Perceptions, benefits, and challenges of using travel nurses

FigureThe nursing shortage continues to threaten healthcare operations and quality patient care, specifically in the inpatient arena. Although the COVID-19 pandemic exacerbated the nursing shortage, the need for nurses isn't new. The workforce has endured periods of instability, with multiple factors contributing to the recent surge in the nursing shortage, including poor workforce planning, unsatisfactory work conditions, burnout, and low enrollment of new students in nursing programs.1-6 To fill staffing needs, many organizations hire travel nurses, who are experienced healthcare professionals working in short-term assignments at hospitals or other healthcare facilities.7 Although there is a clear benefit to having these short-term professional workers, their abundant use is controversial. In revisiting this time-honored strategy of using travel nurses, the literature documents many advantages and disadvantages. Hospitals experiencing staffing shortages, particularly in specialized departments, benefit from the expertise and consistent coverage that travel nurses provide. Travel nurses help maintain adequate nurse-to-patient ratios, ensuring safe, high-quality patient care. They typically work full-time schedules during their contracts, which usually last 13 weeks. Besides providing adequate staffing, travel nurses may reduce the workload and stress on permanent direct care nurses, improve morale, and reduce turnover rates.7 In contrast, higher compensation for travel nurses may lead to growing resentment among the full-time staff, which can negatively impact retention. Additionally, overreliance on travel nurses may discourage hospitals from exploring strategies to recruit and retain permanent staff, such as increasing salaries and improving working conditions. Investing in permanent staff by raising wages and offering bonuses rather than paying for travel nurses is suggested as a more sustainable long-term solution to staffing shortages.7 Additionally, the literature has expanded on the motivations that propel nurses to accept a travel assignment. Although higher pay is a big motivator, there are many other reasons nurses choose to work as travel nurses.4 Gaining more experience at various hospitals is one key motivator for RNs choosing travel nursing. Many seek exposure to more procedures, want to learn about other cultures, and desire to live in other geographical regions.8 The perceived lack of support from leadership has accelerated RNs' decisions to leave an organization, choose a path that offers greater flexibility in scheduling, and escape the toxic effects of institutional politics.4,5 However, travel nurses have a high impact on hospital budgets. Although some authors report that travel nurses tend to have higher salaries than permanent staff, other researchers argue that there's no significant difference in costs between travel nurses and permanent staff when a comprehensive cost analysis is used, incorporating employee benefits, overtime pay, training, and recruitment expenses.7-9 This perception of pay inequity between the two groups of nurses provokes animosity.10 Nurse leaders (NLs) are poised to enlighten their staff about these misconceptions to promote better work cohesiveness. This study aims to explore NL perceptions of the benefits and challenges of using travel nurses and provide alternative workforce solutions. METHODS Design/participants This study used an exploratory-descriptive qualitative design. The participants were recruited through purposive sampling from a professional nurse leader association in California. Data collection/analysis To provide flexibility, participants were invited to participate in interviews voluntarily or to complete anonymous surveys. Participants were asked to complete a demographic questionnaire and provide their opinions about the use of travel nurses in their organization by answering six open-ended questions (see Table 1). The institutional review board protocol was approved as an exempt study by the Human and Animal Protections Board of San Francisco State University. Participants were informed of their right to withdraw from the study at any point. TABLE 1: - Open-ended questions 1. What driving forces contribute to your organization's use of travelers? 2. What are the advantages and benefits of using travelers in your organization? 3. What are the disadvantages and concerns of using travelers in your organization? 4. a. What has been your experience regarding accountability and patient safety when using travelers in your organization? b. What steps have you taken to increase accountability (for example, safety and quality) for travelers? 5. What do you see as potential alternatives when planning a strong future nursing workforce? 6. How has the use of travelers affected organizational culture in your organization? Tell us more about that. Demographic information was analyzed using descriptive statistics. Two researchers analyzed the qualitative descriptive data from the open-ended questions using thematic analysis to identify common themes. All data were deidentified before the analysis. RESULTS Sample characteristics Twenty NLs from various regions of California expressed interest in the study, and 16 participants with experience hiring or working with travel nurses completed the study. Data were collected from February to May 2024 until the data were deemed saturated. The participants' average number of years in nursing was 26.2 (range = 9-47, n = 16), and their average number of years in leadership roles was 17.3 (range = 1-45, n =16). Most participants (93%) identified themselves as females, and 75% of participants reported that their work setting had more than 300 beds (see Table 2). TABLE 2: - Sample characteristics (n = 16) Variables Sex Female 94% Male 6% Ethnicity White alone, non-Hispanic 50% Multiracial, non-Hispanic 12.5% Asian alone, non-Hispanic 18.7% Hispanic 18.7% Education BSN 31.3% MSN 56% PhD or DNP 12.5% Position CNO 25% Director/manager/administrator 63% Educator 6% Charge nurse 6% Size of the current work setting Fewer than 100 beds 6% 100-300 beds 18.7% 301-500 beds 50% 501-800 beds 18.7% 801-1,000 beds 6% Magnet-recognized organization Yes 18.7% No 81.3% Pathway to Excellence-designated organization Yes 25% No 75% Years served as a nurse leader 17.25 years (range 1-45) Years served as a nurse leader in the current organization 7.36 years (range 1-20) Average age 50.2 years (range 33-69) Driving forces of using travel nurses Participants were asked to examine their perspectives on the contributing factors for using travel nurses within their organization. Among the responses, themes mentioned included patient volume, staffing, retention/turnover, and the global pandemic. From May 2020 through April 2021, it's approximated that 3.6 million patients were hospitalized in the US because of COVID-19.11 Many respondents stated that the increase in the number of patients seen during this time contributed to the use of travel nurses. One participant stated, “...the volume of COVID patients in our hospital overtook the hospital. You know, we had no expectation, like ICU beds normally are 20, some 27 or 37, and you know the ICU needs were twice that for some period of time.” The demands of the pandemic had a significant impact on the capacity of the current healthcare workforce. One participant noted: “...(the) primary reason [for using travel nurses] is we did not have enough nurses to take care of the patients.” Moreover, prior to the COVID-19 pandemic, many organizations claimed to already have nursing staffing shortages. According to the U.S. Chamber of Commerce (2024), there's an average of 9 nurses for every 1,000 patients.12 The increase in patients during the pandemic, coupled with low retention rates in the nursing profession, thus contributed to the increased demand for travel nurses. Advantages Travel nurses provide continual benefits to healthcare organizations. Primarily, travel nurses are a short-term solution for many organizations' staffing issues. Unlike traditional staff, agencies screen and contract travel nurses to ensure they have the minimum experience level required and specific skill competencies, including specialty training, and are ready to work for organizations on demand. This recruiting process benefits organizations that hire travel nurses by enabling them to quickly address staffing needs due to leaves of absence, turnover, and sudden increases in patient censuses, as seen during the COVID-19 pandemic. Participants stated: “The advantage was quick acquisition, higher skill set, and an ability to have them for just short bursts of time,” and “(The use of travel nurses) allowed us to continue surgeries with our usual volume, thereby stabilizing revenue generated from surgeries.” Furthermore, some NLs mentioned that the financial costs of travel nurses are lower when evaluating long-term benefits. On average, recruiting, hiring, and orienting full-time staff members cost an organization between $20,000 and $46,000.13 On the other hand, travel nurse onboarding and orientation time is often decreased due to travel nurse agencies' process of vetting their nurses. In addition, Faller and colleagues found further return on investment from having travel nurses in terms of overtime hours.8 When investigating units without travel nurses, core staff worked overtime hours ranging from 3% to 5%, whereas other units used travel nurses to work the hours that otherwise the core staff would have worked as overtime. Moreover, because travel nurses are temporary contracted workers, employers don't have to spend certain additional costs, such as yearly staff development, insurance coverage, and retirement benefits. Additionally, from a regulatory standpoint, travel nurses assist in meeting the nurse-to-patient staff ratios that some states have in place. Disadvantages According to study participants, high short-term costs, competency, and reduced orientation were disadvantages of hiring travel nurses. Although long-term expenses were previously noted, the drawbacks to having travel nurses also include high short-term costs. Particularly, travel nurses' wages are higher when compared with regular staff wages. Participants stated: “The amount of pay travel nurses received is substantially higher than staff nurses, which can make staff nurses feel unworthy and underappreciated,” and “There is a lot of staff resentment by regular staff due to some of their former peers becoming travel nurses and now making twice as much money for the same work.” During the peak times of the COVID-19 pandemic, travel nurses made 151% to 287% of the weekly pay of regular direct care nurses.14 The cost of having an influx of travel nurses during this time naturally increased the financial burden for organizations. However, travel nurses' higher wages were also perceived as a disadvantage to organizational staff morale because staff wages remained unchanged for performing the same duties. Although travel nurses were brought on to work alongside regular staff, NLs sometimes viewed travel nurses as lacking the same performance levels as permanent staff. Some participants felt the agencies' screening of nurses was inadequate, whereas others felt that their organizations' quick onboarding process didn't adequately prepare travel nurses. Participants noted: “[Travel nurses'] qualifications were not equivalent,” and “The biggest disadvantage is you just never know what you are getting.” Travel nurse agencies are responsible for screening their nurses. Nevertheless, NLs perceive that they aren't always fully informed about the competence level of the travel nurses they contract with until the nurses are onboarded. Unlike traditional staff, NLs couldn't always review travel nurses' past work experiences, assess their knowledge, or analyze problem-solving skills that typically would be handled during the interview process. Participants noted: “They [travel nurses] weren't required to complete competency validation like their permanent staff counterparts.” Patient safety and accountability Nurse accountability and patient safety are at the forefront of ensuring positive patient outcomes and experiences. However, the NL participants listed the themes of decreased accountability, competence, and commitment to the organizations. “There is decreased accountability from travel nurses since they know they have short contracts and will not be at the facility long term. There have also been issues with patient safety due to the travel nurses not following hospital processes and using shortcuts with patient care.” “This is always a challenge...less ownership of clinical quality and unit priorities.” “Travel nurses are not fully invested, and accountability is an issue.” Travel nurses often sign contracts with organizations for a limited amount of time, such as 6, 9, or 12 weeks. Due to the nature of the contracts, participants claimed that the short-term assignment to the organization contributed to less accountability from the travel nurses. The quick sign-on and onboarding of travel nurses were also mentioned to add to travel nurses' inability to perform at a certain level. Participants made the following statements. “Travel nurses did get less training and are often unfamiliar with the current practices. Additional training would be beneficial.” “They are onboarded quickly and not integrated to safety and quality expectations. The interviews are only done by recruiting, so no ability to set expectations.” “Some travel nurses have a lack of ownership of the care provided to our community, are lacking in knowledge [and] skills to provide safe care to the population of patients.” When examining accountability and, specifically, patient safety, the literature points to various quality outcomes in determining whether there are significant differences in organizations and units using travel nurses. Outcomes include but aren't limited to patient falls, pressure injuries, medication errors, healthcare-associated infections, patient satisfaction, and length of stay. A systematic review by Vander Weerdt noted that, of 49 outcomes reported, 61% showed no significant link between the use of travel nurses and patient outcomes, 31% showed a negative association, and 8% showed a positive correlation.7 Organizational impact Participants were asked about their perceptions of the organizational impact of using travel nurses in their workplace. The main themes were that travel nurses had a negative effect on staff morale and were unable to adapt to the organization's values and missions. With the significantly higher pay of travel nurses, NLs remarked that direct care nurses felt inadequate and underappreciated. Following are some of the participants' comments. “The amount of pay travel nurses received is substantially higher than staff nurses, which can make the staff nurses feel unworthy and underappreciated.” “(The use of travel nurses) changed the way nurses feel valued when they are seeing someone perform substandard care who gets paid very high amounts of money.” “When the travel nurses sitting next to you are getting paid double or triple your wages and doing less work, not knowing policies, and not following processes, it is frustrating to the staff and leads to staff leaving for positions at other facilities.” When it came to integrating travel nurses into organizations, NLs felt travel nurses fell short of embodying their organizations' core mission, vision, and values. Two participants noted: “(There was) always concern about whether they meet the mission, vision, and values of our organization,” and “They didn't always provide the hospital's caring philosophy and experience we were looking for.” Potential alternatives Many healthcare organizations aim to continue to enhance their nursing workforce and increase staff retention. With such a goal, there's a need for additional alternatives to meet the demands of a changing healthcare workforce and prepare for unpredicted circumstances like the COVID-19 pandemic. Participants were asked to name potential alternatives to using travel nurses. Common themes included creating better academic partnerships to enhance recruitment of new graduate nurses, improving retention, introducing virtual nursing to help with patient-care delivery, flexible scheduling, and promoting work-life balance for permanent staff. Participants noted: “Working stronger with student programs and progression plans... (including) nurse extern programs,” and “Finding alternate ways to expand the nursing clinical sites for increasing cohort size” to enhance recruitment once nurses graduate from nursing school. Organizations must look toward creating bridges between academic programs and ensuring smooth onboarding for novice nurses. The cost of replacing nurses is 1.5 to 2.5 times their salary, and Kiel found that internship transition programs increase retention dramatically, resulting in a return on investment for the healthcare organization.13 A commitment to building stronger relationships between healthcare organizations and nursing schools may strengthen a pipeline in the nursing profession. Furthermore, transforming traditional nursing schedules, usually three 12-hour work shifts, can generate alternatives to creating a more robust nurse workforce. Participants supported a model of seasonal nursing to provide nurses the option to work in desired periods. NLs mentioned innovative open positions to offer staff more adaptability beyond what has been done traditionally. Participants noted: “I've been an advocate for seasonal nurses and nurses who come in for 3 or 4 months,” and “Provide nurses with work-life balance with self-scheduling, alternative full-time-equivalent positions, blended roles, and opportunities to grow within the organization” as a means to support flexibility. DISCUSSION AND LIMITATIONS Travel nurses offer NLs a quick solution to temporary and ongoing nursing shortages, ensuring adequate staffing for emergency/unexpected surges, and healthcare organizations will continue to hire them. There's a perception among NLs that travel nurses don't offer the same level of care that permanent staff do, but this notion isn't backed by evidence.7 It's critical, therefore, that NLs communicate this information to permanent staff and foster a healthy work environment where all nurses from various career entry pathways and employment types are supported and enculturated with effective teamwork, professional development, and ethical principles in accountability and professional practices.15 As the results suggest, widening the pipelines for the incoming new graduate and reentry nurses can contribute to sustaining nursing staff pools. Strategies to retain and mentor a quality nursing workforce substantiate the long-term planning. This study's limitation is its purposive sample of NLs from one region in the US. The study investigators may have recruited NLs who were interested in travel nursing, and participants' experiences may have caused them to have either a positive or negative perception of travel nursing, limiting generalizability. Findings from this project support the replication of the study in other geographical regions. A further study can examine the cost-benefits of using travel nurses in organizations and expand the open-ended questions to include whether NLs interacted with travel nurses to elicit their feedback regarding best seen at other organizations. feedback would benefit organizations because the experience of travel nurses may help organizations improve patient quality and Nurse leadership with to recruitment strategies to address any One organization a hiring offering interviews once an and onboarding and employee so that new on hiring units This same organization worked with to RNs who had the organization to offer them NLs on retention is to a way to turnover and increase retention is for NLs to on retention This may include regular and by as points to in work environment and colleagues suggested that interviews are effective retention strategy NLs key including to with A The of this study add to on travel nurses. To address nursing or an increase in patient travel nurses provide NLs with a solution to meet patient-care travel nurses including high lack of competency to patient safety and lack of accountability to the hiring organization. NLs on retention strategies to a workforce. between NLs and staff is to help nurses and provide workforce flexibility. NLs may also work with to enhance onboarding