ENA Letter on Primary Care and Health Workforce Expansion Act

September 13, 2023 Emergency Nurses Association ENA Government Relations

As part of its ongoing efforts to increase the pipeline of new nurses, promote healthy and safe work environments, workplace violence prevention and address boarding ENA sent the following letter to Senator Bernie Sanders to show support for the Primary Care and Health Workforce Expansion Act.


The Honorable Bernie Sanders                                            
Senate Health, Education, Labor, and Pensions Committee                                             
322 Dirksen Building                                                          
Washington, D.C. 20510                                               

Dear Chairman Sanders:

The Emergency Nurses Association (ENA), representing 50,000 members, would like to express support for your efforts to develop legislation addressing many of the issues facing the health care workforce. We appreciate the opportunity to provide feedback on the draft legislation, the Primary Care and Health Workforce Expansion Act, which you released in July, and offer additional suggestions to strengthen the effort to support the recruitment and retention of nurses across the country. Please find enclosed our original letter dated March 19 highlighting our priorities in this effort.

ENA is committed to working with you to seek long-term solutions that will enhance the supply of nurses, while also supporting changes in the work environment in the emergency department (ED) to improve retention of the existing nursing workforce. We also support substantial investments in the mental health system to ensure individuals receive high-quality behavioral health care, which will both improve patient care and reduce staff shortages in the ED.

As you move forward with consideration of the Primary Care and Health Workforce Expansion Act, we request your consideration of the following recommendations:

  1. Education and Pipeline of New Nurses

    Currently, the U.S. is simply not educating and training enough nurses to meet the increasing demand of our health care system. The draft legislation takes important steps to address this shortfall. Notably, we applaud the inclusion of sections 302 and 303, which reauthorize important nursing workforce development programs located under Title VIII of the Public Health Service Act. For decades, the Title VIII programs have provided loans, scholarships and grants to aid in the education, retention and professional development of the existing nursing workforce, especially as it relates to rural and underserved communities. We would also renew our support for the inclusion of full funding of $530 million across Title VIII programs for FY 2024.

    ENA also strongly supports the inclusion of Section 305, which would provide the framework for a substantial investment in our nation’s nursing schools. This provision supports many of the goals of the Future Advancement of Academic Nursing (FAAN) Act, which provides a $1 billion investment in U.S. colleges of nursing to enhance the enrollment and retention of nursing students, recruitment of nurse faculty, and the modernization of nursing school programs.

    Additionally, ENA recommends that the Committee consider including the National Nursing Workforce Center Act (S. 1150), which would establish a pilot program at HRSA to support state-based nursing workforce centers. These centers apply data-driven approaches to solving the workforce shortage problem, focusing on strategies to address shortages at the local level. This legislation would allow them to expand data collection and analysis efforts to inform local entities on targeted solutions to their workforce issues.

    Taken together, the FAAN Act, Title VIII Nursing Workforce Development programs, and the National Nursing Workforce Center Act will significantly expand the number of student and faculty positions at our nation’s colleges of nursing and help alleviate future nurse staffing shortages.

  2. Retention - Providing a Healthy and Safe Work Environment for Emergency Nurses

    A healthy and safe work environment is key to ensuring that nurses continue to care for patients and not leave the profession. ENA takes a comprehensive approach to improving conditions in the ED, including support for policies to curtail workplace violence, reduce the boarding of patients, and improve mental health resources and care in our communities.
  •    Workplace Violence in Hospital Emergency Departments

    As you know, violence in our nation’s emergency departments is higher than anywhere else in the health care profession. The levels and frequency of violence experienced by emergency nurses have caused many to leave the bedside or quit the nursing profession entirely. Mitigating the impact of workplace violence against emergency nurses and their patients is a primary focus of ENA’s public policy work.

    We applaud and strongly support the inclusion of Section 706 in the draft legislation, which encompasses the Workplace Violence Prevention for Health Care and Social Service Workers Act (S. 1176). These provisions will ensure health care employers, including hospitals, take specific steps to prevent workplace violence and ensure the safety of patients and workers. Importantly, it will require health care and social service employers to develop and implement a comprehensive violence prevention plan which must include procedures to identify and respond to risks that make workplaces vulnerable to violent incidents.

    Additionally, ENA encourages the Committee to include provisions of the Safety from Violence for Healthcare Employees Act (H.R. 2584). This legislation would establish criminal penalties under federal law for individuals who knowingly assault and intimidate hospital employees. Aggravating factors, such as the use of a weapon, would result in enhanced penalties. The SAVE Act, as introduced in the House of Representatives, also authorizes funds to be used to improve hospital workplace safety and security through training, improved screening and better coordination between hospital and law enforcement officials.
  • Boarding in the Emergency Department and Appropriate Care for Mental Health Patients

    The problem of patient boarding in the ED has reached a breaking point in hospitals throughout the United States. Boarding refers to the situation where admitted patients are held in the ED for long periods because no inpatient beds are available. Boarding contributes to burnout and stress among the health care workforce and contributes to nurses opting to leave their work in the ED.

    An important contributing factor to the boarding crisis is the sharp increase in the number of Americans in need of mental health care services. Many patients visit the ED due to a lack of behavioral health resources in the community. Sometimes, patients board in the ED for months while waiting either for a psychiatric bed to become available inside the hospital or a transfer to a specialized psychiatric facility.

    ENA specifically supports the inclusion of sections 501, 502, and 503, which support the expansion of mental, behavioral and substance use programs in several ways. There is great demand for trained professionals in these areas, yet resources supporting existing programs historically have fallen short of the need. Section 501 would assist more students and professionals to pursue behavioral health degrees and certificate programs by funding the Mental and Behavioral Health Education and Training Grants. Section 502 provides direct support to existing professionals burdened with student loan debt to practice in areas of the country where the need is greatest.

    ENA also supports section 503 of the draft legislation, which enacts the Health Care Capacity for Pediatric Mental Health Act. These provisions would establish an important framework for expanding and improving pediatric-specific services related to mental, emotional, behavioral or substance use disorders and conditions, especially in underserved or high-need areas of the country. Unfortunately, the need for these services has spiked in recent years. For instance, a CDC report found a 39 percent increase in visits to the ED for suspected suicide attempts among youths aged 12-17 during February-March 2021 as compared to the same period in 2019. ENA strongly supports this program, which expands much-needed psychiatric care for children and adolescents.

    Lastly, ENA supports efforts to reduce boarding by increasing treatment options for mental health patients outside the ED.  Specifically, we urge the inclusion of the Improving Mental Health Access from the Emergency Department Act (S. 1346) in your draft legislation. S. 1346 would establish a competitive grant program for EDs to implement approaches for securing follow-up care for patients who are experiencing a mental health crisis, including better coordination with regional providers to expedite the transition from the ED; increasing the number of inpatient psychiatric beds to lessen the wait time in placement; and expanding emerging approaches like telehealth to help EDs provide appropriate care in a timely manner. The impact of these policies would be immediate. They would reduce the staffing requirements in hospitals and improve the work environment in EDs, which in turn will improve the recruitment and retention of emergency nurses.

Thank you again for the opportunity to provide our input on the causes of the health care workforce shortage, especially as it pertains to emergency nurses, and solutions for addressing this crisis. We greatly appreciate your commitment to developing bipartisan legislation related to this important issue. If you have any questions or require additional information, please contact ENA’s Chief Government Relations Officer, Richard Mereu, at 202-741-9373.




2023 ENA President

The Emergency Nurses Association is the premier professional nursing association dedicated to defining the future of emergency nursing through advocacy, education, research, innovation, and leadership. Founded in 1970, ENA has proven to be an indispensable resource to the global emergency nursing community. With 50,000 members worldwide, ENA advocates for patient safety, develops industry-leading practice standards and guidelines and guides emergency health care public policy. ENA members have expertise in triage, patient care, disaster preparedness, and all aspects of emergency care. Additional information is available at www.ena.org.