VA Testimony of Cathy Rick, RN before Congress on October 2, 2003

United States Department of Veterans Affairs

STATEMENT OF
CATHY RICK, RN CNAA, FACHE
CHIEF NURSING OFFICER
VETERANS HEALTH ADMINISTRATION
DEPARTMENT OF VETERANS AFFAIRS
BEFORE THE
HOUSE OF REPRESENTATIVES
COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION

October 2, 2003

Chairman Buyer, Ms Hooley, and members of the Subcommittee: I want to thank you for this opportunity to present testimony regarding the impact of the national nursing shortage on the Veterans Health Administration, the nation's largest employer of registered nurses. Today I will share with you the aggressive actions VA is taking to combat the shortage and ensure ongoing quality care for veterans.

Background

National nursing leaders and health care organizations project a shortage of registered nurses that will be unlike any experienced in the past (AACN, 1998). In addition to registered nurses, the nursing workforce includes practical nurses and nursing assistants. However, the registered nurse is at the center of the nursing workforce; the registered nurse coordinates care for the individual veteran patient as well as for the population of veteran patients in our communities. Given the aging of the current registered nurse workforce, the decreasing number of students who choose nursing as a career, and the ever increasing demand for professional nursing services, the current and future number of professional registered nurses ( RN) will be insufficient to meet our national health care needs (Janiszewski (2003) Buerhaus, Staiger, & Auerbach, 2000; Carpenter, 2000). Noted nursing economist Dr. Peter Buerhaus wrote that the total number of nurses per capita will likely peak in 2007 and decline steadily thereafter (1998). This is consistent with a Bureau of Labor Statistics estimate that the need for registered nurses is expected to exceed one million by 2010. The nursing shortage is already challenging hospitals to provide safe care in certain areas. (Stechmiller 2002). At the same time, changes in healthcare delivery will require larger numbers of well-educated nurses who perform increasingly complex functions in hospitals and the community. Market demand will also drive an increased need for nurses. (Peterson 2001). By 2020, the United States RN workforce is forecast to be roughly the same size as it is today, declining nearly 20 percent below RN workforce requirements. (Buerhaus, Staiger, & Auerbach, 2000). A modest increase in enrollment in generic nursing programs was experienced in 2002; however, far larger increases are needed if the trends noted above are to be reversed.

The projected shortage will result in part from a number of substantial changes that continue to take place in the profession. Factors identified that will intensify a nursing shortage are (AACN, 2000; Bednash, 2000; Carpenter, 2000; Curren, Horner, & Eldridge, 2000; Havens & Aiken, 2000):

A decline in enrollment in schools of nursing;
Aging of the nursing workforce (average age nationally, 45.2 yrs, VA 47.4 yrs);
Average age of a new graduate in nursing has climbed to 30.5 in 1995 - 2000 versus 24.3 in 1985 or earlier;
Neither racial nor ethnic minorities nor men enter nursing in numbers that reflect the national population;
Young women, who in the past made up the preponderance of nursing students, now have a wide range of alternative career options available;
Poor image of nursing as a career choice. In a 2001 Gallup Poll of public perceptions of the professions, nurses ranked number one in honesty and high ethics for the second, consecutive year. However, in the same poll, nursing ranks 137 out of 250 professions in desirability;
Pay inequities between nurses and other occupations that require less education and have less responsibility;
Perceived negative work environments, such as: undesirable work schedules, lack of respect and lack of nursing involvement in patient care decisions;
Inadequate numbers of qualified faculty to educate the numbers of nurses needed.

Impact of the Shortage on VA

Registered nurses comprise the largest segment of healthcare workers within the Veterans Health Administration ( VHA N=36,000). VA nursing workforce data support the conclusion that the average age of VA nurses will continue to rise and the number of nurses who are retirement eligible will continue to rise. Based on current trends, retirements will not be abrupt or sudden, but rather a prolonged, gradual, manageable wave of retirements that should extend well beyond 2005. Retirements will require a consistent influx of nurses and ancillary personnel. Difficulties have arisen and will continue as the shortage results in increased time and efforts required to fill registered nurse vacancies.

The Average age of an RN nationally is 45.2 (DHHS 2000); Average age of VA RN is 47.4 (2002)
Average age of a VA RN new hire in FY 2000 was 41.65 years;
VA nurses will be eligible for retirement in large numbers through 2005 ( RNs 35 percent, LPNs 29 percent, Nursing Assistant 34 percent).
55 percent of all VA Nurse Executives are eligible to retire in 2005; 69 percent will be eligible in 2008

VA's nurse turnover rate at 8.3 percent is less than the national average, which is estimated at 20 percent.

VA is an employer of choice for men and ethnic minorities, hiring higher percentages than are reflected in the general population of nurses.

Minority Category	National-RN only (DHHS, 2000)	VA-RN only (FY 2000)
Males	5.4	13.8
African American	4.9	14.62
Hispanic	2.0	5.85
Asian	3.5	9.58

Based on VA PAID data files-- FY 2000 and US Dept of Health and Human Services' Findings from the National Sample Survey of Registered Nurses, March 2000. VA Nurse Anesthetist data are excluded from this analysis.

The Veterans Health Administration convened the Future Nursing Workforce Planning Group in August 2000 to critically review the impact of the national nursing shortage on the Department of Veterans Affairs ( VA), Veterans Health Administration ( VHA). Members represented a variety of clinical and administrative roles within VA as well as organized labor. This group published its findings and recommendations A Call to Action- VA's Response to the National Nursing Shortage in November 2001. This critical report provided a foundation for VA's retention, recruitment, and outreach activities.

VA Registered Nurse Workforce Requirements

In VA's evolving healthcare environment, nurses must possess clinical decision-making and critical thinking skills, and must have professional preparation in community health, patient education, and nursing management/leadership. Professional nurses use a breadth and depth of knowledge to care for veteran patients in multiple health care settings-from the rapid patient assessments and complex care provided during critical stages of an acute illness through the compassionate attention to detail that enhances quality of life for veterans who are making the transition into a long-term care environment.

VA's nurses must be utilized appropriately, provided a safe working environment and provided with sufficient resources to capitalize on their skills and expertise. Reflective of this, VA does offers BSN and MSN prepared nurses more complex clinical and organizational responsibilities. Technological advances in health care treatment and equipment, evolving health care trends, modifications in delivery settings, and consumer expectations will require nurses to constantly adapt to change and varied roles. VA is committed to maintaining an appropriate mix of qualified registered nurses to respond to healthcare trends and will continue to hire and value the contribution of nurses prepared at the associate, baccalaureate, master's and doctoral level.

Based on the intense and complex healthcare environment, the National Advisory Council on Nursing Education and Practice (1996) has recommended that by the year 2010 two-thirds of all practicing nurses must possess a baccalaureate degree if optimal care is to be provided. VA's registered nurse qualification standard requires specific educational degrees precisely to meet these clinical contributions to the delivery of care and since its inception, the percentage of nurses prepared at the bachelors level or higher has risen to 64 percent. Through the adoption of VA's Nurse Qualification Standard and with continued commitment to funding academic education for nurses, VA will be well positioned to attain this recommended educational mix and provide optimal care to veterans.

Fiscal Year	% VA RN's with AD/Diploma	% VA-RN's with Bachelors's or higher
1998	41	59
2001	39	61
2002	36	64

Based on VA PAID data files-- FY 1998-2002. VA Nurse Anesthetist data are excluded from this analysis.

Strategies to Combat the National Nursing Shortage

Utilization Strategies

VA uses its current Nurse Qualification Standards to model those facilities found to have the best patient outcomes such as Magnet Hospitals and Academic Health Centers. These facilities have a significantly higher percentage of baccalaureate prepared nurses than other facilities (average = 59% vs. 34% for all hospitals). Research has shown that patients live longer and that nurse retention and job satisfaction are higher in these institutions and others that differentiate nursing practice based on education. This is substantiated in an article by Dr. Linda Aiken published in the September 24, 2003 issue of the Journal of the American Medical Association (attached), which provides data demonstrating that mortality and failure-to-rescue rates were 19% lower in hospitals where 60% of nurses had BSNs or higher than in hospitals where only 20% had BSNs. This research also shows that a 10% increase in the proportion of hospital staff nurses with BSNs or higher degree was associated with a 5% decrease in mortality rates and a 5% decrease in failure-to-rescue rates.
The Nurse Qualification Standard is focused on both the standard of care provided by nurses as well as the level of education. In keeping with this, VA has a waiver of the educational requirements available for associate degrees nurses who have demonstrated that they meet the performance standards of a higher grade.
VA's Barcode Medication Administration System, Computerized Patient Record, VistA Imagining System and nationally recognized Patient Safety programs provide state of the art technology to enable nurses to make efficient use of their skills and time while providing exceptional safety for both patients and their caregivers. The Nursing Integrated Information System is an attempt to draw data from disparate computer sources and combine it in such a way as to be useful in managing nursing practice. Since the computer systems are being transferred to a different programming language, it is an opportune time to create a computer environment that contributes to nursing care. This effort is a line item in the budget for FY 04.
VA is actively encouraging medical centers to attain Magnet Recognition Status. As noted above, these hospitals have excellent patient outcomes and higher rates of nurse retention and job satisfaction. VA Medical Center Tampa has the distinction of being the first Magnet facility in our system. Four VA facilities-Houston, San Diego, Washington, DC and New York-are in the process of filing their initial applications. Approximately 11 other facilities report that they have begun the staff education and planning process that will lead to the application process in the future.
VA's Office of Nursing Services has created a Program Director position devoted to Workforce Development. The individual in this role will direct and coordinate programs directly impacting recruitment, retention, succession planning and quality of the work environment.
VA Nursing Outcomes Database Project ( VANOD) is a 16-month project for creating a database of nursing sensitive quality indicators that will enable exploration of relationships between nurse staffing and patient outcomes, evidence-based decision-making, and benchmarking for testing best practices. The nursing sensitive quality indicators include falls, pressure ulcers, skill mix, staffing, staff musculoskeletal injuries, patient satisfaction, and RN satisfaction. Twelve randomly selected VA hospitals are included in this pilot project. Two VA Health Services Research teams are participating in the building of the database: VA Puget Sound in Seattle is creating data submission methods and database structure while the Management Decision and Research Center in Boston is creating reporting formats from the data. Future planning is underway to establish nation-wide VA roll out, development of more indicators, and expansion to other care settings such as long term care and ambulatory care.

Retention/Recruitment Strategies

VA's educational requirements have resulted in significant education opportunities that have enhanced both retention and recruitment of registered nurses. The National Nursing Educational Initiative ( NNEI) and Employee Incentive Scholarship programs have provided nearly 50 million dollars to enable 1103 registered nurses and non-nurse VA employees to complete degrees in nursing. Funding for education through the NNEI is likely one reason that VA has little difficulty recruiting associate degree nurses.
In response to nurses identifying a need for better communication and stronger collaboration between nurses and physicians, VA is implementing a Nurse-Physician Collaboration Breakthrough Series designed to foster greater awareness/knowledge of retention, succession planning and nurse-physician interactions as related to quality patient care.
Wide disparity in the utilization of pay and hiring authorities resulted in the publication of VA Pay and Hiring Authorities an annotated reference for clinical and human resources professionals designed to eliminate confusion, encourage flexibility and support recruitment and retention endeavors. This document is available in both electronic and print versions.
VA's newly implemented web-based entrance and exit interviews will allow uniform data collection specific to registered nurses regarding factors that influence nurses to seek or to leave VA employment. The data collected can be aggregated to display facility, network, or national trends and will be of great use to the planning and implementation of future nurse recruitment and retention strategies.
VA has forwarded proposed legislation to the House Veterans Affairs Committee containing initiatives that will have significant impact on our ability to recruit and retain a highly qualified workforce. These initiatives, designed to correct impediments to retention and recruitment identified by VA administrators and nurse leadership, will provide VA medical centers a more competitive edge in hiring and retention. The proposals are as follows:
1. Enable VAMCs to offer flexible tours. Specifically we are proposing the following:
  A) Three 12-hour tours (36 hours) paid as 40 hours;
  B) 9 months of work with 3 months off, with pay apportioned over a 12-month period;
  C) 7 ten-hour days/7 days off, with pay for 80 hours; and
  Inflexibility in work schedules is a major cause of dissatisfaction in nurse employment. A 2000 survey conducted by the American Organization of Nurse Executives (AONE), found that after salary, the top benefit sought by nurses was "flexible scheduling and control over shifts." Providing different options for scheduling would be a way of bringing more nurses into the workplace and retaining their services.
2. Establish a Nurse Executive Special Pay Program
  We are recommending that the Secretary be authorized to approve special pay of $10,000 up to $25,000 per year to the nurse executive at each VA medical center and nurse executive positions in the VACO Nursing Service,
  The special pay would range from a minimum of $10,000 to a maximum of $25,000, based on factors such as the grade of the nurse executive, the scope and complexity of the nurse executive position, the nurse executive's personal qualifications, the characteristics of the healthcare facility, e.g., tertiary, single site or multi-site, nature and number of specialty care units, demonstrated recruitment and retention difficulties, and such other factors as the Secretary deems appropriate. The special pay would not make VA a pay leader; it would however allow medical centers to compete with private sector pay levels and/or to relieve pay compression at the highest levels.
  
  Approximately 55 percent of all VA Nurse Executives are eligible for retirement by 2005; 69 percent will be eligible by 2008. In addition, 35 percent of all current VA registered nurses are eligible to retire by 2005. When coupled with the national shortage, this potential loss of nurses could jeopardize VA's ability to accomplish its healthcare mission.
The Veterans Affairs Learning Opportunity Residency ( VALOR) Program recruits nursing students with outstanding scholastic records for structured summer clinical learning experiences; part-time employment during the school year followed by special hiring incentives for permanent employment at graduation. The program is geared to meet the most frequently identified issue of nursing education for both faculty and students-the need for productive clinical learning.

Outreach Strategies

In collaboration with our academic and community partners, VA encourages innovative actions to increase shared faculty arrangements-moving nursing education toward a model in which nurse clinicians are more actively involved in classroom as well as clinical teaching. Such arrangements offers a "win-win" strategy to VA medical centers as well as our academic partners by addressing the shortage of nursing faculty and providing VAMC's with outstanding opportunities to recruit graduating nurses already inclined to work for VA based on their positive student experiences. One example of a successful shared-faculty collaborative is that between the VA Puget Sound Health Care System and the University of Washington. A video highlighting this initiative has been provided to the Committee.
VA medical centers across the country are taking active roles in community outreach, encouraging youth, teens and adults seeking a second career to enter the nursing professions. A video highlighting this initiative has been provided to the Committee.

The Department of Veterans Affairs Health Care Programs Enhancement Act of 2001 (Public Law 107-35), which took effect on January 23, 2002, established the NCVAN) to, among other things, "consider legislative and organizational policy changes to enhance the recruitment and retention of nurses and other nursing personnel" by the VA. That Act requires the NC VAN to report its findings and recommendations to Congress by May 2004. VA looks forward to the Commission's report.

In conclusion, VA's healthcare workforce is critical to the success of our mission "to care for him who shall have borne the battle, and for his widow, and his orphan"; as such, VA will engage in a growing program of assessing nursing workforce needs and implementing innovative strategies to address them.

Thank you, again, Mr. Chairman, for this opportunity to address the impact of the national nursing shortage on the Veterans Health Administration. I will now be happy to answer any questions that members of the Subcommittee might have.