Health systems facing staff shortages may find relief in the use of temporary nurses.
Growing shortages of nurses are causing staffing problems throughout the industry, including the well-known dilemma of chronic understaffing, which makes covering open shifts a constant scramble. The resulting long hours and overwork can lead to increased medical errors, eroded staff morale, reduced patient satisfaction and outcomes, and eventually higher costs. Temporary nurse staffing can be part of the solution.
Impact of Nurse Staffing Problems
Trending data from the U.S. Bureau of Labor Statistics suggests that staffing stress on nurses has been growing. Average weekly hours worked in hospitals have been rising steadily since the end of the recession to a record high of 37.1 in February 2018. a Nurses represent the single largest profession by far in the healthcare workforce.
At the same time, total job separations, or attrition, have been rising, increasing the pressure on nurse staffing. The annual average rate for total job separations, or total attrition, in health care has increased steadily since the end of the recession, reaching a 10-year high in June 2018.
The problem of nurse shortages and understaffing is well recognized in the healthcare industry. Approximately half of nurse managers in a 2016 survey said that scheduling and staffing problems are frequent and significant at their organizations, causing negative impacts such as low morale, staff stretched too thin, and budget problems from premium pay and shift incentives. Nurse managers said that their biggest concerns related to scheduling and staffing problems—besides morale issues—are patient satisfaction, quality of care, and medical errors. b
A large and persuasive body of research shows that too many work hours can put a severe strain on nurses and other healthcare workers, not only damaging staff morale but also weakening the ability of staff to deliver high-quality patient care. Most clinicians can attest to the truth of these findings from their own experience.
Fatigue is linked to several types of performance problems that can compromise the patient-care environment. c These problems include a decline in short-term and working memory; a reduced ability to learn; impaired critical thinking, innovation, and insight; increased risk-taking behavior; and diminished mood and communication skills.
Work duration, overtime, and the number of weekly hours worked have significant effects on errors, according to a study of 393 nurses covering more than 5,300 shifts. The study found that nurses working shifts lasting 12.5 hours or more were three times more likely to make errors in patient care then nurses working shifts shorter than 8.5 hours, and that the risk of medical errors began to increase when shifts exceeded 8.5 hours. d
Both voluntary and mandatory nurse overtime can negatively affect patient safety and nurse safety. A study that examined the work hours, adverse events, and errors among 11,516 registered nurses found that medication errors and needlestick injuries had the strongest link to nurse overtime. e
Nurses working shifts of 10 hours or longer were up to two and a half times more likely than nurses working shorter shifts to experience burnout and job dissatisfaction and to express an intent to leave their job. f
Cost and Quality of Temporary Nurses
Amid today’s continuing nursing shortages, the conventional solution to hire more staff nurses often gives way to a strategy involving temporary nurses. There is a growing body of research showing parity between staff and temporary nurses in terms of quality and cost.
Persuasive evidence often takes time to catch up with long-held beliefs in health care that temporary nurses cost more and are less qualified than staff nurses. Misconceptions about cost may stem from the fact that healthcare organizations are looking only at salary payment for nurses and not at the full cost of employment. When staff nurses are used to fill gaps, they are usually paid overtime, and because temporary nurses are similarly used to fill gaps in staffing, their cost should be compared with staff nurse overtime, not regular time. A 2017 survey of 100 senior hospital executives from across the country found that the hourly cost of a full-time, permanent nurses is about $6 more than that for a travel nurse. The all-in cost for a permanent, full-time registered nurse is $89 per hour, while the all-in cost for a travel nurse is $83 per hour. For temporary nurses, many of the costs paid for permanent nurses, such as insurance, recruiting, non-productivity and certain payroll costs, are covered by the temporary nurse provider company, not the hospital or other health care organization. Fully loaded payroll costs for permanent nurses represent 76 percent of all-in costs. In contrast, for travel nurses, payroll costs represent 98 percent of all-in costs. g
Regarding quality, studies show that the experience level and educational attainment of temporary nurses is basically the same as staff nurses, and so is the degree of positive patient experience. On average, temporary nurses and permanent nurses have similar levels of education and experience. h
Survey data from 40,356 registered nurses at 665 hospitals and inpatient mortality data for approximately 1.3 million patients were examined among temporary nurses and staff nurses in a 2013 study of fail-to-rescue events. It concluded that higher use of temporary nurses does not affect patient mortality “and may alleviate nurse staffing problems that could produce higher mortality.” i
Furthermore, employment of temporary nurses does not detract from patient satisfaction. A study of 427 acute care hospitals in four states comparing HCAHPS patient survey and other nurse survey data found little evidence that the use of temporary nurses was associated with lower patient satisfaction. Patient satisfaction with nurse communication, pain control, and medication information was unrelated to whether the nurses involved were temporary or permanent. Any findings of association between use of temporary nurses and adverse patient outcomes were found to be due to problems at hospitals that prevented them from recruiting and retaining sufficient numbers of permanent staff nurses. j
Single-hospital studies offer a closer look at the benefits of temporary nurses. A 2015 study of 19 patient-care units in a large academic medical center found no statistical difference between the hourly cost of supplemental nurses and overtime pay for permanent nurses. k
Two single-hospital travel nurse studies also were conducted comparing costs and quality of travel nurses and staff nurses at a moderate-sized regional hospital, with data extracted from 2013 to 2015.
The quality study found that, as travel nurse coverage fluctuated from 0 percent to 44 percent in five units over the two-year period, there were no significant differences in the quality of patient care in 55 of 60 quarterly tests of HCAHPS scores and National Database of Nursing Quality Indicators (NDNQI). In the five tests where significant differences were shown, there were no consistent patterns to demonstrate a relationship between changing travel nurse utilization and HCAHPS and NDNQI scores. As travel nurse coverage changed within the five units, there were no differences when patients were asked if nurses listen carefully, if nurses explain things in a way the patient could understand, if pain was well controlled, if staff did everything they could to help with pain, and if staff explained what medicine was for and described possible side effects. There also were no significant differences in catheter-associated urinary tract infections or in the nursing unit turnover rate. l
In a single-hospital study comparing costs of permanent and travel nurses, staff nurse costs were higher in three of the four units relative to travel nurse bill rates. In two units, staff costs were nearly 10 percent higher. In only one unit were travel nursing bill rates higher. m For accurate comparisons of travel nurse and staff nurse costs, all employer costs need to be included when calculating a healthcare organization’s true total expenditures for core staff nurses. For this study, actual costs included were payroll, benefits, Medicare taxes, and Social Security taxes in the calculation of the full cost of core nursing staff for four units. For the staff nurses, the applied employer costs in benefits and tax load was 27.28 percent (workers compensation and professional liability insurance excluded).
The real cost of staff nurses is probably higher than that reflected in the study. The U.S. Bureau of Labor Statistics found that employer costs, including paid leave, supplemental pay, insurance, retirement/pension, and legally-required benefits, averaged 34.3 percent of total compensation for registered nurses working in private industry hospitals in March 2017. n In addition, other costs could be included, such as premium pay, hire-on bonuses, shift bonuses, recruiting, onboarding, screening and background checks. For travel nurses, most of these costs are covered by the travel nurse company.
Also in this study, travel nurse costs were compared to staff nurse overtime costs, not regular time. Travel nurses and other temporary nurses are utilized to cover time that would normally be covered by core staff overtime, such as nonproductive hours, coverage for census spikes, shortages of specialized nurses, and electronic health record implementation.
Temporary nurses in general, and the large subset of travel nurses in particular, have equivalent levels of education and training to permanent staff nurses. Though clinical processes differ among temporary nurse provider companies, the top travel nurse companies provide screening and quality testing of the same or greater rigor as quality patient-care organizations, along with continuing education to ensure that temporary nurses are up-to-date with compliance training.
Many temporary nurses move in and out of travel and other assignments during their careers, usually working as permanent staff nurses for longer periods of time than they travel or do other temporary nursing work. The reasons for choosing to work as travel nurses are varied, but often include the sensible inclination to experience particular healthcare organizations or geographic locations before they commit to permanent employment there. They often want to assess the culture or work environment of healthcare organizations to determine whether they would be a good fit for working there. Others simply like to travel, experiencing a new place for 13 weeks or longer while they practice their profession.
The purpose of temporary nursing has never been to supplant permanent nurses but to supplement them; the optimum percentage of temporary nurses differs from organization to organization, but it is always a small percentage. Although temporary nurses may receive excellent training, they will not receive the same facility-specific training as permanent nurses. Since temporary nurses make up only a percentage of the overall staff of a hospital or other healthcare organization, the lack of facility-specific training is not a detriment to the unit. In addition, experienced travel or other temporary nurses may have greater specialty training than many permanent nurses. Travel and other temporary nurses often bring to the table many other valuable attributes from outside the facility, such as new knowledge, innovative practices, a different but complementary attitude, a sample of other organizational cultures, or a dose of new energy.
Considering that patient-care quality and cost-containment are top priorities in the healthcare industry, an accurate understanding of the quality and cost of temporary nurses is valuable to clinical and executive leaders at healthcare organizations.
The weekly hours worked in health care and particularly in hospitals are at record highs. At the same time, attrition among healthcare workers has been rising since the end of the recession. And such patterns and trends are occurring amid serious nurse shortages. Taken together, these data strongly suggest that nurses, the single largest profession in the healthcare workforce, are stretched thin.
Given the strong evidence that temporary nurses are equivalent to staff nurses in quality and cost, they should be considered as a safe alternative to understaffing and a viable part of the solution to nurse scheduling and staffing problems.
Marcia Faller, PhD, RN, is executive clinical advisor of AMN Healthcare, Inc., San Diego.
Footnotes
a. Bureau of Labor Statistics, U.S. Department of Labor, Current Employment Statistics, Average Weekly Hours of all Employees, Health Care, Seasonally Adjusted.
b. AMN Healthcare, Predictive Analytics in Healthcare 2016, Optimizing Nurse Staffing in an Era of Workforce Shortages , 2016.
c. Institute of Medicine, Keeping Patients Safe: Transforming the Work Environment of Nurses , 2004.
d. Rogers, A., Hwang, W., Scott, L., Aiken, L.H., Dinges, D.F., “The Working Hours of Hospital Staff Nurses and Patient Safety,” Health Affairs, July/August 2004.
e. Olds, D.M., and Clarke, S.P., “The Effect of Work Hours on Adverse Events and Errors in Health Care,” Journal of Safety Research, April 2010.
f. Stimpfel, A.W., Sloane, D.M., and Aiken, L.H., “The Longer the Shifts for Hospital Nurses, the Higher the Levels of Burnout and Patient Dissatisfaction,” Health Affairs, November 2012.
g. Gregg, T., Hottle, R., Lo, A., and Elmblad, D., KPMG’s 2017 U.S. Hospital Nursing Labor Costs Study , KPMG LLP, 2017.
h. Xue, Y., Smith, J.; Freund, D.A., and Aiken, L.H., “Supplemental Nurses Are Just As Educated, Slightly Less Experienced, and More Diverse Compared to Permanent Nurses,” Health Affairs, November 2012.
i. Aiken, L.H., Shang, J., Xue, Y., snd Sloane, D.M., “Hospital Use of Agency-Employed Supplemental Nurses and Patient Mortality and Failure to Rescue,” Health Services Research, June 2013.
j. Lasater, K.B., Sloane, D.M., and Aiken, L.H., “Hospital Employment of Supplemental Registered Nurses and Patients’ Satisfaction with Care,” Journal of Nursing Administration, March 2015.
k. Xue, Y., Chappel, A., Freund, D., Aiken, L.H., and Noyes, K., “Cost Outcomes of Supplemental Nurse Staffing in a Large Medical Center,” Journal of Nursing Care Quality, April-June 2015.
l. Faller, M., Dent, B., and Gogek, J., “A Single-Hospital Study of Travel Nurses and Quality: What Is Their Impact on the Patient Experience?” Nurse Leader, August 2017.
m. Faller, M., Dent, B., and Gogek, J., “The ROI of Travel Nursing: A Full-Cost Comparison of Core Staff Pay Rates to Travel Nurse Bill Rates,” Nursing Economic, July/August 2018.
n. US BLS, Employer Costs for Employee Compensation—March 2017, Table 14. National Compensation Survey, US Bureau of Labor Statistics, USDL-17-0770. https://www.bls.gov/news.release/pdf/ecec.pdf
