Nurses—specifically those who work at the bedside—are the backbone of the VA healthcare system today. In fact, with more than 80,000 registered nurses and nursing assistants, VA is the nation's largest employer of nurses.

But that backbone has slowly begun to break in specialized services, such as spinal cord injury & disease (SCI/D) care, as nurses have had to work overtime due to understaffing with patients requiring the highest levels of care over sustained periods. Last year, SCI/D nurses worked more than 105,000 combined hours of overtime as turnover, burnout, floating to non-SCI/D wards, and absences due to injury, sickness, and low morale put an even greater burden on those nurses who were available to work.


This problem raised the question of whether the staffing methodology used to decide the number of nurses per SCI/D patient, or more specifically the number of Nursing Hours Per Patient Day (NHPPD), accurately aligned with the growing scale of patient medical demand. Studies conducted in 2012 and 2014 in partnership with the VA Office of Nursing Services, the VA SCI/D system of care service line, and Paralyzed Veterans of America said “no.” The multiple-year studies found that nursing shortages were the result of an aging paralyzed veteran population that was measured by level of function, rather than medical need.

For example, a healthy quadriplegic patient admitted for an annual exam was staffed to the same need as a quadriplegic patient admitted for a severe infection, two completely different circumstances requiring different bedside care.  As a result, individual SCI/D nurses were being assigned too many patients who needed more bedside hours, or NHPPD, due to their level of medical need than one nurse could safely deliver. Symptoms of the problem include missing patient call lights; meals getting to patients late; patients going stretches of time without seeing a nurse; patients taking short cuts to care, such as opting to get bed baths instead of showers; nurses skipping breaks and working longer shifts to meet patient needs; and, ultimately, closing SCI/D inpatient hospital beds.

Broader cases in point can be seen in Palo Alto, Calif.; Memphis, Tenn.; Augusta, Ga.; Hampton, Va.; Albuquerque, N.M.; Syracuse, N.Y.; Seattle, Wash.; and St. Louis, Mo. SCI/D VAMCs, where patients are regularly turned away despite empty beds because staffing levels are based on a nurse staffing methodology developed 15 years ago. One facility in Castle Point, N.Y. shut down an entire long-term care SCI/D inpatient unit. Facility management has had to limit its number of patients, or "cap the census," because the number of available staff has fallen behind the number of patients who need specialized services. Nurse-to-patient ratios have necessarily plateaued even as patient need continues to increase, which means empty beds will remain unstaffed until more nurses are hired to meet demand and bring relief to the current workforce.

The same circumstance is occurring across the system as capping the census, which has the effect of artificially suppressing demand, now regularly occurs at all 24 VA SCI/D centers and 7 SCI/D long-term care centers. Since census capping is not accompanied by tracking wait times or delayed admissions, this leaves a big question as to the exact number of paralyzed veterans who need in-patient acute care, annual exams, or rehabilitation but are being turned away or forced to seek other less-optimal options because SCI/D beds are unavailable.

Of approximately 42,000 SCI/D veterans in this country, only about 12,000 receive specialized care in VA. This means the overwhelming majority are either receiving sub-optimal care elsewhere, going without annual exams and preventative screenings, don’t know they are eligible for VA specialized care, or have been discouraged by the lack of access to VA care. This number increases when those with spinal cord diseases, such as Multiple Sclerosis and Lou Gehrig’s disease, are added.

While hardly anyone disagrees with the need to increase the number of nursing staff in the VA SCI/D system to keep up with patient demand, dispute continues on necessary additional staff. Some in VA argue the relevance of average daily census in determining future staffing needs, even though those censuses were capped and couldn’t possibly account for untracked, unmet demand. This specious argument needs to be exposed for what it is: solely a matter of cost, not patient need.

For others in VA and among veteran advocates, unmet demand is the precise basis of present and future VA SCI/D nurse staffing needs, in this case an additional 1,000 nurses (average of 32 nurses per facility), for which the cost of not doing whatever it takes to improve the system will increase exponentially.

As Warren Buffet once said, "Price is what you pay. Value is what you get." The same is true of VA health care. When it comes to assessing the price for taxpaying citizens to ensure those paralyzed veterans who served our country have their serious medical needs met, there is tremendous accrued value in achieving better clinical outcomes, creating a more sustainable nurse workforce—and, in some instances, saving a life.

That value far outweighs the cost of paying a heavier price later as aging paralyzed veterans wait longer for care and a detached VA leadership, and politically driven proponents of diminishing investment in VA eventually break the back of one of its most critical frontline functions—and it's our nation’s most disabled heroes who will pay. 

Congress must fund the 1000-additional-nurses requirement so that paralyzed veterans who have no private sector alternative get full and timely access to adequate the VA specialized services they need to live and stay healthy.

Sherman Gillums Jr., is the executive director of Paralyzed Veterans of America (, a retired U.S. Marine officer, and a paralyzed veteran.

The views expressed by authors are their own and not the views of The Hill.