VA HEALTH CARE

Oversight 

Improvements 

Needed for Nurse 

Recruitment and 

Retention Initiatives

Report to the Chairman, Subcommittee 

on Oversight & Investigations, 

Committee on Veterans’ Affairs, House 

of Representatives

September 2015

GAO-15-794

United States Government Accountability Office
Highlights of GAO-15-794, a report to the 

Chairman, Subcommittee on Oversight & 

Investigations, Committee on Veterans’

Affairs, House of Representatives

September 2015

VA HEALTH CARE

Oversight Improvements Needed for Nurse 

Recruitment and Retention Initiatives

Why GAO Did This Study

GAO and others have highlighted the 

need for an adequate and qualified 

nurse workforce to provide quality and 

timely care to veterans. VHA faces 

challenges such as increased 

competition for skilled clinicians in 

hard-to-fill occupations such as nurses. 

As GAO has previously reported, 

recruitment and retention is particularly 

difficult for nurses with advanced 

professional skills, knowledge, and 

experience, which is critical given 

veterans’ needs for more complex 

specialized services.

GAO was asked to provide information 

on the recruitment and retention of 

nurses within VHA. This report reviews 

(1) the initiatives VHA has to recruit 

and retain its nurse workforce and 

(2) the extent to which VHA oversees 

its nurse recruitment and retention 

initiatives. GAO reviewed documents 

and interviewed officials from VHA, 

four VA medical centers selected to 

reflect variation in factors such as 

nurse turnover, and regional offices for 

these medical centers. GAO used 

federal internal control standards to 

evaluate VHA’s oversight. GAO also 

interviewed selected stakeholder 

organizations.

What GAO Recommends

GAO recommends VA (1) develop a 

process to help monitor medical 

centers’ compliance with its key nurse 

recruitment and retention initiatives; 

(2) evaluate the adequacy of training 

resources provided to nurse recruiters; 

and (3) conduct a system-wide 

evaluation of its key nurse recruitment 

and retention initiatives. VA concurred 

with the recommendations.

What GAO Found

The Department of Veterans Affairs’ (VA) Veterans Health Administration (VHA) 

has multiple system-wide initiatives to recruit and retain its nurse workforce, but 

three of the four VA medical centers in GAO’s review faced challenges offering 

them. VHA identified a number of key initiatives it offers to help medical centers 

recruit and retain nurses, which focus primarily on providing (1) education and 

training, and (2) financial benefits and incentives. VA medical centers generally 

have discretion in offering these initiatives. The four medical centers in GAO’s 

review varied in the number of initiatives they offered, and three of these medical 

centers developed local recruitment and retention initiatives in addition to those 

offered by VHA. GAO also found that while three of the four medical centers 

reported improvements in their ability to recruit and retain nurses through their 

offering of VHA’s initiatives; they also reported challenges. The challenges 

included a lack of sufficient administrative support for medical centers, 

competition with private sector medical facilities, reduced pool of nurses in rural 

locations with advanced training, and employee dissatisfaction.

VHA’s oversight of its key system-wide nurse recruitment and retention initiatives 

is limited. Specifically, GAO found that VHA conducts limited monitoring of 

medical centers’ compliance with its initiatives. For example, in the past, VHA 

conducted site visits in response to a medical center reporting difficulty with 

implementation of one of its initiatives, and to assess compliance with program 

policies, but it is no longer conducting these visits. Consistent with federal 

internal control standards, monitoring should be ongoing and should identify 

performance gaps in a policy or procedure. With limited monitoring, VHA lacks 

assurance that its medical centers are complying with its nurse recruitment and 

retention initiatives, and that any problems are identified and resolved in a timely 

and appropriate manner. In addition, VHA has not conducted evaluations of the 

training resources provided to nurse recruiters at VA medical centers or the 

overall effectiveness of the initiatives in meeting its nurse recruitment and 

retention goals, or whether any changes are needed. Consistent with federal 

internal control standards, measuring performance tracks progress towards 

program goals and objectives, and provides important information to make 

management decisions and resolve any problems or program weaknesses. For 

example, GAO found that VHA does not know whether medical centers have 

sufficient training to support its nurse recruitment and retention initiatives. In 

particular, there is currently no face-to-face training provided by VHA specifically 

for nurse recruiters, but there is regular training available to those assigned to a 

human resources office as part of training available to all human resources staff. 

Representatives from a national nursing organization reported that clinical nurse 

recruiters at VA medical centers often feel more unprepared for the position than 

those assigned to human resources offices, but no evaluation of this disparity or 

its effects has occurred. Without evaluations of its collective system-wide 

initiatives, VHA is unable to determine to what extent its nurse recruitment and 

retention initiatives are effective in meeting VHA policies and the Veterans 

Access, Choice, and Accountability Act provisions, or ultimately whether VHA 

has an adequate and qualified nurse workforce at its medical centers that is 

sufficient to meet veterans’ health care needs.

View GAO-15-794. For more information, 

contact Debra Draper at (202) 512-7114 or 

draperd@gao.gov.

United States Government Accountability Office
Letter 1

Background 5

VHA Has Multiple Nurse Recruitment and Retention Initiatives, but 

Some Medical Centers Face Challenges That Limit the 

Initiatives’ Usefulness 10

VHA’s Oversight of Its Nurse Recruitment and Retention Initiatives 

Is Limited 18

Conclusions 23

Recommendations for Executive Action 24

Agency Comments 24

Appendix I Selected Characteristics of Veterans Health Administration’s (VHA) 

Nurse Workforce 26

Appendix II Selected Characteristics of Veterans Health Administration’s (VHA) Key 

Nurse Recruitment and Retention Initiatives 28

Appendix III Comments from the Department of Veterans Affairs 29

Appendix IV GAO Contact and Staff Acknowledgments 32

Tables

Table 1: Veterans Health Administration (VHA) Nurse Positions, 

Responsibilities, and Educational Requirements 7

Table 2: Veterans Health Administration’s (VHA) Key Nurse 

Recruitment and Retention Initiatives, as of July 2015 11

Table 3: Veterans Health Administration’s (VHA) Key Nurse 

Recruitment and Retention Initiatives Offered by Four 

Selected Medical Centers during Fiscal Years (FY) 2010 

through 2014 14

Table 4: Number of Veterans Health Administration (VHA) Nurses 

Providing Direct and Indirect Care, by Position Type, 

Fiscal Year (FY) 2010 through FY 2014 26

Contents

Page i GAO-15-794 VA Nurse Recruitment and Retention
Table 5: Number of Nurse Workforce Hires and Losses for FY 

2015 at VA Medical Centers, by Position Type, as of June 

2015 26

Table 6: Veterans Health Administration (VHA) Nurse Turnover 

Rates by Position Type, Fiscal Year (FY) 2010 through FY 

2014 27

Figure

Figure 1: Skill Mix of the Veterans Health Administration’s (VHA) 

Nurse Workforce at VA Medical Centers by Position 

Type, Fiscal Year (FY) 2010 through FY 2014 8

Abbreviations

Choice Act Veterans Access, Choice, and Accountability Act of 2014

FY fiscal year

GPRA Government Performance and Results Act of 1993

LPN licensed practical nurse

NA nursing assistant

NP nurse practitioner

OIG Office of Inspector General

RN registered nurse

VA Department of Veterans Affairs

VHA Veterans Health Administration

VISN Veterans Integrated Service Network

This is a work of the U.S. government and is not subject to copyright protection in the 

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Page ii GAO-15-794 VA Nurse Recruitment and Retention
441 G St. N.W.

Washington, DC 20548

September 30, 2015

The Honorable Mike Coffman

Chairman

Subcommittee on Oversight & Investigations

Committee on Veterans’ Affairs

House of Representatives

Dear Mr. Chairman:

The Department of Veterans Affairs’ (VA) Veterans Health 

Administration’s (VHA) mission is to provide quality and timely care for 

veterans. It is essential that VHA recruit and retain an adequate number 

of skilled clinicians, including nurses, at its 167 medical centers across 

the country to achieve its mission. VHA faces difficulties ensuring it has 

the appropriate clinical workforce to meet the current and future needs of 

veterans due to factors such as national shortages and increased 

competition for clinicians in hard-to-fill occupations, including nurses. We 

previously reported that VHA noted particular difficulty recruiting and 

retaining nurses with advanced professional skills, knowledge, and 

experience, which are particularly important for certain hospital units, 

such as intensive care units, that require higher-intensity nursing.1 In spite 

of an increase in the number of students enrolled in nurse programs 

throughout the U.S., some areas of the country are expected to 

experience a smaller growth in nurses, and demand for nurses with the 

advanced education needed to provide more highly skilled patient care 

will likely persist.2

Recent events have further highlighted the need for adequate and 

qualified clinicians to provide quality and timely care to veterans. In 2014, 

GAO, VA’s Office of Inspector General (OIG), and other stakeholders 

testified before Congress on patient deaths alleged to be related to delays 

1

See GAO, VA Health Care: Actions Needed to Ensure Adequate and Qualified Nurse 

Staffing, GAO-15-61 (Washington, D.C.: Oct. 16, 2014).

2

U.S. Department of Health and Human Services, Health Resources and Services 

Administration, National Center for Health Workforce Analysis. The Future of the Nursing 

Workforce: National- and State-Level Projections, 2012-2015. Rockville, Md.: 2014.

Letter

Page 1 GAO-15-794 VA Nurse Recruitment and Retention

 
in patient care, long patient wait times, and problematic scheduling 

practices at VA medical centers. Some of the stakeholders concluded that 

VHA needed additional clinical staff, including nurses, to provide quality 

care to veterans in a timely manner. In addition, Congress passed the 

Veterans Access, Choice, and Accountability Act of 2014 (Choice Act), 

which appropriated $5 billion to, among other things, hire additional 

clinical staff, including nurses.3 VHA reported that more than 10,000 

additional clinicians and support staff will be hired by the end of fiscal 

year (FY) 2016 to help meet the needs of VA medical centers across the 

country. In January 2015, the VA OIG reported on the five VHA 

occupations with the highest staffing shortages; nursing was second 

among those occupations.4

You asked for information on nurse recruitment and retention at VA 

medical centers. In this report, we reviewed (1) key initiatives VHA has to 

recruit and retain its nurse workforce and (2) the extent to which VHA 

oversees its nurse recruitment and retention initiatives.

To identify key initiatives VHA has to recruit and retain its nurse 

workforce, we reviewed VHA documents and reports describing its 

system-wide recruitment and retention initiatives for nurses. We identified 

as key those initiatives with primary goals that included the recruitment 

and retention of nurses. We reviewed policies and procedures that guide 

VA medical centers in offering these initiatives to nurses, and reviewed 

documentation of annual assessments and program evaluations to 

identify any potential successes or difficulties in recruiting and retaining 

nurses, generally, or by specialty or position type—nurse practitioners 

(NP), registered nurses (RN), licensed practical nurses (LPN), or nursing 

assistants (NA). (Unless otherwise noted, the term “nurses” in this report 

includes all position types.) We interviewed officials from VHA’s central 

office—Office of Nursing Services, Office of Academic Affiliations, 

Healthcare Talent Management, and Workforce Management & 

Consulting—about the key system-wide initiatives they have to help VA 

medical centers recruit and retain nurses. We also reviewed VHA data, 

3

Pub. L. No.113-146, §§ 801(a)-(b) and 802(c), 128 Stat.1754,1801-1802 (Aug. 7, 2014).

4

The VHA occupation with the highest staffing shortage was physicians. See Department 

of Veterans Affairs, Office of Inspector General, OIG Determination of Veterans Health 

Administration’s Occupational Staffing Shortages, Report No. 15-00430-103 (Washington,

D.C.: Jan. 30, 2015).

Page 2 GAO-15-794 VA Nurse Recruitment and Retention

 
such as funding levels for the initiatives, the number of VA medical 

centers offering the initiatives, and the number of nurses that participated, 

from FY 2010 through FY 2014.5 We assessed the reliability of these data 

through reviews of supporting documentation and interviews with 

knowledgeable VHA officials and determined that they were sufficiently 

reliable for our purposes.

In addition, we reviewed documents and interviewed officials and nursing 

staff from four VA medical centers located in (1) Iron Mountain, Michigan; 

(2) Oklahoma City, Oklahoma; (3) San Francisco, California; and 

(4) Wilmington, Delaware about the extent to which they offered VHA’s 

key recruitment and retention initiatives to nurses from FY 2010 through 

FY 2014 and their experiences doing so, as well as any initiatives 

developed locally—at each medical center or its respective Veterans 

Integrated Service Network (VISN).6 In particular, we interviewed medical 

center officials about any successes or difficulties in offering VHA and any 

local initiatives to nurses, any improvements needed to the initiatives, and 

the effectiveness of the initiatives in recruiting and retaining nurses at 

their medical center. We selected the four medical centers to reflect 

variation in factors such as average nurse turnover rate, geographic 

location, rural vs. urban location, and facility complexity.7 For each of the 

four medical centers, we reviewed documents describing any recruitment 

and retention initiatives developed by the medical center or its associated 

VISN, as well as any local policies and procedures used to guide the

medical center in offering VHA and local initiatives. We also interviewed 

officials from the VISNs associated with these four VA medical centers. 

We did not collect information on local initiatives at all VA medical 

centers; therefore, this information is not generalizable system-wide. We 

5

Funding levels for the initiatives are the amounts expended on the initiatives.

6

Each of VHA’s 21 VISNs is responsible for managing and overseeing VA medical centers 

within a defined geographic area.

7

The nurse turnover rate includes any loss, such as retirement, death, termination or 

voluntary separation that removes a nurse employee from VHA. The average nurse 

turnover rates were calculated for FY 2009 through FY 2013 for all nurses within VHA, 

regardless of position. The national average turnover rate over this 5-year period was 

7.2 percent. (Turnover data from FY 2009 through FY 2013 were the most recent data 

available at the time we selected our sites.) VA assigns each medical center a complexity 

score derived from multiple variables to measure facility complexity arrayed along four 

categories, namely patient population served, clinical services offered, education and 

research complexity, and administrative complexity.

Page 3 GAO-15-794 VA Nurse Recruitment and Retention

 
also interviewed representatives of veterans service organizations, 

nursing organizations, and unions that represent nurses at the selected 

medical centers about the recruitment and retention of nurses, including 

the extent to which VHA initiatives have improved the recruitment and 

retention of nurses at VA medical centers.8

To determine the extent to which VHA oversees its key recruitment and 

retention initiatives for nurses, we reviewed documents, such as VHA 

directives, policies, and evaluation plans that describe requirements and 

guidance regarding VHA’s and VISNs’ oversight of the initiatives. We 

interviewed officials from VHA and the VISNs associated with the four VA 

medical centers included in our review regarding their oversight, including 

the extent to which VHA evaluates the effectiveness of the initiatives; 

monitors medical center compliance with the policies related to VHA’s 

recruitment and retention initiatives; provides clear and comprehensive 

communication to medical centers; and collects, assesses, and 

incorporates feedback to improve the initiatives. We reviewed documents, 

such as any local policies or evaluations, and conducted interviews with 

officials from the VA medical centers about the oversight they conduct at 

each of their respective medical centers. We determined whether VHA 

applied appropriate internal controls in its oversight of the key recruitment 

and retention initiatives for nurses by reviewing relevant criteria from 

federal internal control standards.9 We also reviewed relevant criteria 

from GAO’s body of work on effectively managing performance under the

8

We interviewed representatives from the following veterans service organizations: 

Disabled American Veterans and Paralyzed Veterans of America; from the following 

nursing organizations: American Psychiatric Nurses Association, Nurses Organization of 

VA, and Veteran’s Administration Nurse Recruiters Association; and from the following 

unions that represent nurses at the medical centers included in our review: American 

Federation of Government Employees and Laborers’ International Union of North 

America.

9

See GAO, Standards for Internal Control in the Federal Government, 

GAO/AIMD-00-21.3.1 (Washington, D.C.: November 1999); Internal Control 

Management and Evaluation Tool, GAO-01-1008G (Washington, D.C.: August 2001). 

Internal control is synonymous with management control and comprises the plans, 

methods, and procedures used to meet missions, goals, and objectives.

Page 4 GAO-15-794 VA Nurse Recruitment and Retention

 
Government Performance and Results Act of 1993 (GPRA), as enhanced 

by the GPRA Modernization Act of 2010.

10

We conducted this performance audit from October 2014 through

September 2015 in accordance with generally accepted government 

auditing standards. Those standards require that we plan and perform the 

audit to obtain sufficient, appropriate evidence to provide a reasonable 

basis for our findings and conclusions based on our audit objectives. We 

believe that the evidence obtained provides a reasonable basis for our 

findings and conclusions based on our audit objectives.

Nurse recruitment and retention is essential for VHA to carry out its 

mission to provide quality care that improves the health and well-being of 

veterans. In its 2014 Interim Workforce and Succession Strategic Plan, 

VHA identified nurses as the second most mission-critical occupation for 

recruitment and retention; only physicians ranked higher.11 As the 

demand for health care services increases, effective nurse recruitment 

and retention is increasingly important for VHA to ensure an adequate 

and qualified workforce.

In the last 5 years, the number of nurses providing care to veterans has 

increased, and VHA expects it will continue to increase because of the 

expected increased demand for services. In FY 2014, VHA employed 

more than 85,000 nurses who provided both direct and indirect care to 

patients through its health care system.12 The number of nurses providing 

direct patient care has increased from about 72,000 to about 82,000—

10GAO, Managing For Results: GPRA Modernization Act Implementation Provides 

Important Opportunities to Address Government Challenges, GAO-11-617T (Washington, 

D.C.: May 10, 2011); Executive Guide: Effectively Implementing the Government 

Performance and Results Act, GAO/GGD-96-118 (Washington, D.C.: June 1996); 

Managing For Results: Executive Branch Should More Fully Implement the GPRA 

Modernization Act to Address Pressing Governance Challenges, GAO-13-518 

(Washington, D.C.: June 26, 2013).

11Department of Veterans Affairs, Veterans Health Administration, 2014 Interim Workforce 

and Succession Strategic Plan (Washington, D.C.: 2014).

12Direct care includes any services that are provided to a veteran at the bedside; indirect 

care includes administrative and clerical duties that support direct patient care. All direct 

care services are provided at VA medical centers. Indirect care services can be provided 

at VA medical centers, VISNs, or VA’s central office.

Background

VHA’s Nurse Workforce

Page 5 GAO-15-794 VA Nurse Recruitment and Retention

 
approximately a 14 percent increase—from FY 2010 through FY 2014, 

while the number of unique patients served increased from about 6.0 

million to about 6.6 million—approximately a 10 percent increase—during 

this same time period. VHA projects that approximately 40,000 new RNs 

will be needed through FY 2018 to maintain adequate staffing levels, 

including replacing retired nurses, to meet veterans’ needs. (See app. I 

for the number of nurses providing direct and indirect care at VA medical 

centers from FY 2010 through FY 2014.)

In addition to the need for more nurses due to an increasing number of 

veterans, VHA anticipates that changes in veteran demographics, 

including an aging population, will increase the need for nurses to provide 

more complex types of services to care for veterans. In its 2014 Interim 

Workforce and Succession Strategic Plan, VHA reported that after 2015, 

the largest segment of the veteran population will be between 65 and 

84 years of age. Also, the number of women veterans receiving care 

through VHA has nearly doubled since 2004, requiring changes to the 

type of care provided and corresponding skills needed. VHA estimates 

that veteran usage of primary care, surgical specialty care, and mental 

health care will each increase by more than 20 percent over the next 

10 years.

The nurse skill mix—the proportion of each type of nurse (NPs, RNs, 

LPNs, and NAs) of the total nursing staff in a particular unit or medical 

center—is an important component of VHA nurse staffing, as the level of 

education and training for each nurse position determines the types of 

services that can be provided.13 (See table 1 for VHA nurse positions, 

responsibilities, and educational requirements.) For example, intensive 

care units require higher intensity nursing, and may have a skill mix that is 

primarily composed of RNs compared to other types of units that may 

provide less complex care, such as outpatient clinics.

13Under statutory authority, VA establishes the education requirements of its health care 

practitioners, including NPs, RNs, LPNs, and NAs. See 38 U.S.C. § 7401.

VHA Nurse Skill Mix

Page 6 GAO-15-794 VA Nurse Recruitment and Retention

 
Table 1: Veterans Health Administration (VHA) Nurse Positions, Responsibilities, and Educational Requirements

Position type Responsibilities Educational requirements

Nurse practitioner (NP) Independently assesses and evaluates patients, 

provides care, administers medications, 

documents patients’ medical conditions 

including admissions and discharges, analyzes 

test results, establishes treatment plans, and 

operates medical equipment.a

Completed an advanced nursing education program, 

met state licensing requirements, and maintains a 

current certification to obtain an NP license.

Registered nurse (RN) Provides care to patients, administers 

medications, documents patients’ medical 

conditions including admissions and discharges, 

analyzes test results, establishes treatment 

plans, and operates medical equipment.

Completed a nursing education program, met state 

licensing requirements, and passed a nurse licensing 

examination to obtain an RN license.

Licensed practical nurse 

(LPN)

Takes patient vital signs, provides basic care, 

and administers medications, but generally does 

not provide certain complex patient care 

services such as patient assessments or 

administration of intravenous medications.

Obtained a high school diploma or its equivalent and 

passed a licensing examination upon completion of a 

state-approved program available at technical schools 

and community colleges, typically lasting 1 year.

Nursing assistant (NA) Attends to basic patient needs such as providing 

personal care to patients (e.g., assistance with 

bathing, dressing, and hygiene), carries out nonspecialized duties (e.g., measures blood 

pressure), and supports other nursing staff.

Registered as a nursing assistant with relevant state 

health department, and passed a written competency 

examination upon completion of a state-approved 

training program, generally lasting 3 to 12 weeks. 

Source: VHA. I GAO-15-794

Note: Under statutory authority, VA establishes the educational requirements of its health care 

practitioners, including NPs, RNs, LPNs, and NAs.

a

NP scope of practice is determined by the individual medical center and/or relevant state.

In the last 5 fiscal years, RNs comprised the largest percentage of nurses 

within VHA, and were approximately 64 percent of the nurse workforce in 

FY 2014. NPs comprised the smallest percentage over the same period. 

(See fig. 1.)

Page 7 GAO-15-794 VA Nurse Recruitment and Retention
Figure 1: Skill Mix of the Veterans Health Administration’s (VHA) Nurse Workforce 

at VA Medical Centers by Position Type, Fiscal Year (FY) 2010 through FY 2014

Note: The figure reflects the overall VHA nurse workforce, including nurses providing direct and 

indirect care services.

For the first time, in FY 2015, VA began collecting data on the number of 

nurse hires and vacancies at each of its medical centers. For FY 2015, as 

of June, VA medical centers hired approximately 8,600 nurses; 

approximately 5,100 (59 percent) were RNs, and approximately 430 were 

NPs (5 percent), reflecting VHA’s need for nurses with advanced skills 

and education. Despite these new hires, VHA estimated that there were 

about 17,000 vacancies across VA medical centers as of June 2015, with 

about 12,100 (71 percent) for RN positions. (See app. I for the number of 

nurse hires and losses at VA medical centers for FY 2015, as of June.)

Page 8 GAO-15-794 VA Nurse Recruitment and Retention
The average national nurse turnover rate for VHA from FY 2010 through 

FY 2014 was 7.6 percent.14 The turnover rates for NPs and RNs 

increased over this same period, and in FY 2014, were 9.1 percent and 

7.8 percent, respectively. VHA reported high projected losses for nurses, 

such as from retirement, in the next few fiscal years. In 2014, for 

example, VHA reported that by FY 2019, approximately 20 percent of its 

nurses will be eligible for retirement. Retirement and career advancement 

through opportunities elsewhere were the top two reasons why nurses 

reportedly left VHA. In addition, according to findings from VHA’s 2015 

Workforce Planning Report, approximately 12 percent of all nurses that 

left VHA in FY 2012 did so in their first year of employment. (See app I. 

for annual nurse turnover rates by position type for FY 2010 through 

FY 2014.)

VA medical centers are responsible for recruiting and retaining nurses in 

their respective facilities, with VHA providing support to assist them. 

Specifically, VHA has developed initiatives that medical centers may offer 

to help with the recruitment and retention of nurses. VHA also provides 

guidance and policies to its medical centers on the process of recruiting 

and hiring nurses and on the initiatives medical centers may use to help 

with recruitment and retention. Additionally, VHA provides marketing 

services and tools to medical centers, including marketing campaigns that 

advertise the benefits of working at VHA and recruitment brochures that 

medical centers can use at local career fairs. Nurse recruitment begins 

with advertising and publicizing available positions to encourage potential 

candidates to apply, through various channels, including through local 

publications, job fairs, and USAjobs.gov.15 Once medical centers recruit, 

interview, and select a nursing candidate, that nursing candidate goes

through a process known as onboarding and credentialing.16

14The overall nurse workforce turnover rate at each of the VA medical centers ranged 

from 2 percent to 17 percent in FY 2014.

15USAjobs.gov is the federal government’s official website that advertises vacant 

positions. The website also provides information about federal occupations and allows 

candidates to apply for vacant positions online.

16Onboarding and credentialing is the process that health professional candidates must 

complete before they can begin working at VA medical centers. This process involves 

several steps, including VHA verifying candidates’ work experience and credentials, and 

candidates completing a physical examination.

Roles and Responsibilities 

for VHA Nurse 

Recruitment and Retention

Page 9 GAO-15-794 VA Nurse Recruitment and Retention

 
Most medical centers employ nurse recruiters, who are responsible for 

managing the administrative components of the hiring process, as well as 

various aspects of nurse recruitment and retention. The nurse recruiter 

position varies among medical centers. Some medical centers assign the 

nurse recruiter to the medical center’s clinical nursing services office, and 

these nurse recruiters are typically RNs. Other medical centers assign 

nurse recruiters to the medical center’s human resources office, and 

these nurse recruiters may not have clinical backgrounds.

VHA has multiple system-wide initiatives to recruit and retain its nurse 

workforce, but some VA medical centers face challenges in offering them 

to nurses and with recruitment and retention more broadly. We found that 

VHA has eight key initiatives that medical centers may offer to help them 

recruit and retain nurses. (See table 2.) VHA’s initiatives focus primarily 

on providing (1) education and training, and (2) financial benefits and 

incentives.17 (See app. II for VHA expenditures for and nurse participation 

in key recruitment and retention initiatives from FY 2010 through FY 

2014.)

17VHA has other initiatives that may aid in the recruitment and retention of nurses, such as 

special advancements for performance or nursing achievements. For the purposes of this 

report, we focused on VHA’s initiatives whose primary goals included nurse recruitment 

and retention.

VHA Has Multiple 

Nurse Recruitment 

and Retention 

Initiatives, but Some 

Medical Centers Face 

Challenges That Limit 

the Initiatives’ 

Usefulness

Page 10 GAO-15-794 VA Nurse Recruitment and Retention

 
Table 2: Veterans Health Administration’s (VHA) Key Nurse Recruitment and Retention Initiatives, as of July 2015

Initiative Description

Education and training initiatives

RN Transition to Practice Provides 12-month standardized on-the-job training to assist registered nurses (RN) 

with 1 year or less of nursing experience with their transition from entry-level to 

professional nurse. All VA medical centers that hire RNs with 1 year or less of 

experience are required to offer this initiative.

VA Learning Opportunities Residency Provides eligible nursing students who have completed their junior years of

accredited nursing programs with hands-on learning opportunities through full- or 

part-time summer employment at VA medical centers.a VA medical centers must 

submit requests for proposals, and VHA funds selected medical centers for 5 years.

VA Nursing Academic Partnerships Provides funding for partnerships between VA medical centers and schools of 

nursing for baccalaureate degree programs. The partnerships are to provide 

veteran-centric initiatives and opportunities for clinical education at VA medical 

centers. Schools of nursing agree to increase student enrollment by a certain 

number of students for each VA nurse who serves as a faculty member. VA medical 

centers must submit requests for proposals, and VHA funds selected medical 

centers for 5 years. Funds are intended to assist medical centers in developing

residency programs for undergraduate students in collaboration with schools of 

nursing and to assist with hiring faculty and program directors at both medical 

centers and schools of nursing. Selected VA medical centers must also offer a PostBaccalaureate Nurse Residency, which has a defined curriculum based on national 

accreditation standards and clinical requirements for RNs graduating from a 

baccalaureate degree program.b

VA Nursing Academic Partnerships – Graduate 

Education

Provides funding for partnerships between VA medical centers and schools of 

nursing for graduate education programs. The partnerships are to provide veterancentric initiatives and opportunities for clinical education at VA medical centers. 

Schools of nursing agree to increase student enrollment by a certain number of 

students for each VA nurse who serves as a faculty member. VA medical centers 

must submit requests for proposals, and VHA funds selected medical centers for 

5 years. Funds are intended to assist medical centers in developing residency 

programs for graduate students in collaboration with schools of nursing and to assist 

with hiring faculty and program directors at both medical centers and schools of 

nursing. Selected VA medical centers are expected to offer one or more of the 

following residency programs: Acute Care Nurse Practitioner Residency, AdultGerontology Nurse Practitioner Residency, or Psychiatric Mental Health Nurse 

Practitioner Residency.c

Financial benefits and incentives initiatives

Recruitment, retention, and relocation 

incentives

Provides financial incentives for prospective or current VA employees, including 

nurses, in hard-to-recruit or hard-to-retain positions.

Education Debt Reduction Program Reimburses qualifying education loan debt for staff, including nurses, in hard-torecruit positions. Nurses apply directly to the medical center, and applications are 

approved by VHA. The Veterans Access, Choice, and Accountability Act of 2014 

increased the maximum reimbursement per recipient from $60,000 to $120,000. 

VHA reimburses nurses up to $120,000 for 5-year service period.

Page 11 GAO-15-794 VA Nurse Recruitment and Retention
Initiative Description

Employee Incentive Scholarship Program Provides scholarships to healthcare professionals, including nurses, pursuing 

associate, baccalaureate, and advanced degree programs, and replacement 

salaries to VA medical centers with scholarship recipients attending school full time. 

Nurses apply directly to the medical center, and applications are approved by VHA. 

Nurses may receive funds for the equivalent of a 3-year full-time degree program. 

After completing the degree program, nurses must also enter into a service 

obligation, ranging from 1 to 3 years, as a full-time employee. Components of this 

initiative include the National Nursing Education Initiative, which provides 

scholarships to RNs, and the VA National Education for Employees Program, which 

reimburses medical centers for salaries of scholarship recipients who are attending 

school full time.

Flexible work schedules Allows variations in nurse work schedules, such as different shifts, the number of 

days worked per pay period, and options to work part-time schedules.

Source: VHA. I GAO-15-794

Notes: Unless otherwise indicated, VA medical centers had discretion in offering VHA’s recruitment 

and retention initiatives for nurses.

VHA has other initiatives that may aid in the recruitment and retention of nurses, such as special 

advancements for performance or nursing achievements. For the purposes of this report, we focused 

on VHA’s initiatives whose primary goals included nurse recruitment and retention.

a

RNs who were former VA Learning Opportunities Residency students were eligible to be hired at VA 

medical centers at higher salaries based on their performance in the residency, or the number of 

hours they completed as residents.

b

In 2011, VHA introduced the Post-Baccalaureate Nurse Residency as a stand-alone initiative. In 

2015, VHA rolled the residency into the existing VA Nursing Academic Partnerships initiative for new 

applicants to begin in academic year 2015-2016. RNs who complete the Post-Baccalaureate Nurse 

Residency are eligible to be hired at VA medical centers at higher salaries.

c

In 2013, VHA introduced the Psychiatric Mental Health Nurse Practitioner Residency as a standalone initiative. In 2015, VHA introduced a graduate-education initiative—the VA Nursing Academic 

Partnerships – Graduate Education—into which it rolled the residency for new applicants.

With the exception of the mandatory RN Transition to Practice initiative, 

VA medical centers generally have discretion to offer any of VHA’s 

initiatives to nurses, including the discretion to submit requests for 

proposals for any of the initiatives that require them. The four VA medical 

centers in our review varied in the number of initiatives they offered from 

FY 2010 through FY 2014. (See table 3.) For example, one of the medical 

centers in our review offered three of the four education and training 

initiatives—RN Transition to Practice, VA Nursing Academic Partnerships, 

and VA Learning Opportunities Residency. This medical center also 

offered the Post-Baccalaureate Nurse Residency—which, beginning in 

FY 2015, is part of the VA Nursing Academic Partnerships—and 

developed curricula to move participants through the initiatives.18 This 

18In 2011, VHA introduced the Post-Baccalaureate Nurse Residency as a stand-alone 

initiative. In 2015, VHA rolled this initiative into the VA Nursing Academic Partnerships for 

new applicants to begin in academic year 2015-2016.

Page 12 GAO-15-794 VA Nurse Recruitment and Retention

 
medical center also offered all four of the financial initiatives—recruitment, 

retention, and relocation incentives; the Education Debt Reduction 

Program; the Employee Incentive Scholarship Program; and flexible work 

schedules.19 The medical center ceased offering recruitment, retention, 

and relocation incentives in 2013; according to medical center officials, 

VHA introduced new employee performance criteria that medical center 

officials felt were too difficult for employees to achieve or for medical 

centers to provide justification for retention incentives. Officials from all 

four medical centers reported offering flexible work schedules to provide 

nurses with options when trying to maintain work life balance, such as 

offering nurses compressed schedules (e.g., 10-hour shifts, 4 days a 

week).20

19According to officials, the medical center offered flexible work schedules in some, but 

not all, of its units.

20We previously reported on the availability of flexible work schedules at VA. See GAO,

VA Health Care: Improved Staffing Methods and Greater Availability of Alternate and 

Flexible Work Schedules Could Enhance the Recruitment and Retention of Inpatient 

Nurses, GAO-09-17 (Washington, D.C.: Oct. 24, 2008).

Page 13 GAO-15-794 VA Nurse Recruitment and Retention

 
Table 3: Veterans Health Administration’s (VHA) Key Nurse Recruitment and Retention Initiatives Offered by Four Selected 

Medical Centers during Fiscal Years (FY) 2010 through 2014

Initiative

Medical 

Center A

Medical 

Center B

Medical 

Center C

Medical 

Center D

Education and training initiatives

RN Transition to Practice X X X

VA Learning Opportunities Residency X X

VA Nursing Academic Partnershipsa Xb

VA Nursing Academic Partnerships – Graduate Educationc

Financial benefits and incentives initiatives

Recruitment, retention, and relocation incentives X X X

Education Debt Reduction Program X X X X

Employee Incentive Scholarship Program X X X X

Flexible work schedules X X X X

Source: VA medical centers in our review. I GAO-15-794

Note: An “X” in a column indicates that the medical center offered the VHA recruitment and retention 

initiative to nurses for at least 1 year during the 5-year period.

a

In 2011, VHA introduced the Post-Baccalaureate Nurse Residency as a stand-alone initiative. In 

2015, VHA rolled this residency into the existing VA Nursing Academic Partnerships initiative for new 

applicants to begin in academic year 2015-2016.

b

Medical Center B offered the VA Nursing Academic Partnerships during the FY 2010 through FY 

2014 period, as well as the Post-Baccalaureate Nurse Residency when it was a stand-alone initiative.

c

In 2013, VHA introduced the Psychiatric Mental Health Nurse Practitioner Residency as a standalone initiative, and none of the selected medical centers offered this initiative during the period of our 

review. In 2015, VHA introduced a graduate-education track—the VA Nursing Academic Partnerships 

– Graduate Education—into which it rolled the residency for new applicants.

While VA medical centers generally have discretion to offer any of VHA’s 

initiatives, all medical centers that employed RNs with less than 1 year of 

nursing experience were required to offer the RN Transition to Practice 

initiative.21 However, officials from two medical centers in our review 

reported not offering the initiative at all or not offering it across all 5 fiscal 

years. Officials from one medical center offered the RN Transition to 

Practice initiative for 1 year, beginning in 2012, but subsequently decided 

not to hire newly graduated nurses because of the extensive orientation 

and training they required. According to officials, after one of its current 

21In November 2011, VHA issued a directive establishing as VHA policy that VA medical 

centers offer the RN Transition to Practice initiative. Department of Veterans Affairs, VHA 

Registered Nurses (RN) Transition-to-Practice Program, VHA Directive 2011-039 

(Washington, D.C.: Nov. 23, 2011).

Page 14 GAO-15-794 VA Nurse Recruitment and Retention

 
LPNs returned to school to become an RN, this medical center 

coordinated with another VA medical center in the region for this new RN 

to participate in that medical center’s RN Transition to Practice 

curriculum. Officials from the second medical center told us that it offered 

a 16-week program designed to help new nurses acclimate to VA but did 

not offer VHA’s 12-month RN Transition to Practice initiative because 

they did not believe it was required.

In addition to offering VHA’s initiatives, three of the four medical centers 

in our review developed local recruitment and retention initiatives. Two

medical centers developed initiatives to provide employment to train 

student nurses; the medical centers’ initiatives were similar to the VA 

Learning Opportunities Residency. Officials from one of these medical 

centers told us that the medical center developed a local initiative 

because the nursing schools in the region offered associate degrees only; 

whereas, VHA’s initiative requires medical centers to partner with schools 

of nursing with baccalaureate degree programs. The other medical center 

offered the VA Learning Opportunities Residency, as well as its own 

student nurse employment and training initiative. Officials from a third 

medical center in our review told us that the medical center offered a 16-

week RN Transition to Practice initiative to train new RN graduates; these 

RNs are hired on a temporary basis and are hired as full-time employees 

when RN vacancies open.

Officials from three of the four medical centers in our review reported that 

VHA’s initiatives helped improve their ability to recruit and retain nurses, 

as shown in the following examples:

• Officials from one medical center reported that they hired 9 of the 10

nurses who participated in the VHA Post-Baccalaureate Nurse 

Residency as full-time nurses in academic year 2012-2013, the first 

year the medical center offered the initiative. The medical center 

retained 7 of these 9 nurses as of the end of the following academic 

year 2013-2014.

• Officials from another medical center that offered the Education Debt 

Reduction Program reported that, of the six nurses that began the 

program since 2010, five completed the 5-year service agreement 

and, as of April 2015, remained employees of the medical center.

• Officials from one medical center that offered the Employee Incentive 

Scholarship Program reported that 23 nurses completed the program 

over the past 10 years, and, as of February 2015, 21 of those nurses 

have remained employees of the medical center.

Page 15 GAO-15-794 VA Nurse Recruitment and Retention
Despite these successes, however, officials from three of the four medical 

centers in our review reported challenges with offering VHA’s initiatives 

specifically, and recruiting and retaining nurses more broadly, both of 

which limited the initiatives’ usefulness. These challenges—lack of 

sufficient administrative support, competition with private sector medical 

facilities for qualified and skilled nurses, the rural location of the medical 

center, and employee dissatisfaction—may affect medical centers’ ability 

to effectively and efficiently recruit and retain nurses.

• Lack of sufficient administrative support. Officials from one 

medical center reported challenges in efficiently offering some of the 

initiatives due to the lack of sufficient administrative support. 

Specifically, medical center officials reported not having sufficient 

human resources and clerical staff to process in a timely manner the 

paperwork associated with specific VHA recruitment and retention 

initiatives, such as the Employee Incentive Scholarship Program.

• Competition with the private sector. Officials from two medical 

centers reported challenges in recruiting and retaining nurses

because of competition with private hospitals in the area. Officials 

from one medical center told us that they face significant competition 

from local hospitals, as there are multiple private boutique and 

specialty hospitals in their area. Officials stated that competing with 

these hospitals, especially for entry-level nurses, is difficult because 

the hospitals offer generous signing bonuses. Officials from another 

medical center told us that the high cost of living and lower nursing 

salaries compared to the salaries offered by competing medical 

facilities in the area negatively affects the medical center’s ability to 

successfully recruit and retain nurses, specifically RNs and NPs. 

Officials from this medical center told us that they do not have 

sufficient funds, such as funds from VHA’s Education Debt Reduction 

Program, to offer nurses financial incentives to make up for the large 

difference in salaries. In addition, while the Choice Act increased the 

maximum repayment amount for each recipient of the Education Debt 

Reduction Program from $60,000 to $120,000, VHA officials told us 

that VHA did not increase the medical center’s annual funding 

allocation for the program to account for that increase.22 In FY 2014, 

this medical center had turnover rates of 10 percent or higher for NPs, 

22Pub. L. No 113-146, § 302(b), 128 Stat. 1754, 1788 (Aug. 7, 2014), codified at 

38 U.S.C. § 7683(d).

Page 16 GAO-15-794 VA Nurse Recruitment and Retention

 
RNs, and LPNs, above the national average of 7.9 percent for all 

nurses.

• Rural location. Officials from one medical center that has community 

outpatient clinics located in rural areas reported challenges recruiting 

qualified nurses with the requisite experience to work in critical care or 

other specialized units such as mental health. Officials from another 

medical center located in a rural area reported that, while the medical 

center receives high interest in nurse employment generally from the 

community and has a ready applicant pool for some nurses, it also 

faces challenges in recruiting nurses with advanced degrees or 

advanced training and expertise to work in the emergency department 

or intensive care unit because of its rural location.

• Employee dissatisfaction. Officials from one medical center and its 

union reported high levels of nurse dissatisfaction with medical center 

leadership as a result of recent investigations, including by VA’s OIG, 

examining access to care issues in the facility. This dissatisfaction has 

negatively affected the medical center’s ability to retain nurses, 

according to officials from this medical center. In FY 2014, for 

example, this medical center had a 12 percent turnover rate for NPs 

and close to a 30 percent turnover rate for NAs. With some nurses on 

administrative leave and high nurse turnover, officials stated that 

nurses are stepping into positions temporarily and are being asked to 

work additional or longer shifts. Officials stated that the medical 

center’s units are inadequately staffed to care for the medical center’s 

current patient load, which they believe is affecting access and the 

quality of care provided to veterans.

In addition to challenges identified by the medical centers in our review,

VHA also identified a challenge specific to the RN Transition to Practice 

initiative. Officials from the Office of Nursing Services told us that, when 

VHA began to require medical centers to offer the RN Transition to 

Practice initiative in November 2011, VHA did not provide specific funding 

to medical centers to do so and relied on medical centers to determine 

how to fund the initiative, which is financially and staff-resource intensive. 

According to VHA officials, there have been two unintended 

consequences of requiring medical centers to offer this initiative without 

VHA funding. First, some medical centers are deciding to hire 

experienced RNs only, who would not be eligible for the initiative, rather 

than hiring new RNs because of the financial burden associated with the

initiative. Second, some medical centers in rural locations have found it 

difficult to offer the initiative because of a lack of available instructors 

qualified to provide the required training.

Page 17 GAO-15-794 VA Nurse Recruitment and Retention
VHA conducts limited monitoring of VA medical centers to ensure they 

are in compliance with its key nurse recruitment and retention initiatives. 

Consistent with federal internal control standards, monitoring should be 

ongoing in the course of normal program operations and provide 

reasonable assurance of compliance with applicable laws and 

regulations.23 VHA’s Office of Academic Affiliations has a system in place 

for conducting site visits to the medical centers that offer the VA Nursing 

Academic Partnerships initiative. Office of Academic Affiliations officials 

reported that the site visits occur at least once per year to gauge a 

medical center’s adherence to the residency’s policies and contractual 

requirements. In addition to providing consulting services during these 

site visits to all medical centers that offer this initiative, these officials also 

told us that site visit reports are specifically generated for medical centers 

that are offering the initiative for the first time, and these reports are 

provided to the nursing school and medical center leadership. Officials 

told us that they have stopped three medical centers from offering the VA 

Nursing Academic Partnerships initiative when it was in the pilot phase 

due to non-compliance with program policies.

VHA Healthcare Talent Management officials told us that although they 

conducted site visits to medical centers in the past that offered the 

Education Debt Reduction Program, they are currently not conducting site 

visits. Officials reported that these site visits were in response to a 

medical center reporting difficulty implementing the initiatives the office 

manages, and were a method of comprehensively assessing individual 

medical center’s compliance with policies or guidance, as well as being 

consultative in nature. A Healthcare Talent Management official reported 

that the office lacked sufficient staff to enable them to conduct any site 

visits in FY 2015 and that additional staff have been hired, which will 

enable the office to resume site visits in FY 2016.

23GAO/AIMD-00-21.3.1.

VHA’s Oversight of Its 

Nurse Recruitment 

and Retention 

Initiatives Is Limited

VHA Conducts Limited 

Monitoring of VA Medical 

Centers’ Compliance with 

Nurse Recruitment and 

Retention Initiatives

Page 18 GAO-15-794 VA Nurse Recruitment and Retention

 
In addition, although VHA required VA medical centers, as of November 

2011, to offer VHA’s RN Transition to Practice initiative to RNs with 1 year 

or less of experience, the Office of Nursing Services does not have a 

process in place to determine if all medical centers are in compliance. We 

found, for example, that one medical center in our review that employed 

RNs with less than 1 year of experience had not offered the RN Transition 

to Practice initiative; officials from this medical center stated that they 

thought the initiative was recommended and not required. Officials from 

the Office of Nursing Services told us that, when the RN Transition to 

Practice initiative became a requirement in November 2011, there was no 

specific funding provided to medical centers to offer it. Because of this 

lack of funding, officials said that it has been difficult to provide oversight 

of this initiative. With limited monitoring taking place as part of its 

oversight, VHA lacks assurance that its medical centers are complying 

with the recruitment and retention initiatives’ policies and requirements, 

and that any problems can be identified and resolved in a timely and 

appropriate manner.

Although three VA medical centers in our review reported that VHA’s key 

recruitment and retention initiatives for nurses have been helpful, VHA 

has conducted limited evaluations to determine any needed training 

resources or to determine the initiatives’ effectiveness system-wide and 

whether any changes are needed. This lack of evaluation may affect 

VHA’s ability to improve the initiatives and ultimately medical centers’

ability to recruit and retain nurses. Consistent with federal internal control 

standards, measuring performance allows organizations to track the 

progress they are making towards program goals and objectives, and 

provides managers important information on which to make management 

decisions and resolve any problems or program weaknesses.24

According to VHA officials, there are processes in place to determine if 

problems exist with several of its recruitment and retention initiatives. 

First, for the first time, in FY 2015, VHA’s Healthcare Talent Management 

conducted a survey of medical centers as part of the data collection 

process for VHA’s Interim Workforce and Succession Strategic Plan.25

24GAO/AIMD-00.21.3.1.

25Department of Veterans Affairs, Veterans Health Administration, 2014 Interim Workforce 

and Succession Strategic Plan (Washington, D.C.: 2014). 

VHA Has Conducted 

Limited Evaluations of the 

Training Resources 

Provided and Overall 

Nurse Recruitment and 

Retention Initiatives

Page 19 GAO-15-794 VA Nurse Recruitment and Retention

 
The purpose of the survey was to collect information on workforce 

priorities in the field and to gauge barriers to medical centers as they offer 

the three recruitment and retention initiatives managed by Healthcare 

Talent Management.26 The survey responses provided feedback on some 

of the barriers that medical centers faced with offering the initiatives, such 

as an application process for the Education Debt Reduction Program that 

was not user friendly. Healthcare Talent Management officials said they 

plan to use these survey results to make changes to the initiatives it 

manages, and the office plans to continue including questions regarding 

workforce planning priorities in future surveys.

Second, VHA’s Office of Nursing Services is currently conducting a formal 

evaluation of the RN Transition to Practice initiative. According to an 

official, the purpose of the evaluation is to gather information on any 

successes that medical centers have experienced with offering the

initiative. As part of the data collection process, the evaluation team has 

started interviewing program coordinators at selected medical centers, 

and will analyze available participant survey data. In addition, the 

evaluation team plans to survey all medical centers to gauge their 

compliance with the requirement that all medical centers with RNs with 

1 year or less of experience offer the initiative. According to officials, the 

initiative is set to expire in 2016, and VHA will use the information from 

the evaluation to make decisions and set goals regarding the program 

moving forward.

Lastly, the Office of Academic Affiliations uses various tools to assess 

nurse residents’ skill competency and satisfaction with the initiatives it 

manages. For example, it uses an assessment tool to measure nurses’

progress toward the development of core clinical competencies at set 

intervals throughout their participation in the VA Nursing Academic 

Partnerships, specifically the Post-Baccalaureate Nurse Residency. The 

Office of Academic Affiliations also uses a survey to gauge participating 

students’ satisfaction with its training programs and residencies, including 

the VA Nursing Academic Partnerships - Graduate Education initiative, on 

topics such as the learning and working environments, as well as clinical 

faculty skills.

26VHA’s Healthcare Talent Management manages the VA Learning Opportunities 

Residency, the Education Debt Reduction Program, and the Employee Incentive 

Scholarship Program, which includes the National Nursing Education Initiative and the VA 

National Education for Employees Program.

Page 20 GAO-15-794 VA Nurse Recruitment and Retention

 
However, VHA has not conducted any assessments of the adequacy of 

training resources for nurse recruiters. In particular, there are substantial 

differences in the availability of training resources for nurse recruiters, 

who can play a key role in medical centers offering VHA’s nurse 

recruitment and retention initiatives to nurses, according to officials from 

VHA and representatives of a national nursing organization. According to 

a VHA official, there is currently no face-to-face training provided by VHA 

specifically for nurse recruiters, but there is regular training available to 

those assigned to a human resources office as part of training available to 

all human resources staff. Representatives of a national nursing 

organization reported that the clinical nurse recruiters at VA medical 

centers often feel overwhelmed and unprepared in the position because 

of a lack of training and human resources-related information, which may 

have resulted in turnover in that position. VHA officials told us that these 

differences in training for different types of nurse recruiters have existed 

for years, but no review of the training provided to nurse recruiters has 

been conducted. Further, VHA officials told us there are no current plans 

to assess the differences in the training and the effect that it has on the 

effectiveness of nurse recruiters. VHA officials reported that the barrier to 

conducting this type of assessment was resources, both a lack of funding, 

as well as a lack of staff to conduct the assessment.

Furthermore, VHA has not conducted any evaluations of the overall 

effectiveness of the key initiatives in meeting VHA’s system-wide nurse 

recruitment and retention goals. In its 2014 Interim Workforce and 

Succession Strategic Plan, VHA reported that its plan included recruiting 

highly skilled employees in mission critical occupations, which includes 

nurses, who are able to function at the top of the competency level, as 

well as retaining these employees as VHA develops a pipeline of qualified 

nurses that will take on more senior roles.27 In addition, VHA reported that 

it is challenged with ensuring it has the appropriate workforce to meet 

current and future needs that result from shortages and competition for 

certain health care positions, such as nurses. For example, 42 percent of 

VHA’s senior leadership, which includes senior-level nurses, is eligible for 

retirement in 2015, and this percentage will increase over the next 

7 years. The strategic plan noted that VHA has several initiatives, such as 

the Education Debt Reduction Program, to address some of its 

27Department of Veterans Affairs, Veterans Health Administration, 2014 Interim Workforce 

and Succession Strategic Plan (Washington, D.C.: 2014).

Page 21 GAO-15-794 VA Nurse Recruitment and Retention

 
recruitment challenges, but does not discuss the effectiveness of this 

initiative in meeting recruitment goals. VA’s annual report to Congress 

presents statistical information on some of VHA’s recruitment and 

retention initiatives, such as the number of nurses that received financial 

incentives in FY 2014 and the amount of financial incentives paid during 

that time, but does not provide information on the effectiveness of those 

initiatives in the recruitment and retention of nurses.28

VHA officials reported that they hold regular and ad hoc meetings for all 

offices that manage VHA’s nurse recruitment and retention initiatives to 

discuss a variety of topics, such as coordination and effectiveness. For 

example, the Office of Academic Affiliations holds ad hoc meetings with 

the Office of Nursing Services and Healthcare Talent Management to 

coordinate their initiatives related to recruitment and retention. In addition, 

Healthcare Talent Management holds quarterly meetings with the Office 

of Academic Affiliations and the Office of Nursing Services to share data, 

coordinate resources, and offer support for the other offices’ programs. 

Although these offices may meet to discuss the management of the 

initiatives, VHA officials reported no current plans to evaluate the overall 

effectiveness of the initiatives in meeting strategic goals.

A VHA official noted that the lack of evaluations of the overall 

effectiveness of VHA’s initiatives is a gap in the organization’s oversight. 

This official said that the recruitment and retention initiatives for nurses 

are offered at the local medical center level, and their role has primarily 

been to provide consultative services to those facilities. VHA officials 

noted that some data are regularly maintained at the national level, and 

although they are able to gather limited data on the initiatives from the 

medical centers, they need to develop a process to evaluate its initiatives 

to provide better support.

Oversight that includes evaluations of individual initiatives, if conducted, 

could provide VHA with data to identify any resource needs, such as 

training or administrative needs, and difficulties that medical centers are 

experiencing offering the initiatives, such as the lack of adequate 

administrative support as reported to us by medical centers in our review. 

A system-wide evaluation could help ensure that VHA’s recruitment and 

28Department of Veterans Affairs, Department of Veterans Affairs Annual Report On the 

Use of Authorities to Enhance Retention of Experienced Nurses for Fiscal Year 2014

(Washington, D.C.: 2015).

Page 22 GAO-15-794 VA Nurse Recruitment and Retention

 
retention initiatives are effective in meeting departmental goals and that 

resources are effectively allocated across all VA medical centers. 

Evaluation results could also be useful if communicated to relevant 

stakeholders, such as medical centers, to inform them of any compliance 

issues or any operational changes that may be needed. Under federal 

internal control standards, relevant program information and guidance are 

needed throughout an agency to achieve all of its objectives, and should 

be communicated to management and others within the organization in a 

reliable form and within a time frame that enables them to carry out their 

organizational responsibilities, such as the implementation of a program 

or policy.

Adequate numbers of qualified nurses are essential for VHA to meet its 

mission of providing quality and timely health care for veterans. As the 

number of veterans seeking health care increases and the demographics 

of that population continue to change, VHA faces challenges ensuring it 

has the appropriate nurse workforce needed to provide care, including 

more complex, specialized services. In addition, the Choice Act required 

VHA to add additional clinical staff, including nurses, to its workforce to 

increase access to care for veterans. VHA has a number of key initiatives 

to help medical centers recruit and retain nurses; however, challenges, 

including competition with the private sector for qualified and skilled 

nurses and the lack of sufficient administrative support, may limit their 

effectiveness.

Furthermore, VHA’s limited oversight of its key nurse recruitment and 

retention initiatives hinders its ability to assess the effectiveness of these 

initiatives and make any needed adjustments to help ensure its nurse 

workforce is keeping pace with the health care needs of veterans. 

Because of its limited monitoring, VHA lacks assurance that its medical 

centers are offering recruitment and retention initiatives in accordance 

with the policies and guidance that it has developed. Further, limited 

evaluations of medical centers offering VHA’s initiatives have meant VHA 

is unable to systematically identify problems or needed program changes 

to ensure that the initiatives are being offered efficiently and effectively, 

including determining whether medical centers have sufficient training 

resources to support its nurse recruitment and retention initiatives. 

Further, without system-wide evaluations of its collective initiatives, VHA 

is unable to determine to what extent its nurse recruitment and retention 

initiatives are effective in meeting VHA polices and Choice Act provisions, 

or ultimately, whether VHA’s initiatives are sufficient to meet veterans’

health care needs.

Conclusions

Page 23 GAO-15-794 VA Nurse Recruitment and Retention
To help ensure the effective recruitment and retention of nurses across 

VA medical centers, we recommend the Secretary of Veterans Affairs 

direct the Under Secretary for Health to take the following three actions:

1. Develop a periodic reporting process to help monitor VA medical 

center compliance with the policies and procedures for each of its key 

recruitment and retention initiatives;

2. Evaluate the adequacy of training resources provided to all nurse 

recruiters at VA medical centers to ensure that they have the tools 

and information to perform their duties efficiently and effectively; and

3. Conduct a system-wide evaluation of VHA’s key nurse recruitment 

and retention initiatives, to determine the overall effectiveness of 

these initiatives, including any needed improvements, and 

communicate results and information in a timely manner to relevant 

stakeholders.

We provided a draft of this report to VA for comment. In its written 

comments, reproduced in appendix III, VA generally agreed with our 

conclusions and concurred with our recommendations. In its comments, 

VA also provided information on workgroups it was planning to establish, 

as well as its plans for implementing each recommendation, with an 

estimated completion date of October 2017.

As agreed with your office, unless you publicly announce the contents of 

this report earlier, we plan no further distribution until 30 days from the 

report date. At that time, we will send copies of this report to appropriate 

congressional committees, the Secretary of Veterans Affairs, and other 

interested parties. In addition, the report will be available at no charge on 

the GAO website at http://www.gao.gov.

If you or your staff have any questions about this report, please contact 

me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices 

of Congressional Relations and Public Affairs may be found on the last 

Recommendations for 

Executive Action

Agency Comments

Page 24 GAO-15-794 VA Nurse Recruitment and Retention
page of this report. GAO staff who made key contributions to this report 

are listed in appendix IV.

Sincerely yours,

Debra A. Draper

Director, Health Care

Page 25 GAO-15-794 VA Nurse Recruitment and Retention
Appendix I: Selected Characteristics of 

Veterans Health Administration’s (VHA) Nurse 

Workforce

Table 4: Number of Veterans Health Administration (VHA) Nurses Providing Direct and Indirect Care, by Position Type, Fiscal 

Year (FY) 2010 through FY 2014

Position type FY 2010 FY 2011 FY 2012 FY 2013 FY 2014

Nurse practitioner Direct 4,198 4,316 4,480 4,630 4,822

Indirect 48 53 55 67 59

Registered nurse Direct 45,289 46,464 47,651 49,798 52,178

Indirect 2,493 2,508 2,516 2,628 2,789

Licensed practical nurse Direct 12,909 13,238 13,479 13,834 14,169

Indirect 42 52 48 69 75

Nursing assistant Direct 9,852 10,049 10,370 10,811 10,987

Indirect 20 14 12 26 17

Total Direct 72,248 74,067 75,980 79,073 82,156

Indirect 2,603 2,627 2,631 2,790 2,940

Source: VHA. I GAO-15-794

Note: Nurses within VHA provide both direct and indirect care to patients. Direct care includes any 

services that are provided to a veteran at the bedside; indirect care includes administrative and 

clerical duties that support direct patient care. All direct care services are provided at VA medical 

centers. Indirect care services can be provided at VA medical centers, Veterans Integrated Service 

Networks, or VA’s central office.

Table 5: Number of Nurse Workforce Hires and Losses for FY 2015 at VA Medical 

Centers, by Position Type, as of June 2015

Position type Number of nurse hires Number of nurse losses

Nurse practitioner 431 291

Registered nurse 5,104 3,103

Licensed practical nurse 1,371 816

Nursing assistant 1,671 746

Total 8,577 4,956

Source: Veterans Health Administration (VHA). I GAO-15-794

Note: VHA nurse hires refers to the number of nurses that have come on board and are providing 

services at VA medical centers. Nurse workforce losses refers to the number of nurses who have left 

the VHA system for any reason, including retirements, death, termination or voluntary separation that 

removes a nurse employee from VHA; the loss numbers exclude VHA internal transfers.

Appendix I: Selected Characteristics of 

Veterans Health Administration’s (VHA) 

Nurse Workforce

Page 26 GAO-15-794 VA Nurse Recruitment and Retention
Appendix I: Selected Characteristics of 

Veterans Health Administration’s (VHA) Nurse 

Workforce

Table 6: Veterans Health Administration (VHA) Nurse Turnover Rates by Position Type, Fiscal Year (FY) 2010 through FY 2014

Position type FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 5-year average

Nurse practitioner (NP) 5.8% 6.4% 7.2% 9.1% 9.1% 7.5%

Registered nurse (RN)a 6.4 6.9 7.5 7.8 7.8 7.3

Licensed practical nurse 6.9 7.8 8.3 8.4 7.9 7.9

Nursing assistant 10.1 9.2 8.7 8.8 8.9 9.2

Total 7.0 7.4 7.8 8.0 7.9 7.6

Source: VHA. I GAO-15-794

Note: The nurse turnover rate includes any loss, such as retirement, death, termination, or voluntary 

separation that removes a nurse employee from VHA; the loss numbers exclude VHA internal 

transfers.

a

When reporting turnover rates for RNs, VHA includes NPs because NPs are RNs with additional 

credentials and education.

Page 27 GAO-15-794 VA Nurse Recruitment and Retention
Appendix II: Selected Characteristics of 

Veterans Health Administration’s (VHA) Key 

Nurse Recruitment and Retention Initiatives

Expenditures

(Number of participating nurses)

Initiative FY 2010 FY 2011 FY 2012 FY 2013 FY 2014

Education and training initiatives

RN Transition to Practicea n/a

(n/a)

n/a

(n/a)

n/a

(n/a)

n/a

(n/a)

n/a

(n/a)

VA Learning Opportunities Residency 2,856,845

(335)

3,194,961

(349)

3,128,159

(368)

3,675,841

(434)

3,999,113

(475)

VA Nursing Academic Partnershipsb 16,162,888

(640)

14,829,597

(440)

8,479,674

(260)

10,590,642

(162)

10,950,556

(366)

VA Nursing Academic Partnerships – Graduate 

Educationc n/a(n/a)

n/a

(n/a)

n/a

(n/a)

n/a

(n/a)

427,469

(5)

Financial benefits and incentives initiatives

Recruitment, retention, and relocation 

incentives

35,976,421

(6,514)

31,355,259

(5,358)

24,214,577

(5,880)

16,345,604

(2,692)

11,243,725

(1,899)

Education Debt Reduction Programd 5,938,084

(1,607)

5,554,648

(1,353)

6,015,672

(1,300)

4,599,492

(961)

3,079,405

(643)

Employee Incentive Scholarship 

Programe 30,965,399(3,483)

30,006,001

(3,697)

23,353,940

(3,699)

20,701,054

(3,445)

23,806,109

(2,965)

Flexible work schedulesf n/a

(n/a)

n/a

(n/a)

n/a

(n/a)

n/a

(n/a)

n/a

(n/a)

Source: VHA. I GAO-15-794

Note: The term expenditure refers to the actual spending of money, also known as an outlay. 

Participation refers to the number of VHA nurses who participate in the initiative; VHA nurses may be 

represented more than once in the table because nurses are allowed to participate in multiple 

initiatives.

a

Expenditure data are not available because VHA does not provide specific funding to medical 

centers to offer this initiative; funding allocations are the responsibility of individual medical centers. 

Participation data are not available because VHA does not collect data on the number of nurses who 

participate in this initiative.

b

In 2011, VHA introduced the Post-Baccalaureate Nurse Residency as a stand-alone initiative for 

academic year 2012-2013. In 2015, VHA rolled the residency into the existing VA Nursing Academic 

Partnerships initiative for new applicants to begin in academic year 2015-2016. The number of 

participating nurses in FY 2013 and FY 2014 reflects the number of participants in both the residency 

and the partnerships in academic years 2012-2013 and 2013-2014, respectively.

c

In 2013, VHA introduced the Psychiatric Mental Health Nurse Practitioner Residency as a standalone initiative for academic year 2013-2014. In 2015, VHA introduced a graduate-education 

initiative—the VA Nursing Academic Partnerships – Graduate Education—into which it rolled the 

residency for new applicants. The number of participating nurses in FY 2014 reflects the number of 

participants in the residency in academic year 2013-2014.

d

VHA nurses may be represented in more than one fiscal year because nurses can participate in the 

program for up to 5 contract years.

e

VHA nurses may be represented in more than one fiscal year because nurses can participate in the 

program for up to 3 contract years.

f

Expenditure data are not available because funding for flexible work schedules is accounted for in 

medical centers’ budgets for salaries and wages. Participation data are not available because VHA 

does not collect data on the number of nurses who participate in this initiative.

Appendix II: Selected Characteristics of 

Veterans Health Administration’s (VHA) Key 

Nurse Recruitment and Retention Initiatives 

Page 28 GAO-15-794 VA Nurse Recruitment and Retention
Appendix III: Comments from the Department of Veterans Appendix III: Comments from th Affairs e 

Department of Veterans Affairs

Page 29 GAO-15-794 VA Nurse Recruitment and Retention
Appendix III: Comments from the Department of Veterans 

Affairs

Page 30 GAO-15-794 VA Nurse Recruitment and Retention
Appendix III: Comments from the Department of Veterans 

Affairs

Page 31 GAO-15-794 VA Nurse Recruitment and Retention
Appendix IV: GAO Contact and Staff 

Acknowledgments

Debra A. Draper, (202) 512-7114 or draperd@gao.gov

In addition to the contact named above, Janina Austin, Assistant 

Director; Jennie Apter; Shana R. Deitch; Jacquelyn Hamilton; 

Kelli A. Jones; Vikki Porter; and Jessica L. Preston made key 

contributions to this report.

Appendix IV: GAO Contact and Staff 

Acknowledgments

GAO Contact

Staff 

Acknowledgments

(291253) Page 32 GAO-15-794 VA Nurse Recruitment and Retention
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