Committee on Education and the Workforce

Testimony of Carolyn McCullough, MA, RN

Before the Committee on Education and the Workforce

September 25, 2001

Thank you, Chairman Boehner and Congressman Miller, for allowing me to testify at this hearing on behalf of the Service Employees International Union on the current nursing crisis in this country.

My name is Carolyn McCullough. I am a registered nurse (RN), and the National Coordinator for SEIU’s Nurse Alliance. Today I am speaking on behalf of the 1.4 million members of SEIU, more than 710,000 of who work in the health care industry, more than 110,000 of whom are nurses, and more than 120,000 of whom work in nursing homes.

As we all know, this hearing was changed because of the devastating attacks on Sept. 11. Nothing will ever be the same again. As evidenced by these tragic events, thousands of people needed medical care, and nurses were on the frontlines delivering this care. Like any essential emergency personnel, nurses are always ready to provide whatever care is needed in times of crisis, without being asked and without concern about time or being paid. This is what happened on Sept. 11th in New York, Washington, and Pennsylvania. But a crisis like this highlights the essential need to have adequate numbers of nurses available. For this reason, addressing the current nursing crisis and the impending shortage is imperative.

As the largest and fastest-growing union of nurses in the country, SEIU is committed to achieving access to quality health care for all who live and work in America—and quality jobs for all who dedicate their lives to caring for others. In May 2001, our Nurse Alliance released The Shortage of Care, a report that is helping to redefine the nation’s nursing shortage. This report on the nursing crisis is based on the views of nurses in acute care facilities collected as part of a nationwide survey conducted by an independent polling firm.

Conventional wisdom about the shortage has held that it’s a recent crisis driven by demographic shifts in a traditionally female profession. But the fact is that this is the second nurse shortage I have experienced in my career, and it is also the third shortage for many nurses in this room. The roots of this crisis go much deeper than the changing roles and attitudes of women in our society.

With the rise of managed care in the 1980s, long before a nursing shortage began to emerge, hospital administrators moved to cut costs by cutting staff, particularly by laying off huge numbers of registered nurses. Across the country, the industry reduced staffing levels to the point where nurses—increasingly unable to provide our patients with the care we were trained to give—began to leave hospitals for more rewarding and less physically and emotionally taxing jobs.

Nurses in hospitals and related facilities are caring for more patients today than we did a decade ago. And because of restrictions on hospital admissions and lengths of stay imposed by managed care, the patients in hospitals are more acutely ill and in need of greater care.

The result is that hospitals are having increasing difficulties filling vacancies for RNs. This is confirmed by our survey, where:

nurses reported that on average it took nearly 11 weeks (10.77) to fill a nursing vacancy in their unit, and

52 percent of the nurses believed that it takes longer to fill vacancies today than three years ago.

This doesn’t just show nurses’ job dissatisfaction; it signals a real problem for patients. When staff is less experienced and unstable, it is more likely that patient care will suffer.

The hospital industry cites many of these statistics to point to a nationwide "nursing shortage." But a closer look at the data suggests that the real problem is a shortage of nurses willing to work in hospitals under current working conditions. This opinion was also shared by the General Accounting Office in their recent report, "Nursing Workforce: Emerging Nurse Shortages Due To Multiple Factors." We view the situation as a staffing crisis rather than a nursing shortage; systemic understaffing brought on by the restructuring of the industry under managed care has led to dramatically deteriorating working conditions and increasing concern about the quality of patient care which is causing nurses to leave hospitals. This is confirmed in a survey of health care human resource managers conducted by the William M. Mercer consulting company who found three important factors affecting turnover:

"dissatisfaction with the job itself, working conditions, the relationship with the supervisor, or career opportunities;"

"workload and staffing," noting that "a reduction in RN resources has increased the job demands of those remaining in the workforce."

"better pay."

They warn that employers concerned about turnover "should examine their own practices and work environment..."

It cannot be stressed enough that when our nursing profession is in crisis, our nation’s health care system is in crisis.

Inadequate staffing has given rise to increased numbers of medical errors. In 1999, the Institute of Medicine found that between 44,000 and 98,000 Americans die every year in hospitals due to medical errors; more people die of medical errors than from motor vehicle accidents, breast cancer, or AIDS. While the IOM report exposed a national crisis, it did not explore one of the primary causes of it: understaffing. However this issue was comprehensively assessed by a research team from the Harvard School of Public Health led by Professor Jack Needleman, which found that higher RN staffing was associated with a 3 to 12 percent reduction in the rates of patient outcomes sensitive to nursing—in particular urinary track infections, pneumonia, length of stay, upper gastrointestinal bleeding, and shock.

A majority of nurses in our SEIU survey identified understaffing as the cause of medical errors. And the situation, they say, is not improving.

54 percent of nurses say that half or more of the errors they report are the direct result of inadequate staffing.

Despite the growing attention focused on medical errors, most nurses say the rate of incidents has remained unchanged over the last year—while fully 30 percent of nurses say the errors have actually increased.

We also should keep in mind that there are many more medical errors that go unreported for fear of retaliation. Most health care workers who blow the whistle on short staffing and poor patient care have no legal protections against retaliation. Federal whistleblower laws are narrow in coverage and do not apply specifically to the health care industry. That is why we are fighting so hard for a Patients’ Bill of Rights that includes whistleblower protection.

In the state of Maryland, the staffing crisis and the deteriorating conditions it has created have compromised quality care for people in our communities. According to the Maryland Hospital Association, "over half the hospitals throughout Maryland report they have had to close beds, delay and cancel surgeries, disrupt scheduled procedures, and ‘reroute’ ambulances to other facilities for emergency patient care." The MHA says that it is increasingly common for patients arriving in an emergency department "to be held there until adequate staffing becomes available on a patient unit."

In Baltimore, Johns Hopkins Hospital has closed as many as 10 of the 44 beds in its neurology and neurosciences center, because it doesn’t have the nurses to safely staff them. Heidi Zhang, a nurse at Hopkins for 13 years says that "People have come in for elective surgeries and been sent home. I’ve never seen anything like this."

A particularly devastating side effect of the understaffing crisis is the abuse of mandatory overtime by many health care employers. Nurses are often mandated to work back-to-back eight-hour shifts or four extra hours on top of a 12-hour shift to fill gaps in staffing. Of course this threatens patient safety. There is no way an exhausted, overworked nurse is as alert and accurate as a well-rested nurse working a regular shift. Mandatory overtime also places an incredible stress on family life, particularly when last-minute changes have to be made to find child care or care for elderly parents.

Mary Hesse-McBride is a nurse and an SEIU member who used to work in the cardiac intensive care unit at the University Hospital in Madison, Wisconsin. Too many overtime hours drove her out of intensive care—where the nursing shortage is particularly acute—to the outpatient unit. She would often say "I would go to work and I would never know if I was leaving."

Mary Hesse-McBride is not alone. According to our survey, nurses in acute care hospitals work an additional 8.5 weeks of overtime on average every year. Nurses are increasingly required to work excessive amounts of mandatory overtime. They are also required to "float" or be reassigned to units where they lack the experience and training. Nurses are being stretched to the limit, experiencing high levels of stress, chronic fatigue, and work-related injuries. These intolerable work practices lead to further "burnout" and undermine nurses’ sense of professionalism. Combined, these conditions are driving nurses from hospitals.

According to the SEIU survey:

Only 55 percent of acute care nurses plan to stay in hospitals until they retire.

And only 43 percent of nurses under 35 plan to stay in hospitals until retirement.

But 68 percent of nurses say they would be more likely to stay in acute care if staffing levels in their facilities were adequate.

These statistics show a little-discussed fact about today’s "shortage." In reality, the current supply of nurses far exceeds demand. According to a recent Health Resource Services Administration (HRSA) report, there are approximately 500,000 nurses who have licenses but are not practicing in the nursing field. The proportion of RNs employed in hospitals has decreased substantially and consistently from 68 percent in 1988 to 59 percent in 2000.

Deteriorating staffing and working conditions have led many nurses to leave the profession altogether, and fewer young people are entering it: nursing school enrollment has declined in each of the last six years. As a result, the average age of working RNs has increased 7.8 years since 1983 to 45.2. And as these trends continue, there is likely to be a severe nursing shortage in the future. By 2020, we expect that there will be a shortage of 400,000 nurses, when the majority of the baby boomers will be seeking care.

Nurses wish to remain in hospital work, and would do so if staffing and working conditions improve. If these conditions are not improved, nurses’ exodus from hospital care will intensify and in the near future we will face a true shortage. The fact that younger nurses are even less likely to stay in acute care than their older colleagues is a warning sign.

The study by the SEIU Nurse Alliance, The Shortage of Care, is filled with compelling stories by nurses about the tolls of short-staffing. These stories echo those of colleagues nationwide. A Washington State nurse gave the following reason as to why she was leaving hospital nursing:

I have been a nurse for six years and for most of that time I have worked in the hospital environment. It is difficult to tell you how terrible it is to "work scared" all the time. A mistake that I might make could easily cost someone their life and ruin mine. Every night at work we routinely "race the clock." All of us do without lunch and breaks and work overtime, often without pay, to ensure continuity of care for our patients. Yet, we are constantly asked to do more. It has become the norm for us to have patient assignments two and a half times greater then the staffing guidelines established by the hospital itself. I cannot continue to participate in this unsafe and irresponsible practice. So I am leaving not because I don’t love being a nurse, but because hospitals are not safe places: not for patients and not for nurses.

I have focused my remarks principally on hospitals, since that is where the nurse crisis is most severe. There is, however, a related and equally serious problem in nursing homes. While RNs make up a small proportion of the nursing home workforce, and are largely in managerial positions, most of the staff in nursing homes are certified nurse assistants (CNAs) and, to a lesser extent, licensed practical nurses (LPNs) or licensed vocational nurses (LVNs).

SEIU members include more than 120,000 nursing home employees, the vast majority of whom are CNAs and a large number of whom are LPNs/LVNs. Similar to administrators in the hospital industry, nursing home owners have argued that they are facing a shortage of nurses and nurse aides. For this reason they have asked for increased Medicare and Medicaid reimbursement and have resisted the setting of minimum staffing standards.

But just like in hospitals, the real problem isn’t finding people to work in nursing homes. It is keeping them there. Turnover rates for direct care workers in nursing homes are nearly 100 percent, creating a revolving door of caregivers. This renders impossible the continuity of care, which remains a crucial factor in patient morale and patient health. Workers are leaving due to heavy workloads: They simply do not have enough time to care for the number of residents they are assigned to, which leads to stress, guilt, and burnout. Moreover, low wages, lack of health insurance coverage, and high injury rates also make nursing home work unsustainable for many workers.

Just like nurses, more and more people who have become certified to work as nurse aides are leaving the profession. For example, the state of Iowa reported last year that there were between 50 and 60 thousand names on the CNA registry but only 23 to 24 thousand were actively working in nursing homes.

Now that we have outlined the crisis that exists in our hospitals and nursing homes, we can discuss what is being done to change these conditions and what can Congress do to stop the nursing profession from bleeding to death.

Nurses across America are sounding the alarm: staffing levels are too low to provide the quality of care their patients need. In many states, nurses who are in unions have turned to the bargaining table to change their working conditions in order to ensure safer staffing and better patient care. Eliminating mandatory overtime, establishing safe staffing standards, and improving recruitment and retention by increasing pay have been the primary issues in nurse contract negotiations from coast to coast. One has only to look at the number of strikes occurring among nurses in 1999 (21) and 2000 (10), and those so far in 2001 (7) to see that nurses are increasingly determined to resolve the problems they face in hospitals today.

I am proud to report that many members of SEIU’s Nurse Alliance have been able to negotiate limits—if not outright prohibitions—on mandatory overtime. In the Dimension’s Health Care contract, our union has ensured that our hospital’s past practice of not requiring mandatory overtime is followed. And I can tell you that it is an incentive for many nurses to stay on at that hospital. Earlier this year, SEIU nurses at Aliquippa Community Hospital in Pennsylvania became the first in their state to win an agreement in their contract eliminating mandatory overtime. Their hospital CEO, Fred Hyde, recently joined nurses in pressing for a state law in Pennsylvania to protect patients and nurses from mandatory overtime, calling it "involuntary servitude."

SEIU nurses at Kaiser Permanente, the League of Voluntary Hospitals in New York, Swedish Medical Center in Washington state, and many other hospitals have negotiated contracts with breakthrough agreements that give bedside nurses a voice in setting staffing levels through labor-management committees. But while we have made some progress, this issue is too big and too important to the health of our patients, our profession, our hospitals, and our communities to address hospital by hospital and contract by contract.

In addition, while collective bargaining is the only venue that nurses can currently use to protect themselves against unfair and abusive working conditions, such as mandatory overtime, that jeopardize quality patient care, their right to collectively bargain is constantly under threat. Two recent Supreme Court decisions: NLRB v. Health Care & Retirement Corp. of America and NLRB v. Kentucky River Community Care Inc., have eroded nurses’ rights to act collectively under the protection of the National Labor Relations Act. As these challenges to nurses’ ability to address workplace and quality patient care issues through collective bargaining mount, it becomes more imperative that policy-makers act now to ensure decent working conditions for our country’s nurses and thereby ensure safe patient care and a adequate nurse workforce for the future.

SEIU along with other unions and the American Nurses Association have introduced legislation on the state level to establish safe staffing standards, ban mandatory overtime, provide whistleblower protection for nurses when they speak out on understaffing that jeopardizes good patient care, and provide for involvement of direct care nurses in the development of staffing policies.

California was the first state in 1999 to pass legislation to require fixed minimum staff-to-patient ratios in hospitals. The regulation that will spell out the specific statewide standards is expected to take effect next year. In an action of historic proportions, Kaiser Permanente has recently become the first employer to endorse the ratio proposal put forth by the SEIU California Nurse Alliance. There is also safe staffing legislation being considered in New Jersey, New York, Oregon, and Pennsylvania. Legislation was introduced in Illinois with the support of the SEIU Nurse Alliance and the Campaign for Better Health Care. The model bill calls for hospitals and other facilities to: meet minimum staffing requirements set by the legislature, submit annual staffing plans that include a system for determining staffing levels based on acuity (severity of illness or injury), maintain daily staffing records, prohibit mandatory overtime, set maximum hours for nurses, protect whistleblowers, publicly disclose mandated and actual staffing levels, and provide access to unannounced inspections.

Other states are also considering laws prohibiting or restricting mandatory overtime for nurses. Maine and Oregon have just passed legislation banning mandatory overtime. Mandatory overtime legislation has been introduced in Maryland, New Jersey, New York, Rhode Island, Washington, and West Virginia, and may soon be introduced in Connecticut, Massachusetts, Pennsylvania, and Wisconsin. In West Virginia, the SEIU Nurse Alliance successfully introduced legislation that would provide whistleblower protection for nurses who report staffing problems. Similar legislation has passed in the state of Washington.

On the federal level, legislation has been introduced designed to attract new people into the nursing profession by making it easier to access educational and training resources. While we applaud these efforts, this will not address the fundamental problems facing our profession and our patients. America’s hospitals are in a state of emergency. And it’s one that will only grow worse as the nursing shortage grows more severe. Forcing more mandatory overtime or simply relying on new nurse recruitment programs won’t solve the problem either. Likewise, easing immigration rules to attract more foreign nurses or expanding the number of visas allowed for nurses and nursing home workers will only push more caregivers through the revolving doors of our nation’s hospitals and nursing homes. All of these measures will only treat the symptoms, not cure the disease. Unless and until we address the understaffing and poor working and patient care conditions that plague nurses, we will never solve the shortage.

We also need staffing standards that will change the culture of care in nursing homes to one of which ends the assembly line and instead truly values residents and their lives. And we need adequate reimbursement with built-in accountability to ensure that taxpayer dollars are spent on resident care instead of profits. We support many of the recommendations proposed by the National Citizens Coalition for Nursing Home Reform.

Fundamentally, the solution to the nursing crisis lies in the establishment of safe staffing standards in our hospitals.

We must set enforceable minimum staffing standards linked to the acuity of patients, skill of the staff, and skill mix to ensure good quality care in hospitals, emergency rooms and outpatient facilities. But we must make sure that such minimums do not become the maximums.

We must make safe staffing a requirement for all hospitals receiving federal taxpayer dollars.

We must make sure the federal government provides adequate oversight of our hospitals, and that the industry’s self-monitoring system under the Joint Commission on the Accreditation of Healthcare Organizations be reformed.

And we must protect the rights of patients and the rights of health care workers who blow the whistle on staffing problems that jeopardize the quality of care.

To be sure, it will take time to enact and implement staffing standards. The understaffing problem didn’t develop overnight, and neither will the solution.

We must find ways to set meaningful standards for staffing in the health care industry. Understaffing in our nation’s hospitals is a serious problem. It’s a problem that will only be solved through the joint efforts of public officials, nurses, and hospital administrators. And it’s a problem that must be solved if we are to guarantee quality care for patients – and keep skilled nurses in our hospitals.

Additionally, on the education front SEIU would encourage this committee to explore support for the establishment of public-private partnerships that would provide educational programs, including money for tuition, that establish career ladders for nursing assistants to become licensed practical nurses and for licensed practical nurses to become registered nurses. There are tens of thousands of dedicated health care workers in our country’s hospitals, nursing homes and in home care, who leave healthcare employment because of intolerable working conditions and poor pay and benefits. They could be a valuable resource to address our future shortage needs. SEIU is currently working on developing such a program jointly with a number of employers. One of the major objectives is that this program should be worker friendly and we hope to accomplish that through the use of on-line distance learning and a clinical component based in the workplace. Another objective of the program is to establish a prior learning assessment tool that credits the student for prior learning and experience. This would enable them to complete the course work in as expeditious a manner as possible and move them into the workplace where their services are so desperately needed. Obviously these programs would have to be fully credentialed, and the providers must be reputable institutions of higher education. We feel these types of programs should be supported nationally and we would be happy to assist the committee in any way possible.

But there is a step we can take today, immediately, to stop the hemorrhaging—and that’s to put a ban on mandatory overtime. SEIU, along with other unions representing health care workers, are working with Representative Stark to introduce legislation that would ban mandatory overtime. At the SEIU Nurse Alliance Stand for Patients rally on the Capitol steps last May, nurses from around the country talked about the harmful side-effects of mandatory overtime on their patients, themselves, and their families. One nurse said she could not pick up her home phone on a rare day off for fear of being called back into work for another extended shift. Limiting forced overtime will ease the impact of the shrinking supply of nurses by encouraging more nurses to stay in the profession. And it will protect countless patients in the same way that limits on mandatory overtime for train engineers, air traffic controllers, truck drivers, and other occupations where public safety is at risk.

Thirty years ago I became a nurse because I wanted to make a difference. Caring for people when they are ill and at their most vulnerable, especially those so often under served, really appealed to me. I thought I could help them get better and stay healthy, and what I found out is that I really could. I have spent many years as a nurse and along the way I learned that nurses are the critical link between people and health care, and without nurses there is no health care.