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Submission For The Record of Nurses Organization of Veterans Affairs

  • Retention & Recruitment

The Nurses Organization of Veterans Affairs (NOVA) has identified retention and recruitment of healthcare staff members as a critically important issue in providing high quality health care to veterans.  Shorter lengths of stay, higher patient acuity, more sophisticated technologies and procedures, and increasing care complexity place greater demands on health care workers today.  For VHA to provide high quality health care, there must be a dramatic increase in retention and recruitment efforts.

As VHA executives face growing vacancies, elevated turnover due to retirements is imposing an additional tremendous burden on VHA facilities, especially in a time of shortage. The result is lost productivity, increased use of premium labor, escalating recruiting expenditures, and damage to employee morale. 

There are several key issues that impact the ability of VHA to provide excellent health care.

  • Nurse Executive Pay and Pay Cap

Another important issue for retention and recruitment involves Nurse Executive pay.  Recent changes in pay for non-SES leaders in VHA have worsened the issue of pay inequity.  Nurse Executives do not receive pay comparable with their peers.   Due to the recently implemented Physician Pay Bill, Medical Center Chiefs of Staff received substantial pay increases averaging 8% to an average level of $210,000 and reaching $250,000 at the most complex (Tier 1) VA medical centers. 

The mean salary for Nurse Executives is $129,000.  Many Nurse Executives did not receive additional pay in the form of a bonus that is included in retirement computation under Public Law 108-445, because the bonus was not mandatory.  This underscores the need for VA to move quickly to remedy a problem that is already manifesting itself in turnover and in recruitment problems for key upper level positions in the organization. 

Currently, individuals appointed under Section 7306 of Title 38 serve in executive level positions that are equivalent in scope and responsibility to positions in the Senior Executive Service.  Examples of such positions are the Director, Pharmacy Benefits Management Strategic Health Group; Director of Optometry; Director of Podiatry, and Director of Dietetics.  The pay schedule for section 7306 appointees is adjusted each year by Executive Order and is capped at the pay rate for Level V of the Executive Schedule (currently $136,200).  Locality pay is also paid up to the rate for Level III of the Executive Schedule (currently $154,600). 

In addition there is a need to increase the pay limitation contained in 38 U.S.C. 7451 (c)(2) for VA nurses from Level V (currently $136,200) to Level IV (currently $145,400) of the Executive Schedule to address the pay disparity between the Nurse V maximum rate and the GS-15 maximum rate in some geographic areas.)

A change to 38 USC 7451 is needed to increase the pay cap under the nurse locality pay system.  With an increase to EL-IV, each nurse pay schedule that is currently limited by the EL-V cap would be recalculated based upon the existing beginning rate for the grade.

  • CRNAs

This change will also address a growing recruitment and retention problem with Certified Registered Nurse Anesthetists (CRNA).  Presently, the pay of 286 of the 531 CRNAs (54%) in VA is frozen at the ELV level ($136,200). A search of a commercial website that lists job openings for CRNAs revealed that in 66.8% of the listings, the potential pay rates advertised exceed the EL-V salary cap. 

We see this as a potential challenge for the VA in terms of retaining our skilled CRNA workforce and attracting new candidates. 

The alternative to hiring CRNAs is utilizing more, higher priced Anesthesiologists (currently a scarce medical specialty that commands high market pay rates).

  • Lack of Human Resources Support

The loss of experienced human resources staff throughout VHA has had a significant impact on nursing retention and recruitment.  Inexperienced staff members do not have the expertise to provide needed assistance to medical center staff to assist them to successfully recruit and retain qualified healthcare staff.  The VA has developed a succession plan to address this but the loss of experienced staff is an issue.

  • Delays in Background Investigations

Delays related to security and background checks have significantly impacted VHA’s ability to hire.  The increased security requirements cause several months’ delay in bring staff in to VHA facilities. The delays are so extensive that facilities are losing valuable staff members who cannot wait for long lengths of time for the background checks to be completed.  These delays are particularly frustrating due to poor communication of reasons for delays. In addition, background checks for students are creating an additional burden for schools and universities.  For example, most students have already had background checks and fingerprints completed but must complete another set for VHA.  The delays these cause are so severe in some areas that VHA facilities are losing students, a valuable source of future employees.  

  • Information Technology Issues

The VA, as the nation's largest healthcare organization, has the potential to be the leader in defining 21st century evidence-based quality nursing care. Evidence-Based Practice (EBP) is a national nursing strategic goal, which will help to ensure that patients have the best possible outcomes and that resources are allocated appropriately. The Office of Nursing Services (ONS) and the National Nurse Executive Council (NNEC) selected a program team to develop the VA Nursing Outcomes Database — VANOD.

CPRS re-engineering and redesign to focus on nursing software improvements necessary for VANOD have not occurred in a timely manner. Plans for a new and improved CPRS that will allows for ICU equipment connectivity; customization to reflect clinical care & safety; and documentation designed to match clinical workflow have not met implementation schedules. These critical changes will result in increased patient safety, software usability, & data standardization for integrated, consistent, comparable, longitudinal patient health records across the system and must be supported.

  • Performance of Non Nursing Tasks

The National Commission on VA Nursing’s Work Environment recommendation # 1 was to eliminate performance of non nursing tasks by nursing staff.  The top five issues were:  clerical tasks, finding patient care equipment and supplies, housekeeping tasks, troubleshooting technology, and transporting patients.  It remains challenging in many parts of the country to recruit and retain these valuable workers.

  • VA Nursing Academy

The VA Nursing Academy is a collaborative program established between the Office of Academic Affiliations (OAA) and the Office of Nursing Services (ONS).  Through an expansive network of affiliate partnerships between local VA Medical Centers (VAMC) and schools of nursing, the VA Nursing Academy will meet nurse recruitment/retention and nurse faculty needs for the VA and may ultimately impact the nursing shortage nationwide. 

  • Health Professions Scholarship Program

As part of the Academy, financial assistance will be provided to competitively selected VA and non-VA nursing students in exchange for VA service obligations upon graduation and licensing.  The authority to provide this financial assistance will be established by extending the expiration date of the Department of Veterans Affairs Health Professional Scholarship Program (HPSP) described in 38 USC 7611 – 7618 and 38 CFR 17.600 – 17.612. 

The scholarship program will pay tuition, fees, miscellaneous expenses and a monthly stipend to competitively selected participants.  There is no other scholarship program available to non-VA employees at this time.   

  • Patient and Staff Safety

VA Nursing has prioritized the prevention of musculoskeletal injuries to nursing staff in collaboration with national nursing and specialty organizations. The American Nurses Association launched the “Handle with Care” campaign in 2003 to focus education and research efforts on this topic. The VA Patient Safety Center of Inquiry

(Tampa, FL) has created and tested a series of activities known as the Safe Patient Handling and Movement (SPHM) program, and ONS is supporting this program as a top initiative for FY2006.

These SPHM programs have been found to decrease the number and severity of nursing injuries, while improving job satisfaction and patient quality of care and quality of life.  Funding to support full implementation of both of these programs will contribute significantly to recruitment and retention of health care staff.

  • Clinical Nurse Leader

The Clinical Nurse Leader (CNL) initiative was launched in 2004 to deliver clinical leadership at the micro-system level (individual patient care units.)  The CNL is an advanced generalist that delivers and directs practice, evaluates outcomes, assesses risks and works to improve the overall coordination and delivery of care for an in individual/group of patients at the unit level in all VA health care settings.  Evidence suggests that a positive relationship exists between the numbers and educational level of professional nurses involved in direct patient care and the quality of the care outcomes.  Support for this innovative role is critical for retention.

  • Succession Planning

The Office of Nursing Services has placed emphasis on succession planning for nurse executives. There is a program manager dedicated to implementing a program providing support for new nurse executives. In addition, there is a need for formal succession planning for nurse managers, with the development of an assistant nurse manager role.  This is in progress through the Office of Nursing Services.

  • Magnet Hospital Environment

The magnet characteristic was used in the 1981 study of hospitals conducted by Margaret McClure and colleagues of the American Academy of Nursing.  The study determined that a hospital that successfully attracted and retained nurses possessed certain characteristics.  In the early 1990's the American Nurses Credentialing Center launched the Magnet Recognition Program which was based on hospitals (and other health care organizations which were added later) demonstrating these magnet characteristics.

Magnet environments provide supports for the work of nursing – autonomy, maximized participation in Medical Center governance, adequate support personnel, are just some tenets of the Magnet environment.

It is critical that VHA support the environment necessary to provide a model that results in professional satisfaction for the nurse.  Although not necessarily magnet status, the support of the Magnet environment is critical.