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

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