AHA House Testimony on VHA Recruitment and Retention: Is Bureaucracy Holding Back a Quality Workforce?
American Hospital Association
Committee on Veterans’ Affairs
Subcommittee on Health and Subcommittee on Oversight and Investigations
U.S. House of Representatives
VHA Recruitment and Retention: Is Bureaucracy Holding Back a Quality Workforce?
May 17, 2023
Chairmen Miller-Meeks and Kiggans, Ranking Members Brownley and Mrvan, and members of the Subcommittees, I am Robyn Begley, senior vice president of workforce and chief nursing officer at the American Hospital Association (AHA), and chief executive officer of the American Organization for Nursing Leadership (AONL), an affiliate of the AHA. On behalf of the AHA’s nearly 5,000 member hospitals and health systems, along with our clinician partners, I appreciate the opportunity to testify today on health care workforce challenges and successes, including recruitment and retention, outside of the Department of Veterans Affairs.
SUSTAINING THE HEALTH CARE WORKFORCE
A qualified, engaged and diverse workforce is the cornerstone of America’s health care system. Health care workers often say they feel called to serve patients, families and communities. However, long-building structural changes in the health care workforce combined with the profound toll of the COVID-19 pandemic have left hospitals and health systems, including post-acute and behavioral health care providers, facing a national staffing emergency that could jeopardize access to quality, equitable care for the patients and communities they serve. Simply put, our nation cannot maintain access to high quality care for patients and communities without health care workers.
Prior to the COVID-19 pandemic, hospitals were already facing significant challenges making it difficult to sustain, build and retain the health care workforce. In 2017, the majority of the nursing workforce was close to retirement, with more than half aged 50 and older, and almost 30% aged 60 and older. Yet, nursing schools had to turn away over 78,000 qualified applications in 2022, according to the American Association of Colleges of Nursing (AACN), due to lack of faculty and training sites. Data released this month by AACN indicated that the number of students in entry-level baccalaureate nursing programs decreased by 1.4% in 2022, ending a 20-year period of enrollment growth in programs designed to prepare new registered nurses.
The unprecedented scope, scale and severity of nursing workforce challenges also was reflected in the recently released results of a large-scale biennial survey conducted in 2022 by the National Council of State Boards of Nursing and National Forum of State Nursing Workforce Centers. Based on responses from over 53,000 registered nurses and licensed practical and vocational nurses from 45 states, the study estimates that 100,000 nurses left the workforce during the COVID-19 pandemic. In addition, nearly 900,000 nurses – or nearly one fifth of the 4.5 million total registered nurses – intend to leave the workforce due to stress, burnout and retirement. Of particular concern, the study estimated that nearly 189,000 registered nurses younger than age 40 reported an intent to leave the workforce. Large proportions of nurses also reported feeling emotionally drained (50.8%), burned out (45.1%) or at the “end of their rope” (29.4%) either a few times per week or daily.
Hospitals faced similarly troubling trends for physicians and other health care providers. Data from the Association of American Medical Colleges indicates that one-third of practicing physicians will reach retirement age over the next decade. Hospitals also were reporting significant shortages of allied health and behavioral health professionals.
SUPPORTING THE WELL-BEING OF THE HEALTH CARE WORKFORCE
The traumatic impact of COVID-19 has amplified the need for support to improve clinician well-being, destigmatize mental health and address overall wellness. Addressing well-being cannot be isolated from other efforts to improve the work lives and well-being of health care workers, including mitigating workplace violence and expanding access to behavioral health care.
Nurses, physicians and other staff on the front lines of care in U.S. hospitals, emergency departments and health care systems experience high rates of violence. According to a survey of registered nurses working in hospitals during the pandemic, 44% of respondents reported experiencing physical violence and 68% reported experiencing verbal abuse.1 Despite the near-daily occurrence of abuse directed toward health care workers, there is no federal law that protects them by specifying consequences for acts of violence or intimidation. According to a 2022 American College of Emergency Physician (ACEP) survey, 85% of emergency physicians believe the rate of violence experienced in emergency departments has increased over the past five years.
The AHA urges Congress to consider the following policies to support the well-being of the health care workforce:
Protect health care workers from violence. Congress should enact H.R. 2584, the Safety from Violence for Healthcare Employees (SAVE) Act. This legislation would provide federal protections for health care workers against violence and intimidation, as well as provide grant funding to hospitals for violence prevention programs, coordination with state and local law enforcement, and physical plant improvements such as enhanced technology.
Continue to provide grant funding support to well-being focused initiatives. Thanks to the Dr. Lorna Breen Health Care Provider Protection Act of 2022, the health care field received important funding for projects that help support well-being in their workplaces. We encourage Congress to provide additional support for projects and collaborative efforts to scale successful practices on well-being across the health care field, especially those efforts that link well-being with hospital efforts to improve quality and the patient experience.
HOSPITALS AND HEALTH SYSTEMS SUPPORTING THEIR WORKFORCE
Hospitals and health systems exist and can continually care for patients because of the physicians, nurses, technologists, supply chain professionals, facilities management specialists and the many other professionals who work in them. We cannot care for patients without these caregivers and team members. They are always there ready to care, and it is our job to support them.
This is why hospitals and health systems are collaborating to expand training opportunities, ethically recruiting internationally, launching nurse and allied health professional education programs, reimagining workforce models, investing in upskilling and providing nontraditional support for health care workers.
The following are examples of ways hospitals and health systems are supporting the workforce.
- Mary Washington Healthcare in Virginia partners with Germanna Community College on an Earn While You Learn program, onboarding two cohorts of as many as 60 nursing students each year, who work 12-20 hours a week using a clinical rotation model. The program includes an additional nursing school, as well as mentor models for nursing assistants and is exploring an apprenticeship model for other clinical roles, such as surgical technologists.
- Participants in the Jump Start program at MercyOne in Iowa receive a monthly stipend while they finish nursing school. MercyOne covers the cost of board exams and licensing fees, and provides employment upon RN licensure.
- Hospitals also are pursuing private-sector solutions to rapidly train nurses. For example, Galen College of Nursing, one of the nation’s largest nursing schools, includes an accelerated 3-year bachelors of nursing program and multiple educational advancement pathways for nurses at all levels.
- The Chicagoland Healthcare Workforce Collaborative, formed among four hospitals and health systems partnering with Malcolm X Community College and other community organizations, developed a program to fill high-demand jobs and increase retention. The Medical Assistant Pathway Program enables employees to complete a Medical Assistant certification program while still working. The program offers tuition coverage, transportation support and subsidy as well as internal and external mentoring and career coaching.
- The Workforce Readiness Institute is a workforce strategy partnership between Dartmouth Hitchcock Medical Center and Colby-Sawyer College to train licensed practical nurses, medical assistants, surgical techs, pharmacy techs and ophthalmic assistants. It also includes opportunities for existing RNs to complete a BSN and an option for an accelerated nursing degree. Through the program, more than 1,000 people have joined the Dartmouth Hitchcock Medical Center.
- Norton Healthcare’s Student Nurse Apprenticeship Program is a 12-to-18 month program that supports the accredited associate and baccalaureate student nurse. It pairs one student with an RN in acute care to increase a student nurse’s readiness for nursing practice. Student nurses are competitively paid for their time in the program.
- Phoebe Putney Health System developed partnerships with secondary and post-secondary academic institutions to address the nursing faculty shortage. Each partnership is unique, including career exploration for middle and high school students, and funding part-time and full-time classroom and clinical instructors and faculty. They invested $35 million in creating a Living and Learning Community for student nurses, new graduate nurses and early career nursing professionals.
- Over the next three years, Sanford Health headquartered in Sioux Falls, S.D., plans to hire more than 700 internationally trained nurses to work in its health system. Sanford covers housing during the initial transition period and has instituted a program to acculturate nurses to their new communities.
Launching Nursing Programs
- Nearly 60 schools and hospitals across the country partnered to start or expand nursing programs in 2022. These programs range from accelerated BSN programs and virtual nursing programs to brand-new nursing schools and licensed practical nursing programs.
- Corewell Health System in Michigan is providing $20 million to Oakland University — $10 million in grants for nursing students and $10 million to support infrastructure expansion and faculty hiring. Students who receive a grant commit to working for Corewell Health for two years following graduation.
Reimagining Workforce Models
- As part of its ongoing efforts to better recruit and retain talented health professionals amid the significant labor shortages, Pittsburgh-based Allegheny Health Network launched “Work Your Way,” a mobile internal staffing model to provide flexible work-life solutions for nurses, surgical technologists and other team members. This unique program allows health professionals the freedom and flexibility to choose how and when they want to work.
- Jefferson Health’s Nursing SEAL Team reimagines how to address variability in staffing needs by matching preferences of nurses to work in different settings and providing increased flexibility by deploying them to provide specialty nursing care across all of Jefferson’s acute care locations.
- Colorado’s UCHealth plans to invest $50 million in its Ascend leadership program to help current and prospective employees earn clinical certification, participate in foundational learning programs such as English language and college prep, and earn degrees in areas such as social work and behavioral health. Newly hired employees also will be able to earn a high school diploma or GED
- Along with three educational partners, the University Medical Center of El Paso in Texas will pay up to $5,000 annually for two years for employees to earn a degree in nursing, respiratory, imaging or other hard-to-fill fields. Employees maintain full-time employment status and compensation while working part-time. Under another new program, the hospital is offering eligible employees pursuing a health care degree up to $5,250 a year in student loan-repayment assistance.
- To fill the scores of medical assistant openings, Vanderbilt University Medical Center partnered with Nashville State Community College to train current employees, including truck drivers and environmental services staff. During training, workers continue to receive their full salary plus tuition reimbursement. They also train high school students to receive medical assistant certification.
- In Pennsylvania, Geisinger’s Nursing Scholars Program awards $40,000 in financial support to each employee who is pursuing a nursing career and makes a five-year commitment to work as an inpatient nurse.
- St. Luke’s Wood River Medical Center, located in a popular Idaho tourist area, is building single-family homes that will be affordable long-term rentals for employees.
- Bozeman Health in Montana invested in a future workforce housing complex to provide employees with affordable rentals.
- Northwell Health, Johns Hopkins, Cleveland Clinic and BJC Healthcare are among employers offering grants or forgivable loans that can be used for employees’ housing costs.
EXPLORING NEW CARE MODELS
Severe workforce constraints have prompted hospitals and health systems to develop and evaluate innovative new team-based models to support staffing in their organizations. Hospitals have used technology-enabled virtual nursing models to help with remote patient monitoring in order to help provide an extra support to bedside nurses. Looking at their non-physician and non-nursing caregivers, some organizations are using these professionals to take on tasks that may not require a physician or nursing license. Enabling practice at top of one’s education and license can lead to greater staff satisfaction but also better use of limited resources.
Hospitals need flexibility to test, evaluate and – when the evidence supports it – implement new models. That is why we urge policymakers to avoid the use of restrictive staffing rules that limit innovation and threaten to exacerbate health care access challenges, such as nurse staffing ratios or levels. Nurse staffing is a decision based on complex variables under the purview of the nurse such as patient population, care delivery models, unit layout, patient acuity and the education and experience of the nurse. Mandated nurse staffing ratios imply a “one size fits all” approach and impedes the ability to respond to a patient’s care needs in real time.
The AHA and AONL believe mandated nurse staffing ratios are a static and ineffective tool that does not guarantee a safe health care environment, quality or optimum patient outcomes. Staffing ratios are usually informed by older nursing-only care models and do not consider advanced capabilities in technology or interprofessional team-care models. These newer models incorporate not only nurses at various levels of licensure, but also respiratory therapists, occupational therapists, speech-language pathologists, physical therapists and case managers.
Hospitals and health systems across the country are working to advance safety, affordability and value by transforming health care delivery. Mandated approaches to staffing not only limit this innovation but also increase stress on a health care system already facing an escalating shortage of educated nurses. Mandated staffing does not create more nurses.
SUPPORTING ADVANCES IN TECHNOLOGY
Health care workforce shortages have led to challenges but also creative solutions to workflows, workplaces and teams. The broad adoption of telehealth is just one example how we improved where and how patients can access care. Regulatory flexibilities available under the public health emergency allowed exploration of the most effective treatment modalities and locations to allow providers to care for their communities in the midst of surging illness and concerns. The innovative approaches that emerged during the pandemic provide an avenue to rethink care delivery in light of the current workforce capacity. These advances require continued regulatory flexibility and funding to continue. Organizations need additional funding to continue to pilot, test and scale those changes that can best support their current workforce in caring for their communities.
Hospitals and health systems are exploring the use of technology by automating certain clinical documentation, as well as using artificial intelligence to help consolidate and trend large amounts of clinical information to provide insights for delivering care. Technology is not a substitute for caregivers, but it can enhance their ability to practice efficiently and reduce burden. Congress could consider providing support for pilot testing innovative technology solutions that support the health care workforce.
TRAVEL NURSES, TEMPORARY LABOR ISSUES
To help offset the critical shortage of workers and maintain appropriate levels of care for patients, nearly every hospital in the country was forced to hire temporary staff at some point during the pandemic, including contract or travel nurses.2 Hospitals’ reliance on travel nurses and the inflated associated costs to employ them have grown significantly since the start of the pandemic. The AHA has previously pointed out that the rates these staffing firms charge hospitals grew much faster than the rates the firms actually paid the staff,3 meaning the firms pocketed more at the time of greatest need.
The AHA remains concerned that the conduct of some of these travel staffing agencies bears the hallmarks of collusion and perhaps other abuses. The AHA sent letters urging the Federal Trade Commission and the White House to use their authority to investigate these reports of anticompetitive behavior.
Our workforce challenges are a national emergency that demand immediate attention from all levels of government and workable solutions. These include recruiting, revitalizing and diversifying the health care workforce. Congress should consider the following policies to help sustain and support the nation’s workforce:
- Address nursing shortages by investing in nursing education and faculty. Schools of nursing continue to need more faculty, preceptors and clinical training sites to support students, new graduates and prospective students. The Future Advancement of Academic Nursing Act would provide those vital resources to support the needs of nursing students, help retain and hire diverse faculty, modernize nursing education infrastructure, and create and expand clinical education opportunities.
- Provide scholarships and loan repayment. Title VIII Nursing Workforce Development programs such as Nurse Corps help bolster the advanced practice and nursing workforce by addressing the shortage of nursing faculty and clinical sites, as well as funding nursing schools located in rural and underserved communities. The CARES Act reauthorized these critical programs through 2024. Reauthorizing and funding these programs remain a necessity. Congress should ensure nursing students are eligible to receive such benefits to attend nursing schools regardless of the educational institution’s tax status and ensure parity of treatment for hospitals and their workers regardless of tax status in federal health programs, including those enumerated in the Public Health Service Act.
- Reauthorize and increase funding for the National Health Service Corps (NHSC). This program awards scholarships and assists graduates of health professions programs with loan repayment in return for an obligation to provide health care services in underserved rural and urban areas. The AHA supports the Strengthening Community Care Act of 2023 (H.R. 2559) to extend funding for community health centers and the NHSC. The NHSC is a critically important program for both giving clinicians support to offset the substantial cost of their education, while also incentivizing practice in underserved rural and urban health professional shortage areas across the country.
- Increase GME slots. Address physician shortages, including shortages of behavioral health providers, by increasing the number of residency slots eligible for Medicare funding. AHA supports the Resident Physician Shortage Reduction Act of 2023, S. 1302, a bipartisan bill that would lift caps on Medicare-funded residency
- Support foreign-trained health care workers. Support expedition of visas for foreign-trained nurses and continuation of visa waivers for physicians in medically underserved areas.
- Investigate travel nurse agency practices. We urge Congress to direct the Government Accountability Office to study the business practices of travel nurse staffing agencies during the pandemic, including potential price gouging and excessive profits, increased margins that agencies retain for themselves, impact of increased reliance on travel nurses in rural areas, and how these practices contribute to workforce shortages across the country.
The AHA appreciates your recognition of the challenges ahead and the need to examine America’s health care workforce issues. We must work together to solve these issues so our nation’s hospitals and health systems, post-acute and behavioral health care providers can continue to care for the patients and communities they serve.
2 https://www.amnhealthcare.com/siteassets/amn-insights/surveys/amn-survey-of-temporary-allied-healthcare-professional-staff-trends-2021.pdf3 https://www.aha.org/costsofcaring