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.