Nurse staffing is a critical part of health care because of the effects it can have on patient outcomes and nurse job satisfaction. According to VHA, its staffing methodology aims to maximize nurses’ productivity and efficiency, while providing safe patient care by ensuring appropriate nurse staffing levels and skill mix. VHA’s nurse workforce is primarily composed of RNs, licensed practical nurses (LPN), and nursing assistants (NA). These nurses provide care—ranging from primary care to complex specialty care—in inpatient, outpatient, and residential care settings at 151 VAMCs across the country. In addition to the size of the nursing workforce, the nursing skill mix—i.e., the share of each type of nurse (RNs, LPNs, or NAs) of the total—is an important component of nurse staffing. Units vary in their nursing skill mix, depending on the needs of their patients. 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 nursing units that may provide less complex care. (See table 1 for a general description of the types of nursing staff position, responsibilities, and educational requirements.) Although the number of nurses at VAMCs increased from FY 2009 to FY 2013, VHA ranked nurses as the second most challenging occupation to recruit and retain. Specifically, the total number of nurses at VAMCs increased 13 percent from 72,542 in FY 2009 to 81,940 in FY 2013, with similarly proportionate increases within each position type—RN, LPN, and NA. During the same time period, the annual nurse turnover rate at VAMCs—the percentage of nurses who left VHA through retirement, death, termination, or voluntary separation—increased from 6.6 percent to 8.0 percent. Although RNs had the lowest turnover rate among nurses, VHA noted particular difficulty recruiting and retaining for the position, particularly for RNs with advanced professional skills, knowledge, and experience, such as RNs that provide services in medical and surgical VHA projects that approximately 40,000 new nurses will be care units. needed through FY 2018 to maintain current staffing levels and to meet the needs of veterans. See Department of Veterans Affairs, Veterans Health Administration, 2013 Workforce Succession Strategic Plan (Washington, D.C.: 2013). To help ensure adequate and qualified nurse staffing at VAMCs, in July 2010, VHA issued VHA Directive 2010-034: Staffing Methodology for VHA Nursing Personnel. ONS, the VHA office responsible for providing national policies and guidelines for all VHA nursing personnel, led the development of the nurse staffing methodology, which began in 2007. (See fig. 1.) To implement the methodology, each VAMC is required to (1) develop a VAMC-wide staffing plan for its nurse workforce, comprised of individual unit-level staffing plans, and (2) execute that plan. (See figure 2 for an outline of the process for implementing VHA’s nurse staffing methodology.) Each VAMC unit is to develop a staffing plan outlining recommendations on the appropriate nurse staffing levels and skill mix needed in that unit to support high-quality patient care in the most effective manner possible. Specifically, staffing plans are to be developed using expert panels and a data-driven analysis of nursing hours per patient day (NHPPD). VAMC nurse executives—members of senior management within each VAMC— are responsible for implementing the staffing methodology in their respective VAMCs. Expert panels: advisory groups—at the unit and facility level—of VAMC staff with in-depth knowledge of nurse staffing needs. The use of expert panels is intended to apply principles of shared governance, which allows nurses to have influence over the delivery of patient care and involves stakeholders from across the VAMC. VAMC nurse executives are responsible for ensuring that the unit-based expert panels represent all nursing types (RN, LPN, NA) and developing the VAMC’s facility expert panel. Data-driven analysis of NHPPD: involves determining the number and skill mix of nurses needed for each unit by calculating the number of direct patient care nursing hours provided for all patients on that unit during a 24-hour period. The use of NHPPD represents a move away from the more traditional nurse-to-patient ratios that assign a certain number of patients to each nurse. Some research suggests that NHPPD can better capture changes in nurses’ workloads and case mix resulting from admissions and discharges, as well as patient acuity levels, which can impact the amount of time nurses spend with each patient. After developing the staffing plan, each unit-based expert panel presents its plan, which includes staffing recommendations, to the VAMC’s facility expert panel. Those staffing recommendations may include, for example, initiatives to change the number and skill mix of nurses needed for each shift; change the number of nurses required for coverage during predicted absences, such as annual and sick leave; and develop support services for nurses, such as designated individuals to transport patients to other areas of the facility as needed. The facility expert panel—comprised of staff from across the VAMC—reviews each unit-based panel’s staffing plan and aggregates all of the unit plans into one VAMC-wide staffing plan. The VAMC nurse executive reviews the VAMC-wide staffing plan and forwards it to the VAMC director for review and approval. Once approved, the VAMC then begins execution of the initiatives outlined in the VAMC-wide staffing plan. The directive requires each VAMC to conduct an ongoing staffing analysis to evaluate staffing plans annually, at a minimum, and for VAMC directors to incorporate projected staffing needs into their annual budget review. The staffing methodology is being implemented in three phases. In Phase I, VAMCs were to implement the staffing methodology in all inpatient units no later than September 30, 2011. In Phase II, VAMCs are to implement the staffing methodology for all other units, including the operating room, emergency department, and spinal cord injury units. ONS has completed the Phase II pilot for operating room units, and VAMCs are expected to implement the methodology in their operating room units by October 1, 2014. Deadlines for the implementation in other Phase II units have not been set. In Phase III, VAMCs are to use an automated system developed by VHA that (1) merges VHA staffing data used in the staffing methodology and other VHA data, such as human resource data, into one data system, and (2) incorporates the data into staffing-related reports, such as quality-of-care reports. A deadline for Phase III implementation has not been set. In May 2014, the VA OIG found that VAMCs in its review varied in their implementation of the staffing methodology. Specifically, the VA OIG reported that 8 of the 28 VAMCs reviewed had not fully implemented all components of the staffing methodology by September 2013, 2 years past the implementation date required by the VHA directive. As these findings were similar to those of its April 2013 report, the VA OIG stated in its 2014 report, “We re-emphasize the need for all facilities to fully implement the methodology and accurately address patient needs with safe and adequate staffing.” Adequate and qualified nurse staffing at VAMCs is required to provide effective and continuous patient care and to maintain a stable and engaged workplace. The importance of nurse staffing on patient outcomes and nurse job satisfaction has been emphasized by various entities, including The Joint Commission; American Nurses Association; Institute of Medicine; and Agency for Healthcare Research and Quality.and qualifications of nurse staffing to patient outcomes and nurse job satisfaction. For example, studies have shown: Additionally, research has linked the adequacy A link between the adequacy of nurse staffing and patient outcomes, particularly in inpatient units, such as intensive care and surgical units. For example, medication errors, pressure ulcers, hospital acquired infections, pneumonia, longer-than-expected stays, and higher mortality rates each have been associated with inadequate nurse staffing. A link between the qualifications of nursing staff and patient outcomes. For example, one study found that patients cared for in units utilizing more licensed and experienced nursing staff (RNs and LPNs) and fewer unlicensed aides (NAs) had shorter lengths of stay. Other studies linked baccalaureate-prepared nurses to lower mortality rates. A link between nurse staffing and job satisfaction. For example, some studies have linked low job satisfaction to heavy workloads and an inability to ensure patient safety. Other studies found that improving nurse staffing and working conditions may simultaneously reduce nurses’ burnout, risk of turnover, and the likelihood of medical errors, while increasing patients’ satisfaction with their care. Non-VA health care organizations use various approaches to ensure effective nurse staffing. For example, some use fixed nurse-to-patient ratios while others use adjustable, unit-specific minimum staffing levels, and there have been several efforts to address nurse staffing using these different approaches.requiring regulations that mandate specific nurse-to-patient ratios that limit the number of patients cared for by an individual nurse. Other states have passed legislation or adopted regulations addressing nurse staffing without mandating specific ratios or staffing levels. For example, some states require hospitals to have committees responsible for developing unit staffing plans or require public reporting of staffing. All seven VAMCs in our review developed staffing plans using VHA’s nurse staffing methodology and have taken steps to execute them. However, VAMCs experienced problems in both the development and execution of their staffing plans.