STATEMENT OF THOMAS L. GARTHWAITE, M.D.
UNDER SECRETARY FOR HEALTH
VETERANS HEALTH ADMINISTRATION
BEFORE THE
COMMITTEE ON VETERANS' AFFAIRS
UNITED STATES SENATE

June 14, 2001

Mr. Chairman and Members of the Committee:

I am pleased to appear before the committee to discuss VA's nurse staffing situation and the looming crisis in nursing.

VA is able to provide quality care to veterans, and meet most of the demands for nursing staff. However, there are increasing difficulties in filling positions in some locations, and extreme difficulty filling some specialty assignments. We recognize that if national nursing workforce projections are accurate, a shortage of nurses could adversely affect our ability to provide health care for veterans.

The future supply of registered nurses is not assured given the current aging of the registered nurse workforce and the decreasing number of students who choose nursing as a career. National nursing leaders and health care organizations are projecting a shortage of registered nurses that will be unlike any experienced in the past. Additionally, the demand for registered nurses is expected to increase as baby boomers age and require more health care services.

Noted nursing economist Dr. Peter Buerhaus has predicted that the total number of nurses per capita will likely peak in 2007 and decline steadily thereafter. The number of nurses in the workforce is projected to fall nearly 20% below requirements by the year 2020. One-half of the 2.1 million nurses currently in the United States workforce will reach retirement age in the next 15 years. (Buerhaus; DHHS). At the same time, changes in the way health care is delivered will require larger numbers of well-educated nurses who perform increasingly complex functions. These changes are projected for health care delivery in all settings, whether in hospitals or in community settings. Based on current trends, the demand for nurses will grow 23% between 1999 and 2006.

The projected shortage will result in part from a number of substantial changes that continue to take place in the profession. Factors identified that will intensify the nursing shortage include:

• A decline in enrollment in schools of nursing ²
• Aging of the nursing workforce ^{1, 3}
• Average age of a new graduate in nursing has climbed to 30.5 in 1995 - 2000 versus 24.3 in 1985 or earlier ²
• Poor image of nursing as a career choice and more career choices for women ^{1, 2}
• Pay stagnation, after inflation adjustment ¹
• Perceived negative work environment ⁵
• Inadequate numbers of qualified faculty to educate the numbers of nurses needed ²

Registered nurses comprise the largest segment of health care workers within the Veterans Health Administration (VHA). Currently, VHA employs over 35,000 registered nurses and nurse anesthetists. VA nurse employment is stable at this time. VA enjoys a lower turnover rate (9.5 percent in 2000) than the national average of 15%. However, VA is experiencing difficulty in recruiting nurses with certain special qualifications such as intensive care, nurse practitioners or nurse anesthetists. While the difficulties are occurring nationwide, the types of nurses for which there are shortages vary by geographical region. Certain VA medical centers also report difficulties recruiting Licensed Practical Nurses (LPNs) and nursing assistants (NAs).

Based on the new reporting requirement established in Public Law 106-419, after September 30, 2001 we will have a more complete picture of the RN staffing levels and recruitment and retention difficulties at each VHA facility, as well as throughout the system.

VA is more successful than the rest of the healthcare industry at retaining nurses. VA's nurse turnover rate is 9.5% vs.15% for the U.S. This means that when nurses take positions with VA, they are more likely to continue their careers in VA. However, the age of a new nurse hire in VA is 41.65 years. If younger nurses were attracted to VA, they would be more likely to stay with VA, and VA would be less exposed to the looming nurse supply shortage in future years.

Today, 12 percent of the VA nursing population is eligible to retire. Each year, an additional 3.7 to 5.3% of VA nurses become eligible to retire. By 2005, 35% of the current VA nursing workforce will be retirement eligible. Based on past experience, we predict that about two-thirds of these nurses will actually retire by that date. That means that over 1 in 5 VA nurses today will be gone by 2005. VA has been able to successfully recruit to fill these vacancies as they occur. However, as the labor market tightens considerably, recruitment difficulties can be expected.

The retirement eligibility projections for allied nursing occupations are similarly high with 29% of LPNs and 34% of NAs will be retirement eligible by 2005.

The current trends in health care delivery - increased focus on outpatient settings delivering comprehensive wellness and health care, with patients experiencing shorter hospital stays for acute illness episodes - will continue to force changes in the nursing profession.

Nurses must possess clinical decision-making and critical thinking skills, with preparation in community health, patient education and nursing management/leadership. They will require a breadth and depth of knowledge to make rapid patient assessments during critical stages of an acute illness, as well as to assist patients in making the transition from one care setting to another.

Based on this intense and complex care environment, the National Advisory Council on Nursing Education and Practice has proposed that by the year 2010 two-thirds of all practicing nurses must possess a baccalaureate degree if optimal care is to be provided. VA's new Nurse Qualification Standard, with its emphasis on educational achievement, and VA's commitment to funding academic education for nurses completing baccalaureate and higher education are positioning VA to attain this desired mix of educational attainment.

VA is taking steps to ensure that our workforce is ready to meet the challenges by offering career tuition assistance to nurses. VA has implemented two educational assistance programs to enhance recruitment and retention of health professionals such as nurses - the Employee Incentive Scholarship Program ( EISP) and the National Nursing Education Initiative ( NNEI). The EISP provides scholarships of up to $10,000 per year for up to three years for employees to pursue degrees or education in health care occupations for which VA is experiencing staffing problems. In return for VA's tuition and expenses support, employees agree to serve a period of obligated service. As of this month, VHA has awarded 189 scholarships amounting to over $1.7 million, primarily for nursing and pharmacist degrees.

In addition, VA has implemented the NNEI to help ensure that we are able to meet our staffing needs for registered nurses. The NNEI functions like the EISP, but awards scholarships solely to nurses to obtain baccalaureate or post-graduate degrees and training. Already, 1,639 VHA nurses have been awarded more than $18.5 million support for tuition and expenses. The investment that we are making in educating our nurses and other health care professionals, coupled with the requirement that scholarship recipients serve a period of obligated service, will help VA retain quality health care staff, even during times of shortages. It is also noteworthy that the implementation of the EISP and the NNEI has stimulated interest in working for VA.

VA is actively addressing the projected future nurse supply shortage through several initiatives. First, I appointed a VHA Staff Focus Group to develop a comprehensive plan aimed at increasing employee job satisfaction that enables VHA employees to fully develop and use their talents. I have just received this Group's recommendations and am reviewing them now.

Second, the VHA Office of Patient Care Services, Nursing Strategic Healthcare Group (NSHG) has implemented a Future Nursing Workforce Planning Group to advise the Chief Consultant on issues that impact VA's future supply and utilization of registered nurses. This group will make recommendations before the end of this fiscal year for specific actions to address the impending shortage of registered nurses and other nursing staff.

In addition to the work of the national VA groups noted above, a number of VA facilities are initiating programs to combat an impending nursing shortage. Facilities are actively recruiting through the media. Relocation, recruitment and referral bonuses are being used. New youth programs are being developed in several facilities. Structured programs for new hires are in place in many facilities. Facilities report partnerships and special programs for students in middle school and high schools.

Recruitment and retention efforts include the EISP and NNEI described above. These programs provide great benefit to VHA and our nurses. In addition, the Education Debt Reduction Program ( EDRP), being readied for implementation this summer will provide an additional recruitment and retention tool. The EDRP will provide tax-free payments to newly hired employees to help pay the costs of obtaining their training or degrees. This program enables VA to pay up to $24,000 over three years to employees enrolled in the program.

I have attached to my prepared statement a comprehensive listing of all the strategies VA is using to recruit and retain nurses. I will continue to encourage all facilities to use these authorities to the extent necessary to assure quality nursing care for veterans.

We appreciate the opportunity to comment on the committee's draft legislative framework to address nursing shortages in VA. However, we have not yet had the opportunity to develop a departmental position on it, but will do so expeditiously and submit it in writing.

VA will continue to devote talent and resources to averting the impending national shortage of nurses and minimize any impact on the care we deliver. Interventions will be designed and implemented that will ensure the health care system's ability to maintain a highly qualified workforce to provide care for the Nation's veterans.

References

1. Buerhaus, P.I.; Staiger, D.O.; Auerbach, D.I. Implications of an Aging Registered Nurse Workforce. Journal of the American Medical Association, 2000, 283:2948-2954
2. Bednash, G. Nursing Schools' Enrollments Decline as Demand for RNs Continued to Climb. American Association of Colleges of Nursing, February 2000
3. The Registered Nurse Population: Findings from the National Sample Survey of Registered Nurses. U.S. Department of Health & Human Services, March 1996
4. Searching for Trust: America's Message to Hospitals and Health Systems. Reality III, National Focus Group Research, American Hospital Association, 1998-1999
5. Aiken, L. et al. Nurses' Reports on Hospital Care in Five Countries. Health Affairs, May-June 2001:43-53