MINUTES OF THE meeting
of the
ASSEMBLY Committee on Health and Human Services
Seventy-Second Session
February 10, 2003
The Committee on Health and Human Serviceswas called to order at 1:35 p.m., on Monday, February 10, 2003. Chairwoman Ellen Koivisto presided in Room 3138 of the Legislative Building, Carson City, Nevada. Exhibit A is the Agenda. Exhibit B is the Guest List. All exhibits are available and on file at the Research Library of the Legislative Counsel Bureau.
COMMITTEE MEMBERS PRESENT:
Mrs. Ellen Koivisto, Chairwoman
Ms. Kathy McClain, Vice Chairwoman
Mrs. Sharron Angle
Mr. Joe Hardy
Mr. William Horne
Ms. Sheila Leslie
Mr. Garn Mabey
Ms. Peggy Pierce
Ms. Valerie Weber
Mr. Wendell P. Williams
COMMITTEE MEMBERS ABSENT:
None
GUEST LEGISLATORS PRESENT:
None
STAFF MEMBERS PRESENT:
Marla McDade Williams, Committee Policy Analyst
Terry Horgan, Committee Secretary
OTHERS PRESENT:
Debra Scott, Executive Director, Nevada State Board of Nursing
Lisa Black, Executive Director, Nevada Nurses Association
Jane Nichols, Chancellor, University and Community College System of Nevada
Julie E. Johnson, Director and Professor, Orvis School of Nursing, University of Nevada, Reno
Bill Welch, President/CEO, Nevada Hospital Association
Doreen Begley, Nurse Executive, Nevada Hospital Association
Jerri Strasser, Registered Nurse, Service Employees International Union Local 1107 Nurse Alliance
Chairwoman Ellen Koivisto explained that the day’s meeting would be an informational hearing concerning the lack of availability of nurses in Nevada.
Debra Scott, Executive Director of the Nevada State Board of Nursing, presented a handout (Exhibit C) and brochure (Exhibit D) to Committee members. She emphasized the Board was in existence to protect the public, and as a result, applicants for nursing licenses must meet certain minimum educational requirements. Ms. Scott added that the Board also investigated allegations of misconduct on the part of nurses and nursing assistants and clarified that the Board was neither an advocate for nurses nor did it have any authority over medical facilities.
Ms. Scott testified that the Board, which approved schools of nursing, was in support of doubling nursing student enrollment. She also expressed the Board’s desire to remove any unnecessary regulatory barriers for competent people who applied for licensure in Nevada.
The Board of Nursing, Ms. Scott continued, had submitted a bill draft request that would allow an alternative way of licensure so nurses with unencumbered licenses in the states where they resided, could enter Nevada and practice here.
Ms. Scott also added that the Board had adopted a policy regarding increasing the instructor-to-student ratio in other than clinical situations. In addition, the Board had developed a policy to request the Social Security number of an applicant at the end of the application process. Ms. Scott said that would allow more time for foreign nurses to take and pass the national test, at which point they could come into the United States on a visa and be issued a license.
Ms. Scott testified that when the Board considered taking action against a nurse, they first attempted rehabilitation and remediation, which kept more nurses practicing. She also indicated that the Board was a founding member of the Nursing Institute of Nevada.
Assemblyman Horne, referring to reciprocal agreements, inquired how varied the requirements for nursing licensure were across the United States.
Ms. Scott indicated that the requirements were varied; however, she explained that the Board of Nursing wanted to become part of a multi-state or mutual recognition compact. Ms. Scott said the process would work something like a driver’s license, whereby if one were driving in Nevada with an Arizona driver’s license, one would still have to follow Nevada laws. Ms. Scott said that states that would sign the compact would have adopted essential requirements so they could be part of the compact. She added Nevada already had all the essential requirements in its laws.
Assemblywoman Leslie, referencing an item in Ms. Scott’s handout to Committee members, inquired if the Nevada State Board of Nursing was in support of mandatory overtime or against it.
Ms. Scott explained if a nurse was mandated to work another shift after working the regularly scheduled one, that nurse should make the decision based on a self-assessment of ability to provide safe patient care. She indicated there had been difficulty ascertaining what “mandatory overtime” was. Ms. Scott emphasized that the nurse should have a say about whether or not she/he worked overtime hours.
Ms. Leslie followed up by asking whether Ms. Scott was saying that a nurse should have the ability to decline a shift.
Ms. Scott said, “Yes.”
Ms. Leslie then noted that if one could decline a shift, it could not be considered “mandatory.”
Ms. Scott agreed and added that the State Board of Nursing’s position was “sort of against” mandatory overtime.
With no further questions from Committee members, Chairwoman Koivisto called on the next scheduled witness for her testimony.
Lisa Black, Registered Nurse and Executive Director of the Nevada Nurses Association, began her presentation by reading highlights from prepared text (Exhibit E). She observed that the primary reason patients were admitted to hospitals and nursing homes was that they were in need of 24-hour nursing care. Ms. Black also noted that the intensity and acuity of care required, coupled with increased technology, had created a need for a higher-educated, better-skilled nursing workforce than ever before.
Ms. Black testified that current staffing shortages were fundamentally tied to changes in nurse employment practices precipitated by changes in Medicare reimbursement and increased cost-savings measures that had been instituted by managed care. Health care providers began to design programs to reduce expenditures and as a result, highly trained experienced and highly paid personnel were eliminated or redeployed. The impact of those changes, Ms. Black continued, resulted in increased pressure on the remaining licensed nurses, who were required to oversee unlicensed assistants while caring for larger numbers of sicker patients.
Ms. Black noted that the image of professional nursing had changed from a field that offered many opportunities and high job security to one that held great uncertainty and difficult working conditions. Students, she stated, began to shy away from nursing programs, which resulted in nursing schools across the United States matriculating fewer students and cutting back on faculty. That trend, Ms. Black emphasized, had turned around but, she said, Nevada was still not able to produce the numbers of nurses needed by its citizens.
Ms. Black stressed that nurse staffing levels and “skill mix” made a difference to the outcomes of patients. Increased registered nurse staffing, she stated, was directly related to decreases in the incidence of urinary tract infections, pneumonia, shock, upper gastrointestinal bleeding, and decreased lengths of hospital stays. Quoting an October 2002 study published by the Journal of the American Medical Association, Ms. Black stated registered nurse staffing levels had significant effects on preventable hospital deaths among surgical patients. The article also reported that patient load had a direct impact on nurse retention rates. Ms. Black called attention to two additional reasons nurses were leaving the profession: avoidable injuries sustained on the job, such as infection from contaminated needles and sharp objects; and the threat of on-the-job violence, including threats and verbal assaults. Ms. Black indicated that over half the respondents to a 2001 American Nurses Association survey had reported such incidents within the preceding year.
Ms. Black explained that higher wages and aggressive recruitment practices would not completely solve the current crisis because of the ballooning health care needs of the “baby boomer” generation, because too few young people were entering nursing, and because the current nursing workforce was rapidly aging.
In conclusion, Ms. Black expressed the hope that full funding to double enrollment in the state’s schools of nursing would be forthcoming. She noted that solutions to the nursing crisis, including changes in the environment of nursing care and efforts to recruit nurses into the profession, would not be cheap or quick.
Assemblywoman Weber inquired if Certified Nursing Assistants (CNAs) and Licensed Practical Nurses (LPNs) were among the people being recruited.
Ms. Black replied that they were. She added that studies had shown, however, that patient safety was increased and patient outcomes were enhanced when there were increased numbers of registered nurses working at the bedside.
Assemblywoman Weber asked whether recruitment was taking place to move CNAs and LPNs into becoming registered nurses.
Ms. Black indicated recruitment efforts were being undertaken, but she added that those efforts could be improved.
Assemblyman Horne asked if there were specific areas where the need for registered nurses was more acute. He also wondered if registered nurses working in different arenas, for instance, a surgical nurse versus an emergency room nurse, needed different levels of education or experience.
Ms. Black replied that registered nurses were educated at a “generalist level.” Further specialization, she noted, occurred from that point.
Assemblyman Horne, indicating he had erroneously assumed registered nurses needed a bachelor’s degree, inquired how one received education beyond the “generalist level” and whether it occurred at a university or within a hospital setting. Mr. Horne also restated his previous question concerning which medical fields had the most critical need for nurses.
Ms. Black replied that registered nurses could be educated at either an associate’s degree level or a bachelor’s degree level. That level of education, she reiterated, trained them to function in a variety of different health care roles. From there, she said, any further education occurred mainly in the workplace.
Assemblywoman Leslie quoted a survey referenced in Ms. Black’s informational handout that had found hiring temporary or foreign nurses and mandatory overtime were seen as the least effective ways to solve the nursing shortage. She then inquired what a short-term solution to the crisis might be.
Ms. Black noted registry nurses were available; however, she added, they were very expensive.
Assemblywoman Leslie, commenting that no one wanted to be cared for by an exhausted nurse, also expressed sympathy for the hospitals that were dealing with the acute nursing shortage. Ms. Leslie inquired what solution Ms. Black’s association would prefer.
Ms. Black replied that a key component was nurse retention.
Assemblywoman Leslie reiterated that improving working conditions and retaining nurses was probably high on the list of short-term solutions.
Ms. Black agreed.
Assemblyman Hardy opined that another problem exacerbating the crisis was retaining faculty members to teach nurses.
Ms. Black explained that teaching faculty had to have at least a master’s degree in nursing; however, the salary of teaching faculty was about half to two-thirds what could be earned in the private sector.
Assemblywoman Weber, noting Nevada was at the bottom of the list of states in nurses per capita, inquired where Nevada stood as far as nurses’ salaries were concerned.
Ms. Black deferred to later speakers, but stated Nevada’s salaries were competitive.
Chairwoman Koivisto, noting that California was to have new hospital staffing standards in place in 2004, asked whether Nevada’s nurse numbers would suffer as a result.
Ms. Black acknowledged that California would have to do some very aggressive recruiting to meet their new staffing ratios. She assumed California’s salaries and working conditions would be a huge draw to Nevada’s nurses, particularly because so many Nevada communities were border communities.
Jane Nichols, Chancellor for the University and Community College System of Nevada (UCCSN), testified next and indicated her desire to share a plan the UCCSN had been working on for a year and a half. She reminded Committee members that the last Legislature had mandated the UCCSN put together a plan for doubling enrollment in their nursing programs (Exhibit F).
Ms. Nichols explained the plan provided an outline of what the nursing directors at each of the seven nursing programs felt would be the best plan for doubling their nursing enrollment. She noted that the two universities had registered nursing programs that extended through the masters’ degree level, while the community colleges had associate’s registered nursing degree programs, as well as LPN and CNA programs.
Ms. Nichols stressed that a key issue to doubling enrollment was to double nursing faculty positions. She also mentioned that more doctoral-level nurses were required who could teach masters’-level nurses. To teach at the universities and community colleges, a master’s degree was required, she added. Ms. Nichols noted that the Legislature had funded a Western Interstate Commission for Higher Education (WICHE) program, allowing Nevada nurses to obtain doctoral degrees.
Ms. Nichols declared the problem was not only a matter of doubling enrollments, but production of more nurses more quickly and having enough clinical sites to support the nursing programs. As a result, she emphasized, a key part of the plan was to run a year-round nursing program. Ms. Nichols added that to run a twelve-month nursing program would require additional funding because currently, summer school at all institutions was self-funded.
Ms. Nichols mentioned that another portion of the plan involved community colleges establishing relationships with high schools, which would enable high school seniors to take pre-nursing courses in science and mathematics. The idea, Ms. Nichols explained, would be to start students early, let them go year-round, and therefore produce nurses much more quickly. Ms. Nichols also stressed the importance of tutoring students, because even though the nursing program had very rigorous requirements, “with adequate tutoring, all people can learn mathematics and science is accessible for students.”
Ms. Nichols acknowledged there was a “logjam” in enrollment in pre-nursing courses and that each campus was looking at addressing that problem.
Ms. Nichols also voiced enthusiasm for a partnership with the Nevada Hospital Association that had provided support for faculty positions and had already enabled expansion of the number of nursing students. Ms. Nichols said nursing directors had recently reported that there were many qualified students who wanted to be nurses. The price tag for this biennium, Ms. Nichols continued, would be $12 million, and it was a one-time price tag. As the students signed up and as the Legislature funded that enrollment, Ms. Nichols explained, within four years the expense would be “picked up by the funding formula itself and would not be an on going cost.”
Ms. Nichols, observing there was a nursing loan program for nursing students, explained that it was really a scholarship contingent upon the student staying and working in the state of Nevada, and she noted funding for the plan was from tobacco settlement money. However, Ms. Nichols stated she would like to see additional money added.
Bill Welch, President and CEO, Nevada Hospital Association, referenced the California legislation to change hospital-staffing standards by 2004, and pointed out it had been four years since passage, and yet, he stressed, the legislation had been intended to be effective immediately upon passage. Because of the complexity of the issue and the overwhelming problems associated with attempting to implement a numerical staffing ratio, implementation had been deferred each year by California’s governor and legislature. Mr. Welch indicated that the legislation would be phased in over a period of time, beginning in 2004. Mr. Welch, responding to a question asked previously about California medical facilities hiring all of Nevada’s nurses, said if the new California ratios were implemented all at once, there would be a 25 percent deficit of health care workers in the state of California.
Doreen Begley, Nurse Executive, Nevada Hospital Association, spoke from her prepared text (Exhibit G) about the plan to double nursing capacity for the UCCSN programs, the reasons for Nevada’s shortage of nurses, and how to address it.
Referring to the “Doubling Plan,” Ms. Begley announced that all the Nevada schools of nursing had been able to assess their individual campus needs to develop a collaborative, innovative plan that took into consideration the economic use of Nevada’s resources. Ms. Begley added that, rather than being a nursing issue or a hospital issue, the absence of adequate nursing staff was an access-to-care issue directly affecting every citizen in Nevada.
Ms. Begley said that although Committee members had probably heard nurses were leaving the profession because they were unhappy with working conditions, national data proved otherwise. Ms. Begley, quoting Tim Porter O’Grady, a nurse PhD and futurist, stated that 30 years ago, 80 percent of all health care-related procedures had been performed in hospitals. Today, however, 80 percent of those procedures were performed outside of hospitals. Nurses might be leaving hospitals, she noted, but they were not leaving nursing. They were simply following their patients.
Referencing issues of pay, the second most popular reason given for the workforce nursing shortage in Nevada, Ms. Begley stated Nevada ranked in the top 25 percent of the nation in terms of nurse wages.
Ms. Begley noted that ”burnout” was the third reason given for nurses leaving the profession; however, she explained the nursing shortage was causing the burnout.
Addressing the question of why Nevada ranked last in the nurse-to-population ratio in the United States, Ms. Begley stated there were two primary reasons; one was Nevada’s enormous population growth and the second was the lack of expansion in state nursing education programs. Ms. Begley also noted Nevada’s elderly population, who tended to be higher users of health care, had grown by 72 percent.
Ms. Begley pointed out to Committee members what she called Nevada’s “virtual population,” the 4 million visitors to the state each month. That fact lowered nurse-to-population ratios even more, she added.
Ms. Begley testified Nevada would need 716 additional nurses through 2010 each year to be able to provide patients with the nursing care they required and to adequately meet the health care needs of Nevada’s citizens. The longer the Legislature, educators, and the medical profession waited to address the shortage, she cautioned, the worse it would get.
To reverse the current downward trend, Ms. Begley asserted, Nevada must educate its own nurses. She reported that last year the nursing school system had to deny admission to over 255 qualified applicants and noted that nursing students tended to remain in the state where they were educated. Ms. Begley also stressed that there was no problem attracting students to the nursing profession because there were more students interested in becoming nurses than Nevada’s higher education system could accommodate.
Mr. Welch added that the problem was worsening and mentioned that hospital emergency rooms in Clark County were “diverting” patients because no beds and/or staff were available. Mr. Welch noted there were currently 1,200 vacant nursing positions within the state of Nevada. Stating that all hospitals had overtime because it became a question of patient abandonment or access, he indicated two hospitals currently had mandatory overtime. Mr. Welch reported Nevada’s salaries were now in the top 25 percent and, he stressed, bonuses of $5,000 and $10,000 for a one-year commitment were being paid to certain specialty nurses. Mr. Welch said the Nevada Hospital Association had spent hundreds of thousands of dollars over the last few years to fund expansion of Nevada’s nursing programs and scholarships.
Chairwoman Koivisto stated she had been told by a nursing student that one of the difficulties when doing clinical work was finding a working nurse to train with, because a nursing student works under that nurse’s license. She asked if that was how the clinical education worked.
Julie Johnson, Director of the Orvis School of Nursing at the University of Nevada, Reno, explained that the faculty member who was in charge of the group of students was the person responsible.
Assemblywoman Weber asked if there were any “privatized startups in the queue” to train more nurses in Nevada.
Mr. Welch said he was not aware of any. He also mentioned investigating alternatives such as interactive or long-distance-type education to complement and expand the current education system, but had “not found anyone interested.”
Assemblywoman Weber maintained Nevada could use a minimum of 15 schools.
Mr. Welch agreed. Doubling of the nursing programs, he continued, would help address the problem but would not alleviate it. Mr. Welch also explained the building of new hospitals in Clark County was to address the bed capacity issue being driven by the demand of the patients presenting for care as well as the tremendous population growth in that county. He added that over 50 percent of the patients presenting themselves at hospital emergency rooms were presenting themselves for primary care.
Chairwoman Koivisto, referring to nursing staff for the new hospitals, inquired, “If we build them, they will come?”
Mr. Welch replied that if funding of the expansion of the nursing education programs occurred, students would enroll to be trained and educated. The hospitals would open in 2004 and had already begun a national and international recruitment effort to bring nurses into Nevada.
Assemblyman Horne asked whether the hospitals would indeed hire the nurses being trained in the Nevada programs.
Mr. Welch stated that more than $1 million per year was being spent by Nevada hospitals in recruitment efforts. He also mentioned the many ads for nurses in area newspapers.
Assemblywoman Leslie inquired about conclusions in the Nevada Hospital Association’s report that she believed were in direct contradiction to a November 2002 nurses’ association survey concerning working conditions, pay, and burnout. Ms. Leslie also mentioned the majority of nurses surveyed believed hospitals were only doing a fair to poor job of attracting and retaining nurses.
Mr. Welch replied that he did not believe his comments were contrary to what the nurses’ survey reported. He said he tried to communicate the fact that while there were varying opinions on some points, there was also agreement on some of the points. He acknowledged that there were workplace environment and retention issues and reiterated his desire to come back to the Committee and report on two years’, worth of efforts to deal with the nursing shortage and hospital retention efforts.
Assemblywoman Leslie stated she believed retention and safer working conditions were part of the problem.
Ms. Begley informed the Committee that the Nursing Institute of Nevada wanted to do a statewide nursing survey of Nevada’s nurses and indicated it was one of the Institute’s initiatives.
Jerri Strasser, Registered Nurse, member of the Service Employees International Union (SEIU) Local 1107 Nurse Alliance, read her testimony from prepared text (Exhibit H). Ms. Strasser also supplied Committee members with copies of a study by the SEIU entitled, “Where Have All the Nurses Gone?” (Exhibit I).
Assemblyman Hardy, noting Ms. Strasser mentioned a survey of nurses who had left local hospitals, asked “where the experienced nurses were” and how many nurses fell into that category. Mr. Hardy also wondered whether they could be lured back into hospitals by offers of raises, lack of overtime, and better working conditions.
Ms. Strasser said the survey was of nurses who had left employment in Clark County. She did not know how many were inactive, but noted many were working in other settings like surgical centers and physicians’ offices. She mentioned that “mandatory overtime” was sometimes disguised as being “on call.”
Assemblyman Hardy opined that taking registered nurses from offices and surgical centers would not solve the overall nursing deficit because the problem was pervasive in all areas of medicine.
Assemblywoman Weber inquired about the availability of reactivation and refresher programs.
Ms. Scott responded that if a nurse had not practiced for five years and wanted to renew her license, a refresher course was required. She indicated there was at least one out-of-state organization providing refresher courses in addition to one refresher course in both northern and southern Nevada. Ms. Scott also noted there were ten accredited schools of nursing approved in Nevada to do clinicals within Nevada. She added that the schools had the capability to teleconference courses.
Chairwoman Koivisto inquired how many of the schools were taking advantage of the approval and doing clinicals in Nevada.
Ms. Scott replied that she knew of at least three.
With no further business to come before the Committee, Chairwoman Koivisto adjourned the meeting at 3:20 pm.
Terry Horgan
Committee Secretary
APPROVED BY:
Assemblywoman Ellen Koivisto, Chairwoman
DATE: