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. 1.) VHA Has Multiple Nurse Recruitment and Retention Initiatives, but Some Medical Centers Face Challenges That Limit the Initiatives’ Usefulness

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. VHA’s initiatives focus primarily  on providing (1) education and training, and (2) financial benefits and  incentives. The four VA medical  centers in our review varied in the number of initiatives they offered from  FY 2010 through FY 2014. In addition to offering VHA’s initiatives, three of the four medical centers  in our review developed local recruitment and retention initiatives. 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. 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. VHA’s Oversight of Its Nurse Recruitment and Retention Initiatives Is Limited

		VHA Conducts Limited Monitoring of VA Medical Centers’ Compliance with Nurse Recruitment and Retention Initiatives

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. 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. VHA Has Conducted Limited Evaluations of the Training Resources Provided and Overall Nurse Recruitment and Retention Initiatives

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. 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  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. 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. 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. 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. 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.
Why GAO Did This Study

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.

What GAO Found

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.

What GAO Recommends

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.