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. 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. 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.) 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. 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. 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. 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. 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. To help ensure the effective recruitment and retention of nurses across VA medical centers, we recommend the Secretary of Veterans Affairs direct the Under Secretary for Health to take the following three actions: 1. Develop a periodic reporting process to help monitor VA medical center compliance with the policies and procedures for each of its key recruitment and retention initiatives; 2. Evaluate the adequacy of training resources provided to all nurse recruiters at VA medical centers to ensure that they have the tools and information to perform their duties efficiently and effectively; and 3. Conduct a system-wide evaluation of VHA's key nurse recruitment and retention initiatives, to determine the overall effectiveness of these initiatives, including any needed improvements, and communicate results and information in a timely manner to relevant stakeholders. We provided a draft of this report to VA for comment. In its written comments, reproduced in appendix III, VA generally agreed with our conclusions and concurred with our recommendations. In its comments, VA also provided information on workgroups it was planning to establish, as well as its plans for implementing each recommendation, with an estimated completion date of October 2017. As agreed with your office, unless you publicly announce the contents of this report earlier, we plan no further distribution until 30 days from the report date. At that time, we will send copies of this report to appropriate congressional committees, the Secretary of Veterans Affairs, and other interested parties. In addition, the report will be available at no charge on the GAO website at http://www.gao.gov. If you or your staff have any questions about this report, please contact me at (202) 512-7114 or draperd@gao.gov. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. GAO staff who made key contributions to this report are listed in appendix IV. 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) 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.

Summary:
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. 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. 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.