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Highlights

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.

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.

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Recommendations

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.

Recommendations for Executive Action

Agency Affected Recommendation Status
Department of Veterans Affairs 1. To help ensure the effective recruitment and retention of nurses across VA medical centers, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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.
Closed - Implemented
In December 2017, VHA provided documentation of the periodic reporting processes it developed to help ensure that its medical centers are in compliance with program policies and procedures and to assess take up of these initiatives. For example, for some initiatives, VHA collects annual data from the medical centers to determine which medical centers are using the initiatives, whether all forms and evaluations have been completed for program participants, and assess short- and long-term retention rates (1-, 2-, and 5-year rates). For other initiatives, VHA conducts, or is planning to conduct, onsite or virtual visits, and has developed site visit guides to use to assess medical centers' management of the initiatives. VHA has also developed standard operating procedures and other guidance that lays out requirements for routine reporting, such as quarterly and annual reporting, and actions VHA can take against noncompliant medical centers, including requiring corrective action plans or suspending centers' abilities to accept new participants into certain initiatives.
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
2. To help ensure the effective recruitment and retention of nurses across VA medical centers, the Secretary of Veterans Affairs should direct the Under Secretary for Health to 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.
Closed - Implemented
VHA convened a taskforce with accompanying charter to address all three recommendations, including evaluating training resources provided to nurse recruiters. VHA fielded a survey in fiscal year 2015 to all nurse recruiters--including those in both medical centers' nursing services and human resource offices--requesting input on the areas of future trainings nurse recruiters would like to receive. VHA told us that it used the survey results to inform its upcoming nurse recruiter training conferences. VHA held a nurse recruiter training conference in April 2016 that included at least seven of the training areas identified by survey participants.
Department of Veterans Affairs
Priority Rec.
This is a priority recommendation.
3. To help ensure the effective recruitment and retention of nurses across VA medical centers, the Secretary of Veterans Affairs should direct the Under Secretary for Health to conduct a system-wide evaluation of VHA's key nurse recruitment and retention initiatives, to determine the overall effectiveness of these initiatives, including any needed improvements, and communicate results and information in a timely manner to relevant stakeholders.
Closed - Implemented
VHA convened a taskforce with accompanying charter to address all three of GAO's recommendations, including conducting a system-wide evaluation of VHA's key nurse recruitment and retention initiatives and identifying areas for improvement. In October 2018, VHA sent us the results of standalone evaluations of single initiatives (or related groups of initiatives). In March 2019, VHA reported that it convened a workgroup composed of the VHA offices responsible for administering the key initiatives to assess the results of the evaluations as a whole. According to VHA, the eight initiatives all contribute to the recruitment and retention of nurses to meet VHA's nursing workforce goals and are effective to varying degrees but are limited in both size and scope as a result of a lack of resources.

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