Before The House Professional Licensure Committee
Representative Mario J. Civera, Jr., Chairman
March 28, 2001
Good afternoon Mr. Chairman and Members of the Committee. My name is Elizabeth A. Walls, MSN, MBA, RN. I am a Past-President of the Pennsylvania State Nurses Association and I am appearing on their behalf today. The PSNA represents the 204,000 registered nurses throughout the Commonwealth. These registered nurses include hospital staff nurses, long term care nurses, nurse practitioners, clinical nurse specialists, nurse educators, and nurses in management in Pennsylvania.
Thank you for permitting the Pennsylvania State Nurses Association to present information regarding a very entrenched problem within the health care system, the nursing shortage. This critical staffing shortage in hospitals, home care, schools, correctional institutions, assisted living facilities and every other health care delivery system is a crisis, with the potential to become a public health disaster, if not addressed.
There is a growing shortage of nurses at the bedside. Health care employers are reporting difficulties in recruiting and retaining registered nurses. Nurses are reporting that they are assigned too many patients to deliver optimal nursing care and adequately supervise support staff. Patients are hiring "sitters" to assist them in hospitals with short-handed and overworked staff.
There is another immediate critical aspect to this nursing shortage that is of particular concern as we deal with an aging population. Secretary of Aging Richard Browdie released two reports on March 21, 2001 on the state of Pennsylvania's long-term care industry workforce. Not surprisingly the reports commissioned by the Intra-Governmental Council on Long-Term Care found that the shortage of nurses and a high level of turnover cause a multitude of problems for the long term care industry. The two main problems are the limiting of the amount of long term care the industry can provide and the quality of that care. The report strongly suggests that wage and benefit levels, greater involvement in decision making and care planning affect the recruitment and retention of nurses in the long term care industry.
REASONS FOR THE IMMEDIATE CRISIS
The current nursing shortage is directly attributable to several factors.
The last ten years have seen dramatic changes in the manner in which health care is delivered in this nation. 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. 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.
As the word about downsizing became generally known, the nursing profession ceased to be a career of choice for many. Nursing school enrollments have dropped precipitously and instructor core has been reduced.
The result of these occurrences 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.
A DWINDLING SUPPLY OF NURSES
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 that our population will be generally older and in greater need of nursing care.
Assuming that we can attract students to the nursing profession, there is a significant problem with respect to the aging of the nursing faculty. According to the American Association of Colleges of Nursing (AACN), nursing school associate professors and assistant professors are an average age of 52.1 and 48.5 years. This problem is even more acute at the doctoral level where, in 1996, the average age of new doctoral recipients was 45 years. Both the aging of the nursing faculty and overall flat enrollment in doctoral programs that produce nurse educators will impact the capability of nursing schools to educate sufficient numbers of registered nurses to meet future demand.
These two issues, a workforce that is increasingly choosing to not work in direct care because of environmental concerns and a workforce that is aging, must be addressed simultaneously and in an integrated fashion.
BUILDING A WORKFORCE
The American Nurses Association recently conducted a survey on the issue of the nursing shortage. More than half of the RNs responding said that they would not encourage others to enter the profession. With the many career opportunities now available, nursing will not be able to compete with these other opportunities unless working conditions are improved, compensation is increased over the span of a career, the physical demands of the workplace are reduced and the opportunities and responsibilities of the job match the nurse's knowledge and skill.
Any strategy to increase the number of nurses in the years 2010 and beyond must also include a discussion of retaining and returning nurses to the direct care workplace. This means that working conditions must be improved. This means that the workplace must be safe. An example of healthcare facilities that excel in patient care and in the recruitment and retention of nurses are Magnet Hospitals. At these facilities:
Nursing professionals' knowledge is respected in the development of policies.
Nurse practice committees that include direct care nurses are involved in establishing staffing plans based on patient acuity and need.
Nurses do not face retaliation or intimidation for questioning policies or working to change practices that negatively impact on patient care.
Nurses are not forced to work overtime to fill gaps in staffing schedules.
The elimination of practices such as short staffing, mandatory overtime and a disregard for the principles of nursing practice could stop the present erosion of the nursing workforce.
An effort must also be made to make the workplace safe. It should be safe from violence, from bloodborne pathogens (needlestick safety) and from occupational hazards.
Some facilities might suggest that the nursing shortage can be met by allowing the use of more unlicensed assistive personnel (UAPs). 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, they cannot be used to replace nursing skills.
Another concern is that nursing salaries be competitive. Salary increases or signing bonuses are not a solution in themselves. Fair compensation throughout the health care industry is however an important factor in attracting and maintaining a nurse workforce.
SUPPORT NURSING STUDENTS
Access to affordable college programs in nursing is key. Scholarships to offset tuition and other expenses and through increased government aid to nursing programs are essential. We must begin to address this now, results will not be seen for three to five years.
Nursing education programs must be expanded to accommodate new students and make higher education more accessible. The National Advisory Council on Nursing Education and Practice has recommended the completion of baccalaureate courses for nurses with associate degrees due to changes in practice and patient needs. Nursing education must also reflect ethnic, cultural and racial diversity.
Teachers of nursing are needed to replace those who are nearing retirement. Support for graduate education will assist nurses who are preparing to teach.
I have not talked to you today about Pennsylvania specific numbers. The reason for that is there is no current collection of such data. PSNA would encourage you to require the Pennsylvania Board of Nursing to collect relevant demographic and other information concerning nurses. This data could then be provided to a legislatively created nursing workforce center. There must be a systematic way to collect ongoing data about the supply of nurses in Pennsylvania and the future demand for nursing services within Pennsylvania. The data generated from a nursing workforce center and the knowledge about Pennsylvania's population, numbers of schools of nursing and attendance, types of health issues, etc. could be used to identify strategies that are particularly relevant to our Commonwealth and tailored to the particular needs of the State's population and health care systems.
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 nursing care. PSNA supports legislative measures to correct the imbalances spoken to above.
PSNA looks forward to working with the Members of this Committee and you, Mr. Chairman, to address this critical nursing shortage. I'd be pleased to answer any questions you may have. Thank you.