Legislature(2009 - 2010)BUTROVICH 205

03/09/2009 01:30 PM HEALTH & SOCIAL SERVICES

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01:30:05 PM Start
01:31:06 PM SB12
03:00:48 PM Adjourn
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                    ALASKA STATE LEGISLATURE                                                                                  
      SENATE HEALTH AND SOCIAL SERVICES STANDING COMMITTEE                                                                    
                         March 9, 2009                                                                                          
                           1:30 p.m.                                                                                            
MEMBERS PRESENT                                                                                                               
Senator Bettye Davis, Chair                                                                                                     
Senator Joe Paskvan, Vice Chair                                                                                                 
Senator Johnny Ellis                                                                                                            
MEMBERS ABSENT                                                                                                                
Senator Joe Thomas                                                                                                              
Senator Fred Dyson                                                                                                              
COMMITTEE CALENDAR                                                                                                            
SENATE BILL NO. 12                                                                                                              
"An Act relating to limitations on mandatory overtime for                                                                       
registered nurses and licensed practical nurses in health care                                                                  
facilities; and providing for an effective date."                                                                               
     HEARD AND HELD                                                                                                             
PREVIOUS COMMITTEE ACTION                                                                                                     
BILL: SB  12                                                                                                                  
SHORT TITLE: LIMIT OVERTIME FOR REGISTERED NURSES                                                                               
SPONSOR(s): SENATOR(s) DAVIS                                                                                                    
01/21/09       (S)       PREFILE RELEASED 1/9/09                                                                                


01/21/09 (S) HSS, L&C, FIN 03/09/09 (S) HSS AT 1:30 PM BUTROVICH 205 WITNESS REGISTER TOM OBERMEYER Staff to Senator Davis Alaska State Legislature Juneau, AK POSITION STATEMENT: Presented sponsor statement on SB 12. DEBBIE THOMSON, Executive Director and Program Director Alaska Nurses Association POSITION STATEMENT: Opposed SB 12. ROD BETIT, CEO Alaska State Hospital and Nursing Home Association (ASHNHA) POSITION STATEMENT: Opposed SB 12. RON ADLER, CEO Alaska Psychiatric Institute (API) POSITION STATEMENT: Available for questions on SB 12. MARIE ORIAH Northstar Behavioral Services POSITION STATEMENT: Opposed SB 12 MARY STACKHOUSE, RN, Providence Hospital Anchorage since 1988 POSITION STATEMENT: Supported SB 12. EVANGELINE "Angel" DOTOMAIN, President and CEO Alaska Native Health Board (ANHB) POSITION STATEMENT: Had deep reservations with SB 12. CINDY ALKAIER, Assistant Chief Nurse Executive Providence Health and Services Alaska POSITION STATEMENT: Opposed SB 12. MARILYN EDWARDS, Operating Room (OR) Clinical Manager, Providence Alaska Medical Center POSITION STATEMENT: Opposed SB 12. NANCY DAVIS, RN, President Alaska Nurses Association POSITION STATEMENT: Supported SB 12. CHRISTY ORTUSO, RN Director, Neurosciences, Providence Alaska Medical Center, and Member, Board of Directors, American Association of Critical Care Nurses Certification Corporation POSITION STATEMENT: Opposed SB 12. STACY ALLEN, RN, Business Agent Laborers Local 341 POSITION STATEMENT: Supported SB 12. ROGER LEVRENTZ, RN, Clinical Nurse Educator Heart Center Providence Health Care Center POSITION STATEMENT: Opposed SB 12. ACTION NARRATIVE 1:30:05 PM CHAIR BETTYE DAVIS called the Senate Health and Social Services Standing Committee meeting to order at 1:30 p.m. Present at the call to order were Senators Ellis, Paskvan and Davis. SB 12-LIMIT OVERTIME FOR REGISTERED NURSES CHAIR DAVIS announced consideration of SB 12. 1:31:06 PM TOM OBERMEYER, staff to Senator Davis, sponsor of SB 12, offered the sponsor statement for SB 12 as follows: SB 12 prevents registered nurses and licensed practical nurses from being forced to work mandatory overtime, i.e., work beyond an agreed to, predetermined, regularly scheduled shift, and it protects patients from the dangers caused by overworked nurses. Except for Alaska Native health care facilities exempted by this bill under federal law, Senate Bill 12 is applicable to all hospitals and health care facilities licensed in Alaska. Under SB 12 a nurse may not be required or coerced directly or indirectly to work more than 14 consecutive hours without 10 hours of rest; beyond 80 hours in a 14-day period; or to accept an assignment of overtime if, in the judgment of the nurse, the overtime would jeopardize patient or employee safety. Nurses, however, can volunteer to work additional shifts beyond this limit, so long as the nurse does not work more than 14 consecutive hours without 10 hours of rest. In recognizing the complexity in delivering quality nursing care on a 24-hour basis, a number of concessions have been made to Alaska hospitals in this bill. The 14-hour maximum workday with 10 hours rest, which exceeds that allowed in many other states, permits a two-hour transition for nursing supervisors to call in additional help after 12-hour shifts. This provision was intended to help remedy the problem of nurses being called back to work without adequate rest after working a 12-hour shift. A number of exceptions have been provided to allow for longer shifts for flight nurses on medical transport, residential psychiatric treatment centers, school nurses on school sponsored field trips, and official state emergencies. This bill limits hospital reporting of overtime hours to twice a year; it prohibits retaliation for complaints; designates limited employer penalties and requires enforcement for only "knowing" violations. The Journal of the American Medical Association, October 23-30, 2002, reported that nurses who suffer from fatigue, increased patient work-loads, and shifts in excess of 12 hours greatly increase nursing errors and mortality among patients who have common surgeries. In the 1999 report, "To Err is Human," the Institute of Medicine estimated that as many as 98,000 hospitalized Americans die each year as a result of errors in their care. Both nurses and employers alike state that patient safety is paramount, but nurses are allowed to work far beyond their endurance levels, depending on age and condition, unlike other safety- sensitive jobs, including commercial airline pilots, FAA controllers, railroad engineers, and long-haul truckers. Although nurses file few official overtime complaints in part due to busy schedules and fear of retaliation by employers, many nurses have testified to overwork, emotional exhaustion when they are responsible for more patients that they can safely care for, disruption of family life, unexpected shift changes, mandatory overtime, and mandatory on-call. Low numbers of complaints and benign exit interviews belie growing dissatisfaction with the difficult work and quality of life of nurses, which has caused many of them to "burn-out" and to leave the profession. It has been estimated that 500,000 licensed registered nurses have left or are not working in the profession. There is an expected shortage of over 400,000 nurses by 2020. The nursing shortage is a workforce crisis exacerbated by the growing and unavoidable need for increased nursing care by the aging "baby boomer" generation. Bills in Congress to stem the nursing shortage, include financial aid for education of nurses and nurse instructors, and more rigorous regulation of overtime hours and patient safety. Ref: H.R. 2122, and S.1842 in the 110th Congress, and before that, H.R. 791, "The Safe Nursing and Patient Care Act." The nursing profession must attract more young people to replace the aging nurses' workforce which nationwide averages 46 years of age, 48 in Alaska, and is 95 percent women. In 2000 only 9 percent of RNs were under age 25, compared to 25 percent in 1980. Women are finding alternative career choices, so it is important for the nursing profession to create more jobs for nurses with higher wages, greater responsibilities, and better quality of work life. Nurses are often described as having a "flat" career path. Only by considerably more education and experience can they advance in certifications and earnings. They rarely hold positions of authority in hospitals to influence policy decisions regarding nurse/patient ratios, overtime, on-call, and patient safety. Bargaining units help, but only one-half of Alaska's 4,500 licensed registered nurses are represented by bargaining units. Although the University of Alaska has made great progress in increasing the numbers of nursing graduates in Alaska and in improving nursing programs at all levels, these efforts can only be successful through employment and retention if the nursing profession can provide a quality of life comparable to that in other competitive fields. SB 12 will help remedy this problem by encouraging employers to employ and train more nurses rather using mandatory overtime, mandatory on-call, and large numbers of "travelers," as staffing tools to fill both routine and critical care positions on a daily basis. The greatest beneficiaries will be the patients who will receive the care and safety they deserve. 1:36:26 PM DEBBIE THOMSON, Executive Director and Program Director, Alaska Nurses Association, said she wanted to talk to them about the dangers of mandatory overtime and the fatigue and the errors that happen with it. She explained that some say that nurse might just as well have had a drink because the long hours worked by some of them pose some of the most serious threats to patient safety that result in decreasing the reaction time and the speed of mental processing. Periods of wakefulness in excess of 16 hours can produce performance decrements equivalent to a blood alcohol concentration of .05 percent. Alcohol intoxication is defined as .08 to .10 percent varying among the states. MS. THOMSON presented slides from the Michigan Nurses Association Public Policies Association Incorporated on the Cost of Mandatory Overtime for Nurses (written in August 2004), which indicated the likelihood of making an error increases with the number of hours that are worked and are almost three times higher when nurses work shifts lasting 12.5 hours. She found that working overtime increases the odds of making at least one error and it didn't matter if it was 12.5 hours or 8; it was overtime over the originally scheduled shift. Dangers to patient safety include the nurse being less alert, having slower reactions, and making medication errors; causing higher incidence of institutional infections and bed sores. The last two are no longer reimbursable because they are acquired in hospital. 1:41:17 PM The Institute of Medicine (IOM) estimates that about 100,000 hospital deaths can be attributed to medical errors each year, and mandatory overtime is a seriously contributing factor. The final recommendation of the IOM is that all overtime, voluntary, mandatory and involuntary done by nurses should be curtailed. They are working on what to allow the Interns and the Residents in Medicine to work as their shifts. MS. THOMSON said this is not a bargaining issue, but a public and patient safety issue. The Alaska public has a right to expect that the nurse taking care of them is properly rested and alert and that she hasn't been working 16 hours that day already. Patients should not have to worry about staff working conditions when they register at a hospital. Many nurses in the state are not represented by unions; Fairbanks and Mat-Su Valley nurses are to areas. Washington State passed its no mandatory overtime law in 2002. She state that many health care facilities use mandatory overtime to fill staff shortages. One reason for shortages is that nurses are leaving the field because of poor working conditions. One of the reasons that the nursing shortage is as it is today is because qualified nurses are not working in the field or they are leaving the profession because they can no longer work the long hours or safely take care of their patients. A University of Massachusetts study shows a strong link between working overtime and work-related injury. This was found to be true of all occupations and working longer than 12 hours a day was associated with a 30 percent increase in that risk. She provided a list of states which have already passed or banned forced overtime. 1:47:36 PM ROD BETIT, CEO, Alaska State Hospital and Nursing Home Association (ASHNHA), opposed SB 12. He said ASHNHA represents 27 private, federal, state and tribal health care facilities located throughout Alaska and his testimony has been approved by their general membership. He said that the sponsor of SB 12, Senator Davis, is well respected by ASHNHA's members for her commitment to improving health care access and quality in Alaska. They share her goals for increasing eligibility levels for Denali Kid Care to at least 200 percent of the federal poverty level and to have the Alaska Health Care Commission to address Alaska's health care issues. However, they do not believe that SB 12 is needed to assure continued delivery of excellent patient care throughout the state. ASHNHA has a strong a commitment to respect the individual importance of each nurse in their health care delivery mission and to treat each nurse fairly in the work place. Their annual nurse overtime survey demonstrates their commitment is being met. MR. BETIT said that ASHNHA conducted a facility survey on mandatory overtime for the last four years to gain a better understanding of the frequency with which mandatory overtime is used by member facilities. In this context "mandatory" is overtime that is not willingly worked by a nurse and does not include on call overtime hours. It indicated that the number of mandatory overtime hours incurred are minimal and only happens at a few facilities, mostly at the state operated Alaska Psychiatric Institute - and that is down substantially from 2006. They do not have the kind of abuse in mandatory overtime that led to the State of Washington's legislation. 1:50:01 PM He asks his members every year how the individual facilities view the nursing shortage. This time around, eight of the facilities reported that the situation was about the same, nine reported that they thought the nursing shortage was worse and three thought it had improved. The next column showed the kinds of shifts that are worked in each facility - anywhere from 7.5 hours in the state facilities up to 16 in a psychiatric facility. Nurse vacancy rates for 2007/8 were fairly close at 10-12 percent on average across the state, although some facilities were significantly higher like Mt. Edgecumbe that in 2007 reported 25 percent (although they are now down to 12 percent). Providence Valdez reported a 22 percent vacancy rate. The yellow column showed the number of reported mandatory overtime hours throughout the year and that number was coming down; there were four in 2008 that reported some mandatory overtime being assigned. Most of that was at API. The next two columns dealt with on call nurses and these nurses are usually used in specific units that require highly technical skill. The blue column indicated the number of temporary nursing hours that member facilities purchase per year in order to not resort to mandatory overtime to fill their schedules; in 2007 it was nearly quarter million hours. This year, with Fairbanks not reporting yet, there are 200,000 hours. The final column shows the number of grievances, but none have come forward. MR. BETIT said that ASHNHA member facilities have taken a number of steps over the years to minimize the need to use mandatory overtime to fill gaps in nursing shifts. Some examples include financially contributing to the University of Alaska nursing program expansion from 100 to 200 nurses each year, creating clinical experiences for students nurses and recently graduated nurses to gain hands-on nursing experience required to complete their education or to achieve the patient care experiences necessary to become employed in the hospital or nursing home setting, providing distance learning opportunities so local residents can take nursing course in their own community with minimal need to spend large amounts of time out of town to achieve their clinical experiences (very successful in several communities), and purchasing tens of thousands of hours of temporary nursing staff. Even so, approximately half the facilities reporting on this year's survey believe that the nursing shortage situation has worsened. 1:55:01 PM He recapped their concerns with the bill: the data doesn't show that that hospitals and nursing homes are relying on mandatory overtime to fill staffing gaps. On the contrary it shows its usage is rare. Second, ASHNHA believes that working hours and scheduling are appropriately a local employer responsibility to negotiate with its employees. He said that workforce challenges vary for community to community, so a single approach is unworkable. He said a number of facilities are either in negotiations with nursing staff currently or will begin them shortly and they should be given an opportunity to address any concerns rising from the nursing staff. 1:55:51 PM MR. BETIT said it is important to have flexibility to be able to bring a nurse in when a procedure happens, but isn't scheduled, and the right personnel have to be there to make sure it is done correctly. Ongoing monitoring systems operated by federal, state or independent private agencies in Alaska show Alaska health care quality is excellent and none have identified mandatory overtime as a problem related to delivery of excellent patient care, he said. 1:56:58 PM ASHNHA members have contributed funding to support a nursing program and are graduating a lot of nurses but they aren't enough and they are not getting into some of the rural communities where they are desperately needed. Finally, he said, the bill would impose a new reporting burden for facilities that would have to be filed semi-annually and contain detailed work hour information for each staff nurse employed by the facility as well as each contract nurse. 1:57:54 PM SENATOR PASKVAN said it appears that only two facilities allow shifts beyond 14 hours (SB 12), Alaska Pioneer Homes and Northstar Behavioral Health System. All others appear to use fewer. MR. BETIT said that is correct; when his facilities go beyond the 12 or 14 hour shift, it is only for an hour or two, and an on call situation can be very different. 1:59:24 PM SENATOR PASKVAN said asked what definition of "mandatory" the sponsor is using. MR. BETIT said that is a fair question, because that has been one of the issues in a lot of testimony over the last few years. In their context and that of this legislation, if a nurse is working willingly or following a prescribed on-call schedule, it is not mandatory. 2:00:54 PM RON ADLER, CEO, Alaska Psychiatric Institute (API), said he was available for questions. 2:01:26 PM MARIE ORIAH, Northstar Behavioral Services, said she wanted to testify as nurse, mother and wife. She has voluntarily worked at her 16-hour shift, and she needs the hours in this position, because she is a mother of two and their primary care giver; she also home-schools her son. Her husband works in the forest industry and his hours have been cut back. So they are missing one paycheck, but because she has a "Baylor" shift, she is able to pull one extra night shift to supplement that lost income. Many mothers and nurses like her would be placed in a bad position financially. She asked the legislature to reconsider keeping those Baylor positions. 2:04:27 PM CHAIR DAVIS said she could amend the bill to include those positions and they will discuss it at a later time. 2:05:06 PM MARY STACKHOUSE, RN, said she started working in Ketchikan in 1987; she has been at Providence in Anchorage since 1988. During her career she has worked shifts from 8 to 12 hours, and lots of overtime, both voluntary and "not so voluntary" - meaning that it wasn't written in the plan at the hospital that it would be mandatory. She explained that there had been a coercion of sorts with the idea always present that "there is nobody else to replace you, think of your patients, think of your coworkers, you must stay." She said she has never thought of abandoning a patient and that it is cause for loss of licensure; and it means that you have left your patient at the end of your shift when you have not reported off to someone else. The problem she sees with the idea of mandatory overtime is that it is not the nurse's choice. She does not have the ability to say she is too tired to do it. 2:07:52 PM MS. STACKHOUSE said she takes her patients very seriously. In the recent past they have had far more babies in their unit than they had staffing for. Thanks to some of the new people who are in the lead, they have been able to increase their staff; but more nurses are needed. Their census still has big fluxes and when it is high is when nurses are most at risk of not getting a break or even lunch; they can't cover for each other because there are too many babies. She said that it takes an incredible amount of paying attention to new babies to recognize subtle changes to make fine adjustments in medications and they are being born as early as 22 weeks old. She explained if the nurse is too tired or hasn't eaten, she may not be thinking clearly and in critical care they have seconds to respond - with adults it might be a few minutes. If you don't have enough staff and the staff that you have is already exhausted, then you are running the risk of some of their patients not making it through a crisis. Nurses are leaving the profession in droves. Women have a lot of different choices these days, and are choosing not to place themselves in the position of being responsible for others' lives. That way they don't put their families at risk from things they can bring home. On-call time is scheduled, but she would not want to be the patient who is waiting for help when the nurse is too tired to care for them. When her husband has been a patient in the hospital she stays with him, because she knows how short staffed they are and wants to be sure his needs are met. 2:12:35 PM Older nurses won't last forever, and the pool of younger nurses is smaller and smaller. If they are mandated to work overtime, they'll burn out faster. One of her flight attendants recently said she had been a nurse for less than 10 years, but got out because of the working conditions - and mandatory overtime is one of the working conditions that scared her the most. Every nurse will be there in a true emergency, but mandatory overtime is not the way to deal with regular staffing issues. 2:14:59 PM EVANGELINE "Angel" DOTOMAIN, President and CEO, Alaska Native Health Board (ANHB), said they represent 24 regional and tribal health organizations across state and approximately 7,000 employees. They have deep reservations with SB 12. It is the experience of Tribal Health providers that nurses are highly dedicated caring providers who will give their last ounce of skill to care for their patients. ANHB expends a great deal of effort and expense to recruit and retain good nurses to provide care and cover all necessary shifts. 2:16:35 PM They think SB 12 would hurt patient care especially in rural Alaska where all it would take to leave a shift uncovered would be for one or two nurses to decide for any reason or for no reason at all that they do not want to work overtime. The rural tribal health provider would in many cases have no choice but to simply not cover that shift and put other patients at risk. She explained that rural tribal health providers do not have the urban luxuries of calling other off-duty nurses, getting temporary agency nurses to cover a shift on short notice, or redirecting patients to a nearby facility. In practice, SB 12 would make it impossible for them to cover all the shifts in rural facilities. Perhaps this is why almost no rural state has adopted similar legislation. Also, SB 12 is an unfunded mandate that will unnecessarily drive up costs, she said. Rural facilities are having enough trouble staying open already and this will make it worse. SB 12 is designed to solve urban problems and is not applicable to all areas in the state. There are chronic issues with nursing staffing, but they are no different from the challenges in other medical areas. She said that Alaska Tribal Health providers are not purposely understaffing as an abusive labor practice. The reality is that to the degree they have nursing staffing challenges, it is because of the tight national labor pool compounded by the never-ending challenge of figuring out how to get good nurses, doctors, technicians, administrators and others to work and live in remote Alaska locations. SB 12 proponents agree that there are few official overtime complaints by nurses and that there are low numbers of complaints and benign exit interviews. She acknowledged that nursing is a difficult profession, but the challenges come with the territory and all must schedule their work to meet the needs of their patients - and - this issue can be addressed differently. Because of the well-documented nurse shortage in Alaska there is a very tight labor market for nurses that gives them significant leverage in negotiating the terms and conditions of their employment. She thanked the committee and asked them to vote no. 2:21:26 PM SENATOR PASKVAN asked if there was a rural exemption, what size community should be exempt. MS. DOTOMAIN replied that is difficult to say because if something is put in place that makes recruitment easier in urban Alaska, that makes it tougher on recruiting in rural facilities. 2:22:43 PM CHAIR DAVIS suggested she get together with the Nurses Association to work on possible language for this particular bill. 2:23:22 PM CINDY ALKAIER, Assistant Chief Nurse Executive, Providence Health and Services Alaska, opposed SB 12. She said that most Alaska hospitals have been successful at avoiding mandatory scheduled overtime recognizing that nurses need rest between their shifts. Providence has not scheduled mandatory overtime within its facility. Secondly, this bill does not appropriately address the on-call situations currently present in their operating rooms, post anesthesia care unit, cath lab, and dialysis unit. "On call" is defined as being available within 30 minutes (when there is a life threatening incident). The issue of on call is not easy to solve since hospitals provide 24 hour emergency services. Nurses work in their OR cath lab which deals with removing clots when there are strokes, acute MIs and caring for babies with cardiac defects. 2:25:16 PM Dialysis also has emergency situations after normal operating hours when someone has overdosed on drugs or has a life threatening need for dialysis. It takes specialized training and experience to function in those specialized areas; requiring training for sometimes as much as two years. Routine procedures are scheduled during regular hours, but if an emergency occurs after hours they have to be able to call trained people in. This bill treats on call the same as any other work. If a nurse has just worked a shift and is on call on the same day she could easily go over 80 hours in 4 days. Some nurses choose to take their on call on the days they are scheduled to work so it doesn't interfere with their regular scheduled days off. This legislation would impact their ability to manage their own schedule and their own time off. Requiring an on-call staff person to fulfill their on-call obligation as mandatory overtime will adversely impact the ability of hospitals to provide emergency surgery, heart caths and emergency dialysis. 2:28:29 PM MS. ALKAIER said one of the complications of feeding a premature baby is the possibility of obstruction of the bowel and if that isn't operated on immediately, the baby will die. If they cannot get someone on call to come in, the family will be told they can't treat their patient. This could happen in any emergency, so they need the flexibility to bring staff in to care for those emergent situations. Hospitals have safeguards in place to ensure good quality care and have detailed inspections by the federal government, the State Department of Public Health and private accrediting agencies such as joint commissions. Quality performance improvement, staffing competencies and patient satisfaction are monitored continuously. To maintain accreditation, hospitals are required to measure patient acuity and care requirements and provide adequate hours of nursing care to meet those requirements. In addition, their hospital's ability to maintain the confidence of the community determines their future success. Providence believes if there are problems with mandatory overtime at their facilities it should be handled during collective bargaining. 2:31:27 PM Providence is scheduled to begin union negotiations this month and mandatory overtime and on call will be part of that. She asked them to allow them to deal with these problems then. 2:31:58 PM CHAIR DAVIS said she understood they'd started negotiations in January or February. MS. ALKAIER replied no; their first meeting will be March 19. CHAIR DAVIS encouraged them to take these issues up with nurses at the bargaining table. She said she didn't believe any nurse would not stay to do what needs to be done in an emergency; but if emergencies are ongoing, that is a workload, not an emergency, and it does cause a hazard. MS. ALKAIER said the on call work she refers to has to do with the emergencies that come up in the middle of the night. Regular staff don't know how to deal with some of those emergencies and they have to call in a special team. If they lose on call staff, those teams may not even answer the phone. They need to have those on call people available in the cases of those emergencies. 2:34:48 PM SENATOR PASKVAN said hospitals are in the business of providing care in emergencies; so he wanted to know how routine emergencies are. Does it happen weekly? If it's weekly, then it's routine. 2:35:29 PM MS. ALKAIER explained that some emergencies, like a ruptured intestine in a baby, only happen about twice a year, but if one person is lost because they can't get the care they need when that happens, then it's unacceptable. Other things come up more frequently like a ruptured appendectomy, but an OR team can handle that. It's only when a second crisis comes up at the same that no one is there. She repeated when specialized people are needed, they can't just bring any nurse in. The on-call people are in specialized teams. It's only when someone comes in at night with a heart attack that was unexpected who needs to have that surgery right then or they are going to die - that the team has to be called in. Only a handful of nurses know how to do those kinds of procedures. 2:37:42 PM MARILYN EDWARDS, Operating Room (OR) Clinical Manager, Providence Alaska Medical Center, said it would be devastating to enact a "one size" solution in to state law to solve a mandatory nurse overtime concern that does not exist at the Providence operating room. Her immediate concerns revolve around safe quality patient outcomes and a safe work environment for her OR staff. MS. EDWARDS said the OR nurses pride themselves on providing optimum work life balance care while taking good care of their patients. The OR is fully staffed and less than half of her nurses work full time. She has 48 OR registered nurses; this includes 2 educators, 1 RN traveler, 16 specialty clinical nurses, and 1 registered dialysis nurse. Eight of these 48 nurses work 12-hour shifts, 4 of these 12-hour shifts were added in the past year at the request of these 4 RNs. Seven nurses work 10-hour shifts and 33 work 8-hour shifts. She said that 22 RNs work a 1.0 fulltime equivalent position, 9 RNs work at .9 fulltime equivalent, 4 RNs work a .8, 2 RNs work a .6. They have 10 registry RNs who are required to work 3 shifts per month and a minimal on call. She explained that a 1.0 fulltime employee working 6:46 a.m. to 3:15 p.m. Monday through Friday has an average of one evening call, one night call and two weekend shifts, either as scheduled shifts or call per four-week period. A 12-hour RN, a .9 fulltime usually has night or weekend call. Much of this call is assigned around the individual RN's request because they may want the call scheduled when they are also scheduled to work to allow them to have consecutive days and nights off at a time to spend with their families. MS. EDWARDS said she has 2 RN team leaders that volunteer to take second night call more often. One team leader averages 7 to 9 orthopedic call shifts per month; the one heart team leader voluntarily averages 14 to 17 shifts or more per month. During the interview process for a new position in the OR, all OR staff candidates are advised of the call requirements. The assigned call coverage is necessary to provide rapid (30 minutes from notification) response for emergent patient care above what they are routinely staffed for based on volume trends of operation. 2:41:26 PM She has read and heard of anecdotal stories of nurses being tired and unable to provide quality safe care to patients. While this is true at some facilities, Providence provides time off to be with sick or dying relatives and did that with one of their cardiac nurses; others covered her shift while traveling nurses interviewed for a fill in. If their OR nurses had not been allowed to cover the call shifts due to already meeting their call and work requirements as set out by SB 12, they could not have accepted heart patients while that nurse was gone. The patient would have to be diverted; this means a facility doesn't have staff for a procedure. If all three facilities in Anchorage go on divert, actually no one is on divert. Someone needs to care for that patient. 2:43:17 PM NANCY DAVIS, RN, President, Alaska Nurses Association, said she works now as a hospice nurse and has worked as a public health nurse. She was chief of Public Health Nursing for the state; so she is familiar with nurse issues across Alaska. She supported SB 12. "It is a patient safety issue." She said that this state deserves assurance that all nurses will be rested and capable of taking care of their patients. She didn't think any nurse wanted less than to provide the best possible care for her paitent; but sometimes it is difficult to do that. MS. DAVIS said, however, there are times when health care pressures and health care facility pressures create an extra burden and this is why the mandatory overtime prohibition is important. She feels the bill has adequate safeguards to deal with unforeseen emergency circumstances, and the midnight surgeries and car accidents would fall under that category. All nurses would rise to that occasion. Those emergencies should not be the standard plan of staffing for dealing with shortages, though. She said the bulk of the ANHSHA's data comes from discussions with administrators, not staff-level nurses. The Alaska Nurses Association did a survey last spring speaking with nurses across the state, and they found that nurses are routinely asked to work overtime without sufficient rest between shifts. "It's really an issue for patient safety." As for being a bargaining issue, Ms. Davis said, not all nurses work under collective bargaining unit, and one union they talked to declined to make it an issue because they said the legislature would take care of it. "Someone needs to take care of this and I believe SB 12 is a good answer." MS. DAVIS also remarked that one of the nurses commented on the impact of the economy and how the overtime is necessary for her to provide for her family. But Ms. Davis said she fears that the economic pressures are going to increase the likelihood of mandatory overtime as people lose their jobs and nurses seek to try to cover the economic needs of their families and perhaps ask for additional overtime in order to make ends meet. SB 12 is the best assurance for patient safety regardless of what her personal needs might be as a nurse for her own economic welfare. She believed that a standard statewide approach to defining maximum work hours and minimum rest period is the best way to do it. 2:49:13 PM CHRISTY ORTUSO, RN, Director, Neurosciences, Providence Alaska Medical Center, said she is also a Board of Directors Member of the American Association of Critical Care Nurses Certification Corporation, the largest specialty nursing certification corporation in the country. They have pioneered healthy work environments and looking at the nurses' role in maintaining them over several years. Anecdotally she related how she chose to work overtime to be able to buy a house and how she was concerned about language in SB 12 that would limit her choice to working certain hours. She has been in Alaska less than three years; before that she worked in hospitals where mandatory overtime was used to staff the units in one of the worst nursing shortage experienced in the past two decades, and she was never mandated to work because she chose to work. The nurses she has known over the years have valued that flexibility as one of the driving reasons for staying in nursing. Her experience in Alaska is that hospitals are very well staffed when she compares it to her 26 years of experience in the Northeast. MS. DAVIS said she is currently on faculty at two universities, UAA and the University of Phoenix, and she has contacts with nurses across the United States and one concept comes out clearly in her classrooms - nurses need for autonomy and making their own choices. Everything she reads about Alaska indicates that mandatory overtime is not a great problem here; small instances of it can be resolved by developing healthier work environments and allowing nurses to rise to the professional standard they have wanted to work in throughout the years. 2:54:56 PM STACY ALLEN, RN, Business Agent, Laborers Local 341, said she represents about 265 nurses at Alaska Regional Hospital, supported SB 12. No one has mentioned the conflict that nurses feel between their ethical, moral and legal responsibilities as a patient advocate and their personal need to not work more than is safe for themselves or the public. She recalled from nursing school how nurses is uniquely placed to be the patient's advocate, and the public has come to expect a high degree of care ethically and physically. More studies are coming out talking about things that keep nurses from the profession or keep them from hospital nursing; one is the stress some feels in knowing they are not safe to work, but there is no one else to replace you or the person being called in to replace you is just as tired as you are. SB 12 levels the playing field not for just the individual nurse, but for the institutions themselves. It sets a minimum standard that the public has a right to expect in health care. 2:57:29 PM ROGER LEVRENTZ, RN, Clinical Nurse Educator, Heart Center, Providence Health Care Center, said he is responsible for staff in the cath lab, the observation unit and their cardiovascular intervention unit. He said the cath lab is a highly specialized area where people having strokes, heart attacks and other life threatening problems receive care. Staff consists of RNs, cardiovascular technologists and radiology technologists; they all have extensive specialized training. They care for patients of every age from neo-natal to over 100 years old. It is not unusual for them to be called in at 2 a.m. and the restrictions SB 12 would impose would negatively impact their ability to provide care for the patient population due to the unavailability of trained staff. CHAIR DAVIS announced that she would bring SB 12 back at a later date. 3:00:48 PM There being no further business to come before the committee, Chair Davis adjourned the meeting at 3:01 p.m.

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