Dr. Pittman. I do think it would be interesting to think 
about a GAO report on the effects of the way we pay hospitals 
for nurse labor and support staffing labor.

    I think that is the root of their behavior and the Federal 
Government bears some responsibility for that. I am not in any 
way saying that this is an either, or I think that the laws are 
imperative to create a minimum threshold. But if we want 
hospitals--we want to encourage them to do the right thing, we 
need to use the dollars, taxpayer dollars that we pay them, to 
rethink how we are paying them.

    I think there are lots of creative ideas and lots being 
written about that, and it would be worth--it would be worth a 
report.

    Ms. Tanzi. I have an idea too. We understood that the 
Federal Government and the State Government gave Robert Wood 
Johnson an enormous amount of money during COVID, which never 
trickled down.

    This was, I understand it was a broad base of what it could 
be used for. It was never used for the workers, never used for 
the workers. I would love to know--oh, yes, no hazard pay. No 
hazard pay, Robert Wood Johnson.

    What I want to know is where is all this money going and 
who has the power to say, show us where this money is going? 
They took our health care benefits away. They are self-insured. 
What was the purpose of that except for being cruel?

    Their tactics are terrible, and it doesn't show any kind of 
concern for humans. So, what kind of place is making policies, 
making decisions that doesn't care about the fundamental basic 
rights of the humans?

    The Chair. Are they just----

    [Technical problems.]

    The Chair. Let me just say this, that I would just, for the 
record, mention that to the best of my knowledge, this is a 
hospital system, Barnabas, that received $833 million from the 
Federal Government.

    This is a hospital that has received $3.5 billion in 
revenue alone from Medicare and Medicaid. So, yes, the Federal 
Government has played a big role. Other questions that I did 
not ask? All right, let me just say this, and I say this to the 
management, I don't understand what you are doing.

    I do not understand how you can go to your community and 
say you want to provide high quality care to your patients, and 
you have the leading experts on quality care, 1,700 of them, 
saying you are not doing it.

    I got to tell the management I understand that politicians 
are not held in high regard, but maybe CEOs of large 
corporations are held in even less high regard. But I would 
hope very much that the management at Robert Wood Johnson comes 
back to the table, they sit down and negotiate a reasonable 
contract, which must include adequate patient nurse ratios.

    That instead of being at odds with their union, they work 
together to become a model for this country as to what a good 
hospital could be. Well, let me just conclude, our health care 
system is broken. There are so many problems. But today we are 
dealing with one of the major ones.

    I just, on a personal note I want to thank the union here 
with their incredible courage. You are standing up--you are 
standing up not just yourselves. You are standing up for your 
patients, and that is an incredible, noble thing to do.

    Thank you very much. And that is the end of our hearing, 
and I want to thank everybody and all of you who are here. I 
finally got to ask unanimous consent, which is not hard to get 
because I am the only Senator here, to enter into the record 
over 25 statements and documents from individuals and 
stakeholder groups related to the conversation today.

    [The following information can be found on page 40 through 
146 in Additional Material.]

    The Chair. This Committee stands adjourned.

                          ADDITIONAL MATERIAL
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
              prepared statement of senator cory a. booker
    Thank you, Chairman Sanders, for holding this important hearing. It 
has been 84 days since 1,700 nurses went on strike at Robert Wood 
Johnson (RWJ) University Hospital New Brunswick for improved staffing 
ratios, fair wages, and decent benefits. Eighty-four days that the 
1,700 nurses haven't seen the patients they serve and have gone without 
a paycheck. And since September, the nurses haven't had healthcare.

    This isn't a story unique to Robert Wood Johnson or New Jersey: 
just this year, there have been 18 healthcare strikes, and there were 
40 healthcare strikes in 2022. More healthcare workers have gone on 
strike in the last 2 years than in the last three decades. And we are 
seeing them win--from fair staffing ratios to better pay rates, these 
nurses are fighting for their communities and making incredible, 
transformational change for their industry and our Country.

    For too long, our economy hasn't worked for working people, and the 
nurses here today know this too well. Nurses haven't seen meaningful 
wage increases in decades--wages were largely stagnant for nurses 
between 1995 and 2015 despite increasing demand for healthcare over the 
same timeframe. Americans' cost of living has increased, but the 
incomes of America's workers just hasn't kept up.

    While hospital systems continue to consolidate and post record 
profits, nurses have been squeezed into increasingly dangerous 
workplace conditions. A study from the University of Pennsylvania 
showed that in hospitals with high patient-to-nurse ratios, each 
additional patient per nurse was associated with a 7 percent increase 
in the likelihood of death and a 7 percent increase in the odds of 
failure to respond effectively to post-surgical complications. Each 
additional patient per nurse was associated with a 23 percent increase 
in the odds of nurse burnout.

    Throughout the pandemic, we hailed nurses as heroes. We owe these 
heroes not just words, but the fair contracts and safe environments 
they deserve. Over the last few months, I have shared the same message 
with both hospital administration and RWJ's nurses represented by 
United Steelworkers (USW) Local 4-200: RWJBarnabas must come to a good-
faith agreement with USW Local 4-200, one that provides nurses with 
safe standards, quality working conditions, affordable healthcare, and 
living wages that support the employees, the hospital community, and 
patients. These nurses are parents, they are daughters and sons, they 
are friends, and they are empathetic caregivers in their community who 
must be able to get back to work in an environment that is safe and 
where they feel valued. I support RWJ nurses, and nurses everywhere, in 
the fight for a safer workplace and better working conditions.
                                 ______
                                 
                   prepared statement of mark manigan
    Chairman Sanders, Ranking Member Cassidy and Members of the 
Committee, my name is Mark E. Manigan. I am the President and Chief 
Executive Officer for RWJBarnabas Health, the largest and most 
comprehensive academic health care system in the State of New Jersey. 
On behalf of our nearly 38,000 employees and 9,000 physicians, I 
appreciate this opportunity to provide written testimony to the Senate 
Committee on Health, Education, Labor, and Pensions.

    Although I am unable to appear in person at today's field hearing, 
I have the utmost respect for this Committee and its staff and support 
your efforts to identify solutions that improve the delivery of care in 
this country and address the ongoing, nationwide nursing shortage that 
is challenging every hospital in every state. These are serious issues 
that require serious attention, and I believe the innovative work we do 
for our patients and the communities we serve at RWJBarnabas Health can 
contribute greatly to this discussion.

    I want to assure the Members of this Committee that contrary to the 
narrative of the misinformed or those seeking to purposely mislead the 
public, RWJBarnabas Health is proud of its relationship and partnership 
with our brothers and sisters in organized labor. Nearly a quarter of 
our employees are in a union. RWJBarnabas Health currently has over 
$1.3 billion in construction projects underway with organized labor. 
For months, we bargained in good faith with the United Steel Workers 4-
200 (USW 4--200), who represent our nurses in New Brunswick, and I am 
happy to report, that while slower than I had hoped, we continue to 
make real progress in negotiations. I can tell you, as an organization, 
we believe strongly in the collective bargaining process, and we look 
forward to continuing to make progress at the bargaining table--where 
negotiating belongs.

    I am troubled by the inaccurate and misleading assertions put forth 
by the Chairman in recent public comments. Unlike a significant number 
of health care organizations in the Northeast and around the country, 
RWJUH has safe staffing guidelines in place that are derived from 
national, evidence-based practice by peer academic medical centers. 
These guidelines were agreed to by the USW 4-200 negotiating committee, 
representing RWJUH nurses, in multiple contract settlement offers from 
the hospital that they failed to ratify. Our patients receive safe and 
compassionate care across all of our services, as evidenced by multiple 
quality indicators and national quality rankings, which reflect our 
unwavering commitment to the communities we serve.

    Our negotiating team at RWJUH has met with the union six (6) times 
since October 6, 2023, including this past Sunday, October 22, with the 
goal of reaching a fair and equitable resolution that provides the 
highest-quality patient care and creates a safe and supportive working 
environment for our nurses. I believe and humbly ask that you 
understand that is where my focus should be at this time, as well as 
working with our team to maintain the delivery of care for our 
patients.
          RWJBarnabas Health Commitment to Patients and Staff
    RWJBarnabas Health is one of the State of New Jersey's largest 
private employers and a not-for-profit health care organization 
covering eight counties and more than five million residents. While we 
take pride in the incredible array of health care services we provide, 
many of which are regionally and nationally recognized, what 
distinguishes RWJBarnabas Health, and what we are most proud of, is our 
deep commitment to the most vulnerable among us. RWJBarnabas Health 
plays a vital role as part of New Jersey's safety net. We are, by two 
times, the state's largest provider of medical care to those who can't 
afford to pay and to beneficiaries of the Medicaid program.

    As I noted earlier in my testimony, RWJBarnabas Health is a proud, 
pro-labor organization in a historically pro-labor state. We have long-
term and deep relationships with many labor unions that represent all 
levels of the health care professionals we employ. We have successfully 
negotiated previous labor contracts with 29 independent bargaining 
units across the system, including seven nursing unions. We respect and 
support our workers' rights to organize and to peacefully protest.

    Like all health care organizations, we continue to work hard to 
address labor shortages across all professions. Every hospital in every 
state has been impacted by a nationwide nursing shortage that began 
long before but was only further exacerbated by the pandemic. We are 
competing statewide, regionally and nationally for a finite number of 
people amidst a surge of significantly acute patients who require our 
care. The challenges are daunting, but we persist.

    The pandemic put our Nation's entire health care system and, in 
particular, hospitals like ours in the Northeast, to the test. We are 
eternally grateful for all that our nurses, physicians and other 
frontline staff did to save lives and treat our patients during one of 
the most difficult, tragic, and challenging public health emergencies 
of the past century. I am among the first to recognize the immense toll 
the pandemic took on our employees, especially our nurses, causing many 
to leave the profession. In response, RWJBarnabas Health has taken 
demonstrative steps to make operational improvements, lift wages and 
address staffing across our entire system. To be frank, we are a 
different hospital system today than we were just a short time ago, and 
any hospital that has failed to learn from the pandemic and implement 
needed changes is letting down both its patients and staff.

    In an October 9, 2023 op-ed published on nj.com and in the Star-
Ledger, Cathy Bennett, president and CEO of the New Jersey Hospital 
Association (NJHA), addressed the impact the nursing shortage is having 
on our state's hospitals. She rightly argues that the complex process 
of safe staffing requires a flexible and collaborative approach that 
allows nursing leaders to adjust to fluctuating volumes and varying 
patient acuity. I agree with NJHA that this can be best achieved 
through evidence-based approaches, including acuity-based staffing 
tools, nurse-led committees, and tracking, rather than legislative 
oversight or mandated staffing ratios. President Bennett is spot on 
when she says that hospitals across our state, and arguably the Nation, 
need greater legislative and budgetary support to expand critical 
pipelines and nursing education programs, strengthen workforce 
diversity, and enhance healthcare delivery.

    Washington's focus on addressing the national nurse staffing 
shortage and health care reimbursement rates, which have plateaued and 
failed to keep up with rising costs, is certainly welcomed. 
Unfortunately, Congress has failed to pass legislation that would 
inject significantly more resources into strengthening nurse pipelines 
and creating more educational opportunities to help address the 
staffing shortage. Although we have taken steps to significantly reduce 
our reliance on contract nurses across the RWJBarnabas Health system 
prior to the current strike at RWJUH, the shortage of nurses has made 
it impossible for us to entirely eliminate agency support. An April 
2023 report by the American Hospital Association found that hospitals 
across the country are facing a $100 billion annual shortfall in 
reimbursement from Medicare and Medicaid with hospital expenses rising 
17.5 percent between 2019-2022, while reimbursements increased only 7.5 
percent during the same period. Among the factors placing increased 
financial constraints on hospitals, the AHA cited critical workforce 
shortages forcing hospitals to rely more on contract labor, as well as 
historic inflation driving up the costs of medical supplies and 
equipment. Furthermore, while the American Rescue Act provided much 
needed support to help us get through the pandemic, most of those 
available funds have lapsed at a time when hospitals, including those 
in our system, continue to face financial challenges.
           RWJBarnabas Health Commitment to Community Benefit
    RWJBarnabas Health is privileged to be part of the fabric of the 
great State of New Jersey--a state rich in economic opportunity, 
diversity and culture, all of which contribute to the betterment of the 
lives of its outstanding residents. The system includes 12 (12) acute 
care hospitals, three (3) acute care children's hospitals, Children's 
Specialized Hospital with a network of outpatient pediatric 
rehabilitation centers, a freestanding 100-bed behavioral health 
center, two (2) trauma centers, a satellite emergency department, 
ambulatory care centers, geriatric centers, the state's largest 
behavioral health network, comprehensive home care and hospice 
programs, fitness and wellness centers, retail pharmacy services, 
affiliated medical groups, multi-site imaging centers and two (2) 
accountable care organizations. Our footprint covers eight counties 
with over five million residents.

    For more than 140 years, RWJBarnabas Health has been an anchor 
institution in New Jersey. As the state's largest and most 
comprehensive academic health care system, our clinical programs have 
made us a destination for care, especially for patients facing complex 
conditions. We are honored to be a part of the generational legacy of 
so many New Jersey residents. Our team works tirelessly to ensure all 
are treated with compassion, empathy, and respect, and provided with 
the highest-quality and most equitable care.

    RWJBarnabas Health is much more than a critical health care 
provider. Our commitment does not begin with a visit to a doctor or a 
hospital. It starts with creating educational and economic opportunity, 
safe and affordable living conditions, and access to healthy food. 
RWJBarnabas Health is a robust economic engine contributing more than 
$5.5 billion to the New Jersey economy per year, and we harness that 
horsepower for the benefit of our diverse communities, in particular, 
the disadvantaged. Since 2019, our hire-local-buy-local ``anchor 
mission'' has led to more than $214 million of spending with local and 
diverse vendors. We have intentionally recruited and hired 3,000 
teammates from ALICE (asset limited, income constrained) neighborhoods. 
We funded the construction of a public elementary school and have 
developed career path programs for students with multiple educational 
institutions. We have ``fall--proofed'' senior homes and subsidized 
affordable housing for the working poor and the homeless as well as 
transitional housing for families suffering from illness-related 
financial hardship.

    To address food insecurity and health, RWJBarnabas Health has built 
a greenhouse in Newark, distributed thousands of meals to the hungry, 
funded local community gardens, hosted farmers markets and established 
food hubs with local farmers in our cities, embedded nutritional 
programs in schools and community centers, and our Wellness on Wheels 
van traverses the state offering cooking classes on healthy eating.

    We are also investing in the future health and well-being of all 
New Jerseyans. RWJBarnabas Health has dedicated more than $1 billion, 
through our transformative partnership with Rutgers University, to 
increase access to groundbreaking clinical trials and innovative 
medical care. The partnership also trains and develops the health care 
providers who will take care of the next generation of New Jerseyans. 
Further, to make sure cutting-edge clinicians have the most effective 
settings in which to practice, from 2020 through 2025, RWJBarnabas 
Health will have invested more than $4.7 billion in new equipment, 
technology and facilities, with a sizable portion of that in 
underserved communities, creating thousands of jobs along the way.

    We have implemented programs to reduce disparities in maternal 
health outcomes by focusing on prenatal care and education, enhanced 
clinical services for the unique needs of the LGBTQ community, 
partnered with the state on the ``Arrive Together'' program pairing 
mental health professionals with police on 911 response calls, 
implemented post-incarceration programs focused on providing health and 
social support services, and built fields and parks throughout the 
state, including the incredible Field of Dreams facility in Toms River, 
an inclusive playground and park for those with special needs.

    In drawing erroneous conclusions about RWJBarnabas Health's 
commitment to the community in a recent Report entitled ``Executive 
Charity: Major Non-Profit Hospitals Take Advantage of Tax Breaks and 
Prioritize CEO Pay Over Helping Patients Afford Medical Care,'' the 
Chairman respectfully relied on inaccurate information. The American 
Hospital Association called the Report's findings ``mistaken,'' ``just 
plain wrong'' and that its ``tunnel-visioned `research' neglects to 
consider that under the law community benefit is defined by much more 
than charity care and includes patient financial aid, health education 
programs and housing assistance, just to name a few.''

    For the record, RWJBarnabas Health provided approximately $651 
million in community benefit as defined by the Internal Revenue Service 
(IRS) and reported on Forms 990, Schedule H, Part I for calendar year 
2021, in furtherance of its Federal tax-exempt, not-for-profit status. 
This does not include $220 million in uncollectible patient accounts in 
2021, which equate to bad debt, nor a $184 million Medicare shortfall 
for the same year. When you aggregate all the sources of net community 
benefit, our unfunded costs represent 11.29 percent of our total 
expenses for 2021 of $5.769 billion. In 2021, RWJBarnabas Health also 
provided $142 million in charity care, representing nearly 2.5 percent 
of all expenses that year.

    We thank the residents of New Jersey for their continued support of 
RWJBarnabas Health and for trusting us with their health care needs. As 
we step into the future, we look forward to witnessing all we will 
accomplish together in our continued pursuit of a healthier New Jersey.
                                Closing
    I want to thank the Committee for its time and thoughtful 
consideration. Although I respectfully question the motives of the 
Chairman in choosing the timing and location of today's field hearing, 
RWJBarnabas Health welcomes the opportunity to share our expertise and 
experience and participate in substantive policy discourse to improve 
our Nation's health care. RWJBarnabas Health is committed to its stated 
mission to build healthy communities through our care delivery at our 
facilities and through our significant work in the communities we 
serve. We are committed to investing in cutting-edge technologies, 
developing innovative procedures and treatments, and expanding our 
services to provide the best quality care for our patients. And we are 
committed to being a best-in-class employer, supporting our staff, 
offering competitive wages and benefits, and providing opportunities 
for workforce development.
                                 ______
                                 
                  [summary statement of mark manigan]
    I am the President and Chief Executive Officer for RWJBarnabas 
Health, the largest and most comprehensive academic health care system 
in the State of New Jersey. Although I am unable to appear in person at 
today's field hearing, I have the utmost respect for this Committee and 
its staff and support your efforts to identify solutions that improve 
the delivery of care in this country and address the ongoing, 
nationwide nursing shortage that is challenging every hospital in every 
state.

    I want to assure the Members of this Committee that contrary to the 
narrative of the misinformed or those seeking to purposely mislead the 
public, RWJBarnabas Health is proud of its relationship and partnership 
with our brothers and sisters in organized labor. Nearly a quarter of 
our employees are in a union. RWJBarnabas Health currently has over 
$1.3 billion in construction projects underway with organized labor. 
For months, we bargained in good faith with the United Steel Workers 4-
200 (USW 4-200), who represent our nurses in New Brunswick, and I am 
happy to report, that while slower than I had hoped, we continue to 
make real progress in negotiations. As an organization, we believe 
strongly in the collective bargaining process, and we look forward to 
continuing to make progress at the bargaining table--where negotiating 
belongs.

    I am troubled by the inaccurate and misleading assertions put forth 
by the Chairman in recent public comments. Unlike a significant number 
of health care organizations in the Northeast and around the country, 
RWJUH has safe staffing guidelines in place that are derived from 
national, evidence-based practice by peer academic medical centers. 
These guidelines were agreed to by the USW 4-200 negotiating committee 
in multiple contract settlement offers from the hospital that they 
failed to ratify. Our patients receive safe and compassionate care 
across all of our services, as evidenced by multiple quality indicators 
and national quality rankings, which reflect our unwavering commitment 
to the communities we serve.

    Our negotiating team at RWJUH has met with the union six (6) times 
since October 6, 2023, including this past Sunday, October 22, with the 
goal of reaching a fair and equitable resolution that provides the 
highest-quality patient care and creates a safe and supportive working 
environment for our nurses. I believe and humbly ask that you 
understand that is where my focus should be at this time, as well as 
working with our team to maintain the delivery of care for our 
patients.

    The pandemic put our Nation's entire health care system and, in 
particular, hospitals like ours in the Northeast, to the test. We are 
eternally grateful for all that our nurses, physicians and other 
frontline staff did to save lives and treat our patients during one of 
the most difficult, tragic, and challenging public health emergencies 
of the past century. I am among the first to recognize the immense toll 
the pandemic took on our employees, especially our nurses, causing many 
to leave the profession. In response, RWJBarnabas Health has taken 
demonstrative steps to make operational improvements, lift wages and 
address staffing across our entire system. To be frank, we are a 
different hospital system today than we were just a short time ago, and 
any hospital that has failed to learn from the pandemic and implement 
needed changes is letting down both its patients and staff.

    In an October 9, 2023 op-ed published on nj.com and in the Star-
Ledger, Cathy Bennett, president and CEO of the New Jersey Hospital 
Association, addressed the impact of the nursing shortage and rightly 
argues that the complex process of safe staffing requires a flexible 
and collaborative approach that allows nursing leaders to adjust to 
fluctuating volumes and varying patient acuity. I agree with NJHA that 
this can be best achieved through evidence-based approaches, including 
acuity-based staffing tools, nurse-led committees, and tracking, rather 
than legislative oversight or mandated staffing ratios. RWJBarnabas 
Health welcomes the opportunity to share our expertise and experience 
and participate in substantive policy discourse to improve our Nation's 
health care.

                     prepared statement of alan lee
    Chairman Sanders, Ranking Member Cassidy and Members of the 
Committee, my name is Alan Lee. I am the President of Robert Wood 
Johnson University Hospital (RWJUH) in New Brunswick, NJ I welcome this 
opportunity to provide testimony to the Senate Committee on Health, 
Education, Labor, and Pensions and thank you for your careful 
consideration of the information I am sharing herein.

    I respectfully submit this written testimony in lieu of appearing 
before the Committee. The cadence of our negotiations has increased and 
we believe a contract is attainable in the near future. We cannot risk 
anything taken out of context in this hearing that might hinder our 
ability to reach an agreement to bring our nurses back inside so that 
they can resume their noble profession and support themselves and their 
families. Ending this strike is paramount.

    As the Committee is fully aware, the nurses at RWJUH, represented 
by the United Steel Workers Local 4--200 (USW 4-200), have been on 
strike since August 4, 2023. As the leader of this organization, I 
state to you emphatically and with a clear conscience that we did 
everything possible to avert this labor action. Furthermore, we have 
done everything possible to bring our nurses back inside since that 
day. We have negotiated in good faith and transparently, and have 
offered more in settlement proposals than any other organization of 
similar scope has in our market. We have respected the nurses' right to 
protest during this labor action despite relentless and abhorrent 
behavior impacting our sickest patients through noise and intimidation. 
Sadly, they went too far and assaulted a replacement nurse and began to 
intentionally block physicians reporting to the hospital to perform 
lifesaving interventions. Despite this behavior, which the union 
ultimately acknowledged was egregious and signed a consent order to 
cease and desist, we have kept our focus on settling our contract and 
delivering excellent patient care.

    Upon completion of this testimony, I respectfully submit that the 
esteemed Committee will have a clearer picture of two important points. 
First, that the hospital is committed to providing our nurses with fair 
and equitable compensation and ensuring safe staffing levels that meet 
criteria based on patients' acuity and the volume of the patients we 
treat. Second, RWJUH has fulfilled our obligation to care for our 
communities at all levels--which is no small feat given the complexity 
of our academic medical center--during this labor action. This is a 
sacred obligation, one for which we have paid an unfortunately high 
price to achieve during the strike.

    Ensuring delivery of the highest quality, always-safe patient care 
and working toward a resolution that brings our dedicated nursing staff 
back to the bedside remain my top priorities and the focus of my 
attention. These cannot be characterized as mutually exclusive. They 
are equally important. Closing the hospital was simply not an option.
         Background on Robert Wood Johnson University Hospital
    RWJBarnabas Health is the largest, most comprehensive academic 
health care system in New Jersey, with a service area covering eight 
counties with five million people. It is a not-for-profit, safety-net 
organization and the largest charity care provider in New Jersey. 
RWJUH, an RWJBarnabas Health facility, is New Jersey's largest academic 
medical center through its deep partnership with Rutgers University. I 
am proud of our contributions to health care in New Jersey. RWJUH is 
ranked in the top five of New Jersey hospitals by both U.S. News & 
World Report and Newsweek.

    RWJUH has 640 licensed beds, is home to a nationally ranked 
children's hospital and, in partnership with Rutgers Cancer Institute 
of New Jersey, is the flagship location of New Jersey's only National 
Cancer Institute (NCI)-designated comprehensive cancer center. RWJUH is 
one of only seven hospitals in the world to achieve the prestigious 
Magnet Designation from American Nurses Credentialing Center six 
consecutive times. Two of the other hospitals to achieve this status 
are also in the State of New Jersey. RWJUH is one of three state-
designated Level I Trauma Centers; an Advanced Comprehensive Stroke 
Program, as designated by The Joint Commission; a regional transfer 
center for cardiovascular care, stroke, neuroscience, trauma, 
pediatrics, and oncology; and performs kidney, pancreas and heart 
transplantations. RWJUH treated more than 90,000 patients in its adult 
and pediatric emergency departments last year.

    Due to its role as a quaternary care facility, RWJUH employs health 
care professionals at the highest echelons of their specializations. 
Most clinical care providers and ancillary clinical team members have 
the highest levels of certifications and extensive experience, as is 
appropriate for addressing the sickest patients and the most complex 
conditions.

    Like every hospital in New Jersey and the country, we are working 
hard to overcome a nationwide nursing shortage. Despite those 
challenges and the intense competition for employment, RWJUH continues 
to make positive strides in nurse recruitment, hiring and retention. We 
have added over 200 registered nurse positions since May 2022 to 
bolster our always-safe nurse staffing guidelines and have achieved a 
vacancy rate that is nearly half the national average. To retain and 
attract nurses with top certifications, commitment to nursing education 
and essential experience, RWJUH pays the highest wages in the state and 
is committed to protecting that status.

    New Jersey is a pro-labor state and RWJBarnabas Health and RWJUH 
have and always will be union-friendly organizations. I respect our 
employees' right to organize and peaceably protest. Throughout the 
current labor action, RWJUH has continued to negotiate transparently 
and in good faith toward reaching a fair and equitable agreement on a 
contract with our valued nurses. It is not due to the hospital's offers 
or efforts that the nurses continue to strike.
Good Faith and Transparent Negotiations with United Steel Workers 4-200
    See attached addendums:

          I. Summary of negotiation sessions with USW-4-200

          II. Infographic of the RWJUH always-safe nurse staffing 
        guidelines; Chart of the RWJUH nurse vacancy rate comparison to 
        national nurse vacancy rate

    Negotiations between RWJUH and USW 4-200, the union representing 
our esteemed nurses, began in April 2023, far ahead of the contract 
expiration date of June 30, 2023. We have held several face-to-face 
negotiation sessions and met multiple times through a Federal mediator 
in hopes of reaching a resolution. Since October 6, 2023, we have met 
six (6) times with varying degrees of progress. Our most recent session 
was Sunday, October 22. All contract settlement offers by RWJUH have 
extended wage increases that ensure RWJUH nurses are the highest paid 
in the State of New Jersey compared to their peers and committed to 
staffing guidelines that meet or exceed current proposed legislation in 
New Jersey and those that have passed in states like California with 
mandated nurse ratios.

    Let me be clear: RWJUH did not want this strike. In fact, we did 
everything we could to avert it. We twice accepted USW 4-200's demands 
and offered to go to binding arbitration or submit to a board of 
inquiry, but the union refused. We requested numerous times for union 
leadership to continue negotiating rather than strike. We informed them 
in July that striking workers stood to lose not only pay but also 
employee benefits, which require a minimum number of hours worked each 
month to be eligible. And we repeatedly pleaded with the union to 
consider the impact of a strike--especially a prolonged strike--for 
nurses and their families. Make no mistake, the decision to strike was 
the union's and the union's alone.

    According to publicly available data, RWJUH nurses are the most 
highly paid in New Jersey and our nurse vacancy rate is nearly half the 
national average. As an academic medical center providing the highest 
acuity care, our existing staffing guidelines are established from 
evidence-based practice with peers nationally to address the sickest 
patients and volumes that are among the highest in the state. As 
essential members of the care team, RWJUH is committed to providing 
nurses with a safe and supportive work environment and a healthy 
lifestyle.

    The negotiation team put forth by USW 4-200 to represent our nurses 
has often bargained outside of industry standard protocol and have 
presented as sometimes disorganized, unprofessional and chaotic in 
their approach. For example, on July 17, they signed a memorandum of 
agreement (MOA) with the hospital that included the union's own 
staffing proposal and a compensation settlement that would have ensured 
RWJUH nurses are paid on average 14 percent higher than any other 
nurses in New Jersey. That agreement implied a commitment by the union 
leadership to endorse and recommend the settlement to their membership 
for ratification. Instead, they extended little support for the MOA and 
delivered an overwhelming no-vote by the members that is 
extraordinarily unusual once an agreement is signed. Inexplicably, from 
that point forward, the union has presented no reasonable, articulate 
or administrable path to a settlement. This behavior, and lack of 
educating their members on settlement offers, is atypical of bargaining 
negotiations and has been non-productive.

    This lack of professionalism in negotiating is tragically 
detrimental to our nurses who have lost wages and benefits during this 
strike. At one point, the union publicly claimed it was unaware that 
members would lose eligibility for health benefits even though an 
update posted by the union to USW 4-200's website in July specifically 
informed its members of the pending deadline.
The High Cost of Delivering Care Throughout This Prolonged Labor Action
    The union's decision to walk off the job and prolong this strike 
has also had significant economic consequences for the hospital that we 
will have to carefully manage for years to come. To date, RWJUH has 
paid more than $103 million for strike-related expenses, including 
replacement nurses with the highest levels of certification and 
experience in acute care and specialized clinical areas. Caring for our 
patients is our No. 1 priority. We make no apologies for doing 
everything necessary to ensure the hospital remains fully operational 
and our patients continue to receive the highest quality, always-safe 
care. What would we have told our patient from Princeton, who waited on 
a heart transplantation list for more than 2 years, if we had not been 
able to accept his donor heart and transplant it into him on August 4--
the first day of the strike? Closing the hospital was never an option 
and will never be an option. We strongly challenge the assertion that 
engaging highly skilled, compassionate and reputable agency nurses to 
help us at this time is anything but honorable and necessary. We owe 
these nurses a debt of gratitude.

    That said, the compounded tragedy of this situation is that these 
funds absolutely could have been better utilized to further invest in 
patient care, staff wages, and improvements throughout the hospital. We 
implored the union to continue to bargain with us while our nurses 
stayed at the bedside, earned wages and were covered on our health and 
wellness programs. They elected to strike.
                                Closing
    RWJUH stands firm in its commitment to fair and respectful wages, 
safe staffing standards based on patient acuity and volume, and 
accountability toward meeting staffing guidelines for our nurses. 
Accountability is not equivalent to punitive financial penalties that 
might actually undermine our organization's ability to deliver care to 
our patients and meet our community benefit mission. We will not agree 
to fines that have no administrative rigor and no stake by the union. 
This blank check request by USW 4-200 undermines their credibility as 
champions of patient safety and denigrates the noble nursing profession 
they represent.

    I want to thank the Committee for affording me this opportunity to 
provide testimony. I hope that it aids you in important national dialog 
regarding the escalating costs of health care, the disparity in 
reimbursement to providers who front the cost of this care and the 
burden it places on our essential healthcare workers who want to help 
vulnerable people and also sustain their families. We look to our 
leaders to help us to identify and address the root causes of 
attracting fresh talent into health care, preventing burnout for those 
already in our noble industry and enabling an equitable and healthier 
public across the United States.

    I am proud to share the tremendous work we do at Robert Wood 
Johnson University Hospital and the comprehensive care we provide. 
RWJUH is steadfast in its commitment to always-safe, highest quality 
patient care. I have the utmost respect for our dedicated nursing 
colleagues. Their invaluable contributions to our patients, our 
community and our hospital are greatly appreciated. It is my sincere 
hope that we can reach a fair and equitable resolution with USW 4-200 
so we can welcome our nurses back as soon as possible.
                                 ______
                                 
                    [summary statement of alan lee]
    My name is Alan Lee. I am the President of Robert Wood Johnson 
University Hospital (RWJUH) in New Brunswick, NJ, I respectfully submit 
this written testimony in lieu of appearing before the Committee. The 
cadence of our negotiations has increased, and we believe a contract is 
attainable in the near future. We cannot risk anything taken out of 
context in this hearing that might hinder our ability to reach an 
agreement to bring our nurses back inside so that they can resume their 
noble profession and support themselves and their families. Ending this 
strike is paramount.

    As the leader of this organization, I state to you emphatically 
that we did everything possible to avert this labor action. Every day 
since August 4, we have done everything possible to bring our nurses 
back inside. This includes negotiating in good faith and transparently 
and offering more in settlement proposals than any other organization 
of similar scope has in our market. We have respected the nurses' right 
to protest during this labor action despite relentless and abhorrent 
behavior impacting our sickest patients through noise and intimidation. 
Sadly, they went too far and assaulted a replacement nurse and began to 
intentionally block physicians reporting to the hospital to perform 
lifesaving interventions.

    There are two important points that I want to convey through this 
testimony: first, that the hospital is committed to providing our 
nurses with fair and equitable compensation and ensuring safe staffing 
levels that meet criteria based on patients' acuity and the volume of 
the patients we treat. Second, RWJUH has fulfilled our obligation to 
care for our communities at all levels--which is no small feat given 
the complexity of our academic medical center--during this labor 
action. Ensuring delivery of the highest quality, always-safe patient 
care and working toward a resolution that brings our dedicated nursing 
staff back to the bedside remain my top priorities and the focus of my 
attention. These cannot be characterized as mutually exclusive. They 
are equally important. Closing the hospital was simply not an option.

    According to publicly available data, RWJUH nurses are the most 
highly paid in New Jersey and our nurse vacancy rate is nearly half the 
national average. As an academic medical center providing the highest 
acuity care, our existing staffing guidelines are established from 
evidence-based practice with peers nationally to address the sickest 
patients and volumes that are among the highest in the state. As 
essential members of the care team, RWJUH is committed to providing 
nurses with a safe and supportive work environment and a healthy 
lifestyle. However, the negotiation team put forth by the union 
representing our nurses has sometimes exhibited a disorganized, 
unprofessional and chaotic approach. For example, on July 17, they 
signed a memorandum of agreement (MOA) with the hospital that included 
the union's own staffing proposal and a compensation settlement that 
would have ensured RWJUH nurses are paid on average 14 percent higher 
than any other nurses in New Jersey. That agreement implied a 
commitment by the union leadership to endorse and recommend the 
settlement to their membership for ratification. Instead, they extended 
little support for the MOA and delivered an overwhelming no-vote by the 
members that is extraordinarily unusual once an agreement is signed. 
Inexplicably, from that point forward, the union has presented no 
reasonable, articulate or administrable path to a settlement. This 
behavior, and lack of educating their members on settlement offers, is 
atypical of bargaining negotiations.

    New Jersey is a pro-labor state and RWJUH will always be a union-
friendly organization. I respect our employees' right to organize and 
peaceably protest and am committed to continue to negotiate in good 
faith toward reaching a fair and equitable agreement on a contract.

                                 ______
                                 
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                 
    [Whereupon, at 10:30 a.m., the hearing was adjourned.]

                                   [all]