Ms. Phyllis Norman

August 31, 2006

Testimony of
Phyllis Farrell Norman, RN, MBA, CNAA, BC
Vice President, Patient Care Services, Harris Methodist Fort Worth Hospital
(member of Texas Health Resources)
Before the Senate Judiciary Committee Field Hearing
August 31, 2006

Mr. Chairman and committee members: Thank you for the opportunity to appear today to discuss my thoughts on the proposed SKIL Bill, S. 2691, particularly as it pertains to the recruitment of foreign nurse graduates.

I have been licensed as a registered nurse in the state of Texas since 1969 and for the past 32 years have worked for Texas Health Resources (THR) formerly Harris Methodist Health System. THR is the largest multi-hospital system in North Central Texas composed of 13 hospitals, providing a variety of acute care and wellness related health care services to 29 counties with a total population of 6.9 million residents. In 2005 1.1 million patients were provided services by THR facilities. THR is a member of the Texas Hospital Association (THA) and the American Hospital Association (AHA).

I am the Chief Nursing Officer at Harris Methodist Fort Worth Hospital (HMFW), the largest tertiary care facility in Fort Worth. In my position, I have responsibility to provide the highest level of patient care available to the patients served by our hospital. This requires me to recruit and retain professional nurses in order to be able to offer these services without interruption. We need an adequate number of qualified registered nurses (RNs) available to fill vacancies in a timely fashion as they arise. Currently, HMFW has 82 RN vacancies which is a 5% vacancy rate for the hospital. In January 2006, the Dallas Fort Worth Metroplex reported an 8.6% RN vacancy rate, or 1295 unfilled RN positions.

The healthcare industry is facing tremendous challenges to its ability to provide the kind of quality, compassionate care to which we are committed. This situation is expected to worsen in the future. These challenges include an aging population, an increased rate of obesity, and the development of chronic health conditions in each of those populations, which places huge demands on existing healthcare services as well as requiring us to increase access to and availability of services in the future. These trends will require increasing numbers of healthcare workers, especially RNs. As you may know, this country is experiencing a shortage in many healthcare related professions with registered nurses heading up the list. Texas predicts the need for 41,000 more RNs by 2010 and 60, 000 by 2015. The Health Resources and Services Administration projects a shortage of one million RNs by the year 2020 in the United States.

You may wonder why the U.S. is unable to produce the number of qualified RNs needed to meet its own needs. Ensuring an adequate supply of RNs requires strategies to expand the number of people who enter health care careers, to retain those already in the workforce, and to improve the fexibilty of that workforce in responding to expanding and contracting demand for services and changes in the methods of delivering those services. Nursing is a very demanding profession intellectually, physically and emotionally. As other professional opportunities have improved, especially for women, fewer individuals are interested in healthcare careers with all of the stress, difficult hours and risks of injury. Other careers often offer better pay and benefits and fewer lifestyle compromises.

Nonethelesss, we have had a growing number of applicants to the nation's nursing programs. Unfortunately, the nursing education system lacks the capacity to accept all of the qualified applicants. In fact, for the 2005 academic year, over 150,000 qualified applicants were turned away from the nation's nursing schools (including diploma, associate degree, and bachelor's degree programs). .In 2005 over 11,000 Texas nursing school applicants were denied admission because enrollment is full. There is no quick remedy to this problem, because it stems from a shortage of trained nursing faculty and insufficient clinical facilities. Both of these causes require significant amounts of money and time to fix.

Faculty shortages are due primarily to poor faculty salaries compared to those paid to practicing nurses by healthcare facilities, making it difficult for academic institutions to recruit and retain qualified faculty members, who must have higher levels of education than required for most practice positions. Hospitals and training programs have collaborated by sharing nursing staff with advanced degrees to serve as faculty and by providing grants to acquire new faculty members. This has resulted in an increase in Texas student enrollment of 39% between the academic years 2000 and 2005. However, this is not sufficient to meet the growing needs of the population.

Another driving force causing the shortage is the aging RN population. The average age of an RN is 46, and they tend to retire earlier than many other occupations due to the physical, mental, and emotional demands of the job. Within the next ten years, a large portion of the most experienced RN population will begin to decline due to full or partial retirement. Hospitals have and continue to invest considerable time, energy and resources in retention programs in order to retain these workers, including incorporating "best practice" strategies developed by the Texas Nurses Association in their "Nurse Friendly Hospital" designation and the American Nurses Credentialing Corporation's Magnet Recognition Award for Excellence in Nursing Services.

More will need to be done at the federal and state levels to improve the salaries of nurse educators, recruit more nurses to teach, and create additional clinical facilities. Even with adequate funding the lead time for these changes will be long. And the funding is far from adequate at this time. It is the collision of this stark reality with the growing patient care needs that makes the availability of qualified immigrant nurses so crucial. We require the same qualifications and provide the same salaries and benefits to these nurses as we do for those hired domestically. This is not about saving money. On the contrary, it is costly and time-consuming to recruit from abroad. But without this international supply, we could not fill our staffing needs. Whatever one hospital system might do to recruit extra domestic nurses just comes out of the total national supply, still leaving a shortage to be addressed from abroad.

It is estimated that 15% of new nurses being licensed in the U.S. each year are foreign graduates. Any interruption of their avaialbilty has an immediate and very detrimental effect on the healthcare industry, making an already difficult situation worse. But just such an interruption already occurred in 2005 and another looms for this fall. Without Congressional action we face a crisis in this area.

In January 2005, visa numbers for skilled employment-based immigrants were oversubscribed and a waiting list was established for the largest sending countries--China, India and the Philippines. The effect was a three-year hold on admissions of these immigrants. Although other categories of skilled workers were also affected, most of those employees were already in the U.S. and could continue to work while waiting for their green cards. Nurses do not have such a temporary work category, so they had to wait abroad. Luckily, through the initiative of the AHAand the leadership of your colleague, Senator Kay Bailey Hutchison, Congress was persuaded to "recapture" 50,000 visas that were unused from past years and made them available for nurses and physical therapists. However, that pool will be used up by November--more than half to accommodate the dependents of the workers.

And this time the waiting list will not be limited to the three countries sending the most employment-based immigrants, but will apply to the whole world. And instead of a three-year delay, the wait will stretch to five years. Imagine losing 15% of the new nurses beginning work for each of the next five years--a total of over 70,000 fewer nurses than the current, inadequate supply. Hospitals and their patients cannot absorb that kind of a hit.

There are already tremendous delays in obtaining visas for foreign nurses. THR alone experienced great difficulties and delays in trying to recruit 150 nurses from the Philippines in 2001. After five years, only 1/3 of those nurses have actually successfully completed visa requirements and begun to work in this country. To add the impending cut-off of visas to the long delays already in the process would be a catastrophe.

Luckily, there is a ready solution at hand. Mr. Chairman, your excellent SKIL Bill addresses this problem along with providing many other improvements to employment-based, legal immigration. It does so by taking nurses and physical therapists out from under the annual worldwide cap for skilled workers. It does so based on the existing designation of these professions by the Secretary of Labor as "shortage occupations" receiving blanket labor certification. Should the shortage be resolved by other measures to increase the domestic supply, these professions would go back under the cap. So there is no danger of flooding the market with such immigrants if they are not needed.

The result of not having enough RNs translates into closed hospital beds, overcrowded emergency departments, delayed treatment, elimination or reduction of services, and denied access to some patients seeking care. All have a detrimental impact on the quality of care provided to our citizens which impacts entire communities.

As I have explained, we face a crisis within the next three months. We urge that Congress pass the SKIL Bill, either as part of Comprehensive Immigration Reform, as a separate bill, or as a rider to a year-end spending measure. Whatever the procedure, the remedy is urgently needed by patients in Texas and across the country. Without an adequate supply of new nurses, hospitals cannot provide the high quality care that these patients need and deserve.