VA Health Care: Improved Staffing Methods and Greater Availability of Alternate and Flexible Work Schedules Could Enhance the Recruitment and Retention of Inpatient Nurses
Published: 2008-10-24T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Registered nurses (RNs) are the largest group of health care providers employed by VA's health care system. RNs are relied on to deliver inpatient care, but VA medical centers (VAMC) face RN recruitment and retention challenges. VAMCs use a patient classification system (PCS) to determine RN staffing on inpatient units by classifying inpatients according to severity of illness to determine the amount of RN care needed. GAO reviewed VAMC inpatient units for (1) the usefulness of information generated by VA's PCS; (2) key factors that affect RN retention; and (3) factors that contribute to delays in hiring RNs. GAO performed a Web-based survey of all VAMC nurse executives; interviewed VA headquarters officials and VAMC nursing officials, and conducted RN focus groups at eight VAMCs visited by GAO. The findings of GAO's survey are generalizable to all nurse executives; however, findings from the focus groups at the eight VAMCs are not generalizable.
section_title: What GAO Found
paragraphs: VAMC nursing officials--nurse executives who are responsible for all nursing care at VAMCs and nurse managers who are responsible for supervising RNs on VAMC inpatient units--GAO interviewed reported that although VA inpatient RNs are required to input patient data into VA's PCS, they do not rely on the information generated by PCS because it is outdated and inaccurate. These nursing officials noted that VA's PCS does not accurately capture the severity of patients' illnesses or account for all the nursing tasks currently performed on inpatient units. Because of the shortcomings of VA's PCS, nurse managers use data from a variety of sources to help set RN staffing levels for their inpatient units. At four of the eight VAMCs GAO visited, nurse managers told GAO that they set RN staffing levels for their inpatient units by adhering to the historical staffing levels that had been established for the units. Three VAMCs GAO visited set their RN staffing levels using data on the RN staffing levels found in inpatient units in other hospitals with similar characteristics. VA reported it is proposing to develop a new RN staffing system. However, VA has not developed a detailed action plan that includes a timetable for building, testing, and implementing the new nurse staffing system. VA nursing officials reported that VA's ability to retain its RNs is adversely affected by two main factors. First, inpatient RNs reported that they spend too much time performing non-nursing duties such as housekeeping and clerical tasks. Second, even though VAMCs were authorized in 2004 to offer RNs two alternate work schedules that are generally desired by nurses--such as working three12-hour shifts within a week that would be considered full-time for pay and benefits purposes--few nurse executives reported offering these schedules; therefore, few RNs work these schedules. Specifically, according to nurse executives GAO surveyed only about 1 percent of many inpatient units offered alternate schedules and less than 1 percent of RNs actually worked these schedules. The availability of flexible work schedules, for example, working eight 10-hour shifts over a 2-week period, are more widely available among VAMCs but are still limited, according to GAO's survey of nurse executives. Nursing officials and RNs noted other factors affecting retention such as reliance on supplemental staffing strategies--for example, RN overtime--and insufficient professional development opportunities. Both VA nurse executives and nursing officials identified limitations in VA's process for hiring RNs and VA-imposed hiring freezes and lags as major contributing factors causing delays in hiring RNs to fill inpatient vacancies at VAMCs. VA nursing officials reported that hiring freezes and lags at VAMCs and delays resulting from limitations in VA's hiring process can discourage prospective candidates from seeking or following through on applications for employment at these facilities. Although VA has recently taken steps to address some of the factors that are reported to contribute to RN hiring delays, it is too early to determine the extent to which these steps have been effective in reducing hiring delays

section_title: Letter
paragraphs: In 2007, the Department of Veterans Affairs (VA) employed almost 43,000  registered nurses (RN) who provided care to veterans in VA medical  centers (VAMC) across the country. RNs are the largest group of health  care providers employed by VA’s health care system, and VA relies on the  services provided by these nurses. Maintaining its RN workforce is critical  to VA’s provision of care to its veteran population. Studies in general have  shown, for example, that a shortage of RNs, especially when combined  with increased patient workload, can adversely affect patient outcomes  and therefore the quality of care patients receive. Hospitals with lower  levels of RN staffing have been shown to have higher rates of adverse  events such as urinary tract infections and pneumonia. Conversely, an  increase in RN staffing has been associated with a reduction in adverse  patient care events and with better quality outcomes such as fewer  infections.
To ensure adequate staffing at VAMCs, Congress passed legislation in 2002  requiring VA to develop a national staffing policy, including a policy on  nurse staffing. The law required that VA establish a policy on the staffing  levels and expertise required to provide care to veterans at VAMCs. The  need for a new nurse staffing system was also highlighted in 2004 when  the VA Office of Inspector General (OIG) issued a report that raised  concerns about the adequacy of RN staffing levels on VA’s inpatient units  and identified instances in which bed closures or diversions of patients to  other inpatient facilities in the community resulted in part because of  inadequate staffing. The VA OIG further found that staffing challenges at  VAMCs resulted from the lack of a consistent staffing methodology and a  lack of effective recruitment and retention strategies. To address the  staffing issues raised in the OIG report and in light of the 2002 law, VA  committed to design and implement a new nurse staffing system, which it  has not yet completed. As noted in the 2004 VA OIG report, to avoid  inadequate RN-staffing levels and the consequences for patient care, two  issues are important: determining the right number and skill mix of RNs  required to care for veterans, and recruiting and retaining a sufficient  supply of RNs to meet required staffing levels.
In determining the right number and skill mix of RNs needed to care for  patients on inpatient units, nurse managers in hospitals typically consider  various factors, including the number of patients and their care needs  based on the seriousness of their illnesses, experience and qualifications  of the RN staff, availability of support services such as housekeeping and  patient transport, and budgetary factors. In considering these factors,  many hospitals use a patient classification system (PCS) as a key tool to  help nurse managers estimate the amount of nursing care needed by  inpatients. By using such a system, nurse managers can more accurately  and consistently predict RN staffing. Over time, more of the patient care  at VAMCs has shifted from inpatient to outpatient settings, and veterans  are older and sicker and therefore have more intensive nursing care needs.  Like other hospitals with inpatient care units, the VA has a PCS that is  intended to be used to help determine appropriate RN staffing levels to  meet the nursing care needs on VAMC inpatient units. Established in the  1980s for use by its VAMCs, VA’s PCS is a computer-based system that is  designed to predict the RN staffing levels needed on inpatient units based  on patient acuity, which is a measure of the type and severity of illness.  Specifically, VA’s PCS produces an estimate of RN hours per patient day  (HPPD) needed by inpatient units to care for their patients. The PCS  estimates are based on data that is entered into the PCS system on a daily  basis on the number of patients in each unit and each patient’s level of  acuity. This estimate can then be used to set RN staffing levels.
With respect to retaining the RNs it currently employs and recruiting new  RNs, VA faces substantial challenges. In congressional testimony in 2007, a  VA official discussed the challenges the department faces in retaining RNs  in VA’s workforce, in part, because many VA RNs are nearing retirement  eligibility age. VA data show that in fiscal year 2005, 13 percent of VA’s  RNs were eligible for retirement, and VA projects this number to increase  to 22 percent by 2012. According to the Office of Personnel Management  (OPM), flexible work schedules allow workers to balance their work and  personal commitments. To enhance retention of VA RNs, the Congress  passed legislation authorizing VA in 2004 to allow its VAMCs to offer RNs  two alternate work schedules that would allow RNs either to work three  12-hour shifts per week (and get paid for 40 hours) or work 9 months each  year with 3 months off (and get paid 75 percent of their salary year round).
Further, VA, like other health care providers, also faces challenges  recruiting new RNs in order to maintain its RN workforce levels. In its  2007 to 2011 workforce succession strategic plan, VA identified recruiting  RNs as its top recruitment priority, and in 2007 congressional testimony, a  VA official reported that the department had taken steps to streamline  VA’s hiring process to address delays in filling vacant RN positions. VA’s  focus on recruiting RNs has occurred in the context of a nationwide RN  shortage, which has further exacerbated VA’s RN recruitment challenges.  For example, the Health Resources and Services Administration—an  agency within the Department of Health and Human Services—has  projected that by the year 2020, 44 states will experience a shortage of  nurses, and that by 2020, the nation’s RN shortage will grow to more than  one million nurses.
This report provides information on current RN staffing practices on  inpatient units at VAMCs. We specifically discuss (1) how useful the  information generated by VA’s PCS is for determining RN staffing levels on  inpatient units, (2) key factors that VAMC nursing officials and RNs  identify that affect RN retention on inpatient units, and (3) factors that  VAMC nursing officials identify as contributing to delays in hiring RNs to  fill vacant positions.
To fulfill our objectives, we conducted a Web-based survey of VAMC nurse  executives and interviewed VA headquarters officials in the Office of  Nursing Services (ONS), VAMC nursing executives, VAMC inpatient unit  nurse managers, and VAMC human resources (HR) officers. In addition,  we conducted inpatient RN focus groups at eight VAMCs, obtained data as  of April 2008 on the number of VA RNs who use alternate work schedules,  interviewed representatives of state hospital associations, and reviewed  and analyzed industry and agency reports and studies. For the purpose of  this report, we use the term VAMC nursing officials to include VAMC nurse  executives and inpatient unit nurse managers. In conducting the Web- based survey, we surveyed all VA nurse executives at VAMCs. The survey  was sent to 140 VAMC nurse executives and obtained a 63 percent  response rate, which allows us to generalize the results to all nurse  executives at VAMCs. Based on our review of the completed surveys, we  determined that the data were sufficiently reliable for our purposes. In  selecting VAMCs as sites to conduct our interviews and focus groups, we  judgmentally selected eight VAMCs located in Denver, Colorado; Houston,  Texas; Minneapolis, Minnesota; New York, New York; Portland, Oregon;  Seattle, Washington; Tampa, Florida; and Togus, Maine. We selected these  VAMCs in order to include in our review the various types of inpatient  units found at these medical centers such as intensive care, surgery, and  medicine units. At the eight VAMCs we visited, 219 inpatient RNs from  three shifts (day, evening, and night) attended the focus groups. Attendees  at our focus groups included RNs of different ages, nurse experience  levels, and length of tenure at VA. The results of our analyses at these  VAMCs are not generalizable because the VAMCs selected are not  necessarily representative of all VAMCs. The information presented in our  focus group summaries accurately capture the opinions provided by the  inpatient RNs who attended the focus groups at the eight VAMCs we  visited. However these opinions cannot be generalized to all inpatient RNs  at the eight VAMCs we visited or to all inpatient RNs at VAMCs.
We performed a systematic review of the completed Web-based survey of  VA nurse executives to assess the reliability of the data obtained from the  survey. We checked each survey for problems such as key questions left  unanswered, patterns of skipped questions, unclear written responses, and  out of scope entries. We also assessed the reliability of data obtained from  VA headquarters officials related to the number of VA RNs who use  alternate work schedules. We contacted VA headquarters officials, who  provided information on the quality checks they performed on these data.  Based on our review and the information provided to us from VA officials,  we determined that the data we used in our report were adequate for our  purposes. For a detailed description of our scope and methodology, see  appendix I. Selected results from our survey and a summary of responses  from our focus groups are provided in appendix II and appendix III. We  conducted this performance audit from May 2006 through September 2008  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.
subsections: section_title: Background
paragraphs: RNs, along with other nursing support staff, provide care to patients on  inpatient units at VAMCs. VA RNs are responsible for assessing and  providing care to patients, administering medications, documenting  patients’ medical conditions, analyzing test results, and operating medical  equipment. To obtain an RN license, an individual must complete a nursing  education program, meet state licensing requirements, and pass a nursing  licensing examination. Several types of clinical and ancillary support staff  assist RNs in caring for patients on inpatient units. Nursing support staff— such as licensed practical nurses (LPN) and nursing assistants (NA)— perform nursing duties such as recording patient vital signs and assisting  with bathing, dressing, and personal hygiene. In addition, ancillary support  staff perform housekeeping, patient transport, and food service duties.  Clinical support staff—such as lab technicians—also assist RNs in their  patient care duties, for example, by drawing and testing blood or  performing electrocardiograms (EKG).
Recognizing that developing and maintaining a strong cadre of RNs at  VAMCs is vital to providing high quality of care to our nation’s veterans,  the Congress and VA have both made efforts to better ensure that RN  staffing levels at VAMCs are appropriate and to enhance recruiting and  retention of RNs. These efforts include:    To improve RN staffing, retention and job satisfaction, and patient  outcomes, VA is actively encouraging its medical centers to take part in a  nationwide program called the Magnet Recognition Program®. This  program was developed by the American Nurses Credentialing Center  (ANCC) to recognize health care organizations that provide nursing  excellence and quality patient care. In order to attain Magnet™ status,  hospitals must meet certain requirements, including requirements related  to staffing practices and quality monitoring. Some research indicates that  facilities that have attained Magnet™ status have better patient outcomes,  significantly higher percentages of baccalaureate-prepared nurses, and  higher nurse job satisfaction rates. As of 2008, three VAMCs have attained  Magnet™ status, four VAMCs have completed the application process, and  22 VAMCs are in the process of applying for Magnet™ status.
With respect to recruiting and hiring, VA has taken several actions. For  example, in 2007, VA launched the VA Nursing Academy, a program  designed to develop a pool of RN candidates for employment in VAMCs.  Similarly, VA’s Learning Opportunities Residency program is designed to  attract baccalaureate nursing students to work as RNs at VAMCs upon  graduation. VA also has several other initiatives to enhance the  educational preparation of its health care staff and scholarships for  current employees pursuing degrees in nursing. These initiatives, which  serve as recruitment and retention tools, include an education loan  repayment program and scholarships for employees seeking health care  careers. In August 2007, a VA Recruitment Process Redesign Workgroup  made recommendations to redesign the recruiting and hiring of health  care practitioners within VA, including RNs. The work group analyzed  VA’s hiring process and identified barriers and delays in hiring. The work  group’s findings and recommendations included a timeline for nurse  hiring. As discussed later in this report, VA is in the process of  implementing actions recommended by this work group.
To enhance recruiting and retention of RNs at VAMCs, the Congress  passed legislation in 2004 authorizing two alternate work schedules for  RNs employed by the VA. One of these alternate schedules allows RNs to  work three 12-hour shifts that are considered a 40-hour work week for pay  and benefits purposes. The other alternate work schedule allows RNs to  work full-time for 9 months with 3 months off duty within a fiscal year and  be paid 75 percent of the full-time work rate for each pay period of that  fiscal year. In addition to these alternate work schedules, executive  branch government agencies—including the VA—are authorized by OPM  to offer flexible work schedules. A flexible work schedule is an 80-hour  biweekly basic work requirement that allows an employee to determine  his or her own schedule—arrival and departure times—within the limits  set by the agency. The standard work schedule for full-time VA  employees is ten 8-hour work days within a 2-week period.
section_title: VAMC Nursing Officials Cannot Rely on Information from VA’s PCS to Determine RN Staffing Levels for VA Inpatient Units
paragraphs: VAMC nursing officials reported that although VA RNs are required to  input patient data into VA’s PCS, many said they cannot rely on the  information generated by PCS because the PCS is outdated and  inaccurate. Because of the shortcomings of VA’s PCS, nurse managers use  various other data to help set RN staffing levels for their inpatient units,  such as historical staffing levels and benchmarking RN staffing levels to  inpatient units in hospitals with similar characteristics. VA is proposing  action to develop a new nurse staffing system but did not provide a  detailed action plan and milestones for building and implementing such a  system.
subsections: section_title: VAMC Nursing Officials Report That Information from VA’s PCS Is Outdated and Inaccurate
paragraphs: VAMC nursing officials we interviewed told us that VA’s PCS does not  generate reliable information that would allow them to better predict the  RN staffing levels required for their inpatient units. These nursing officials  cited two key limitations of this information—it is outdated and  inaccurate. VA headquarters officials in the Office of Nursing Services  (ONS) and VA’s OIG also reported that PCS has significant limitations. In  2004, VA’s OIG also recommended that VA develop a new standardized  nurse staffing methodology capable of accurate staffing estimates and VA  concurred with the OIG’s recommendation. According to nursing officials  we interviewed, VA’s PCS was developed in the 1980’s based on time and  motion studies of RNs conducted over 20 years ago; as a result, the  information the system produces does not account for all the tasks  currently performed by RNs on inpatient units. For example, VA’s PCS  does not account for certain recent RN tasks—such as the administration  of certain intravenous medications or monitoring of a patient’s abnormal  heart activity—that were once limited largely to intensive care units that  cater to sicker patients but are now performed on other inpatient units.  Similarly, VA’s PCS generates estimates that do not reflect tasks  associated with VA’s computerized bar code medication administration  (BCMA) system that was fully implemented in 2003, more than a decade  after the development of VA’s PCS. These RN tasks include tracking,  monitoring, and reporting medication administration performed using the  BCMA on an inpatient unit.
VAMC nursing officials also told us that VA’s PCS produces inaccurate  data with respect to patient acuity levels, which in turn can generate  erroneous HPPD estimates. Specifically, a key piece of data VA nurses  enter into the VA PCS is the acuity level for each patient on an inpatient  unit. To do this, RNs use one of five PCS categories, with category 1  representing patients requiring the lowest level of care and category 5 the  highest level of care. Nursing officials we interviewed at VAMCs we visited  and officials with VA’s ONS reported that VA’s PCS does not accurately  capture the actual acuity level of patients on inpatient units  According to VAMC nursing officials we interviewed, nursing staff at  VAMCs are required to classify patients by acuity level on a daily basis  using VA’s PCS. However, nursing officials reported that classifying  patients by acuity level using the PCS is not a productive use of their time  because the information output from the PCS is not useful for RN staffing  purposes. In addition, officials with the VA OIG and ONS told us that the  information contained in VA’s Computerized Patient Record System  (CPRS)—concerning a patient’s illness, medical condition, and  treatments—is not integrated with, or available within VA’s PCS when  nurses assess and assign patients to one of the five acuity levels.
VA’s ONS is proposing to convene an interdisciplinary team—consisting of  headquarters and field staff—to develop a more effective RN staffing  system for VA by 2012, according to VA’s Chief of Nursing Services. The  Chief told us that the new RN staffing system will include a database that  reflects up-to-date nursing tasks as well as information from patients’  computerized medical records, and that this database will also be used to  evaluate the effectiveness of nursing care at VAMCs. The Chief also  reported that as part of the new RN staffing system, VA may upgrade or  replace its PCS. In developing a new or upgraded PCS, VA needs to ensure  that all current nursing tasks and patient acuity are accurately captured.  However, ONS did not provide a VA charter for the interdisciplinary team  or a detailed action plan with specific timelines for the building, testing,  and implementation of an updated system for staffing RNs on inpatient  units in its VAMCs.
section_title: Instead of Relying on Information from PCS, VA Medical Centers Use a Variety of Data Sources to Set RN Staffing Levels
paragraphs: Instead of relying on the information generated by VA’s PCS, VAMCs use  various other data to determine RN staffing for inpatient units. Our  survey of nurse executives coupled with our visits to VAMCs provides  insights into the types of data used and shows that information used for  staffing RNs varies considerably among VAMCs. Results from the survey  show that nurse managers typically consider a combination of data to  estimate both the number of RNs and the RN skill levels their inpatient  units require. The survey results also show that the types of data most  commonly used by inpatient unit nurse managers across VAMCs are the  average number of patients typically cared for on the unit, HPPDs, the  acuity level of patients on the unit, the number of RN staff historically  assigned to the unit, and the ratio of RNs to patients on the unit.
Nurse managers at the eight VAMCs we visited told us how they use  various data to help set RN staffing levels for their inpatient units. At four  VAMCs we visited, nurse managers told us that they set RN staffing levels  for their inpatient units by adhering to the historical staffing levels that  had been established for the units. According to these nurse managers,  they inherited their RN staffing levels when they assumed their position as  manager of the unit. These nurse managers told us that the staffing levels  for their inpatient units were established more than a decade ago. Nurse  managers at another facility we visited told us that they consider data on  the number of patients on the unit, HPPDs, nurse-to-patient ratios, and  historic staffing levels to estimate the RN staffing needs on their units.
Nurse managers using historical RN staffing levels to set current RN levels  told us that this method does not adequately match RN staffing levels to  the needs of inpatient units. Nurse managers at the four VAMCs that use  such historical data said that historical RN staffing levels had not matched  the acuity levels of their patients, which has increased over time.
The other three VAMCs we visited have attained Magnet™ status and are  required to set their RN staffing levels by benchmarking them against data  on RN staffing levels found in non-VA facilities that have attained  Magnet™ status. VA and non-VA Magnet™ facilities are grouped for  benchmarking based on inpatient units with similar characteristics.  Magnet™ facility RN-staffing data are available to facilities participating in  the Magnet Recognition Program®. The nurse executive at one Magnet™  VAMC that benchmarks told us that it had not experienced RN staffing  problems, and unit nurse managers at this VAMC expressed general  satisfaction with RN staffing levels.
section_title: VAMC Nursing Officials and RNs Identify Several Factors That Could Adversely Affect Retention of Inpatient RNs
paragraphs: VAMC nursing officials and inpatient RNs reported that two main factors  adversely impact RN’s job satisfaction and ultimately could impact VA’s  ability to retain RNs. First, according to these groups, some inpatient RNs  are dissatisfied about spending too much time performing non-nursing  duties, such as cleaning beds after a patient is discharged or answering  unit telephones. Second, even though VAMCs were authorized in 2004 to  offer RNs two alternate work schedules, few nurse executives reported  offering these schedules; as a consequence, few RNs work these  schedules. Both nursing officials and inpatient RNs working on inpatient  units told us that the limited availability of flexible and alternate work  schedules affects the ability of RNs to balance work and personal  commitments. In addition to these two main factors, inpatient RNs cited  other factors affecting retention, such as reliance on supplemental staffing  strategies, for example RN overtime, and insufficient professional  development opportunities.
subsections: section_title: VAMC Nursing Officials Report That Performing Non-Nursing Tasks Could Negatively Impact RN Retention
paragraphs: VAMC nursing officials at five VAMCs we visited reported that RNs on  inpatient units routinely perform non-nursing tasks, such as housekeeping  tasks and transporting patients to other areas of the hospital for tests,  because inpatient units often lack ancillary support staff or nursing  support staff to perform these tasks. In 2001, we reported that job  dissatisfaction because of inadequate support staff was reported to be a  major contributor to retention problems in the nursing workforce.  According to VAMC nurse executives we surveyed many of their VAMCs  did not have access to ancillary support services around the clock. For  example, as table 1 shows, the percentage of nurse executives at VAMCs  who had support staff available around the clock ranged from   13 percent—for staff available to administer electrocardiograms—to   53 percent, for staff available to draw and test samples.
Nursing officials at VAMCs we visited indicated that RNs performing non- nursing tasks reduces RN job satisfaction and has caused some RNs to  leave VA to accept jobs at other hospitals where RNs are required to  perform fewer non-nursing tasks. Nursing officials also reported that RNs  prefer to focus on providing nursing care to patients and that RNs  performing non-nursing tasks could adversely affect the retention of RNs  on inpatient units.
Nursing officials from VAMCs and a representative of a state hospital  association we interviewed cited three main factors—budgetary  constraints, institutional practices, and retention and recruiting—that  contributed to insufficient ancillary and nursing support staff to assist RN  on inpatient units.
Budgetary constraints can delay hiring ancillary and nursing support staff  mainly through hiring freezes or lags. A VA official told us that hiring  freezes and hiring lags are used for budgetary reasons or to manage  personnel costs. According to nursing officials, a hiring freeze may be  initiated by the regional network or imposed by a single VA medical  center. During a hiring freeze, inpatient units typically require authority  from a VAMC resource board to fill a vacant position.
Institutional practices at some VAMCs lead to some categories of ancillary  and support staff’s being unavailable during evening or weekend shifts,  resulting in the need for RNs to perform additional tasks during these  shifts. For example, housekeeping staff and laboratory staff who draw  blood samples are not always available. In other cases, support staff do  not perform all of the tasks associated with a certain function, resulting in  the need for RNs to perform the tasks. For example, patient escort staff do  not always assist in getting patients onto a stretcher or into a wheelchair  for transport.
Recruiting and retaining ancillary and support staff can be difficult  because a limited supply of support staff can lead to competition among  local hospitals. According to a representative of a state hospital  association we interviewed, there is a national shortage of allied health  professionals—such as NAs, clinical laboratory technicians, radiology  technicians, and physical therapists—in the hospital setting that can affect  the workload of RNs.
section_title: VAMC Nursing Officials and RNs Report That Limited Use of Alternate and Flexible Work Schedules Has the Potential to Adversely Impact Retention
paragraphs: VAMC nursing officials we interviewed and inpatient RNs who attended  our focus groups at VAMCs reported that the limited availability and use of  alternate and flexible work schedules at VAMCs limit the ability of RNs to  balance their work and personal life needs and could adversely impact the  retention of RNs. In 2008, we reported on the importance of work  schedules that offer flexibility being available for older employees, who  are nearing or are at the age when they may consider retirement as an  incentive to remain working.
While VA received legal authority in 2004 to offer alternate work schedules  to RNs, these schedules are rarely used at VAMCs. Available 2007 data  from VA show that less than half of one percent of the approximately  43,000 RNs employed by VA use alternate work schedules. There is low  usage mainly because inpatient units at VAMCs do not usually offer such  alternate work schedules. According to our survey of nurse executives,  one alternate work schedule—36 hours per week—was reported by only 1  percent of surgical, mental health, medical, polytrauma, and intensive care  units, while the second alternate work schedule—working full time for 9  months with 3 month off duty—was not offered at all. Several nursing  officials we interviewed noted that not offering alternate work schedules  can be a deterrent to retaining RNs. Half of all nurse executives reported  that the lack of alternate and flexible schedules at their VAMC was one of  the primary reasons for difficulty competing with local hospitals in  recruiting and retaining RNs. VAMC nursing officials noted, however, that  the ability to implement alternate work schedules at their VAMCs may be  constrained by factors such as limited RN staffing.
Flexible work schedules are more widely available than alternate work  schedules at VAMCs. VAMCs offer several types of flexible work  schedules—such as 10 and 12-hour schedules—and the availability of  these flexible work schedules vary by the type of inpatient unit. Nurse  executives we surveyed reported that the most frequently used flexible  schedule was the 12-hour schedule, which was reported for 68 percent of  medical intensive care and critical care units and 30 percent for nursing  home units. Other flexible work schedules were used less frequently: for  example, according to nurse executives we surveyed the use of the   10-hour schedule was reported by 13 percent of medical units and only   1 percent of spinal cord injury units. As was the case with alternate work  schedules, several nursing officials we interviewed noted that the ability to  implement flexible work schedules at their VAMCs was constrained by the  number of RNs available to cover the various shifts.
According to VAMC nursing officials, offering flexible work schedules is  an important factor in recruiting and retaining RNs. Half of VA nurse  executives we surveyed reported that one of the primary reasons for the  difficulty in competing with local hospitals in retaining inpatient RNs was  that flexible work schedules were not offered on some units at their  medical center. We were told that many private hospitals use flexible work  schedules as a way to improve nurse retention. A nursing official reported  that a survey by the American Organization of Nurse Executives—a  professional organization for nurse leaders and executives—found that  after salary, the top benefit desired by nurses was flexible work schedules.  One state hospital association representative we interviewed reported that  42 percent of the hospitals surveyed in their state offered flexible work  schedules.
section_title: VAMC Nursing Officials and Inpatient RNs Reported That Reliance on Supplemental Staffing and Insufficient Professional Development Opportunities Could Adversely Impact RN Retention
paragraphs: VAMC nursing officials and inpatient RNs cited other factors that could  adversely impact job satisfaction, and ultimately, the retention of RNs at  VAMCs, including reliance on supplemental staffing strategies and  insufficient professional development opportunities.
A reliance on supplemental staffing strategies, such as RN overtime  because of inadequate RN staffing levels on their unit, are factors that  could adversely impact RN job satisfaction and ultimately retention. For  example, when there is an unplanned absence, nurse managers use  supplemental staffing strategies or operate the units short-staffed. Forty– eight percent of nurse executives reported that inpatient units worked  short-staffed at some point, and 41 percent of nurse executives reported  that mandatory RN overtime was used as a supplemental staffing strategy.  Nurse managers reported that in some instances, they get an RN to work a  part of the next shift or the entire next shift, or float staff as a result of a  staff vacancy, staffing shortages, or an increase in the number of  inpatients on the unit. Moreover, one nurse manager reported that  “burnout” can stem from a reliance on supplemental staffing strategies.
According to RNs who attended our focus groups, insufficient professional  development and training opportunities for inpatient RNs are RN-retention  issues. For example, inpatient RNs noted that access to training and  professional development activities for RNs can be limited. For example,  RNs on the evening and night shifts sometimes find it difficult to  participate in professional development activities and education  programs.
section_title: VAMC Nursing Officials Identified Limitations in VA’s Hiring Process and VA-Imposed Hiring Freezes as Contributing Factors to RN Hiring Delays
paragraphs: VAMC nursing officials we surveyed and interviewed reported that delays  resulting from limitations in VA’s hiring process and hiring freezes and lags  at VAMCs can often discourage prospective RN candidates from seeking  or following through on applications for employment at VAMCs. Although  VA has recently taken steps to address some of the factors that contribute  to RN hiring delays, it is too early to determine the extent to which these  steps have been effective in reducing hiring delays.
subsections: section_title: Limitations in VA’s Hiring Process Include Delays in Securing Necessary Approvals, Poor Coordination, and a Shortage of Experienced and Well-Trained HR Officials
paragraphs: VAMC nurse executives we surveyed and nursing officials we interviewed  identified limitations in VA’s hiring process. Nursing officials identified  three areas of limitations—delays in securing necessary approvals from  medical center resource boards to fill RN vacancies; poor coordination  between nursing and HR officials involved in hiring; and a shortage of  experienced and well-trained HR officials. Collectively, these factors  result in significant delays in filling RN vacancies. We surveyed VAMC  nurse executives to estimate the time it typically takes VAMCs to fill RN  vacancies and found that 44 percent reported it took 45 to 80 days to fill  inpatient RN vacancies at VAMCs in 2007 compared to the 24- to 45-day  target timelines that VA set in 2007. One-third of nurse executives we  surveyed reported that it took more than 80 days to fill RN vacancies at  their VAMCs. In contrast, local hospitals usually hired RNs in less than   21 days, according to nursing officials we interviewed. Nursing officials  during our site visits reported that these delays contribute to VAMCs’  losing applicants to local hospitals as well as reliance on supplemental  staffing strategies to maintain RN staffing levels on inpatient units.
Delays in gaining approval to fill RN vacancies: One factor VAMC nursing  officials identified as contributing to hiring delays is the period of time  during which officials wait to get approval from a VA medical center  resource board—an internal board that controls the medical center’s  budget and the number of authorized staff positions—to fill an RN  vacancy.
Poor coordination between nursing and HR officials: VAMC nursing  officials identified poor coordination between nursing and HR officials as  another factor that contributed to delays in filling RN vacancies. HR  officials are involved in handling application paperwork, interviewing RN  applicants, scheduling screening activities such as physical examinations  and background checks, and verifying employment references. VA’s  Recruitment Process Redesign Workgroup recently issued several  recommendations aimed at improving coordination in filling RN vacancies.  Poor coordination can occur when nursing officials must wait for  information from HR officials before a job offer can be made to an  applicant. For example, VAMC nursing officials we interviewed stated that  they may have to wait a few weeks for HR officials to determine an  appropriate salary estimate based on an applicant’s educational  qualifications and experience, a process that must take place before a job  offer can be made to an RN applicant. In our survey, about 65 percent of  nurse executives cited the inability to provide a salary estimate promptly  to an applicant as one of the primary reasons they lost RN applicants to  competing, non-VA hospitals. Poor coordination can also occur during the  pre-employment process. According to nursing officials, RN applicants  may make multiple visits to the medical center for pre-employment  physicals and verification of state licenses because these activities have  not been coordinated into one visit for the RN applicant.
Shortage of experienced HR officials: VA headquarters and VAMC nursing  officials identified the shortage of experienced and well-trained HR  officials who process RN employment applications and hiring paperwork  as a factor that contributes to RN hiring delays. VAMC nursing officials we  interviewed reported that VAMCs have suffered a “brain drain” of  experienced HR officials through retirement or attrition. VA noted in its  recent workforce succession strategic planning report that it faces a  challenge caused by a “lack of trained HR staff and expertise in the area of  human resources.” VA’s ability to address delays in filling RN vacancies  depends, in part, on its ability to retain experienced HR officials and to  recruit and train new ones. According to VA, new HR recruits must acquire  a good grasp of the breadth and complexity of HR knowledge and skills  required by the federal government and VA. For example, VA noted that an  effective HR official must possess specific knowledge of the complex  laws, rules, and regulations for more than 300 VA occupations.
section_title: VAMC Nursing Officials Report Periodic Hiring Freezes Imposed by VAMCs Delay Initiation of Hiring Process to Fill RN Vacancies
paragraphs: VAMC nurse executives we surveyed reported that hiring freezes and lags  delayed the initiation of the hiring process to fill RN vacancies. Forty-four  percent of VA’s nurse executives we surveyed reported that they  experienced a medical center hiring freeze between 2002 and 2007. On the  average, nurse executives we surveyed reported experiencing two hiring  freezes during this period, and 45 percent of nurse executives reported  that the hiring freezes they experienced lasted on average from 7 to   12 months. Furthermore, 67 percent of nurse executives we surveyed  reported that they experienced a hiring lag—that is, a temporary delay in  hiring or a recurring process intended to control expenditures by limiting  hiring to a certain number of new employees in a given pay period. About  one-third of the nurse executives we surveyed indicated that these hiring  freezes contributed to delays in the hiring process, and nearly half of nurse  executives reported that a lag in hiring also contributed to delays that may  dissuade potential applicants. Some nursing officials we interviewed told  us that once the word has spread in the local community that the VAMC  has imposed a hiring freeze, the medical center has difficulty recovering  from the effects of the hiring freeze. In some cases, nursing officials  reported that it took up to 2 years for RNs to reapply for VA employment  because some applicants were not aware that VA’s hiring freeze had  ended.
section_title: Efforts Are Under Way to Address Some of the Factors Contributing to RN Hiring Delays
paragraphs: VA has a number of efforts under way at both the national level and at  individual VAMCs to reduce shortages in its healthcare workforce,  including RNs. On a nationwide basis, VA has authorized its medical  centers to implement several changes recommended by the Recruitment  Process Redesign Workgroup that studied recruitment and hiring at VA.  These recommendations may address some of the factors that contribute  to delays in filling RN vacancies. According to VA officials, these changes  are designed to increase flexibility and efficiency without weakening the  process of screening candidates’ professional credentials. Collectively,  VA’s recent changes consist of ways to (1) complete applicant interviews  and physical examinations on the same day, (2) make a job offer to an RN  applicant within 30 days, (3) allow use of electronic education transcripts  in lieu of paper transcripts sent through the mail, and (4) create additional  HR positions to help meet VA’s future needs as its experienced HR  officials retire.
In addition to implementing VA’s nationwide efforts, nursing officials at  eight VAMCs we visited cited a number of steps that have been taken at  individual VAMCs to increase efficiency and reduce hiring delays. These  steps include:  Improved communication and coordination between HR and nursing  officials during the hiring process in various ways. For example, seven of  the eight VAMCs we visited reported that they improved coordination and  communication between nursing and HR officials involved in hiring RNs  by better tracking an applicant’s paperwork and coordinating other pre- employment activities, including scheduling interviews and physical  examinations on the same day when possible. In addition, two of the eight  VAMCs have increased their interactions through regular meetings.  Nursing officials at two VAMCs we visited told us that they have  implemented a program called “On the Floor in 24,” an effort which allows  the VAMC to bring an RN on board within 24 days by better coordinating  and expediting steps in the hiring process.
Hiring RNs under temporary appointments until screening activities such  as physical examinations, drug tests, and background checks are  completed. Nursing officials at five VAMCs we visited told us that they  have hired some RNs on a temporary appointment status until screening  activities are completed. Moreover, another VAMC we visited implemented  a program called “On-Demand Hiring,” established by nursing and HR  officials, which involves hiring an RN with the aid of a nurse recruiter.  VAMC nursing officials reported that the nurse recruiter may then provide  the applicant a salary range; afterwards, HR officials become involved by  making a job offer to the RN applicant and proceed with screening  activities such as arranging to have fingerprints taken for a background  check, scheduling a physical examination, and drug tests. Seven VAMCs  we visited implemented a computerized process to expedite the  verification of RNs’ professional credentials.
Hiring a nurse recruiter as a contact point between RN applicants and HR  officials to handle application paperwork. Nursing officials at four VAMCs  we visited reported that they have hired a nurse recruiter who will act as  the focal point for coordinating with HR in posting RN vacancies and  various steps in the RN hiring process.
Implementing new procedures to make the hiring process more efficient.  These procedures include delegating authority to sign nursing personnel  actions, creating an application tracking database, and delegating  authority from HR to nursing officials to give provisional salary quotes to  applicants. Nursing officials at one VAMC we visited told us that before  these recent changes to the hiring process, they usually had to wait for HR  to provide an estimated starting salary to interested applicants who may  have other job offers to consider.
Table 2 summarizes the actions taken by VAMCs we visited to reduce  delays in filling RN vacancies.
While VA’s national and local efforts to reduce hiring delays are  commendable, most are relatively recent, and it is too early to determine  the extent to which these efforts will reduce RN hiring delays or whether  they are sustainable.
section_title: Conclusions
paragraphs: To better ensure that RN staffing levels on inpatient units in its VAMCs are  adequate to provide quality care to its patients, VA must be vigilant on two  fronts. First, it is important that the department expeditiously proceed  with planning and implementing a nurse staffing system that accurately  reflects patient needs and RN workload requirements. The inaccuracy of  VA’s current PCS limits its usefulness in helping to establish adequate RN  staffing levels and reveals a larger problem—VA does not have a viable  system to accurately determine the RN staffing needs for inpatient units.  VA recognizes the need to develop a new standardized nurse staffing  system capable of accurate staffing estimates. Without an accurate nurse  staffing system, VAMCs and nursing officials do not have good information  as a basis for making sound judgments about the RN staffing needs of  inpatient units and often must use supplemental RN staffing strategies to  match RN staffing levels with patient care needs. Excessive use of  supplemental RN staffing strategies can in turn adversely impact RN  morale and job satisfaction and may lead to RN retention problems.
Second, as the number of VA RNs who may consider retirement increases  and the nation continues to face an RN shortage, it is important that VA  maximize its ability to hire new RNs, as well as to retain RNs that it  currently employs. To help address RN retention at VAMCs, VA can use  OPM-authorized flexible work schedules and congressionally authorized  alternate work schedules; however, VAMC nursing officials reported  limited availability and use of alternate and flexible schedules. VA’s ability  to maintain its RN workforce could be enhanced if it can expeditiously  hire qualified applicants and offer more flexible and alternate work  schedules for RNs. Further complicating VAMC RN staffing problems is  that RNs often perform non-nursing tasks that lead to job dissatisfaction.  Where RNs must perform non-nursing tasks because ancillary and nursing  support staff are not available, it is important that nurse managers have  the ability to adjust unit RN staffing levels so that nurses have adequate  time to perform these duties. Developing a staffing approach that can  accurately determine adequate RN staffing levels may also support VA’s  ability to help RNs balance their work and personal commitments through  the offering of alternate work schedules to RNs.
section_title: Recommendations for Executive Action
paragraphs: To improve the ability of VAMCs to determine RN staffing levels needed  for inpatient units and to recruit and retain inpatient RNs, we recommend  that the Secretary of Veterans Affairs direct the Under Secretary for Health  to implement the following three recommendations    develop a detailed action plan that includes a timetable for building,  testing, and implementing the new nurse staffing system;    ensure that the new nurse staffing system provides RN staffing estimates  that accurately account for both the actual inpatient acuity levels and  current nursing tasks performed on inpatient units and adequately take  into account the level of ancillary and nursing support that is available on  VAMC inpatient units; and    assess the barriers to wider availability of alternate and flexible work  schedules for RNs at VAMCs and explore ways to overcome these barriers.
section_title: Agency Comments and Our Evaluation
paragraphs: In commenting on a draft of this report, VA concurred with our findings  and recommendations and provided a description of actions that it plans  to take to address our recommendations.
Regarding our first recommendation—that VA develop a detailed action  plan for building, testing, and implementing a new nurse staffing system— VA stated that it has long recognized the need for an automated and data- driven nurse staffing methodology and noted some of the challenges in  developing and implementing such a system. VA reported that the pilot  implementation of the proposed nurse staffing system is expected to be  completed next year and plans to implement the new system on all  inpatient units by 2012. VA provided a copy of a three-phase plan for the  creation, testing, and implementation of a new staffing methodology for  nursing personnel on inpatient units. While the first phase of VA’s plan  appears to be in-process and the second phase addresses staffing in areas  other than inpatient units, the third phase of VA’s plan—which includes  the development of an automated scheduler application and a patient  acuity application—is pending approval by VA’s Office of Information.  This third phase in VA’s plan is critical to developing an automated and  data-driven nurse staffing methodology, and we would encourage VA to  approve this phase of the plan as soon as possible.
To address our second recommendation—that VA ensure its new nurse  staffing system accurately account for factors including available ancillary  and nursing support—VA stated that its new nurse staffing system will  include indicators for ancillary and nursing support and that nurse staffing  projections will be determined based on nurse responsibilities.
Concerning our third recommendation—that VA assess the barriers to  wider availability of alternate and flexible work schedules and explore  ways to overcome these barriers—VA stated that it plans to convene a task  force to fully assess barriers to the effective use of alternate and flexible  work schedules for RNs and to identify potential solutions for overcoming  these barriers. The task force will present its findings by June 2009.
VA’s written comments are reprinted in appendix IV.
We are sending copies of this report to the Secretary of Veterans Affairs,  appropriate congressional committees, and other interested parties. We  will also provide copies to others upon request. In addition, the report is  available at no charge on the GAO Web site at http://www.gao.gov.
If you or your staff members have any questions about this report, please  contact me at (202) 512-7114 or at williamsonr@gao.gov. Contact points  for our Offices of Congressional Relations and Public Affairs can be found  on the last page of this report. GAO staff members who made major  contributions to this report are listed in appendix V.
section_title: Appendix I: Scope and Methodology
paragraphs: We examined the Department of Veterans Affairs’ (VA) inpatient  registered nurses (RN) staffing practices at VA medical centers (VAMC)  and the challenges VA faces in hiring and retaining RNs. Specifically, we  identified (1) how useful the information generated by VA’s patient  classification system (PCS) is for determining RN staffing levels on VA  inpatient units, (2) key factors that nursing officials and RNs identify that  adversely affect RN retention on inpatient units, and (3) factors that  nursing officials identify as contributing to delays in hiring RNs to fill  vacant positions.
To examine how VAMCs determine the RN staffing levels needed for  inpatient units, we conducted a Web-based survey of all VA nurse  executives at VAMCs. A nurse executive is a member of the executive  leadership team at a VAMC and is responsible for all nursing care  delivered at the VAMC. The survey was sent to 140 VA nurse executives  and obtained a 63 percent response rate, which allows us to generalize the  results to all VA nurse executives at VAMCs. To field the survey, we  contacted a VA headquarters official in the Office of Nursing Services  (ONS) to obtain a list of VAMC nurse executives, and the official provided  email addresses for the nurse executives. See appendix II for the results of  our VA nurse executive survey. To gain further information on RN staffing,  we interviewed VAMC nurse executives and VAMC inpatient unit nurse  managers responsible for determining inpatient RN staffing levels at eight  VAMCs we visited located in Denver, Colorado; Houston, Texas;  Minneapolis, Minnesota; New York, New York; Portland, Oregon; Seattle,  Washington; Tampa, Florida; and Togus, Maine. We selected these VAMCs  because of their geographic variation and to capture various types of  inpatient units including medical intensive care, critical care, surgical  intensive care, surgery, medicine, behavioral health, nursing home, and  spinal cord injury. The findings from these eight VAMCs we visited cannot  be generalized to all VAMCs. To assess VA’s PCS and the information  reported by nursing officials we reviewed the literature to identify relevant  best practices in nurse staffing and the design of systems used to classify  patients and interviewed representatives from state hospital associations  in states where we conducted visits to VAMCs about the use of staffing  methodologies and supplemental staffing strategies.
To identify the factors that nursing officials and RNs identify as adversely  affecting RN retention, we obtained April 2008 VA data on the number of  VA RNs who use alternate work schedules. In addition, we interviewed  nurse managers responsible for supervising RNs on inpatient units at the  eight VAMCs we visited and conducted focus groups with inpatient RNs to  get their perspectives on retention issues. The inpatient RNs in our focus  groups typically deliver care at the patient bedside on inpatient units. The  219 RNs who participated in our focus groups were from three shifts (day,  evening, and night) at the eight VAMCs we visited. Attendees at our focus  groups included RNs of different ages, nurse experience levels, and  lengths of tenure at VA. (See table 3 for a demographic profile of VA RNs  who attended our focus groups.) During each focus group session, we  provided RNs an opportunity to offer their opinions on a variety of issues  related to their experience working at VA. For each focus group we  utilized a series of structured questions to gain RNs’ opinions on nurse  staffing, recruitment, and retention issues. A summary of the responses  from our focus groups are provided in appendix III. We also interviewed  representatives from state hospital associations in states where we  conducted visits to VAMCs about the local retention challenges affecting  RNs.
To identify the factors that contribute to delays in hiring RNs to fill vacant  positions, we used results from our Web-based survey of nurse executives  and interviewed VA headquarters officials, human resources (HR) officials,  and nurse managers who recruit RNs at the eight VAMCs we visited. In  addition, we reviewed VA policies, guidance, and reports related to RN  staffing, retention and hiring issues and obtained, from VA headquarters  officials, work schedule data on VA RNs who use alternate work schedules  contained in VA’s Personnel Accounting Integrated Data (PAID) System  which houses VA’s payroll and human resources information. We also  interviewed representatives from state hospital associations in states  where we visited VAMCs about RN recruitment challenges.
We assessed the reliability of the data obtained from our Web-based  survey of VA nurse executives and from VA headquarters officials. We  performed a systematic review of the completed surveys by checking each  survey for problems such as key questions left unanswered, patterns of  skipped questions, unclear written responses, and out-of-scope entries.  The information presented in our focus group summaries accurately  capture the opinions provided by inpatient RNs who attended the focus  groups at the eight VAMCs we visited. However these opinions cannot be  generalized to all inpatient RNs at the eight VAMCs we visited, or to all  inpatient RNs at VAMCs. We contacted VA headquarters officials  responsible for VA’s PAID system to gain an understanding of the  completeness and accuracy of the data and whether quality checks were  performed on these data. Based on this assessment we determined that  these data were adequate for our purposes.
We conducted this performance audit from May 2006 through September  2008 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.
Selected results from our survey and a summary of responses from our  focus groups are provided in appendix II and appendix III.
section_title: Appendix II: Analysis of GAO Survey of VA Medical Center Nurse Executives
paragraphs: To obtain the views of VA nurse executives on various staffing,  recruitment, and retention issues, we conducted a Web-based survey of VA  nurse executives employed at VAMCs. The survey contained questions on  topics such as nurse executives’ views on the use of supplemental staffing  strategies at the VA medical center where the executives work, RN  vacancies, recruitment and retention challenges, and the use of hiring  freezes or lags in hiring. Some of these questions are listed below. Not all  column totals add to 100 percent because of rounding, multiple answers to  some questions that ask respondents to check all that apply, or no  response checked by VA nurse executives for some questions.
Q1: As of March 31, 2007, which of the following services or departments  at this facility employed support staff for all shifts (day, evening, and  night)?
Checked  (percentage)
Q2: What were the effects on inpatient units of having bedside non- management RN vacancies? (percentage)
1.  RN overtime increased   2.  RN floated to the unit with vacancies   3.  Staff on units worked with fewer staff (short staffed)  4.  Number of patient beds were capped   5.  Used contract/agency RNs   6.  Used fee-basis RNs   7.  Patients were diverted to non-VA facilities   34 (percentage)
8.  RN turnover on the unit  9.
Q3: What strategies did this facility use to supplement bedside non- management RN staffing? (percentage)
Q4: Based on your experience recruiting for bedside non-management  RNs, what has been the average length of time it has taken to fill a position  from the time you were authorized to recruit and fill the vacancy by an  approved form SF 52 to the time an RN comes on board?
Checked (percentage)
Q5: What steps did this facility take in the last 5 years to simplify or  shorten the hiring process for new RNs? (percentage)
1.
Improved communication to keep applicant  informed about steps and paperwork required  in hiring process  2.  Brought in RNs under temporary appointments 3.  Used VA’s expedited VetPro credentialing  4.  Hired a nurse recruiter   5.
Q6: Why did this facility hire bedside non-management RNs on temporary  appointments? (percentage)
Q7: Did this facility experience a Veterans Integrated Service Network  (VISN)-imposed or facility-imposed hiring freeze that affected its ability to  hire bedside non-management RNs in the last 5 years? (During a hiring  freeze units typically require authority from a resource board or other  similar entity within the facility or VISN to fill a vacant RN position.) (percentage)
Q8: What was the average length of the VISN or facility imposed hiring  freezes that affected your ability to hire bedside non-management RNs?
Checked (percentage)
Q9: Did this facility experience a lag in hiring that affected its ability to  hire bedside non-management RNs in the last 5 years? (A lag in hiring is a  temporary delay in hiring RNs or can be a recurring process that delays  hiring, i.e., only allowing a certain number of RNs to be brought on board  per pay period or requiring vacant positions to be approved by an entity  such as a resource board.)
Checked (percentage)
Q10: What type of restrictions imposed during a hiring freeze or lag  affected your ability to fill bedside non-management RN positions?
VISN freeze  (percentage) center freeze (percentage)
Hiring lag (percentage)
1.  Recruitment for vacant RN positions  needed approval by the equivalent  of a resource board   26 (16)
51(31)
62 (38)
2.  Recruitment for each RN position  needed approval by the equivalent  of a resource board  31 (19)
49 (30)
61(37)
3.  Hiring for vacant RN positions  deferred for a period of time  25 (15)
38 (23)
46 (28)
4.  Overtime for RNs increased   21 (13)
38 (23)
59 (36)
5.  Limits placed on recruitment for a  18 (11)
33 (20)
36 (22)
6.  Limited number of RN positions filled 15 (9)
31(19)
38 (23)
7.  Did not recruit for certain RN  15 (9)
28 (17)
33 (20)
8.  Limits were placed on number of  RNs that could be hired in a pay  period   11 (7)
23 (14)
31(19)
9.  Use of contract/agency RNs  10 (6)
15 (9)
34 (21)
10.  RNs hired under temporary  5 (3)
13 (8)
13 (8)
11.  No vacant RN positions were filled  8 (5)
7 (4)
7 (4)
2 (1)
3 (2)
8 (5)
Q11: How difficult has it been to compete with local health care  establishments in recruiting bedside non-management RNs?
Checked (percentage)
Q12: What are the primary reasons for the difficulty in competing with  local health care establishments in recruiting bedside non-management  RNs?
New  Graduates  (percentage) (percentage)
1.  Hiring process was lengthy   76 (57)
89 (67)
2.  RNs were required to rotate shifts   65 (49)
68 (51)
3.  Unable to make position offers promptly   65 (49)
71 (53)
4.  Shortage of RNs in the local market area  48 (36)
67 (50)
5.  Salary level low compared to locality pay area   48 (36)
63 (47)
6.  Alternate or flexible work schedule was not offered on  51 (38)
57 (43)
7.  Tuition reimbursement not available at time of  36 (27)
32 (24)
8.  Recruitment incentives were not sufficient   29 (22)
36 (27)
9.  Difficult to recover from hiring freeze  28 (21)
35 (26)
10.  Reimbursement for continuing education not sufficient   25 (19)
28 (21)
11.  Determining salary was delayed by professional  21 (16)
24 (18)
12.  Recruitment incentives were not available   27 (20)
25 (19)
13.  Tuition reimbursement not sufficient  19 (14)
17 (13)
14.  Reimbursement for continuing education not available   16 (12)
17 (13)
15.  VA benefit package was not as attractive as local  13 (10)
13 (10)
13 (10)
15 (11)
Q13: How difficult has it been to compete with local health care  establishments in retaining bedside non-management RNs?
Checked (percentage)
Q14: What are the primary reasons for the difficulty in competing with  local health care establishments in retaining bedside non-management  RNs? (percentage)
Question 15: As of March 31, 2007, which of the following staffing  methodologies were used to determine staffing levels for inpatient care for  inpatient units at this facility? (percentage)
section_title: Appendix III: Summary of RN Focus Group Questions and Responses at the Eight VAMCs We Visited
paragraphs: The table lists the questions we asked RNs at the eight VAMCs we visited  and their five most frequent responses.
What attracted you to work at VA?
What keeps you working at VA?
What is not at your facility now that  would keep you working here?
What contributes to the RN  shortage?
Lack of support for new hires    Lack of support staff (i.e., RNs performing non- nursing tasks)
How would you improve  recruitment and hiring?
Shorten VA’s hiring process    Better advertisement for RN positions  Increase outreach (i.e., to nursing schools)
How is staffing determined?
Available full-time equivalent employees (FTEE)
What types of supplemental  staffing strategies are used?
section_title: Appendix IV: Comments from the Department of Veterans Affairs
section_title: Appendix V: GAO Contact and Staff Acknowledgments
paragraphs: Randall B. Williamson at (202) 512-7114 or williamsonr@gao.gov.
subsections: section_title: Acknowledgments
paragraphs: In addition to the contact named above, Marcia A. Mann, Assistant  Director; N. Rotimi Adebonojo; Mary Ann Curran; Linda Diggs; Martha A.  Fisher; Krister Friday; Susannah Bloch; and Suzanne Worth made major  contributions to this report.
section_title: Related GAO Products
paragraphs: VA Health Care: Recruitment and Retention Challenges and Efforts to  Make Salaries Competitive for Nurse Anesthetists. GAO-08-647T.  Washington, D.C.: April 9, 2008.
VA Health Care: Many Medical Facilities Have Challenges in Recruiting  and Retaining Nurse Anesthetists. GAO-08-56. Washington, D.C.:  December 13, 2007.
Nursing Workforce: HHS Needs Methodology to Identify Facilities with a  Critical Shortage of Nurses. GAO-07-492R. Washington, D.C.: April 30,  2007.
Nursing Workforce: Emerging Nurse Shortages Due to Multiple Factors.  GAO-01-944. Washington, D.C.: July 10, 2001.