VA Health Care: Oversight Improvements Needed for Nurse Recruitment and Retention Initiatives
Released: 2015-10-30T00:00:00


Highlights: section_title: Why GAO Did This Study
paragraphs: 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.

section_title: What GAO Found
paragraphs: 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.

section_title: What GAO Recommends
paragraphs: 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.

section_title: Letter
paragraphs: 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. 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.

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  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. 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.

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,  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. 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). 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. 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  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.

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. We also reviewed relevant criteria  from GAO’s body of work on effectively managing performance under the  Government Performance and Results Act of 1993 (GPRA), as enhanced  by the GPRA Modernization Act of 2010.

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.
subsections: section_title: Background
paragraphs: 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. 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.
subsections: section_title: VHA’s Nurse Workforce
paragraphs: 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. The number of nurses providing  direct patient care has increased from about 72,000 to about 82,000— 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.

section_title: VHA Nurse Skill Mix
paragraphs: 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. (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.

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.)

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.)

The average national nurse turnover rate for VHA from FY 2010 through  FY 2014 was 7.6 percent. 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.)

section_title: Roles and Responsibilities for VHA Nurse Recruitment and Retention
paragraphs: 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. Once medical centers recruit,  interview, and select a nursing candidate, that nursing candidate goes  through a process known as onboarding and credentialing.

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.

section_title: VHA Has Multiple Nurse Recruitment and Retention Initiatives, but Some Medical Centers Face Challenges That Limit the Initiatives’ Usefulness
paragraphs: 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. (See app. II for VHA expenditures for and nurse participation  in key recruitment and retention initiatives from FY 2010 through FY  2014.)

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. This  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. 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).

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. 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  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.

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. In FY 2014,  this medical center had turnover rates of 10 percent or higher for NPs,  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.

section_title: VHA’s Oversight of Its Nurse Recruitment and Retention Initiatives Is Limited
subsections: section_title: VHA Conducts Limited Monitoring of VA Medical Centers’ Compliance with Nurse Recruitment and Retention Initiatives
paragraphs: 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. 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.

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.

section_title: VHA Has Conducted Limited Evaluations of the Training Resources Provided and Overall Nurse Recruitment and Retention Initiatives
paragraphs: 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.

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.

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. 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.

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. 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  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.

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  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.

section_title: Conclusions
paragraphs: 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.

section_title: Recommendations for Executive Action
paragraphs: 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.

section_title: Agency Comments
paragraphs: 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   page of this report. GAO staff who made key contributions to this report  are listed in appendix IV.

section_title: Appendix I: Selected Characteristics of Veterans Health Administration’s (VHA) Nurse Workforce
subsections: section_title: Total

section_title: Appendix II: Selected Characteristics of Veterans Health Administration’s (VHA) Key Nurse Recruitment and Retention Initiatives
paragraphs: Appendix II: Selected Characteristics of  Veterans Health Administration’s (VHA) Key  Nurse Recruitment and Retention Initiatives (Number of participating nurses)

Initiative  Education and training initiatives  RN Transition to Practice  n/a  (n/a) n/a  (n/a) n/a  (n/a) n/a  (n/a) n/a  (n/a)

2,856,845  (335)

3,194,961  (349)

3,128,159  (368)

3,675,841  (434)

3,999,113  (475)

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  Education  Financial benefits and incentives initiatives  Recruitment, retention, and relocation  incentives  Education Debt Reduction Program  n/a  (n/a) n/a  (n/a) n/a  (n/a) n/a  (n/a)

427,469  (5)

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)

5,938,084  (1,607)

5,554,648  (1,353)

6,015,672  (1,300)

4,599,492  (961)

3,079,405  (643)

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) n/a  (n/a) n/a  (n/a) n/a  (n/a) n/a  (n/a) n/a  (n/a)

section_title: Appendix III: Comments from the Department of Veterans Affairs

section_title: Appendix IV: GAO Contact and Staff Acknowledgments
subsections: section_title: GAO Contact

section_title: Staff Acknowledgments
paragraphs: 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.


Question-summary annotations: questions: question: What is the status of the VHA's workforce recruitment programs?
answer: 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.
child_questions: question: What is the nature of these initiatives?
answer: 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.

question: How did the medical centers in GAO's review vary?
answer: 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.
child_questions: question: What else did GAO find?
answer: 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.
child_questions: question: What was the nature of these challenges?
answer: 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.

questions: question: What is the status of nurses in the VA system?
answer: GAO and others have highlighted the need for an adequate and qualified nurse workforce to provide quality and timely care to veterans.
child_questions: question: What challenges does VHA face in this regard?
answer: VHA faces challenges such as increased competition for skilled clinicians in hard-to-fill occupations such as nurses.

question: What kinds of nurses are particularly hard to recruit and retain?
answer: 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.

questions: question: What was GAO asked to provide?
answer: GAO was asked to provide information on the recruitment and retention of nurses within VHA.
child_questions: question: What does this report analyze?
answer: 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.

question: What did GAO review?
answer: 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 also interviewed selected stakeholder organizations.
child_questions: question: What standards did GAO use to evaluate VHA's oversight?
answer: GAO used federal internal control standards to evaluate VHA's oversight.