Testimony: Nursing Workforce

Statement of

The Hospital and Healthsystem Association of Pennsylvania

for the

Pennsylvania House of Representatives Labor & Industry Committee

Informational Meeting on the Nursing Workforce Crisis

May 7, 2024

The Hospital and Healthsystem Association of Pennsylvania (HAP)-representing more than 235 hospitals and health systems throughout the commonwealth, as well as the patients and communities they serve-appreciates the committee's work to focus on and prioritize legislative efforts to address Pennsylvania's health care workforce emergency. We particularly appreciate this informational meeting to elevate and honor nurses' voices.

Nurses have intimately and personally felt the tremendous strain of our nation's health care workforce crisis. Nursing shortages were on the rise even before COVID-19. For years, Pennsylvania's aging population has meant that more health care professionals are retiring at exactly the same time that more older Pennsylvanians need more health care.

The pandemic fundamentally changed the entire health care sector, and nursing. Nurses were strained by 24/7/365 direct care of the highest intensity, even as the supports and structures they had traditionally relied upon ceased to function. Their commitment was unwavering and the trauma they experienced is real.

Hospitals are dedicated to, and investing in, increasing and supporting bedside nurses, as well as the professionals who assist their vital work. These efforts are showing results; but more is needed to support current nurses and develop the next generation of caregivers to meet Pennsylvania's growing needs.

Hospitals are also renewing focus and investment in initiatives to protect staff amid increasing violence and abuse targeting health care professionals. HAP stands ready to work actively with the sponsors of House Bill 2247 and other stakeholders to advance legislation that will help keep health care workers safe.

With this testimony, we will highlight the ways hospitals are already working hard to grow and support nurses, how care delivery is evolving to elevate nurses' work, and public policies that can help address the nursing workforce emergency.

Hospitals are working hard to grow nurses and the professionals who support them.

There is a well-documented, national nursing shortage. The National Council of State Boards of Nursing estimates that 20 percent of the nation's nurses-including more than 600,000 registered nurses (RN)-plan to leave the workforce in the next three years. The U.S. Bureau of Labor Statistics projects that, from 2022-2032, there will more vacancies (193,000) added each year than new RNs (177,400) over the entire decade.

The challenge is not exclusive to RNs or to hospitals. Workforce shortages throughout the health care continuum-in settings such as behavioral health, post-acute, long-term, and community-based care, for example-dramatically compound the strain on hospital care teams.

And, while the national forecasts are grim, within the next two years, Pennsylvania is projected to experience the worst RN shortage in the nation. A Mercer report suggests that the commonwealth will need an additional 20,345 nurses to meet our growing need for care. Today's gap will continue to widen as the commonwealth, and the commonwealth's current nurses, age.

Hospitals and health systems are aggressively recruiting and training nurses and other direct-care professionals who support them. HAP's most recent survey of Pennsylvania hospitals found that nearly all:

• Increased base pay (97%).

• Offered flexible work schedules (95%).

• Provided professional development and/or tuition reimbursement (89%).

Roughly half offered sign-on, schedule-based, and/or referral bonuses (56%) and retention bonuses (49%). To address the needs of their teams, 39 percent of Pennsylvania hospitals provide child care, compared to fewer than 6 percent of employers nationally who do so.

These are among the factors that helped hospitals reduce turnover for direct care professionals by 28 percent last year.

Despite this progress, hospitals still report statewide average vacancy rates of 14 percent for RNs and 19 percent for nursing support professionals. Average vacancies are even greater in rural communities-26 percent and 28 percent for RNs and nursing support staff, respectively. And we have already discussed that simply filling current vacancies will not be enough to alleviate the strain on current nurses.

You are well aware that many hospitals operate nursing education programs. Even those that don't are working with educators and other community partners to strengthen pipelines into both nursing and allied health professions. Many have programs that encourage and support employees-and sometimes their family members-as they seek education and advancement in health care careers. It is common for an employee to start their career as a nurse aide or patient care tech, complete nursing education with the hospital's support, and become an RN.

HAP's survey found that:

• Nearly all hospitals are partnering with four-year colleges/universities and community colleges (99%) and high schools (92%) on workforce development.

• More than half are also partnering with trade/technical schools and/or community organizations (55%).

• Many are reaching all the way to the middle school level (25%).

Reading Hospital's high school internship program, for example, invites local students to explore health care careers through hands-on learning. Nearly a third of participants have remained engaged with the hospital through additional job shadowing, college internships, and/or employment.

Allegheny Health Network's Talent Attraction Program recruits students from underrepresented communities to work at one of the system's hospitals while going to school for careers in nursing and allied health. AHN pays the students' full tuition and pairs each with a mentor to help them develop professionally and address barriers such as transportation, food insecurity, or housing instability.

St. Luke's University Health Network partnered with the Hispanic Center Lehigh Valley to create Cultural & Linguistic Workforce Development Centers. This initiative provides training for health care careers alongside other supports such as English as a Second Language or GED programs.

Conemaugh Health System's School of Nursing is offering guaranteed job placements with 100 percent student loan forgiveness for graduates who pass the NCLEX. Children's Hospital of Philadelphia is partnering with Mastery Schools to create a high school focused on preparing students for health care careers. Meadville Medical Center, in response to the anticipated closure of a local practical nursing education program, is launching an Institute for Healthcare Professionals to train caregivers in high-demand areas.

These are just a few examples. Similar initiatives are underway at hospitals and health systems across the state.

Hospitals are working with their nurse leaders to transform care models to support and elevate nurses.

Along with developing the next generation of caregivers, hospitals are focused on re-engaging those who have left the workforce and supporting current nurses.

Penn Highlands Healthcare has developed its Return-to-Work program to help nurses who have chosen to take time away from practice reenter the workforce when they're ready. Returning nurses participate in a five-week residency that includes accelerated education to meet credentialing requirements and expedite their return to the bedside.

Penn Medicine's Pennsylvania Hospital has created a Clinical Nurse Ambassador program to tap experienced nurses to mentor new-to-practice nurses who are working the night shift. The veteran professionals provide clinical, professional, and emotional support as newer clinicians grow in experience, expertise, and confidence. The effort has meaningfully reduced turnover among new night-shift RNs.

Jefferson Health is re-engaging retired nurses through its Nurse Emeritus Program. Participants lend their expertise to mentor new nurses, teams, and leaders and also help support special projects.

Hospitals are also fundamentally changing care models to better support bedside RNs.

Guthrie Robert Packer Hospital, for example, started with a pilot and has since expanded to a system-wide transition to a team nursing model that includes RNs, licensed practical nurses (LPN), and other care partners. They began by bringing their RNs together to discuss tasks the RNs believed could safely be delegated to LPNs, within the allowable scope of practice. The idea was to empower RNs to dedicate more of their time practicing at the top of their professional abilities, while other professionals more widely shared much of the day-to-day, direct care responsibility.

Their outcomes are remarkable. Every single quality-of-care measure they tracked improved. Patient and nurse satisfaction increased. Their vacancy rate fell to zero, completely eliminating the need for travel nurses.

Similar shifts are happening throughout the state. HAP's survey found that the number of LPNs who are supporting RNs and providing direct patient care have increased significantly. Hospitals also reported implementing or expanding programs such as telehealth, virtual nursing, and hospital-at-home programs that support bedside RNs.

Geisinger, for example, is expanding the virtual nursing program it launched last year. Experienced nurses provide 24/7 remote support from a systemwide center for tasks such as admissions, discharges, and virtual rounds. The program brings a triple benefit: keeping veteran nurses engaged who would otherwise retire or leave the bedside due to the physical demands; easing the workload on other RNs, freeing them up to focus on more hands-on patient care; and increasing patient satisfaction as needs are met more quickly.

In another example, following a successful pilot at its Surgery and Rehabilitation Hospital, WellSpan Health is expanding its use of artificial intelligence to support nurses with patient monitoring. The pilot resulted in a 15 percent decrease in patient falls, 21 percent improvement in patient experience related to nurse communication, and an 11 percent reduction in RN turnover.

HAP's survey found that hospitals are making significant investments workplace safety to protect employees amid rising violence against health care workers. During 2023, nearly all hospitals:

• Provided staff education on safety protocols (97%).

• Implemented enhanced security measures (95%).

• Provided de-escalation training (95%).

• Enacted initiatives to promote respectful behavior (93%).

These strategies include approaches like providing clinical staff with duress badges to ensure they can quickly and easily call for help, installing weapons detections systems, promoting a culture where there is not a stigma around reporting violence, and establishing rapid response teams to intervene when a patient or visitor becomes aggressive or threatening.

Across the commonwealth, hospitals are implementing new Joint Commission standards prompted by increasing cases of workplace violence. These requirements are intended to prevent violence through leadership oversight, policies and procedures, reporting systems, data collection and analysis, post-incident strategies, training, and education.

Hospital nurses bear the weight of a fragile health care continuum.

It takes an array of interconnected providers to support communities' physical and behavioral health care needs. Hospitals are the anchors and the safety net at the end of the continuum. By choice, by mission, and by law, hospitals treat every person who arrives in our EDs, no matter their circumstances. Hospitals are also charged with coordinating safe, appropriate discharge strategies for patients who no longer need our care.

With limited youth and elder protection resources and fewer available nursing home beds, for example, hospitals are increasingly being used as safe places to care for vulnerable Pennsylvanians.

With an in adequate supply of behavioral health and substance use services, patients are coming to hospitals in greater distress and staying in hospitals days, weeks, and months after their acute care needs are met, simply because there are no other options available. This is particularly true for the great number of Pennsylvanians who have complex needs, like a chronic health condition, an intellectual disability, and a history of anti-social behavior, for example.

As a result, hospital nurses are consistently adapting and flexing their skills to attend to patients well beyond acute physical care.

The commonwealth must do better. It is vital that we recognize and invest in the community and facility capacity necessary to provide the appropriate services Pennsylvanians need, when and where they need them. Doing so is not only the right thing to do for patients; it's also the right thing to do for caregivers.

Hospitals are prioritizing public policies to help grow the numbers of Pennsylvania nurses and the professionals who support them.

Growing the commonwealth's nursing workforce will require a multifaceted and sustained effort. Pennsylvania's nursing shortage has been years in the making and won't be solved overnight.

The good news is that this is not a partisan issue. Each of you, the administration, every person in the hearing room, and thousands of others share the goal of making sure that all Pennsylvania nurses-no matter whom they serve or where they practice-are respected and supported in delivering the best possible care.

Thank you for your support of House Bill 2200, enabling implementation of the interstate Nurse Licensure Compact. This is a critical step to empowering Pennsylvania to more easily recruit nurses from outside the commonwealth.

Significant barriers to increasing the number of new nurses we can train-and, thus, significant opportunities for public policy to have meaningful impact-are shortages of nursing instructors and clinical education space. The lack of educators is due, in part, to retirements and financial disincentives for practicing nurses to teach. On average, advanced practice nurses earn $120,000 annually while master's level educators earn about $84,000 a year. We encourage you to consider ways to offset the earnings disparity between nurses who practice and those who educate and invest in clinical education space.

To increase the number of available instructors, we also encourage you to reach out to the Board of Nursing to explore flexibility in credentialing requirements to serve as a faculty assistant for up to five years. This work could, potentially, help the commonwealth benefit from the wealth of expertise and clinical experience of nurses who would like to extend beyond or have recently left the bedside.

HAP also supports Senate Bill 817 which creates a primary care workforce initiative that provides grants to expand opportunities for health care students to complete clinical rotations at Federally Qualified Health Centers.

Telehealth can extend the reach of current providers and better support nurses. HAP appreciates and supports the intent of House Bill 1512 to require insurance coverage for telehealth and has also worked closely with stakeholders over several sessions to help craft Senate Bill 739, which considers a wider array of issues that arise within the complexities of the health care space. We encourage you to work closely with your colleagues in the Senate to reach bipartisan, bicameral consensus on telehealth legislation to support Pennsylvania nurses and patients.

HAP also encourages you to consider opportunities to remove unnecessary barriers between well-qualified providers and patients, such as through House Bill 1825 and Senate Bill 25, which allow proven nurse practitioners who have safely cared for patients for at least three years or 3,600 hours to work without a formal physician collaboration agreement.

Additional, commonsense steps that you can take immediately include:

• Fixing a discrepancy in current Pennsylvania law by clarifying that nursing education programs be certified by a U.S. Department of Education-accredited organization, which includes both regional and national accreditation agencies (House Bill 1403).

• Removing a redundant process by which the State Board of Nursing must currently review and approve applications for a student's ability to sit for the state licensure exam (House Bill 590).

• Allowing required face-to-face interviews of direct care workers to be conducted using real-time, two-way video (House Bill 155).

• Making investments in developing additional behavioral health professionals and building capacity in behavioral health programs across the state (House Bill 849).

• Expanding the Pennsylvania Targeted Industry Program by including four-year pre-physician assistant programs and bachelor's degree programs in nursing, public health, and community health (House Bill 262).

• Allowing high school juniors and seniors to earn up to two credits if they have worked in a congregate health care setting, including a hospital (Senate Bill 1104).

• Expanding the Pennsylvania Nurse Aide Training program and allowing nurses to immediately take the Certified Nurse Aide exam after completing their education (Senate Bill 1102).

• Authorizing, in limited instances and specific settings, trained nursing assistants to become "certified medication aides" (Senate Bill 668).

• Increasing support for J1 visas to empower hospitals to recruit more international professionals.

HAP looks forward to partnering with you on these and other policies to support Pennsylvania nurses and patients.

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Topics: Access to Care, Behavioral Health, Public Health, State Advocacy, Telehealth, Workforce

Revision Date: 5/7/2024

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