The standard work schedule for full-time VA  employees is ten 8-hour work days within a 2-week period. VAMC Nursing Officials Cannot Rely on Information from VA’s PCS to Determine RN Staffing Levels for VA Inpatient Units

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 input patient data into VA’s PCS, many said they cannot rely on the  information generated by PCS because the PCS is outdated and  inaccurate.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 headquarters officials in the Office of Nursing Services  (ONS) and VA’s OIG also reported that PCS has significant limitations. 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. 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. 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. 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. VAMC Nursing Officials Identified Limitations in VA’s Hiring Process and VA-Imposed Hiring Freezes as Contributing Factors to RN Hiring Delays

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. Recommendations for Executive Action

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. 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. 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 findings from these eight VAMCs we visited cannot  be generalized to all VAMCs. 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. Appendix II: Analysis of GAO Survey of VA Medical Center Nurse Executives

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.
Why GAO Did This Study

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.

What GAO Found

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