VA Testimony of Sandra K. Janzen, RN before Congress on October 2, 2003

United States Department of Veterans Affairs

STATEMENT OF
SANDRA K. JANZEN, MS, RN, CNAA
ASSOCIATE CHIEF OF STAFF/NURSING
JAMES A. HALEY VETERANS' HOSPITAL
BEFORE THE
HOUSE OF REPRESENTATIVES
COMMITTEE ON VETERANS' AFFAIRS
SUBCOMMITTEE ON OVERSIGHT AND INVESTIGATION

October 2, 2003

Mr. Chairman, I am Sandra Janzen, the Associate Chief of Staff for Nursing responsible for nursing practice at the James A. Haley VA Hospital in Tampa, Nursing Home Care Units in Tampa and Orlando, and large clinics in Orlando, Viera and Port Richey, Florida. I thank you for holding these hearings on the nursing shortage and its implications for the Department of Veterans Affairs (VA).

I am presenting testimony before this Subcommittee to discuss the Magnet Nursing Services Recognition Program and how Magnet credentialing may improve recruitment and retention associated with the nursing shortage in VA facilities. In March 2001, our VA facility was the first, and is still the only VA health care facility that has successfully achieved Magnet recognition. The concept of Magnet recognition emerged during nursing research of the nursing shortage in the 1980s that studied successful hospitals that were not experiencing a nursing shortage, compared to most hospitals in the country. These hospitals demonstrated superior ability to recruit and retain professional nurses.

Characteristics of Magnet organizations included participative management style, nursing staff involvement at all programmatic levels, collegial nurse-physician relationships, supportive organizations, and highly qualified transformational nursing leaders. In the 1990s, these same characteristics continued to be manifested in successful organizations and were formally adopted by the American Nurses Credentialing Center as standards for Magnet recognition. In 2002, the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) publicly acknowledged the importance of a supportive work culture such as Magnet in its report Healthcare at the Crossroads.

Today, Magnet recognition is achieved through a stringent and comprehensive process that includes organizational self-assessment based on Magnet criteria, development of an action plan to enhance administrative and clinical programs, and a written application that details how the organization meets the criteria. The application is appraised and scored to determine the degree of excellence achieved by the organization. When an organization exceeds the excellence score, a rigorous site visit is scheduled to verify, clarify, and substantiate the application. This site visit is primarily focused on the professional nurse to determine models used by staff to provide excellent nursing care and how organizational leaders supported nurses in their practice of nursing.

Magnet recognition is a journey toward nursing excellence for patient care provided in an environment in which leaders listen to the voice of nursing as the patient's strongest advocate. Patient care requires a team of professionals and Magnet standards ensure interdisciplinary collaboration.

This award for excellence might be viewed as an organizational excellence award for nursing similar to the Baldrige Award. It focuses on nursing excellence in practice as demonstrated by clinical outcomes and quality management indicators related to effective staffing. Magnet recognition is not just recognition for nursing services, but recognition for the entire organization that actively supports and highly values the nursing contribution to patient outcomes.

How can a Magnet journey ease the effects of the nursing shortage? The application requires a serious evaluation of work processes that support patient care and the environment where nurses provide care. How do we know that Magnet recognition has helped us? Tampa VA Medical Center's nursing recruitment and retention situation has improved significantly in the past two years. Our RN turnover rate has dropped from 14.5% (2002) to 10.2% (2003), nearly 9% lower than the Florida average. The vacancy rate at the Tampa VA Medical Center fluctuates between 7% and 8%. This rate compares very favorably with the community average in West Central Florida, despite adding new positions to activate more critical care beds, managing double-digit growth in outpatient care, and treating the highest volume of patients in the VA health care system. In 2001, our facility used supplemental agency staff in our intensive care units and acute care areas due to staff shortages. Although agency use never exceeded 2% of all RN hours, today our units are staffed without any additional agency nurses, and we have been able to successfully recruit highly qualified staff to activate a 26% increase in critical care beds.

Despite a highly competitive nursing market in the Tampa Bay area, we have successfully recruited sufficient registered nurses to expand inpatient capacity. Our staffing levels have stabilized, and nurses are spending more of their working hours with patients. Our VA Tampa Nurses perceive staffing levels to be adequate, and, just as importantly, they report that they have sufficient time to meet patient needs. These same nurses report high levels of satisfaction with their ability to care for patients. Our staff is more satisfied with the improved and consistent staffing levels. We conduct an annual nurse satisfaction survey, and our results have improved in two major areas, organizational policy involvement and pay. Our nurses are involved in determining how patient care is to be carried out, and they feel appropriately paid for their work.

Consistent with research of Magnet facilities, VAMC Tampa's clinical outcomes are very good compared to external benchmarks. For example, our patient fall rate is below national benchmarks despite aggressive implementation of initiatives to minimize restraint use. Our pressure ulcer rate compares favorably to external benchmarks. Patient satisfaction with care is high, and nurses routinely receive compliments. These outcomes are achieved by a highly motivated, engaged staff, who place the highest value on providing patient care. We have a highly educated staff, who are valued as key members of an interdisciplinary team. We promote a culture where education is held in high regard. Sixty-five percent of our nurses have a bachelors or master's degree, compared to national reports of 38% to 48%. The importance of higher levels of educational preparation was illustrated in a recent study by Linda Aiken, PhD., RN, who found that a 10% increase in baccalaureate-prepared nurses resulted in a 5% decrease in unexpected surgical mortality. (JAMA, September 24, 2003 - Vol 290, No. 12, pp. 1617-1623).

Being a Magnet organization requires achievement of, and adherence to, higher standards of practice. Magnet standards provide a framework for performance improvement, require measurement against the best in the industry, and monitor satisfaction of nurses who pride themselves as being among the best who work for a great healthcare organization. As you can see, our investment in these requirements has resulted in significant benefit to our veteran patients and to our staff.

I again thank you Mr. Chairman for holding this very important hearing. An energized, satisfied, and well-educated professional nursing workforce is achievable in VA. The challenges of workforce shortages can be overcome by nurses who are able to practice in a professional environment and serve one of our most important patient populations, the veterans who serve this country.

Mr. Chairman, this concludes my statement. I will now be happy to answer any questions that members of the Subcommittee might have.