September 26, 2001

Testimony by
Ernest C. Klein, Jr., CAE
Executive Director
Indiana State Nurses Association

Good afternoon: I am Ernest Klein, Executive Director of the Indiana State Nurses Association. Thank you for this opportunity to present some information to you.

I would like to state first of all that I will often use the word "nurse" and "nursing" but I will be speaking specifically about Registered Nurses. I am sure though that LPNs share many of the same concerns. I will also be talking about national trends, but be assured that these issues are happening in Indiana.

As this Commission is aware, health care institutions across the state are experiencing a crisis in direct care staffing, and we are standing on the precipice of an unprecedented shortage of nurses. This emerging shortage of nurses is very real and very different from any experienced in the past. The concept of supply and demand is not working this time. Usually when there is a demand for nurses such as in the late 1980’s, salaries go up and the supply increases. This time, in spite of increased salaries and huge sign-on bonuses, the supply of nurses is not increasing. Projections show that these current shortages are just a minor indication of the systemic shortages that will soon confront our health care delivery system.

The current staffing crisis is directly attributable to several factors. The last ten years have seen dramatic changes in the manner in which health care is delivered. As a consequence of the tightening of the reimbursements for health care, many facilities and institutions took various means to decrease their health care costs. After almost a decade of constant health system changes, reorganization, reengineering, and changes in reimbursement and funding mechanisms, the overall environment of health care has deteriorated to such an extent that we are now faced with a crisis in a shortage of direct care providers. As RNs typically represent the largest single expenditure for hospitals (averaging 20 percent of the budget), we were some of the first to feel the pinch. Lesser-skilled, lower-salaried assistive staff were hired as replacements; and RN salaries decreased in both actual and real terms. During this restructuring, experienced and highly paid nurses were eliminated from the workforce through layoffs, early retirement buy-outs, and attrition with resulting relocation into positions that were not direct care. The overall impact of the changes in the 1990s was to increase pressure on staff nurses who were required to oversee unlicensed aides while caring for a larger number of sicker patients.

The result is that the environment or working conditions for those remaining in the nursing workforce worsened, forcing many frustrated and exhausted nurses to leave positions of direct care. These nurses surely did not recommend a nursing career to others.

The Division of Nursing, U.S. Department of Health and Human Services, has predicted that by the year 2010, the number of nurses will not meet the demand for nurses. In fact, the years following 2010 show a dramatic widening between the supply of registered nurses in relation to the demand for registered nurses.

The average age of working nurses is 43.3 years. We can anticipate that over the next ten to fifteen years these nurses will be aging and/or retiring. They will be retiring at a time when our population will be generally older and in greater need of nursing care.

The Indiana Hospital and Health Association reports there are some 1,200 openings for RNs in hospitals across Indiana. We have all been hearing about the difficulties encountered in finding nurses to take these positions. I often hear from staff nurses who tell me that the reason for these vacancies is dissatisfaction with the work environment. The Congressional Research Service, in a report this past May, suggests that there is a misdistribution of labor rather than a shortage per se. Nurses are, understandably, reluctant to accept positions where they will face unsafe conditions, inappropriate staffing levels, be confronted by mandatory overtime, inappropriately rushed through patient care activities, and face retaliation if they report unsafe practices.

This means that the workplace must be safe. It should be safe from violence, from bloodborne pathogens (needlestick safety), and from occupational hazards. Findings from the Health and Safety Survey released by the American Nurses Association on September 7 revealed that fewer than 20 percent of nurses responding felt safe in their current work environment. Seventeen (17) percent of nurses responding had been physically assaulted in the past year and more than half (56.6 percent) were threatened or experienced verbal abuse. The implementation of a federal law to require the use of safer needle devices has made a significant impact; however, almost 20 percent of nurse respondents revealed that their facilities still do not provide safe needle devices for injections, IV insertions, and phlebotomy procedures. An even greater percentage (39 percent) confirmed that their facilities continue to use powdered latex gloves, a hazard known to cause severe allergic reactions in patients and workers with latex allergies. Continued exposure to latex is a significant factor in developing an allergy. Additionally, nurse respondents stated that more than half the facilities in which they worked didn’t have lifting and transfer devices readily available for moving patients. Use of lifting devices can significantly decrease nurses’ risk of back injuries.

Nurses across the state are also expressing concerns about the increase in the use of mandatory overtime as a staffing tool. Employers may insist that a nurse work an extra shift (or more) or face dismissal for insubordination as well as being reported to the state board of nursing for patient abandonment. Our concerns about the use of mandatory overtime are directly related to patient safety. We know that sleep loss influences several aspects of performance, leading to slowed reaction time, failure to respond when appropriate, false responses, slowed thinking, and diminished memory. In fact, 1997 research by Dawson and Reid at the University of Australia showed that work performance is more likely to be impaired by moderate fatigue than by alcohol consumption. Their research shows that significant safety risks are posed by workers staying awake for long periods. It only stands to reason that an exhausted nurse is more likely to commit a medical error than a nurse who is not being required to work a 16-hour shift. Nurses are placed in a unique situation when confronted by demands for overtime. Ethical nursing practice prohibits nurses from engaging in behavior that they know could harm patients. At the same time, RNs face the loss of their license--their careers and livelihoods--when charged with patient abandonment.

In addition, nurses must be able to speak out about quality-of-care problems without fear of retaliation or loss of their jobs. Patient advocacy is the heart of nurses’ professional commitment. In turn, patients depend on nurses to ensure that they receive proper care. Patients must be assured that nurses and other health care professionals, acting within the scope of their expertise, will be able to speak for them without fear of retaliation. Whistleblowing by nurses usually results from concern about issues that jeopardize the health or safety of patients or occupational safety and health violations that place the employee at risk. Although they are responsible for patient care and well-being, nurses often are powerless when another health care provider performs unethical or life-threatening practices. This lack of protection prevents many nurses (because of fear of reprisal) from taking the risk of trying to protect public health and safety. Reprisal has included dismissal, harassment, and blacklisting.

The safety and quality of care provided in the nation's health care facilities is directly related to the number and mix of direct-care nursing staff. More than a decade of research shows that nurse staffing levels and skill mix make a difference in the outcomes of patients. Studies show that when there are more nurses, there are lower mortality rates, shorter lengths of stay, better care plans, lower costs, and fewer complications. In fact, four HHS agencies--the Health Resources and Services Administration, Health Care Financing Administration, Agency for Healthcare Research and Quality, and the National Institute of Nursing Research of the National Institutes of Health--recently sponsored a study on this very topic. The resulting report, released on April 20, 2001, found strong and consistent evidence that increased RN staffing is directly related to decreases in the incidence of urinary tract infections, pneumonia, shock, upper gastrointestinal bleeding, and decreased hospital length of stay. In addition to the important relationship between nurse staffing and patient care, several studies have shown that one of the primary factors for the increasing nurse turnover rate is dissatisfaction with workload/staffing. ANA's recent survey states that 75 percent of nurses surveyed feel that the quality of nursing care at the facility in which they work has declined over the past two years. Out of nearly 7,300 respondents, over 5,000 nurses cited inadequate staffing as a major contributing factor to the decline in quality of care. More than half of the respondents believed that the time they have available for patient care has decreased. The University of Pennsylvania research shows that 70-80 percent of more than 43,000 registered nurses surveyed in five countries reported that there are not enough RNs in hospitals to provide high quality care. Only 33 percent of the American nurses surveyed believed that hospital staffing is sufficient to "get work done." This survey reflects similar findings from a national survey taken by the Henry J. Kaiser Family Foundation (1999) that found that 69 percent of nurses reported that inadequate nurse staffing levels were a great concern. The public at large should be alarmed that more than 40 percent of the nurses who responded to the ANA survey stated that they would not feel comfortable having a family member cared for in the facility in which they work.

We strongly encourage acute care facilities to implement and use a valid and reliable staffing plan based on patient acuity. Adequate staffing levels allow nurses the time that they need to make patient assessments, complete nursing tasks, respond to health care emergencies, and provide the level of care that these patients deserve.

4. NON-SOLUTIONS

Some facilities might suggest that the nursing shortage can be met by allowing the use of more unlicensed assistive personnel. De-skilling the workforce actually raises health care costs. Allowing unlicensed assistive personnel to perform nursing tasks for which they have not been trained or educated is harmful to patient care. Nurses at the bedside are essential to quality care. Increasing the ratio of nurses to patients has been shown to reduce medication errors, pressure ulcers, incidence of pneumonia, post-operative infections, and mortality rates. Unlicensed assistive personnel play an important role in providing support services to ensure that nurses have the time to provide nursing care; however, they cannot be used to replace nursing skills.

I have deep concerns about the use of immigration as a means to address the emerging nursing shortage. We have been down this road many times before without success. The influx of foreign-trained nurses only serves to further delay debate and action on the serious workplace issues that continue to drive American nurses away from the profession. There are serious ethical questions about recruiting nurses from other countries when there is a worldwide shortage of nurses. The removal of foreign-trained nurses from areas such as South Africa, India, and the Caribbean deprives their home countries of highly trained health care practitioners upon whose skills and talents their countries heavily rely.

• Nurses are not forced to work overtime to fill gaps in staffing schedules. Nurses are supported in continuing their professional development.

Just ten years ago we were emerging from the nursing shortage of the late 1980's. Nursing workforce issues had caught the attention of the highest reaches of the Reagan and Bush Administrations. HHS Secretary, Doctor Otis Bowen, established a Commission on Nursing which released recommendations in 1988 on methods to improve the work environment for nurses. These 16 recommendations, released in December 1988, are still very relevant today--they include issues such as the need to adopt innovative nurse staffing patterns, the need to collect better data about the economic contribution that nurses make to employing organizations, the need for nurse participation in the governance and administration of health care facilities, and the need for increased scholarships and loan repayment programs for nursing students. Perhaps if these recommendations had been fully implemented, we would not be here today.