Politics

How Covid-19 has changed nursing


In 2016, I was working as an ICU nurse in Reno, Nevada. But I didn’t live in Reno. In fact, I hadn’t trained as a nurse in the US at all; I’m from Canada and went to nursing school there. My initial contract was for just 13 weeks. I was what was called a travel nurse — someone who was brought in from a different city, and sometimes even from a different country — to meet a hospital’s temporary staffing needs.

At the start of my contract, we had a couple of days of onboarding and were then expected to hit the ground running. Every morning, I would report to the trauma ICU, one of four ICU units in the hospital, and only then find out where I was assigned, which was sometimes outside the ICU entirely.

Six years ago, travel nursing jobs like my Reno gig were a fringe part of the nursing landscape. But that’s changed. During the pandemic, the need for travel nurses has soared, and so have the wages paid them. Because I was a former ICU and travel nurse, I received frequent emails from travel nursing agencies when the pandemic first erupted, offering upward of $6,000 per week and occasionally as high as $10,000, if I were willing to relocate on as little as 48 hours notice to one of the cities experiencing a Covid-19 surge.

This was a steep increase from the average US ICU travel nurse’s salary of $1,800 per week, per this 2019 report. (I didn’t accept any of them, but I have to admit it was tempting.)

The rise of the travel nurse in the time of Covid-19 isn’t that surprising. From the earliest days of the pandemic, registered nurses bore the brunt of the increased strain on the health care system. With ICUs across the country overflowing, hospitals were forced to open specialized Covid-19 wards and staffing was strained. Nurses were often required to work grueling hours with heavy patient loads, a shortage of personal protective equipment (PPE), and limited access to Covid-19 testing.

As we enter the third year of Covid-19, the staffing shortage is only getting worse. Many nurses are facing burnout, choosing less arduous roles in non-hospital settings, or retiring from the profession altogether. Others are staying in the profession, but leaving the hospitals that employ them for travel nursing agencies, which offer them better-paying, short-term contracts.

In travel nursing, rather than working directly for a hospital as permanent employees, nurses are hired by a staffing agency, which then arranges time-limited contracts with hospitals to meet temporary or seasonal staffing needs. Over the course of the pandemic, crisis demand for additional staff sent travel nursing wages skyrocketing, and thousands of nurses across the country accepted these offers. While travel nurses previously represented 3-4 percent of all nursing staff across the nation, the figure has risen to 8-10 percent.

Travel nurses are extremely valuable to hospitals, rapidly and flexibly providing critical staff during case surges. But relying so heavily on temporary staff brings disruption. With many of their permanent nurses leaving for lucrative travel gigs, hospitals are increasingly being forced to bring in travel nurses from elsewhere to make up the deficit, leaving teams fragmented. This is especially hard on small rural hospitals, which lack the resources to compete with larger hospital networks.

The massive pay discrepancy is likely a temporary side effect of the crisis and various economic and funding constraints, but the underlying situation is not about to disappear. Covid-19 has taken a nurse shortage that predated the pandemic and dramatically worsened it.

Relying on temporary staff weakens hospital teams, drawing away the best and most experienced nurses and making it that much harder to onboard new staff, train students, and provide high-quality care. With more and more nurses burning out and quitting by the day, hospitals and the federal and state governments have yet to address the factors that would help frontline health care workers stay in the profession. Travel nurses are at best a temporary fix, and the long-term cost is unsustainable.

How travel nursing works

Travel nursing didn’t begin with the Covid-19 pandemic. The idea originated in New Orleans in 1978, as a response to the annual influx of patients during Mardi Gras. The practice became more prevalent over the next decade; by the late 1980s, travel positions had become widely available.

Travel nurses are hired by a staffing agency, rather than a hospital; the agency then arranges contracts with hospitals to provide nurses during periods of temporarily high demand and usually arranges housing for the nurses in their destination city. The standard contract is 13 weeks long, though nurses can sometimes choose to extend it to six months or longer.

Nurse puts on PPE.

Registered nurse Jenni Knapmiller dons PPE as she prepares to care for a Covid-19 patient in Coronado, California, on December 14, 2020.
Mario Tama/Getty Images

In the past, travel nursing wages varied widely by state and region and were often higher than permanent staff salaries (though some of that difference came from the free housing or housing stipend and other incidentals that were often included). Since the start of the Covid-19 pandemic, though, the pay for travel nurses has increased dramatically, and much faster than permanent salaries.

“When I worked as a travel nurse, there wasn’t that much of a discrepancy between my wage and permanent staff,” said Mary Jorgensen, an operating room nurse at UW Health in Madison, Wisconsin, and a former travel nurse. “We were more attracted to travel nursing for the lifestyle of going to different locations. But now that hospitals have this over-reliance on travel nurses to try to make up for the nursing shortage crisis, the amount they’re spending on travelers is astronomical.”

Over the past 18 months, it has become common for many nurses to double their paycheck by choosing the travel route. It’s not for everyone. It requires high levels of adaptability, independence, and tolerance for uncertainty, not to mention the personal freedom to pick up stakes and move temporarily, but for nurses who can take advantage of the opportunity, travel nursing can provide a financial windfall.

Lydia Mobley, a travel nurse with the major travel nursing agency Fastaff, believes that health care workers deserve more pay, and that travel nursing offers a route toward that end. “I know two amazing nurses who are some of my best friends, who are travel nurses and they are single mothers, but they still make travel work because they just want to give their kids the best life possible,” Mobley told me. Thirteen-week contracts also mean that nurses can choose to take breaks to recover in between periods of intense workload.

Mobley also sees the novelty with each contract as a perk, offering nurses (and by extension the hospitals they normally work for, and in the past at least, usually returned to) the chance to learn how other hospitals operate. “Even if a hospital happens to have maybe some older, outdated policies, at least you learned, ‘Hey, that’s a way that that probably should be done,’” she said.

In my case, the experience was very positive. It felt good to be where I was most needed, and to bring my own background and experience to an understaffed unit. By the end of my initial 13-week contract, which I chose to extend for a total of six months, I was familiar with the hospital’s processes, and actually able to provide support and mentoring to the many recently-graduated nurses on the permanent staff.

For hospitals, travel nurses provide a huge advantage in flexibility and response time in a crisis. It’s extremely difficult to hire and fully train a cohort of permanent nursing staff fast enough to respond to a surge in case numbers, which can happen in weeks or even days. Hiring travelers also means that when local case numbers begin to drop, a travel agency can send its nurses on to other states with the highest needs.

Bart Valdez, CEO of Ingenovis Health (which owns Fastaff as well as several other travel nursing agencies), told me how his company was among the first agencies to send nurses to early Covid-19 hotspots like Washington and New York. These staff became early “veterans of Covid,” he said, bringing their experience of the challenges of Covid-19 patients to other facilities.

“A less stable ecosystem”

But there are real downsides to taking this model too far, which are apparent to travel nurses as well as the permanent staff.

Health care workers care for a Covid patient in the ICU.

A team of health care workers care for a Covid-19 patient in the ICU on December 16, 2020 in Reno, Nevada.
Patrick T. Fallon/AFP via Getty Images

For one thing, hospitals end up paying far more in hourly wages for staff who are less familiar with local conditions, which can erode nurses’ teamwork and the quality of care for patients.

Kelly O’Connor, another registered nurse from UW Health, mentioned a colleague of hers left Madison, Wisconsin, for a travel position in Milwaukee the very same week that O’Connor’s unit resorted to hiring a travel nurse from Milwaukee to fill the vacancy at a much higher cost to her hospital. Travel nurses are not only paid a higher hourly wage, but the agencies generally mark up the bill by 32 to 65 percent to turn a profit. (Texas has recently resorted to banning nurses currently in permanent positions from accepting contracts in-state in an attempt to circumvent this dynamic.)

Increasingly relying on travel nurses more often can also warp the inner workings of a hospital. “There was a time when travel nurses were used appropriately, as a ‘Band-Aid,’ but this is beyond that,” O’Connor says. “There’s so much that goes into a hospital running smoothly, and historically if a travel nurse was needed, they were able to pop in, understand the ecosystem quickly, and everything would function as normal.”

But now, she notes, “we’re relying on them too much, and they’re thrown into a less stable ecosystem without the support to figure it out.”

The delicate “ecosystem” of a well-run hospital unit is made up of all the staff needed to keep a medical center running: doctors, pharmacists, lab techs, respiratory therapists, and of course, nurses. To mentor new staff and train travel nurses, the unit needs a certain base of experienced nurses, with years of commitment and investment in the local hospital and community. But with high levels of staff turnover — and many experienced nurses shifting away from bedside care or choosing early retirement due to burnout — this essential resource is in jeopardy.

When the nursing ranks are chronically understaffed and overstrained, even the best nurses can’t spare the time to properly mentor a new staff member, and instead have to tag-team just to cover all the basic tasks.

O’Connor described a revealing situation she found herself in: She realized only in the final few days of a new nurse’s multi-week orientation that she had never found time to show her trainee where the wheelchairs were kept. That’s a basic if important piece of information that would usually have been covered in week one.

“I used to feel that I helped the new nurse grow, and now more often than not we’re having to rely on each other just to get through the workload,” she says. “Nursing is already so hard. This is only making it harder than it needs to be.”

The cost of good care

If experienced, committed permanent nurses are so essential to a hospital’s functioning, providing value that no temporary travel nurse can replace, why aren’t they compensated accordingly?

Nurse cares for Covid patient in the ICU.

A registered nurse prepares a Covid-19 patient for therapy in the ICU on December 14, 2020 in La Mesa, California.
Mario Tama/Getty Images

One contributing factor may be that during the pandemic, crisis funding from government institutions such as the Federal Emergency Management Agency (FEMA) couldn’t easily be allocated to hiring more permanent staff, or toward efforts to retain existing experienced staff via retention bonuses, hazard pay, or other support.

But there are systemic issues at work as well. The National Nurses United is the largest professional association of registered nurses, with more than 175,000 members working at the bedside in nearly every state. Its latest report — titled “Protecting Our Front Line: Ending the Shortage of Good Nursing Jobs and the Industry-Created Unsafe Staffing Crisis” — explores the background of the nursing shortage and the worsening conditions during Covid-19. It lists a number of specific policy recommendations, such as mandated staffing ratios and better workplace safety regulations, that they believe will help create sustainable, rewarding jobs and keep nurses in the field.

Such reforms were needed before the pandemic, and are even more necessary now. The spike in travel nursing demand and pay shows that the system as it exists now is not equipped to respond to a major crisis without significant disruptions that will have serious consequences down the line. The worsening personnel shortage, with many nurses retiring and leaving the profession entirely, is a symptom of a system that prioritizes the short term at the expense of sustainability.

Travel nurses have been a part of the nursing workforce for decades, and as a supplement for temporary needs, they are very valuable. But it’s not fair to either travel nurses, or the patients they care for, to ask them to take on so much of the ongoing essential duties of running a hospital unit.

A hospital relying too heavily on travel nurses will lose institutional knowledge, be less able to fit in new hires or provide nursing students with a strong education, and will end up being a frustrating and draining work environment, leading to more burned-out nurses and a worsening staff shortage at a time when the US can least afford it.



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