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.