Legislature(2009 - 2010)BUTROVICH 205

03/09/2009 01:30 PM Senate HEALTH & SOCIAL SERVICES

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01:30:05 PM Start
01:31:06 PM SB12
03:00:48 PM Adjourn
* first hearing in first committee of referral
+ teleconferenced
= bill was previously heard/scheduled
Heard & Held
+ Bills Previously Heard/Scheduled TELECONFERENCED
          SB  12-LIMIT OVERTIME FOR REGISTERED NURSES                                                                       
CHAIR DAVIS announced consideration of SB 12.                                                                                   
1:31:06 PM                                                                                                                    
TOM OBERMEYER, staff to Senator Davis, sponsor of SB 12, offered                                                                
the sponsor statement for SB 12 as follows:                                                                                     
     SB   12  prevents   registered   nurses  and   licensed                                                                    
     practical nurses  from being  forced to  work mandatory                                                                    
     overtime,   i.e.,    work   beyond   an    agreed   to,                                                                    
     predetermined,  regularly   scheduled  shift,   and  it                                                                    
     protects   patients   from   the  dangers   caused   by                                                                    
     overworked  nurses.  Except  for  Alaska Native  health                                                                    
     care  facilities exempted  by this  bill under  federal                                                                    
     law, Senate Bill 12 is  applicable to all hospitals and                                                                    
     health care facilities licensed in Alaska.                                                                                 
     Under  SB 12  a nurse  may not  be required  or coerced                                                                    
     directly   or  indirectly   to   work   more  than   14                                                                    
     consecutive hours  without 10 hours of  rest; beyond 80                                                                    
     hours in  a 14-day period;  or to accept  an assignment                                                                    
     of  overtime if,  in  the judgment  of  the nurse,  the                                                                    
     overtime would  jeopardize patient or  employee safety.                                                                    
     Nurses,  however,  can  volunteer  to  work  additional                                                                    
     shifts beyond  this limit,  so long  as the  nurse does                                                                    
     not  work more  than  14 consecutive  hours without  10                                                                    
     hours of rest.                                                                                                             
     In  recognizing the  complexity  in delivering  quality                                                                    
     nursing  care   on  a  24-hour   basis,  a   number  of                                                                    
     concessions have been made to  Alaska hospitals in this                                                                    
     bill.  The 14-hour maximum workday  with 10 hours rest,                                                                    
     which  exceeds  that  allowed  in  many  other  states,                                                                    
     permits a  two-hour transition for  nursing supervisors                                                                    
     to call  in additional help after  12-hour shifts. This                                                                    
     provision was  intended to help  remedy the  problem of                                                                    
     nurses being called back to  work without adequate rest                                                                    
     after working a 12-hour shift.                                                                                             
     A number of exceptions have  been provided to allow for                                                                    
     longer shifts  for flight nurses on  medical transport,                                                                    
     residential   psychiatric  treatment   centers,  school                                                                    
     nurses on  school sponsored  field trips,  and official                                                                    
     state   emergencies.    This   bill   limits   hospital                                                                    
     reporting  of  overtime  hours  to  twice  a  year;  it                                                                    
     prohibits   retaliation   for  complaints;   designates                                                                    
     limited  employer  penalties and  requires  enforcement                                                                    
     for only "knowing" violations.                                                                                             
     The  Journal  of   the  American  Medical  Association,                                                                    
     October 23-30,  2002, reported  that nurses  who suffer                                                                    
     from fatigue, increased  patient work-loads, and shifts                                                                    
     in excess  of 12 hours greatly  increase nursing errors                                                                    
     and   mortality   among   patients  who   have   common                                                                    
     surgeries. In the  1999 report, "To Err  is Human," the                                                                    
     Institute of Medicine estimated  that as many as 98,000                                                                    
     hospitalized  Americans die  each year  as a  result of                                                                    
     errors in their care.   Both nurses and employers alike                                                                    
     state that patient safety is  paramount, but nurses are                                                                    
     allowed  to work  far  beyond  their endurance  levels,                                                                    
     depending on  age and  condition, unlike  other safety-                                                                    
     sensitive  jobs, including  commercial airline  pilots,                                                                    
     FAA  controllers,  railroad  engineers,  and  long-haul                                                                    
     Although nurses  file few official  overtime complaints                                                                    
     in part  due to busy schedules  and fear of retaliation                                                                    
     by employers,  many nurses have testified  to overwork,                                                                    
     emotional  exhaustion  when  they are  responsible  for                                                                    
     more    patients   that    they    can   safely    care                                                                    
     for, disruption  of   family  life,   unexpected  shift                                                                    
     changes,  mandatory  overtime, and  mandatory  on-call.                                                                    
     Low numbers  of complaints  and benign  exit interviews                                                                    
     belie growing  dissatisfaction with the  difficult work                                                                    
     and quality  of life of  nurses, which has  caused many                                                                    
     of them to "burn-out" and to leave the profession.                                                                         
     It has been estimated  that 500,000 licensed registered                                                                    
     nurses have left or are  not working in the profession.                                                                    
     There is  an expected  shortage of over  400,000 nurses                                                                    
     by 2020.   The nursing  shortage is a  workforce crisis                                                                    
     exacerbated  by the  growing and  unavoidable need  for                                                                    
     increased  nursing  care  by the  aging  "baby  boomer"                                                                    
     generation.   Bills in  Congress  to  stem the  nursing                                                                    
     shortage,  include  financial   aid  for  education  of                                                                    
     nurses  and   nurse  instructors,  and   more  rigorous                                                                    
     regulation of  overtime hours and patient  safety. Ref:                                                                    
     H.R.  2122,  and  S.1842 in  the  110th  Congress,  and                                                                    
     before that,  H.R. 791, "The  Safe Nursing  and Patient                                                                    
     Care Act."                                                                                                                 
     The nursing  profession must attract more  young people                                                                    
     to   replace   the   aging  nurses'   workforce   which                                                                    
     nationwide averages 46 years of  age, 48 in Alaska, and                                                                    
     is 95  percent women.   In 2000 only  9 percent  of RNs                                                                    
     were  under age  25, compared  to 25  percent in  1980.                                                                    
     Women are finding alternative career  choices, so it is                                                                    
     important  for the  nursing profession  to create  more                                                                    
     jobs   for   nurses    with   higher   wages,   greater                                                                    
     responsibilities,  and  better  quality of  work  life.                                                                    
     Nurses are  often described as  having a  "flat" career                                                                    
     path.    Only  by   considerably  more   education  and                                                                    
     experience  can  they  advance  in  certifications  and                                                                    
     earnings.  They  rarely hold positions of  authority in                                                                    
     hospitals  to  influence   policy  decisions  regarding                                                                    
     nurse/patient  ratios, overtime,  on-call, and  patient                                                                    
     safety.  Bargaining units  help, but  only one-half  of                                                                    
     Alaska's   4,500   licensed   registered   nurses   are                                                                    
     represented by bargaining units.                                                                                           
     Although  the  University  of  Alaska  has  made  great                                                                    
     progress   in  increasing   the   numbers  of   nursing                                                                    
     graduates in  Alaska and in improving  nursing programs                                                                    
     at  all levels,  these efforts  can only  be successful                                                                    
     through  employment   and  retention  if   the  nursing                                                                    
     profession can provide a quality  of life comparable to                                                                    
     that  in  other competitive  fields.  SB  12 will  help                                                                    
     remedy this problem by  encouraging employers to employ                                                                    
     and train more nurses  rather using mandatory overtime,                                                                    
     mandatory  on-call, and  large numbers  of "travelers,"                                                                    
     as  staffing tools  to fill  both routine  and critical                                                                    
     care  positions   on  a  daily  basis.    The  greatest                                                                    
     beneficiaries  will be  the patients  who will  receive                                                                    
     the care and safety they deserve.                                                                                          
1:36:26 PM                                                                                                                    
DEBBIE THOMSON,  Executive Director and Program  Director, Alaska                                                               
Nurses Association,  said she  wanted to talk  to them  about the                                                               
dangers  of mandatory  overtime and  the fatigue  and the  errors                                                               
that  happen with  it. She  explained  that some  say that  nurse                                                               
might  just as  well  have had  a drink  because  the long  hours                                                               
worked by some  of them pose some of the  most serious threats to                                                               
patient safety  that result in  decreasing the reaction  time and                                                               
the speed of mental processing.  Periods of wakefulness in excess                                                               
of 16  hours can produce  performance decrements equivalent  to a                                                               
blood alcohol concentration of  .05 percent. Alcohol intoxication                                                               
is defined as .08 to .10 percent varying among the states.                                                                      
MS.   THOMSON  presented   slides   from   the  Michigan   Nurses                                                               
Association Public Policies Association  Incorporated on the Cost                                                               
of Mandatory Overtime for Nurses  (written in August 2004), which                                                               
indicated the  likelihood of making  an error increases  with the                                                               
number  of hours  that  are  worked and  are  almost three  times                                                               
higher  when nurses  work shifts  lasting 12.5  hours. She  found                                                               
that working overtime  increases the odds of making  at least one                                                               
error and  it didn't  matter if it  was 12.5 hours  or 8;  it was                                                               
overtime over the originally scheduled shift.                                                                                   
Dangers to  patient safety  include the  nurse being  less alert,                                                               
having slower  reactions, and  making medication  errors; causing                                                               
higher incidence  of institutional infections and  bed sores. The                                                               
last two are no longer  reimbursable because they are acquired in                                                               
1:41:17 PM                                                                                                                    
The  Institute of  Medicine (IOM)  estimates  that about  100,000                                                               
hospital deaths  can be attributed  to medical errors  each year,                                                               
and mandatory  overtime is a  seriously contributing  factor. The                                                               
final recommendation of the IOM  is that all overtime, voluntary,                                                               
mandatory  and involuntary  done by  nurses should  be curtailed.                                                               
They are working  on what to allow the Interns  and the Residents                                                               
in Medicine to work as their shifts.                                                                                            
MS. THOMSON  said this is  not a  bargaining issue, but  a public                                                               
and  patient safety  issue.  The  Alaska public  has  a right  to                                                               
expect that the nurse taking care  of them is properly rested and                                                               
alert  and  that  she  hasn't  been working  16  hours  that  day                                                               
already. Patients  should not have  to worry about  staff working                                                               
conditions when they  register at a hospital. Many  nurses in the                                                               
state are not represented by  unions; Fairbanks and Mat-Su Valley                                                               
nurses are  to areas.  Washington State  passed its  no mandatory                                                               
overtime law in 2002.                                                                                                           
She  state  that  many  health   care  facilities  use  mandatory                                                               
overtime to  fill staff  shortages. One  reason for  shortages is                                                               
that  nurses  are  leaving  the field  because  of  poor  working                                                               
conditions. One  of the reasons  that the nursing shortage  is as                                                               
it is  today is because qualified  nurses are not working  in the                                                               
field  or they  are leaving  the profession  because they  can no                                                               
longer  work  the  long  hours  or  safely  take  care  of  their                                                               
patients.  A University  of Massachusetts  study  shows a  strong                                                               
link between  working overtime and work-related  injury. This was                                                               
found to  be true of all  occupations and working longer  than 12                                                               
hours a  day was associated  with a  30 percent increase  in that                                                               
risk. She provided a list of  states which have already passed or                                                               
banned forced overtime.                                                                                                         
1:47:36 PM                                                                                                                    
ROD  BETIT,   CEO,  Alaska  State   Hospital  and   Nursing  Home                                                               
Association (ASHNHA),  opposed SB  12. He said  ASHNHA represents                                                               
27  private, federal,  state and  tribal  health care  facilities                                                               
located throughout Alaska and his  testimony has been approved by                                                               
their  general membership.  He said  that the  sponsor of  SB 12,                                                               
Senator  Davis, is  well respected  by ASHNHA's  members for  her                                                               
commitment  to  improving  health  care  access  and  quality  in                                                               
Alaska. They  share her goals  for increasing  eligibility levels                                                               
for  Denali Kid  Care  to at  least 200  percent  of the  federal                                                               
poverty level  and to have  the Alaska Health Care  Commission to                                                               
address  Alaska's  health  care  issues.  However,  they  do  not                                                               
believe  that SB  12 is  needed to  assure continued  delivery of                                                               
excellent patient care throughout the  state. ASHNHA has a strong                                                               
a commitment to  respect the individual importance  of each nurse                                                               
in their  health care  delivery mission and  to treat  each nurse                                                               
fairly  in the  work place.  Their annual  nurse overtime  survey                                                               
demonstrates their commitment is being met.                                                                                     
MR.  BETIT  said  that  ASHNHA conducted  a  facility  survey  on                                                               
mandatory  overtime for  the last  four  years to  gain a  better                                                               
understanding of  the frequency with which  mandatory overtime is                                                               
used  by  member  facilities.  In  this  context  "mandatory"  is                                                               
overtime that  is not willingly  worked by  a nurse and  does not                                                               
include on call  overtime hours. It indicated that  the number of                                                               
mandatory overtime  hours incurred  are minimal and  only happens                                                               
at  a  few  facilities,  mostly  at  the  state  operated  Alaska                                                               
Psychiatric  Institute  - and  that  is  down substantially  from                                                               
2006. They  do not have the  kind of abuse in  mandatory overtime                                                               
that led to the State of Washington's legislation.                                                                              
1:50:01 PM                                                                                                                    
He  asks his  members every  year how  the individual  facilities                                                               
view  the  nursing  shortage.  This time  around,  eight  of  the                                                               
facilities reported that  the situation was about  the same, nine                                                               
reported that  they thought  the nursing  shortage was  worse and                                                               
three thought it had improved.   The next column showed the kinds                                                               
of shifts  that are worked in  each facility - anywhere  from 7.5                                                               
hours  in  the  state  facilities  up  to  16  in  a  psychiatric                                                               
facility. Nurse  vacancy rates  for 2007/8  were fairly  close at                                                               
10-12  percent  on  average  across   the  state,  although  some                                                               
facilities were  significantly higher like Mt.  Edgecumbe that in                                                               
2007  reported 25  percent  (although  they are  now  down to  12                                                               
percent). Providence Valdez reported a 22 percent vacancy rate.                                                                 
The  yellow  column  showed  the  number  of  reported  mandatory                                                               
overtime hours  throughout the  year and  that number  was coming                                                               
down;  there  were four  in  2008  that reported  some  mandatory                                                               
overtime being  assigned. Most of that  was at API. The  next two                                                               
columns dealt  with on call  nurses and these nurses  are usually                                                               
used in specific  units that require highly  technical skill. The                                                               
blue column indicated the number  of temporary nursing hours that                                                               
member facilities  purchase per  year in order  to not  resort to                                                               
mandatory  overtime  to fill  their  schedules;  in 2007  it  was                                                               
nearly  quarter  million hours.  This  year,  with Fairbanks  not                                                               
reporting yet,  there are 200,000  hours. The final  column shows                                                               
the number of grievances, but none have come forward.                                                                           
MR. BETIT said that ASHNHA  member facilities have taken a number                                                               
of steps  over the years  to minimize  the need to  use mandatory                                                               
overtime to  fill gaps in  nursing shifts. Some  examples include                                                               
financially  contributing to  the  University  of Alaska  nursing                                                               
program  expansion from  100 to  200 nurses  each year,  creating                                                               
clinical experiences  for students nurses and  recently graduated                                                               
nurses to  gain hands-on nursing experience  required to complete                                                               
their  education  or  to achieve  the  patient  care  experiences                                                               
necessary  to become  employed in  the hospital  or nursing  home                                                               
setting,  providing  distance  learning  opportunities  so  local                                                               
residents can  take nursing  course in  their own  community with                                                               
minimal  need to  spend  large amounts  of time  out  of town  to                                                               
achieve their  clinical experiences  (very successful  in several                                                               
communities),  and  purchasing  tens  of thousands  of  hours  of                                                               
temporary  nursing   staff.  Even  so,  approximately   half  the                                                               
facilities  reporting  on this  year's  survey  believe that  the                                                               
nursing shortage situation has worsened.                                                                                        
1:55:01 PM                                                                                                                    
He recapped their  concerns with the bill: the  data doesn't show                                                               
that that  hospitals and nursing  homes are relying  on mandatory                                                               
overtime  to fill  staffing gaps.  On the  contrary it  shows its                                                               
usage is  rare. Second,  ASHNHA believes  that working  hours and                                                               
scheduling are  appropriately a local employer  responsibility to                                                               
negotiate with  its employees. He said  that workforce challenges                                                               
vary  for  community  to  community,  so  a  single  approach  is                                                               
unworkable.  He  said  a  number  of  facilities  are  either  in                                                               
negotiations  with nursing  staff  currently or  will begin  them                                                               
shortly and  they should be  given an opportunity to  address any                                                               
concerns rising from the nursing staff.                                                                                         
1:55:51 PM                                                                                                                    
MR. BETIT said it is important  to have flexibility to be able to                                                               
bring a nurse  in when a procedure happens,  but isn't scheduled,                                                               
and the right personnel have to be  there to make sure it is done                                                               
correctly. Ongoing monitoring systems  operated by federal, state                                                               
or  independent private  agencies  in Alaska  show Alaska  health                                                               
care  quality is  excellent and  none  have identified  mandatory                                                               
overtime as  a problem related  to delivery of  excellent patient                                                               
care, he said.                                                                                                                  
1:56:58 PM                                                                                                                    
ASHNHA  members have  contributed  funding to  support a  nursing                                                               
program  and are  graduating  a  lot of  nurses  but they  aren't                                                               
enough  and  they  are  not   getting  into  some  of  the  rural                                                               
communities where they are desperately needed.                                                                                  
Finally, he  said, the bill  would impose a new  reporting burden                                                               
for  facilities that  would have  to be  filed semi-annually  and                                                               
contain  detailed  work hour  information  for  each staff  nurse                                                               
employed by the facility as well as each contract nurse.                                                                        
1:57:54 PM                                                                                                                    
SENATOR PASKVAN  said it appears  that only two  facilities allow                                                               
shifts  beyond  14  hours  (SB  12),  Alaska  Pioneer  Homes  and                                                               
Northstar  Behavioral Health  System.  All others  appear to  use                                                               
MR. BETIT  said that  is correct; when  his facilities  go beyond                                                               
the 12 or  14 hour shift, it is  only for an hour or  two, and an                                                               
on call situation can be very different.                                                                                        
1:59:24 PM                                                                                                                    
SENATOR  PASKVAN said  asked what  definition of  "mandatory" the                                                               
sponsor is using.                                                                                                               
MR. BETIT  said that is  a fair  question, because that  has been                                                               
one of the issues in a lot  of testimony over the last few years.                                                               
In their  context and  that of  this legislation,  if a  nurse is                                                               
working willingly or following a  prescribed on-call schedule, it                                                               
is not mandatory.                                                                                                               
2:00:54 PM                                                                                                                    
RON ADLER, CEO,  Alaska Psychiatric Institute (API),  said he was                                                               
available for questions.                                                                                                        
2:01:26 PM                                                                                                                    
MARIE ORIAH,  Northstar Behavioral  Services, said she  wanted to                                                               
testify as nurse, mother and  wife. She has voluntarily worked at                                                               
her  16-hour shift,  and she  needs the  hours in  this position,                                                               
because she is a mother of  two and their primary care giver; she                                                               
also  home-schools  her son.  Her  husband  works in  the  forest                                                               
industry and  his hours have been  cut back. So they  are missing                                                               
one paycheck, but  because she has a "Baylor" shift,  she is able                                                               
to pull  one extra  night shift to  supplement that  lost income.                                                               
Many  mothers and  nurses  like  her would  be  placed  in a  bad                                                               
position  financially. She  asked the  legislature to  reconsider                                                               
keeping those Baylor positions.                                                                                                 
2:04:27 PM                                                                                                                    
CHAIR  DAVIS said  she  could  amend the  bill  to include  those                                                               
positions and they will discuss it at a later time.                                                                             
2:05:06 PM                                                                                                                    
MARY STACKHOUSE,  RN, said  she started  working in  Ketchikan in                                                               
1987; she has been at  Providence in Anchorage since 1988. During                                                               
her career she has worked shifts from  8 to 12 hours, and lots of                                                               
overtime, both  voluntary and "not  so voluntary" -  meaning that                                                               
it wasn't  written in the plan  at the hospital that  it would be                                                               
mandatory. She explained that there  had been a coercion of sorts                                                               
with  the idea  always  present  that "there  is  nobody else  to                                                               
replace you,  think of  your patients,  think of  your coworkers,                                                               
you must stay."                                                                                                                 
She said she  has never thought of abandoning a  patient and that                                                               
it is  cause for loss  of licensure; and  it means that  you have                                                               
left your  patient at  the end  of your shift  when you  have not                                                               
reported off to someone else. The  problem she sees with the idea                                                               
of mandatory overtime  is that it is not the  nurse's choice. She                                                               
does not have the ability to say she is too tired to do it.                                                                     
2:07:52 PM                                                                                                                    
MS. STACKHOUSE  said she  takes her  patients very  seriously. In                                                               
the recent past they have had  far more babies in their unit than                                                               
they had staffing  for. Thanks to some of the  new people who are                                                               
in the  lead, they have  been able  to increase their  staff; but                                                               
more nurses  are needed.  Their census still  has big  fluxes and                                                               
when it is high is when nurses are  most at risk of not getting a                                                               
break  or even  lunch; they  can't cover  for each  other because                                                               
there are too  many babies. She said that it  takes an incredible                                                               
amount  of paying  attention to  new babies  to recognize  subtle                                                               
changes  to make  fine adjustments  in medications  and they  are                                                               
being born as  early as 22 weeks old. She  explained if the nurse                                                               
is too  tired or hasn't  eaten, she  may not be  thinking clearly                                                               
and in critical  care they have seconds to respond  - with adults                                                               
it might  be a few  minutes. If you  don't have enough  staff and                                                               
the  staff that  you  have  is already  exhausted,  then you  are                                                               
running the risk of some of  their patients not making it through                                                               
a crisis.                                                                                                                       
Nurses are leaving the profession in  droves. Women have a lot of                                                               
different  choices these  days,  and are  choosing  not to  place                                                               
themselves  in  the position  of  being  responsible for  others'                                                               
lives.  That way  they  don't  put their  families  at risk  from                                                               
things they  can bring home.  On-call time is scheduled,  but she                                                               
would not  want to be  the patient who  is waiting for  help when                                                               
the nurse  is too tired  to care for  them. When her  husband has                                                               
been a  patient in the hospital  she stays with him,  because she                                                               
knows how short  staffed they are and wants to  be sure his needs                                                               
are met.                                                                                                                        
2:12:35 PM                                                                                                                    
Older nurses won't  last forever, and the pool  of younger nurses                                                               
is smaller  and smaller. If  they are mandated to  work overtime,                                                               
they'll burn  out faster. One  of her flight  attendants recently                                                               
said she  had been a  nurse for less than  10 years, but  got out                                                               
because of  the working  conditions -  and mandatory  overtime is                                                               
one of  the working  conditions that scared  her the  most. Every                                                               
nurse will be  there in a true emergency,  but mandatory overtime                                                               
is not the way to deal with regular staffing issues.                                                                            
2:14:59 PM                                                                                                                    
EVANGELINE  "Angel" DOTOMAIN,  President and  CEO, Alaska  Native                                                               
Health Board (ANHB),  said they represent 24  regional and tribal                                                               
health  organizations   across  state  and   approximately  7,000                                                               
employees.  They have  deep reservations  with SB  12. It  is the                                                               
experience  of Tribal  Health providers  that  nurses are  highly                                                               
dedicated  caring providers  who will  give their  last ounce  of                                                               
skill to  care for their patients.  ANHB expends a great  deal of                                                               
effort and expense  to recruit and retain good  nurses to provide                                                               
care and cover all necessary shifts.                                                                                            
2:16:35 PM                                                                                                                    
They  think SB  12 would  hurt patient  care especially  in rural                                                               
Alaska where all  it would take to leave a  shift uncovered would                                                               
be for  one or  two nurses  to decide  for any  reason or  for no                                                               
reason at all  that they do not want to  work overtime. The rural                                                               
tribal health provider would in many  cases have no choice but to                                                               
simply not cover that shift and put other patients at risk.                                                                     
She explained that rural tribal  health providers do not have the                                                               
urban  luxuries   of  calling  other  off-duty   nurses,  getting                                                               
temporary  agency nurses  to cover  a shift  on short  notice, or                                                               
redirecting patients  to a  nearby facility.  In practice,  SB 12                                                               
would make  it impossible  for them  to cover  all the  shifts in                                                               
rural facilities. Perhaps  this is why almost no  rural state has                                                               
adopted similar legislation.                                                                                                    
Also, SB 12 is an  unfunded mandate that will unnecessarily drive                                                               
up costs,  she said. Rural  facilities are having  enough trouble                                                               
staying  open already  and  this will  make it  worse.  SB 12  is                                                               
designed to  solve urban  problems and is  not applicable  to all                                                               
areas  in  the  state.  There are  chronic  issues  with  nursing                                                               
staffing, but they are no  different from the challenges in other                                                               
medical areas. She  said that Alaska Tribal  Health providers are                                                               
not  purposely understaffing  as an  abusive labor  practice. The                                                               
reality  is  that  to  the  degree  they  have  nursing  staffing                                                               
challenges,  it  is because  of  the  tight national  labor  pool                                                               
compounded by the  never-ending challenge of figuring  out how to                                                               
get good nurses, doctors,  technicians, administrators and others                                                               
to work  and live  in remote Alaska  locations. SB  12 proponents                                                               
agree that there  are few official overtime  complaints by nurses                                                               
and  that there  are low  numbers of  complaints and  benign exit                                                               
She acknowledged that nursing is  a difficult profession, but the                                                               
challenges come  with the territory  and all must  schedule their                                                               
work to meet the  needs of their patients - and  - this issue can                                                               
be addressed  differently. Because  of the  well-documented nurse                                                               
shortage in Alaska there is a  very tight labor market for nurses                                                               
that  gives them  significant leverage  in negotiating  the terms                                                               
and  conditions of  their employment.  She thanked  the committee                                                               
and asked them to vote no.                                                                                                      
2:21:26 PM                                                                                                                    
SENATOR PASKVAN asked  if there was a rural  exemption, what size                                                               
community should be exempt.                                                                                                     
MS.  DOTOMAIN  replied  that  is  difficult  to  say  because  if                                                               
something is put in place  that makes recruitment easier in urban                                                               
Alaska, that makes it tougher on recruiting in rural facilities.                                                                
2:22:43 PM                                                                                                                    
CHAIR  DAVIS   suggested  she  get   together  with   the  Nurses                                                               
Association  to work  on possible  language  for this  particular                                                               
2:23:22 PM                                                                                                                    
CINDY  ALKAIER,  Assistant   Chief  Nurse  Executive,  Providence                                                               
Health and  Services Alaska,  opposed SB 12.  She said  that most                                                               
Alaska  hospitals  have  been successful  at  avoiding  mandatory                                                               
scheduled  overtime recognizing  that  nurses  need rest  between                                                               
their  shifts. Providence  has not  scheduled mandatory  overtime                                                               
within its facility.                                                                                                            
Secondly, this  bill does not  appropriately address  the on-call                                                               
situations  currently  present  in their  operating  rooms,  post                                                               
anesthesia care unit,  cath lab, and dialysis unit.  "On call" is                                                               
defined as  being available  within 30 minutes  (when there  is a                                                               
life threatening incident).  The issue of on call is  not easy to                                                               
solve since hospitals provide 24  hour emergency services. Nurses                                                               
work in  their OR cath lab  which deals with removing  clots when                                                               
there are strokes,  acute MIs and caring for  babies with cardiac                                                               
2:25:16 PM                                                                                                                    
Dialysis  also has  emergency situations  after normal  operating                                                               
hours  when  someone  has  overdosed  on  drugs  or  has  a  life                                                               
threatening need for dialysis. It  takes specialized training and                                                               
experience  to function  in  those  specialized areas;  requiring                                                               
training for sometimes  as much as two  years. Routine procedures                                                               
are scheduled  during regular hours,  but if an  emergency occurs                                                               
after hours they have to be able to call trained people in.                                                                     
This bill treats on  call the same as any other  work. If a nurse                                                               
has just worked a shift and is on  call on the same day she could                                                               
easily go  over 80 hours  in 4 days.  Some nurses choose  to take                                                               
their  on call  on the  days  they are  scheduled to  work so  it                                                               
doesn't  interfere with  their regular  scheduled days  off. This                                                               
legislation  would  impact  their  ability to  manage  their  own                                                               
schedule  and their  own  time off.  Requiring  an on-call  staff                                                               
person to fulfill their on-call  obligation as mandatory overtime                                                               
will  adversely  impact  the  ability  of  hospitals  to  provide                                                               
emergency surgery, heart caths and emergency dialysis.                                                                          
2:28:29 PM                                                                                                                    
MS. ALKAIER said one of  the complications of feeding a premature                                                               
baby is the  possibility of obstruction of the bowel  and if that                                                               
isn't operated on immediately, the  baby will die. If they cannot                                                               
get someone  on call  to come  in, the family  will be  told they                                                               
can't treat  their patient. This  could happen in  any emergency,                                                               
so they need the flexibility to  bring staff in to care for those                                                               
emergent situations.                                                                                                            
Hospitals have  safeguards in place  to ensure good  quality care                                                               
and  have detailed  inspections  by the  federal government,  the                                                               
State  Department  of  Public   Health  and  private  accrediting                                                               
agencies   such  as   joint   commissions.  Quality   performance                                                               
improvement, staffing  competencies and patient  satisfaction are                                                               
monitored continuously. To  maintain accreditation, hospitals are                                                               
required  to measure  patient acuity  and  care requirements  and                                                               
provide   adequate  hours   of   nursing  care   to  meet   those                                                               
requirements.  In addition, their  hospital's ability to maintain                                                               
the confidence of the community  determines their future success.                                                               
Providence  believes   if  there  are  problems   with  mandatory                                                               
overtime  at  their  facilities   it  should  be  handled  during                                                               
collective bargaining.                                                                                                          
2:31:27 PM                                                                                                                    
Providence is  scheduled to begin  union negotiations  this month                                                               
and mandatory  overtime and  on call  will be  part of  that. She                                                               
asked them to allow them to deal with these problems then.                                                                      
2:31:58 PM                                                                                                                    
CHAIR DAVIS  said she understood  they'd started  negotiations in                                                               
January or February.                                                                                                            
MS. ALKAIER replied no; their first meeting will be March 19.                                                                   
CHAIR DAVIS encouraged  them to take these issues  up with nurses                                                               
at the  bargaining table. She  said she didn't believe  any nurse                                                               
would not stay to  do what needs to be done  in an emergency; but                                                               
if  emergencies  are   ongoing,  that  is  a   workload,  not  an                                                               
emergency, and it does cause a hazard.                                                                                          
MS. ALKAIER said  the on call work  she refers to has  to do with                                                               
the emergencies that come up in  the middle of the night. Regular                                                               
staff don't know  how to deal with some of  those emergencies and                                                               
they have to call in a special  team. If they lose on call staff,                                                               
those teams  may not  even answer  the phone.  They need  to have                                                               
those  on   call  people   available  in   the  cases   of  those                                                               
2:34:48 PM                                                                                                                    
SENATOR PASKVAN said  hospitals are in the  business of providing                                                               
care  in   emergencies;  so  he   wanted  to  know   how  routine                                                               
emergencies are.   Does  it happen weekly?  If it's  weekly, then                                                               
it's routine.                                                                                                                   
2:35:29 PM                                                                                                                    
MS.  ALKAIER explained  that some  emergencies,  like a  ruptured                                                               
intestine in a  baby, only happen about twice a  year, but if one                                                               
person is  lost because they  can't get  the care they  need when                                                               
that happens, then  it's unacceptable. Other things  come up more                                                               
frequently  like a  ruptured  appendectomy, but  an  OR team  can                                                               
handle that. It's only when a  second crisis comes up at the same                                                               
that no one is there.                                                                                                           
She repeated when specialized people  are needed, they can't just                                                               
bring any nurse in. The  on-call people are in specialized teams.                                                               
It's only  when someone  comes in  at night  with a  heart attack                                                               
that was unexpected who needs to  have that surgery right then or                                                               
they are going to  die - that the team has to  be called in. Only                                                               
a handful of nurses know how to do those kinds of procedures.                                                                   
2:37:42 PM                                                                                                                    
MARILYN   EDWARDS,   Operating   Room  (OR)   Clinical   Manager,                                                               
Providence Alaska  Medical Center,  said it would  be devastating                                                               
to  enact a  "one  size" solution  in  to state  law  to solve  a                                                               
mandatory  nurse overtime  concern  that does  not  exist at  the                                                               
Providence operating room. Her  immediate concerns revolve around                                                               
safe quality  patient outcomes  and a  safe work  environment for                                                               
her OR staff.                                                                                                                   
MS.  EDWARDS said  the OR  nurses pride  themselves on  providing                                                               
optimum work  life balance care  while taking good care  of their                                                               
patients.  The OR  is fully  staffed and  less than  half of  her                                                               
nurses  work full  time. She  has 48  OR registered  nurses; this                                                               
includes  2  educators,  1 RN  traveler,  16  specialty  clinical                                                               
nurses,  and  1 registered  dialysis  nurse.  Eight of  these  48                                                               
nurses work 12-hour shifts, 4  of these 12-hour shifts were added                                                               
in the  past year  at the  request of these  4 RNs.  Seven nurses                                                               
work 10-hour shifts  and 33 work 8-hour shifts. She  said that 22                                                               
RNs work  a 1.0 fulltime  equivalent position,  9 RNs work  at .9                                                               
fulltime equivalent,  4 RNs  work a .8,  2 RNs work  a .6.   They                                                               
have 10 registry RNs who are  required to work 3 shifts per month                                                               
and a minimal on call.                                                                                                          
She explained that  a 1.0 fulltime employee working  6:46 a.m. to                                                               
3:15 p.m.  Monday through  Friday has an  average of  one evening                                                               
call, one night call and  two weekend shifts, either as scheduled                                                               
shifts or call per four-week period.  A 12-hour RN, a .9 fulltime                                                               
usually has night or weekend call.  Much of this call is assigned                                                               
around  the individual  RN's request  because they  may want  the                                                               
call  scheduled when  they are  also scheduled  to work  to allow                                                               
them to have  consecutive days and nights off at  a time to spend                                                               
with their families.                                                                                                            
MS. EDWARDS  said she  has 2  RN team  leaders that  volunteer to                                                               
take second night call more often.  One team leader averages 7 to                                                               
9 orthopedic  call shifts  per month; the  one heart  team leader                                                               
voluntarily averages 14 to 17 shifts or more per month.                                                                         
During the  interview process for a  new position in the  OR, all                                                               
OR staff  candidates are  advised of  the call  requirements. The                                                               
assigned call coverage is necessary  to provide rapid (30 minutes                                                               
from notification) response for  emergent patient care above what                                                               
they  are  routinely  staffed  for  based  on  volume  trends  of                                                               
2:41:26 PM                                                                                                                    
She  has read  and heard  of  anecdotal stories  of nurses  being                                                               
tired and unable to provide  quality safe care to patients. While                                                               
this is true at some  facilities, Providence provides time off to                                                               
be with  sick or dying relatives  and did that with  one of their                                                               
cardiac nurses;  others covered her shift  while traveling nurses                                                               
interviewed  for a  fill in.   If  their OR  nurses had  not been                                                               
allowed to  cover the  call shifts due  to already  meeting their                                                               
call and  work requirements as set  out by SB 12,  they could not                                                               
have  accepted heart  patients  while that  nurse  was gone.  The                                                               
patient would have to be  diverted; this means a facility doesn't                                                               
have staff for a procedure.  If all three facilities in Anchorage                                                               
go on  divert, actually  no one  is on  divert. Someone  needs to                                                               
care for that patient.                                                                                                          
2:43:17 PM                                                                                                                    
NANCY DAVIS,  RN, President, Alaska Nurses  Association, said she                                                               
works now  as a hospice nurse  and has worked as  a public health                                                               
nurse. She was  chief of Public Health Nursing for  the state; so                                                               
she is  familiar with nurse  issues across Alaska.  She supported                                                               
SB 12. "It  is a patient safety issue." She  said that this state                                                               
deserves assurance that all nurses  will be rested and capable of                                                               
taking care of their patients.  She didn't think any nurse wanted                                                               
less than to provide the best  possible care for her paitent; but                                                               
sometimes it is difficult to do that.                                                                                           
MS.  DAVIS  said,  however,  there are  times  when  health  care                                                               
pressures  and health  care facility  pressures  create an  extra                                                               
burden  and this  is why  the mandatory  overtime prohibition  is                                                               
important. She  feels the  bill has  adequate safeguards  to deal                                                               
with  unforeseen   emergency  circumstances,  and   the  midnight                                                               
surgeries and car  accidents would fall under  that category. All                                                               
nurses would rise to that  occasion. Those emergencies should not                                                               
be  the standard  plan of  staffing for  dealing with  shortages,                                                               
She said  the bulk  of the ANHSHA's  data comes  from discussions                                                               
with administrators,  not staff-level  nurses. The  Alaska Nurses                                                               
Association did a survey last  spring speaking with nurses across                                                               
the  state, and  they found  that nurses  are routinely  asked to                                                               
work  overtime  without  sufficient rest  between  shifts.  "It's                                                               
really an issue for patient safety."                                                                                            
As for being  a bargaining issue, Ms. Davis said,  not all nurses                                                               
work under collective bargaining unit,  and one union they talked                                                               
to  declined  to   make  it  an  issue  because   they  said  the                                                               
legislature would  take care of  it. "Someone needs to  take care                                                               
of this and I believe SB 12 is a good answer."                                                                                  
MS. DAVIS also  remarked that one of the nurses  commented on the                                                               
impact of the  economy and how the overtime is  necessary for her                                                               
to provide for her family. But  Ms. Davis said she fears that the                                                               
economic  pressures  are  going  to increase  the  likelihood  of                                                               
mandatory overtime as  people lose their jobs and  nurses seek to                                                               
try to  cover the  economic needs of  their families  and perhaps                                                               
ask for additional overtime in order  to make ends meet. SB 12 is                                                               
the  best assurance  for patient  safety regardless  of what  her                                                               
personal needs might be as a  nurse for her own economic welfare.                                                               
She  believed  that a  standard  statewide  approach to  defining                                                               
maximum work hours and minimum rest  period is the best way to do                                                               
2:49:13 PM                                                                                                                    
CHRISTY  ORTUSO, RN,  Director, Neurosciences,  Providence Alaska                                                               
Medical Center, said  she is also a Board of  Directors Member of                                                               
the American  Association of  Critical Care  Nurses Certification                                                               
Corporation,   the   largest  specialty   nursing   certification                                                               
corporation  in the  country. They  have  pioneered healthy  work                                                               
environments and looking at the  nurses' role in maintaining them                                                               
over several years.                                                                                                             
Anecdotally  she related  how she  chose to  work overtime  to be                                                               
able to buy  a house and how she was  concerned about language in                                                               
SB 12 that  would limit her choice to working  certain hours. She                                                               
has been in Alaska less than  three years; before that she worked                                                               
in  hospitals where  mandatory  overtime was  used  to staff  the                                                               
units in  one of  the worst nursing  shortage experienced  in the                                                               
past two decades, and she was  never mandated to work because she                                                               
chose  to work.  The nurses  she has  known over  the years  have                                                               
valued  that  flexibility  as  one of  the  driving  reasons  for                                                               
staying in  nursing. Her experience  in Alaska is  that hospitals                                                               
are very  well staffed when  she compares it  to her 26  years of                                                               
experience in the Northeast.                                                                                                    
MS. DAVIS said  she is currently on faculty  at two universities,                                                               
UAA  and the  University of  Phoenix, and  she has  contacts with                                                               
nurses  across  the  United  States and  one  concept  comes  out                                                               
clearly in her  classrooms - nurses need for  autonomy and making                                                               
their own  choices. Everything she  reads about  Alaska indicates                                                               
that  mandatory  overtime is  not  a  great problem  here;  small                                                               
instances  of it  can be  resolved by  developing healthier  work                                                               
environments  and allowing  nurses  to rise  to the  professional                                                               
standard they have wanted to work in throughout the years.                                                                      
2:54:56 PM                                                                                                                    
STACY ALLEN,  RN, Business  Agent, Laborers  Local 341,  said she                                                               
represents  about   265  nurses  at  Alaska   Regional  Hospital,                                                               
supported SB  12. No one  has mentioned the conflict  that nurses                                                               
feel between  their ethical, moral and  legal responsibilities as                                                               
a patient advocate and their personal  need to not work more than                                                               
is safe for themselves or the public.                                                                                           
She recalled  from nursing school  how nurses is  uniquely placed                                                               
to be the  patient's advocate, and the public has  come to expect                                                               
a high degree of care  ethically and physically. More studies are                                                               
coming  out  talking  about  things that  keep  nurses  from  the                                                               
profession or keep them from  hospital nursing; one is the stress                                                               
some feels in knowing they are not  safe to work, but there is no                                                               
one else to replace you or  the person being called in to replace                                                               
you is just as  tired as you are. SB 12  levels the playing field                                                               
not  for just  the  individual nurse,  but  for the  institutions                                                               
themselves.  It sets  a minimum  standard that  the public  has a                                                               
right to expect in health care.                                                                                                 
2:57:29 PM                                                                                                                    
ROGER  LEVRENTZ,  RN,  Clinical  Nurse  Educator,  Heart  Center,                                                               
Providence Health Care  Center, said he is  responsible for staff                                                               
in the  cath lab, the  observation unit and  their cardiovascular                                                               
intervention unit. He  said the cath lab is  a highly specialized                                                               
area where  people having strokes,  heart attacks and  other life                                                               
threatening  problems  receive  care.   Staff  consists  of  RNs,                                                               
cardiovascular  technologists and  radiology technologists;  they                                                               
all have  extensive specialized training. They  care for patients                                                               
of every  age from  neo-natal to  over 100 years  old. It  is not                                                               
unusual for them  to be called in at 2  a.m. and the restrictions                                                               
SB  12 would  impose  would negatively  impact  their ability  to                                                               
provide care for the patient population due to the                                                                              
unavailability of trained staff.                                                                                                
CHAIR DAVIS announced that she would bring SB 12 back at a later                                                                

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