VA Health Care:

Improved Staffing Methods and Greater Availability of Alternate and Flexible Work Schedules Could Enhance the Recruitment and Retention of Inpatient Nurses

GAO-09-17: Published: Oct 24, 2008. Publicly Released: Oct 24, 2008.

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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are required to input patient data into VA's PCS, they do not rely on the information generated by PCS because it is outdated and inaccurate.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

Recommendations for Executive Action

  1. Status: Open

    Comments: August 2010: VA concurred with the recommendation, and chartered a Staffing Methodology Action Team (SMAT) to revise the current staffing methodology process for nursing personnel. The SMAT developed a plan to implement the new staffing system. The first phase of the plan, the initial pilot implementation phase, focused on nursing staff requirements for all inpatient points of care. This phase, completed in March 2009, included participation from Veterans Integrated Service Networks (VISNs) 1, 6, 15, 16, and 20, and tested the new process. The second phase will provide guidance to include additional points of care, other than inpatient. A methodology for Community Living Centers (CLC) has been developed, and efforts to address outpatient care have been initiated. The third and final phase will provide the guidance for a fully automated system that encompasses initial data entry through report production, including automated methods that integrate with VA databases. This phase is awaiting approval. A new draft Veterans Health Administration (VHA) directive, Staffing Methodology for VHA Nursing Personnel, has been issued.

    Recommendation: To improve the ability of VAMCs to determine RN staffing levels needed for inpatient units and to recruit and retain inpatient RNs, the Secretary of Veterans Affairs should direct the Under Secretary for Health to develop a detailed action plan that includes a timetable for building, testing, and implementing the new nurse staffing system.

    Agency Affected: Department of Veterans Affairs

  2. Status: Open

    Comments: VA concurs with this recommendation. As of July 2010, VA stated that the Staffing Methodology for VHA Nursing Personnel will include a prediction of the numbers and skill mix of staff recommended for the practice setting based on desired nursing hours per patient day (NHPPD). Factors that will contribute to the staffing calculations will include clinical, human resource and administrative indicators. Indicators that will be standardized will include unit turbulence (admissions, discharge and transfer), employee leave (annual, sick, military) and indirect patient care activities (systems improvement, employee education and research). Development of tools to support outpatient care (primary, home based and specialty clinics) are currently under development and are planned for implementation in the fall of 2010. Development of tools to support operating rooms, emergency rooms and specialty inpatient are planned for implementation by fall 2011.

    Recommendation: To improve the ability of VAMCs to determine RN staffing levels needed for inpatient units and to recruit and retain inpatient RNs, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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.

    Agency Affected: Department of Veterans Affairs

  3. Status: Closed - Implemented

    Comments: VA concurred with this recommendation. As of July 2009, VA stated that the Office of Nursing Service (ONS), in conjunction with the Office of Workforce Management and Consulting (WMC), has assessed barriers to the effective use of alternate and flexible work schedules (AWS) for Registered Nurses (RNs), and identified two barriers. First, the restrictions imposed by the paid system (dFas) restricts the scheduling of nursing personnel from working a Saturday/Sunday night tour of duty that crosses pay periods. Second, the law as written restricts flexibility in scheduling personnel in configurations that are not clearly three 12 hours per one work week. General Counsel (GC) has determined that no flexibility exists in the law that would provide an equitable solution for implementation. ONS and WMC are working with GC to craft proposed legislation to convert the language of the law to allow for implementation. Once this language is passed the enhancement to dFas will need to be incorporated to comply with the regulation. WMC will draft implementation guidelines following the current restrictions to be sent to all Nurse Executives by August 1, 2009. ONS will then survey the Nurse Executive group in November 2009 to determine use of the AWS and identify additional barriers.

    Recommendation: To improve the ability of VAMCs to determine RN staffing levels needed for inpatient units and to recruit and retain inpatient RNs, the Secretary of Veterans Affairs should direct the Under Secretary for Health to assess the barriers to wider availability of alternate and flexible work schedules for RNs at VAMCs and explore ways to overcome these barriers.

    Agency Affected: Department of Veterans Affairs

 

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