Legislature(2001 - 2002)
04/09/2002 01:40 PM Senate L&C
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* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
+ teleconferenced
= bill was previously heard/scheduled
ALASKA STATE LEGISLATURE
JOINT SENATE LABOR & COMMERCE COMMITTEE
AND HOUSE LABOR & COMMERCE COMMITTEE MEETING
April 9, 2002
1:40 p.m.
SENATE MEMBERS PRESENT
Senator Ben Stevens, Chair
Senator Alan Austerman
Senator Loren Leman
Senator Bettye Davis
SENATE MEMBERS ABSENT
Senator John Torgerson
HOUSE MEMBERS PRESENT
Representative Lisa Murkowski, Chair
Representative Andrew Halcro, Vice Chair
Representative Kevin Meyer
Representative Norman Rokeberg
Representative Harry Crawford
Representative Joe Hayes
HOUSE MEMBERS ABSENT
Representative Pete Kott
OTHER MEMBERS PRESENT
Representative Sharon Cissna
Representative Peggy Wilson
COMMITTEE CALENDAR
Nursing Workforce Issues
WITNESS REGISTER
Ms. Pat Senner, President
Alaska Nurses Association
Anchorage AK
Mr. Dennis Murray
Administrative Director
Heritage Place Nursing Facility &
Chairman, Alaska State Hospital and Nursing Home Association
Anchorage AK
Ms. Susan Snippen, Director of Nursing
Wildflower Court Nursing Home
Juneau AK
Ms. Laraine Derr, President and CEO
Alaska State Hospital and Nursing Home Association
Juneau AK
Ms. Karen Perdue, Associate Vice President
University of Alaska
3211 Providence Dr.
Anchorage AK
Ms. Vivian Lee
Yukon Kuskokwim
No address provided
Ms. Rebecca Nance-Gamez
Deputy Commissioner
Department of Labor & Workforce
Development
PO Box 21149
Juneau, AK 99802-1149
Ms. Theresa Reed
Alaska Nurses Association
Providence Hospital
Anchorage AK
Ms. Ken Simmons
Alaska Nurses Association
Anchorage AK
Ms. Maggie Flanagan
Alaska Nurses Association
Anchorage AK
Ms. Camille Soleil
Executive Director
Alaska Nurses Association
Anchorage AK
Ms. Barbara Huff-Tuckness
Director
Governmental and Legislative Affairs
Teamsters Local 959
Juneau AK
Ms. Angelina Zinski
Public Health Nurse
Anchorage AK
Ms. Nancy Davis
Chief, Public Health Nursing
Department of Health and Social Services
POB 110611
Juneau AK 99811-0611
Dr. Nicholas Koletti
Medical Director
Alaska Psychiatric Institute
Anchorage AK
Dr. Tina DeLapp
Director, School of Nursing
University of Alaska
Anchorage AK
ACTION NARRATIVE
TAPE 02-18, SIDE A
Number 001
CO-CHAIR BEN STEVENS called the Senate and House Labor & Commerce
Committees to order at 1:40 p.m. Committee members present at the
call to order were Senators Austerman, Davis and Chair Stevens
and Representatives Halcro, Meyer, Crawford and Chair Murkowski.
Representative Wilson was also present. Co-Chair Stevens
announced the committees would hear from individuals in the
nursing profession about issues facing the nursing workforce
environment, the educational challenges and the shortages in the
workplace at this meeting. He hoped committee members could bring
forth solutions to the nursing shortage problem as a result of
this meeting.
CO-CHAIR LISA MURKOWSKI, House Labor and Commerce Committee, said
she appreciated the invitation to join the Senate Labor and
Commerce Committee to participate in this overview. She
commented, "The nursing shortage has been identified as one of
those that is acute and we need to address it…"
MS. PATRICIA SENNER, President of the Alaska Nurses Association,
told members she had been a nurse for 20 years. She stated:
A March 28 headline in the Anchorage Daily News reads
'Providence Diverts Victims.' The article goes on to
state that the Anchorage hospitals routinely tell 911
dispatchers that they can't accept more emergency
patients usually because they don't have the critical
care beds or the nursing staff for them. This article
highlights one of the current effects the nursing
shortage is having on the delivery of healthcare in
Anchorage and Alaska.
The nursing shortage has its roots in several
converging factors, both demographic and environmental.
The average age of an RN in Alaska is 45.1 years
compared to 43.3 years nationally. In the state 71.6%
of the registered nurses are over the age of 40. I'd
like to refer you to this graph from [indisc.] shows
the age distribution of registered nurses and here's
this big area in the middle that is the age 41 - 50 and
that's not the way this curve ought to look. The curve
ought to be high in the 31 - 40s and then taper off.
You'll also notice that the nurses age group 51 - 60
represent half of those, age 45 - 50. So, in the next
10 years half of the nurses working now will probably
leave the field.
The aging of the nursing workforce reflects in part the
age distribution of the state's population, but it also
reflects the fact that fewer young people, women in
particular, are going into nursing. When I was a child
I would eagerly await the arrival of Time Magazine so I
could read the Medicine Section. In those days the
family expectation was that I would become a nurse.
Nowadays, the expectation would probably be that I
would become a doctor. Today, women in particular have
a greater number of career opportunities available to
them.
In the 1990s there was a concerted movement by health
insurance entities, and it continues today, to try to
contain the rising cost of health care by decreasing
the reimbursement rates and by shortening hospital
length of stays. This resulted in the patients in
hospitals being sicker and, therefore, requiring more
nursing services. At the same time, hospitals responded
to the decrease in reimbursement by reducing the number
of RNs and replacing them with unlicensed assistive
personnel. Nurses found themselves having to take care
of a greater number of patients who were also sicker.
This led to many unsafe situations and nurses would end
their shift totally exhausted and worried that they had
not provided adequate care for their patients. Over
time, the stress of the situation led many nurses to
leave the profession.
In the 1990s when nurses complained about the unsafe
nature of their work environment, the employer's
response was often, 'Take it or leave it. There are
plenty more nurses where you came from.' This obviously
is no longer the case. Another general employer
response was, 'If you work smarter, you can handle more
patients.' The problem with that is that a nurse cannot
be in two or three places at once. The patient in Room
306 is experiencing chest pain, the patient in 308 has
serious bleeding from a surgical wound and the patient
in 309 has become confused and is trying to rip out all
his tubes. Nurses find themselves with just barely
enough time to take care of the technical side of their
responsibilities and have little time left to assist
patients and their families with the emotional side of
their illness. One nurse told me recently that she
hardly has time to talk with her patients any more.
Hospital nursing is physically very demanding work.
From the time you come to work until your shift ends,
you're usually in a constant dead run. Nurses
frequently work 12-hour shifts and consider themselves
lucky to get a lunch break. There has been considerable
press about the increase in obesity in America and that
fact influences the physical demands of the health care
workers. The lifting, turning and bending required to
care for patients leads to joint deterioration over
time. Hospital nursing is exhausting work and this why
most RNs who work in the hospital retire some time in
their mid-50s rather than in their mid-60s. This means
that the nursing shortage that we feel now is only
going to get worse over the next 5 to 10 years.
Further compounding the problem is the fact that the
general population is aging. The dreaded words, 'the
incidence of this increases over the age of 40' means
that a greater percentage of the population is in need
of medical services and, therefore, nursing services. I
recently had a retired office nurse come up to me and
say, 'Pat, you have to do something about the nursing
shortage, because I was pulled out of retirement to
work because they couldn't find anyone else to work and
I'm just getting too old for this.'
An immediate response to the nursing shortage by some
employers has been to force nurses to work mandatory
overtime. People who are testifying after me are going
to talk more about that particular issue. Nurses are
already working a lot of voluntary overtime, but the
nurse who has already worked a 12-hour shift is
obviously not safe to have him or her work 24 hours
straight. This only serves to lead to injuries,
mistakes and earlier exit of nurses from the
profession. Mandatory overtime and the nurse-patient
ratios are the two main issues the nurses at Providence
went out on strike on over three years ago.
The Alaska Nurses Association and the American Nurses
Association feel that the solution to the nursing
shortage is twofold. The first part of the solution is
to work to interest more young people in becoming
nurses and provide them with educational opportunities
and funding. The second part of this solution is to
improve the work environment so the existing nurses can
continue to work as long as possible and that new
nurses who train don't leave the profession
prematurely. Some of these solutions the legislature
can help us with directly and some require a joint
effort by the community, the health care providers and
the nursing profession.
Specific recommendations we think the legislature can
assist us with are as follows:
After the budget shortfall has been successfully dealt
with, I meant Representative Peggy Wilson's HB 449,
which would provide for tuition loan reimbursement for
nurses who work in Alaska - with the budget shortfall,
we would suggest investigating doing this jointly with
employers, looking into providing grants to employers
or entities such as the Nurses Association to provide
post-grad specialty training in areas such as ER, ICU
and OR nursing. Many states have already passed
legislation prohibiting mandatory overtime. Alaska may
want to consider similar legislation. Other states are
beginning to pass legislation mandating specific nurse
patient ratios. We have some reservations about doing
this, particularly since we have so many small
hospitals. The key is really mandating certain nurse
patient ratios based on what is called acuity [indisc.]
illness level of the patients, rather than the specific
name of the unit in which they are residing.
Finally, support strong legislation and regulations in
workplace safety. I know there's someone after me who
[indisc.] specific to this area. In particular, nurses
and other health care providers need ergonomic
regulations related to lifting. The population is not
going to get any less heavy.
The hospitals, communities and nurses need to work
together to address the nursing shortage in a
meaningful way. We look forward to working with the
legislature and employers and recruiting people to the
profession and creating a work environment that will
provide them with a long and satisfying career.
MR. DENNIS MURRAY, Administrative Director, Heritage Place
Nursing Facility, and current chair of the Alaska State Hospital
and Nursing Home Association (ASHNHA) said and that in general,
everyone understands the problems; they now have to come up with
solutions. The nursing shortage has been identified as the most
critical employee shortage in the state. ASHNHA has copies of
reports that offer recommendations. ASHNHA has been working with
the University Task Force and UA Vice President Karen Perdue on
ways to increase the number of nurse graduates. He suggested the
legislature support Representative Wilson's legislation on
tuition forgiveness and funding.
MS. SUSAN SNIPPEN, Director of Nursing, Wildflower Court Nursing
Home, said Wildflower Court is a 44-bed, long-term care skilled
nursing facility that has been affected by the nursing shortage
over the years. For example, three full-time registered nurse
positions have gone unfilled for the past two years. Wildflower
Court has addressed that problem for the short term by hiring
temporary employees from agencies. That is an expensive solution
for a not-for-profit agency because all additional expenses are
paid directly from the services provided to residents in the
facility.
Wildflower Court's greatest hope to resolve the nurse shortage is
the improving nursing program at the University of Alaska in
Anchorage and Juneau. She has appealed to educators to promote
long-term care nursing as a career rather than as a fall-back
position in light of Alaska's aging population.
MS. LARAINE DERR, President of the Alaska State Hospital and
Nursing Home Association, said ASHNHA has been looking at this
problem for some time. Three years ago ASHNHA convened a summit
to talk about the nursing workforce. The Alaska Department of
Labor and Workforce Development (DOLWD) has provided a $30,000
grant to begin to address staff development of the different
levels of nursing and a $30,000 to conduct a summit to be held
next week to chart the course for the next decade. ASHNHA is also
working with the task force at the University of Alaska to
educate more nursing students. She pointed out it is important to
educate children in the earlier grades about different
professions because studies show that by the time they reach
fifth grade, students are thinking about what kind of work they
want to do as adults.
MS. KAREN PERDUE, Associate Vice President, University of Alaska,
said she has been focusing on health care issues. She gave the
committee a report [overhead slides] on the task force that
finished its work yesterday. The task force's charge was to
describe what the University could do to help the health care
industry address the current and projected need for facility
based nursing. She pointed out the nursing shortage is in more
than facilities but because the University could sit down with
ASHNHA in a quick fashion, it focused on resolving the need for
facility based nurses.
She said about 400 nurse vacancies in Alaskan health care
facilities were reported in a 2001 survey and that about half of
the nurses work in hospitals and nursing homes. DOL projects a
demand of about 220 additional nurses through 2008. These figures
take into account a 40% retirement rate and a 40% growth in
demand over the next decade. The causes of the shortage are
complex. Alaska's nursing workforce is aging. Nursing is a
physically demanding and stressful profession and nurses have
other career options. Nurses are in demand because they are very
talented people. The need for nursing services has increased
because of the aging population and community care. She added,
"There is a crisis and the situation is deteriorating on a pretty
rapid basis here."
MS. PERDUE showed the committee a graph of the aging nurse
workforce nationwide and said that Alaska's workforce is a little
bit older. She said increased salaries help with recruitment; the
mean salary in Alaska is about $25 per hour now. Nursing
graduates should double by 2006 and even though that is an
ambitious goal, it will not oversupply the market. The existing
nursing program at the University is very strong, but it should
be expanded to include innovation and flexible nursing options,
including distance delivery, because not all students can come to
Anchorage. The University also want to make sure students can get
credit for the number of years of service. The University cannot
tackle this problem alone. It has been talking with industry
representatives about how to finance the increases and believe it
has formed a very good partnership so far.
The University believes students need financial assistance and
are often unable to attend non-stop, because they have to stop to
work. Finally, she said workplace issues exist, but if the focus
is on them, the demand for nurses will not be met. An aging
workforce means they have to get young people into nursing.
Financial assistance will not only help students get started, but
to finish school.
MS. PERDUE said to double the nursing program output, the
University will have to work hard to get expansion funding. Right
now it spends about $3 million per year on nursing education in
the state; next year it will need about $1.2 million more to
achieve this same goal. The University is talking to industry to
get help.
The University needs to clear the waiting list of eligible
students wanting to get into the program. If it can clear the
waiting list, it can begin to get graduates on the street. Like
everyone else, the University needs to adjust faculty salaries.
She informed members that not only is the University doubling the
size of the program in Anchorage and doing a summer program, it
is also creating either a new or expanded program in seven
separate campus sights, including Bethel, Kenai, Juneau,
Ketchikan, Sitka, Fairbanks and Kodiak.
MS. PERDUE explained that the University needs help from
hospitals on critical health issues and relies heavily on
Providence, API, the Alaska Native Medical Center and Alaska
Regional Hospital. The hospitals have been very gracious about
helping to educate students. She showed members a slide of the
University's costs, including the one time and ongoing costs.
[Indisc.]
MS. VIVIAN LEE, Yukon Kuskokwim, said she has 52 nursing
positions in the hospital and 18 vacancies. They have six
additional RN positions in village operations and two in
behavioral health (which are filled). She noted, "Nursing is a
demanding career requiring knowledge, critical thinking and
requires many physical skills…"
MS. LEE thought students should be exposed to health care careers
in grammar and high schools. She asked for increased funding for
nursing and a scholarship program with a payback offer for
staying in the state to get people into the program. Rural nurses
need to be trained in their area so they can stay.
MS. REBECCA NANCE-GAMEZ, Deputy Director, DOLWD, commented on a
slide presentation called "Registered Nurses Profile" from the
department's Development/Research and Analysis Section.
Registered nurses include all nurses who obtain training through
a 2, 3, 4 year or masters level program. She said:
Although the effects of supply and demand mismatch are
felt throughout the state, rural Alaska is particularly
vulnerable. In Alaska's rural communities where job
opportunities are scarce, high skilled, high wage
registered nurse positions often go to outsiders. The
aging of the baby boom generation fueled an increase in
the need for quality health care. The aging of the RN
workforce will make it increasingly difficult to meet
this need.
Exhibit 1 shows that in 1998 the estimated employment level for
nurses was 3,900, one of the largest occupations in the state.
Alaska employers routinely import nurses from the Lower 48 and
for abroad. In 2000, 14.8% of nurses working in Alaska were non-
residents of the state.
Exhibit 2 shows that in 2001, over 7,000 Alaskans were licensed
RNs, more than the number working in the profession. The RN
profession continues to be dominated by women. In 1999 women
comprised 91.7% of Alaska's nursing workforce.
The top private sector health care employers in 2000 were
Providence Alaska Medical Center, the Inner Health System, which
is formerly Lutheran Health Systems of Fairbanks, and Alaska
Regional Hospital in Anchorage.
Based on the most recent occupational forecasts for nurses from
1998 - 2008, employment in the broad nursing category is
projected to grow nearly 40% and much faster than all other
average occupations and the average growth is 16.6% (exhibits 1 &
4). Over 45% of nurses working in Alaska in the first quarter of
2000 will reach retirement age in the next 15 years.
In addition to a faster than average growth rate, the number of
nurses needed in Alaska to fill new jobs resulting from industry
growth will increase by nearly 1,600. Alaska's statewide
employment for nurses in 2008 is projected to reach nearly 5,500.
If the 2008 projections hold true, nursing will be the largest
single health care occupation and the seventh largest occupation
in the state. The occupation side of nurses compares with other
large size occupations such as bookkeeping, accounting and
auditing, clerks, sales supervisors and managers.
The nursing shortage is not just an Alaskan problem. Using
national data, the U.S. Department of Labor has determined that
nursing is a shortage occupation and that fact resulted in
special provisions for nursing under the Immigration Act of 1990.
In 2000, the mean hourly wage for nurses in Alaska was $25.08 per
hour and nationally it's $22.31 per hour. In Washington State the
mean hourly wage of nurses was $24.22. In the year 1999 the
average male nurse in Alaska earned $43,000 per year and in the
same year female nurses earned approximately $37,000.
MS. THERESA REED, Alaska Nurses Association, said she is a staff
nurse in critical care at Providence Hospital. She described a
typical day in her unit. Some nurses have been working 16-hour
shifts and on the day that a patient was diverted to another
hospital, Providence had two beds open but was 12 nurses short.
Six nurses are leaving over the next six weeks due to wages and
benefits. In a ten-day period in her unit alone, 12 nurses worked
15 shifts of overtime.
A lot of the experienced nurses are leaving and this is
frustrating because they do a lot of the teaching. One of the
major reasons they are leaving is because they are primary care
givers for everyone but they have no health care after
retirement. Another reason is poor wages; they haven't received a
raise in over six years. Another reason is injuries, either
repetitive motion back injuries or assaults from patients. Two of
her staff need to have surgery because of this. There is a lot of
chronic pain and no ergonomic evaluations. It's not atypical for
a nurse to have to lift a 250 lb. patient.
TAPE 02-18, SIDE B
MS. REED said that stress is another big problem; the work loads
are heavier and there are less resources available. It's not
unusual to get no break for 12 hours. Nurses are exposed to a lot
of violence and there is no flexibility as far as lifting weight
goes. If you can't lift it, you can't work at the bedside no
matter how much knowledge you have. The use of protective latex
gloves is another issue because many nurses are allergic to
latex.
She said overtime isn't mandatory, but there have been a number
of instances with their three dialysis nurses who could not leave
when their shift ended. Some of the major fears for nurses are
not being able to care for themselves after they retire, getting
a disease, making a mistake because they are too busy that they
can't catch everything, having to work overtime and not having a
stable and predictable home life.
MS. REED said nurses do love their profession, but they need
better ergonomic standards, lift teams, better retirement
packages, health care after retirement and better pay. She
cautioned the state needs to encourage people to come into this
profession.
MR. KEN SIMMONS said he works in a hospital, and this is the
second nursing shortage he has been through. The other One
occurred in the late 70s and early 80s. Some of the similarities
are increased patient to nurse ratio, frequent calls for
increased shifts, increased fatigue and, over the last couple of
years, decreasing morale among the staff.
Some of the differences involve the educational system. When he
graduated in 1978 from Ohio, he graduated in a class of 120. Last
year he visited the same school and the graduating class had less
than 20 students. The applicants just weren't there and when he
attended, there was a waiting list. There were diploma programs,
associate degree programs, and a baccalaureate program. He
understands that not just all of the diploma programs have
disappeared, but some of the associated degree programs have as
well.
There is an aging nursing workforce with the average age being
47. Patient acuity is higher, which makes the job of the nurse
much more difficult. More nurses are needed rather than less.
Temporary nurses sometimes come in, but the down side to that is
that they get comparatively little orientation to the hospital. A
typical new nurse at a hospital gets two to six weeks of
orientation and training and a traveling nurse may get hours or
less before they start work.
Administration is providing an in-service class on how registered
nurses can delegate more of the skilled tasks to their nursing
assistants, but the bottom line to that is the nurse who is
delegating that task is still responsible for seeing that it is
carried out appropriately.
The bottom line is the safety and well being of the patient and
creative ways need to be found to enhance that. As the workload
gets harder, nurses get burned out and more of them will leave
the workforce as they have a lot of other options.
MS. MAGGIE FLANAGAN, Alaska Nurses Association, said she has 25
years of experience working in health care and 20 years as an RN.
She said that health care has become one of the most dangerous
industries in the United States. According to the U.S. Bureau of
Labor Statistics, it is now more dangerous to work in a nursing
home than in mining or construction. She commented, "In an
industry already in crisis, we are losing nurses at a frightening
rate to occupational illnesses and injuries."
She said that in the last decade reports are doubling of illness
and injury rates in the health care industry. She noted, "All
Alaskans are effected as health care consumers by the
consequences of poor working conditions in the health care
industry."
MS. FLANAGAN said that training and recruiting of nurses is
important in solving the nursing shortage, but retention is the
key. This can be accomplished with a safe and healthy work
environment. Only about half of Alaska's registered nurses are
working as nurses and the Alaska Department of Labor is proposing
a general safety and health program, which addresses three major
occupational hazards: work place violence, indoor air quality and
ergonomics. Two-thirds of all non-fatal workplace assaults occur
in health care facilities. It is estimated that 38% of all nurses
will experience a back injury at some point in their career. It
is also estimated that 12% of nurses are leaving nursing every
year due to these muscular skeletal injuries. Nurses and cleaning
personnel in health care facilities are in the top ten list for
occupational asthma. Alaska nurses desperately need a strong and
protective health and safety program with full legislative
support.
MS. CAMILLE SOLEIL, Executive Director, Alaska Nurses
Association, read a letter from Marjorie Stock, a critical care
nurse in Anchorage. She was unavailable today because of her
schedule. The letter reads:
I have worked in the critical care nursing area since
1980. During this period I have weathered other nursing
shortages in many other states and hospitals. This
shortage is different. As a member of the Anchorage
Chapter of the American Association of Critical Care
Nurses, I will take the opportunity to discuss patient
care issues with my peers at other Anchorage hospitals.
Each facility is experiencing a similar nursing crisis.
I'll direct my comments to the critical area, because
that's where I have first-hand knowledge.
We have a critical shortage of registered nurses that
have critical care training and/or certification.
Hospitals are staffing intensive care units with newly
trained nurses and nurses lacking in critical care
education and skills. In many cases, experienced
critical care nurses will be able to mentor these new
nurses, which is not always possible due to increased
demand for experienced nurses.
Affiliate services have been cut drastically over the
past few years in an effort to cut health care costs.
In addition to [indisc.], the intensive care nurse must
perform duties formerly accomplished by [indisc.]
pharmacy, lab, housekeeping, physical therapy,
respiratory therapy, social services, IV teams, lift
and transport teams and maintenance. In addition,
computer charting has taken the nurse further away from
the bedside. In an effort to make everything look
perfect on paper, we've lost the quality time to care
for patients, our whole reason for being there in the
first place.
Mandatory overtime has been used to try to serve the
community [indisc.] like closing the emergency room to
critical patients. More critical care beds will not
solve this problem; we need [indisc.] nurses. Newly
graduated nurses are not being mentored as they enter
the workplace. It takes years to develop the critical
thinking [indisc.] necessary for the intensive care
patients. These new RNs will soon burn out and seek
jobs out of acute care or enter different fields
altogether. Introducing clinical nurse specialists into
intensive care units would go far to alleviate this
problem.
Retention of the experienced critical care nurse is an
area that has been greatly overlooked. As the demand
placed on them becomes impossible, [indisc.} where they
are not faced with life and death decision every day.
An expert critical care nurse I know just told me last
week that she now feels that a huge weight has been
lifted off her shoulders. She left my ICU for a less
acute care position. The problem is multi-faceted and I
do not have all the answers, but if any of you has been
a patient or has had a family member in a hospital
recently, you've undoubtedly seen some of the things
I've described. When there's only one critical care bed
open in the City of Anchorage and this happens
frequently, it is not good for anyone. Remember it's
not the beds, it's the lack of critical care trained
RNs that is the problem.
MS. SOLEIL agreed that the issue of mandatory overtime is
serious. It endangers patients and encourages qualified nurses to
drop out of the field of nursing. Several states including Maine,
Minnesota, New Jersey, Oregon and Washington have already passed
statutes addressing mandatory overtime. She stated, "Alaska needs
to join these states in our campaign to attract and retain
qualified nurses."
She said committee packets contain a statement issued by the
Alaska Nurses Association opposing the use of mandatory overtime
as a staffing tool. Another solution would be to examine
[indisc.] hospital, [indisc.] specifically focused on [indisc.]
empowering nurses in the decision-making process. This
certification is available through AMCC and has a very high
retention rate for those hospitals that use it.
MS. BARBARA HUFF-TUCKNESS, Director, Governmental and Legislative
Affairs, Teamsters Local 959, said the Teamsters represent public
health nurses who work for the city as well as [indisc.]. She
said the shortage has different impacts on smaller hospitals and
larger ones. Nurses have to be more multi-skilled, which costs a
smaller facility more to bring them in. She suggested setting up
some sort of a calling hall for nurses in the state. A second
issue is the rapidly aging nursing workforce. Another is
providing an orientation opportunity in the smaller hospitals,
especially for new nurses. Another problem in small hospitals is
a low census will result in sending nurses home, which will make
their paycheck inconsistent. [INDISC.]
MS. ANGELIA ZINSLI, Public Health Nurse, said she was speaking on
behalf of the registered nurses and nurse practitioners in
Anchorage and that their clinic is short staffed. The public
health system in Alaska relies upon nurse practitioners and
registered nurses to promote and maintain Alaska's health. They
are increasingly dependent on state and federal grants to fund
services to people in their communities who have little or no
access to health care. They provide the same high level of care
with less funding and fewer physicians every year.
MS. ZINSLI said that many times when a position comes open, they
don't have qualified applicants, primarily because of the failure
of adequate monetary compensation and leave time. Some positions
stay open for an extended period of time or become eliminated
completely in order to maintain core services with budget cuts.
Nurse practitioners and public health RNs must be prepared at a
minimum at the baccalaureate level. Nurse practitioners are
required to be prepared at the Masters level and maintain
national certification.
She stated that nursing is a highly respected profession and
should be compensated as any other profession with equal
educational and licensing requirements, regardless of gender.
Additional options for nursing recruitment and retention would be
to include tuition reimbursement for nursing students as well as
tuition reimbursement for nurses returning to college.
MS. NANCY DAVIS, Chief, Public Health Nursing, Department of
Health and Social Services, said she has been a registered nurse
for 33 years and has worked in public health nursing for 31 of
those. She has been a resident of the state for the past 22
years. She supported the concerns expressed by others about how
the nursing shortage in Alaska is getting worse. She remarked:
When a shortage erodes services one by one and reduces
access to health services and information, it leaves
our population more vulnerable to disease and
disability. It is less of a spotlight issue, but it is
a crisis that looms for our future health and
prosperity.
She said there are about 190 nurses in the department that work
for the state as nurses. Some of the job titles do not include
the word "nurse." They work in over 30 communities across the
state in criminal detention facilities, the Division of Family
and Youth Services, social work offices and the Alaska
Psychiatric Institute. The Division of Public Health has the
largest number of nurses in the department with about 127 nurses.
She said that a few years ago they had an average 4.6 months per
vacancy and they thought that was pretty bad, but now after two
years, vacancies average 7.8 months. Finding nurses to work in
some of the more remote locations is also an issue. She pointed
out that in the public health nursing workforce, 18 nurses could
retire today based on age and length of service. 49 nurses will
need to be replaced because of age and leaving the workforce over
the next 5 to 7 years. They are finding that most public health
nurses are being hired at the entry level, which means they
haven't had any public health nursing experience and will need a
fair amount of training and orientation time in order to get them
to a level of independent functioning expected of public health
nurses. This is a big problem in rural communities where
applicants want a community that supports their lifestyle rather
than a Peace Corps type of opportunity.
She said that most public health nurses are government employees
so there isn't a lot of flexibility in either benefits or salary
negotiations. That is difficult in a competitive job market. She
suggested that being able to offer bonuses would increase
recruitment.
MS. DAVIS informed members that based on a federal effort, the
Nurse Reinvestment Act, as of April 1, public health facility
nurses were included in a federal nursing education loan
repayment program. "This is the best news we've had in the last
25 or 30 years. They have received three applicants as a result
of that change and they hope that will continue to stimulate
applicants to work for public health.
She said the University's plan to educate more nurses is Alaska's
best long-range solution, but in the near term the department
needs to recruit aggressively. They need stimulation for health
careers in the schools and it needs to be more than an incidental
exposure. Alaska needs a government personnel system that is able
to respond to changing market forces and steep competitive
situations for nursing positions. The state needs continuous
recruitment, not just vacancy based recruitment and flexible
salary options to be able to provide some incentive for very
experienced nurses to bring their experience into the workforce.
She noted that talk of budget cuts and hiring freezes definitely
affects recruitment for nurse positions and also makes it
difficult for other nurse employers in Alaska to attract nurses.
She said, "We become not a very attractive economic environment."
MS. DAVIS told members that the last time there was a hiring
freeze in the state, public health nurses were actually exempted,
but it stalled their applicant pool for about two years because
their spouses found it difficult to find jobs, as well.
2:10 p.m.
DR. NICHOLAS KOLETTI, Medical Director, Alaska Psychiatric
Institute (API), supported Ms. Davis' comments. He said he would
offer the following comments to specifically address the nursing
shortages at API.
Today at API one out of five of our lying registered
nurse positions are vacant. We have lost eight nurses
alone since January of this year. Currently, 10 full-
time registered nurse positions are vacant and in
addition they have three registered nurse positions on
extended family or medical leave due to their on-the-
job injuries. It would be impossible to cover API's
inpatient units 24 hours a day, seven days a week with
our current pool of nurses without using overtime and
we are forced to use mandatory overtime to
appropriately staff our facility. My need to require
nurses to work mandatory overtime has created a vicious
circle. The competition is fierce for nurses
everywhere, so why should a nurse stay in a job or take
a job where their employer requires them to work
overtime when they could make more money somewhere else
and not be forced to work overtime.
Mandatory overtime is especially hard on our staff
because they can never plan their lives. They cannot be
sure day to day if they can be home to cook dinner,
pick up their children from school, attend the parent
teacher meeting or go with friends to a hockey game.
You should know that admissions to API have increased
over 50% in the past five years with the stays being
much shorter now and our patient turnover is much
higher adding to increased stress. Throw in mandatory
overtime and you can see why we're losing nurses and
why we cannot recruit them. This problem has reached
crisis proportion and we do need help. The state needs
incentives to recruit and retain nurses.
There is no way to insure that all the facilities in
the state can recruit and retain nurses. The State will
likely need to further increase nursing salaries. If we
could pay a competitive wage, we could probably attract
more nurses, thus filling our vacancies and eliminating
or at least greatly reducing our reliance on the use of
mandated overtime.
As a second point that has been discussed by previous
speakers, Alaska must rely on its educational
institutions to help us meet our present and our future
need for nurses. Unless the state has a large enough
pool of nursing positions from which to draw, no health
care facility in Alaska, including API, will be able to
fill their vacancies almost regardless of hourly wage.
While API directly trains almost 100 nursing students a
year, only a minority of nursing students are really
interested in inpatient psychiatry. Fewer even then are
committed to the treatment of API's patients who suffer
from severe and chronic mental illness. The work at API
is difficult and challenging and the competition for
psychiatric nurses is very real. API must compete with
other Anchorage and Alaska mental health providers for
nurses who work in this field.
API is working as creatively as we can in the midst of
this crisis, but flexibility in our ability to attract
and retain nurses is clearly limited. As Ms. Davis just
noted, the state is at a very profound disadvantage
compared to the private sector in recruiting and
retaining nurses.
Finally, one last point, there is one way that API,
unlike any other hospital or health care facility in
the state, is at a particular disadvantage. API cannot
stop accepting patients, because we lack the number of
nurses to appropriately staff a patient unit. Private
hospitals can divert a patient or they cannot accept a
patient if they lack the necessary number of nurses to
enable them to open up another bed. Their mental health
patients are voluntary and private hospitals do not
have to accept patients if their unit is full or if
they lack the staff. At API, we can never divert and we
can never refuse an appropriate patient no matter what
our staffing or our acuity level. AS 47.30.760
unequivocally states that 'treatment shall always be
available at a state operated hospital.' This is why we
must mandate staff overtime when we have vacancies or
when staff are ill. We have no choice. For that reason
alone we need your assistance in the making the state a
more competitive employer for nurses.
CHAIRMAN STEVENS thanked Dr. Koletti and all the people who have
come forward to testify today.
3:15 p.m.
TAPE 02-19, SIDE A
SENATOR AUSTERMAN asked what criteria the department uses to deal
with the growing Asian nursing population.
MS. SENNER said the Board of Nursing could best address that, but
foreign nurses have to pass the same nursing boards that American
nurses have to pass, as well as an English proficiency test. She
noted:
Almost all the countries are suffering a nursing
shortage at the same time, so everyone was looking to
the Asian Pacific nurses to try to fill their vacancies
and Providence Hospital recently made a trip down
there. So, in fact, it's gotten so critical that the
Philippines is now suffering a nursing shortage. So,
they've been threatening to stop the export of nurses.
So, everyone had kind of the same idea and the pool is
close to being exhausted.
SENATOR AUSTERMAN asked how we accept some of the educational
aspects of other cultures.
MS. SENNER replied that we do and explained that nationally there
is a non-profit group that reviews transcripts from foreign
nurses and tells the State Board of Nursing what their training
is equivalent to in America.
REPRESENTATIVE HALCRO said he was looking at one of the reports
from the University of Alaska/Nursing Education Task Force and a
sub-note said that there are approximately 900 registered nurses
in Alaska who are not in the workforce. He asked what kinds of
programs they are using to try to lure these people back into the
workforce or to use them for training.
MS. SENNER said there was a discrepancy because a large number of
nurses (over 6,000) hold Alaska licenses but do not live in the
state. 'Travelers' hold Alaska licenses. She noted Representative
Halcro was referring to a college recruiting survey, which
surveyed nurses at the time of their licensure in the year 2000
when over 90% of them said they were working in the nursing
force. She thought there was a conflicting bit of information
there.
DR. TINA DELAPP, Director, School of Nursing, UAA, clarified that
the report actually only recorded the responses of the Alaska
licensees who had Alaska zip codes as their home residence. So,
in reality, the number of respondents who hold licenses and are
not working in nursing in Alaska is probably about 75%. She
explained that licensees are often long past the normal age of
retirement. Some of their faculty is well into their sixties and
seventies. Being a nurse becomes part of one's identity - the
oldest nurse in Alaska is 92 years old.
She said there had been attempts to have RN refresher courses for
nurses who have been out of the workforce for a particular length
of time, but the numbers of nurses to use it would be so low that
it wouldn't be cost effective.
[MS. PERDUE commented, but her comment was inaudible.]
MS. SENNER said that those nurses would not go far in filling the
gap, even if all the 92 year olds would come back.
REPRESENTATIVE HALCRO asked for an example of other reasons why
nurses would not come back into the profession.
MS. DELAPP said there could be lifestyle issues and other reasons
that would make it unattractive for someone to consider accepting
either full or part time employment in an RN position.
REPRESENTATIVE HALCRO asked what programs, if any, were being
offered by hospitals to help nurses cope with the stress of their
added workload.
DR. DELAPP said she thought they were focusing their energy on
trying to find people to fill those positions. She explained:
The reality is that part of the stress is a function of
the fact that nurses are forced in short-staffed
situations and the way to correct that is to add more
nurses to the workforce - to fill the positions that
are vacant…so that they're not having to care for one
and a half or two times the number of patients that
they can safely provide care to - so that there are
three nurses to help [indisc.] instead of just two
nurses - so that there is somebody to do that one to
one monitoring…. Really the bottom line is that we need
to get more nurses into the workforce - so that there
is a sufficient field from which employers can draw to
fill these vacant positions...
MS. REED agreed and added that hospitals need to be more flexible
with hours and allow nurses to work what they want, for example a
split shift. They have lost 25 nurses, because they don't want
mandatory overtime hours, but who might be willing to come back.
SENATOR DAVIS asked if she had any suggestions for legislative
action in writing so they could work on this issue in the
interim. She asked for salary comparisons of state versus the
private sector and the different classifications of nurses.
MS. SENNER replied that Representative Peggy Wilson has
legislation that deals with reimbursement for loans and she has
copies of laws that have been passed in other states regarding
mandatory overtime. She said they are trying to keep the cycle
from getting worse, "At API the more mandatory overtime they have
to serve, the more likely they are to leave that facility. So
we're trying to break that bad cycle that can happen." She said
she also has copies of legislation on nurse/patient ratios
enacted by other states. The Department of Labor is working on
ergonomic regulations.
CO-CHAIR MURKOWSKI thanked all who participated and commented
that she was astounded at some of the statistics, for example
that 91% of the workforce is female. She noted that while many
are making efforts to get more individuals into the profession,
there is pay inequity based on gender, which is a glaring fact.
She noted if she had a daughter who might be interested in a
nursing career, she would advise her to look at something else at
this point. She liked the idea of working with children at a
younger age to view this as a field that they might want to
choose but, based on statistics right now, she thought it
wouldn't look enticing. She then adjourned the meeting at 3:30
p.m.
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