Abstract
Over the past 2 years, in tandem with the effects of the COVID-19 pandemic, an interesting professional choice phenomenon occurred in the health care sector. Nurses' decisions to incorporate travel nursing into their career paths created a shift in the US nurse staffing landscape. What influenced this shift? Will the trend continue as the new “norm”? What leadership approaches can be harnessed to preserve continuity of expert nursing service delivery to patients? The authors present perspectives and offer suggestions to navigate the sea change that manifested in the wake of the pandemic.
Key Points.
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A professional choice phenomenon occurred across the US nursing workforce during the COVID-19 pandemic.
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Many RNs nationwide decided to pursue travel nursing.
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Industry experts offer perspectives on motivating factors leading to this phenomenon and approaches to navigate the new nursing resource landscape.
Travel nursing has long served as a niche profession born out of the need to supplement the permanent staff workforce. Hospitals typically turn to contingent workforce firms to help bridge temporary workforce vacancies created by occurrences such as attrition, temporary leaves of absence, seasonal patient volume surges, newly opened units, and implementation of electronic medical records. Historically, the travel RN market was characterized by a stable ratio of approximately 1 travel RN job opening per 1,000 permanent RN job openings (Aya Healthcare, unpublished data, 2021). For nurses, the pandemic accelerated an evolving mindset about career planning. The concept of “tour of duty” has taken on fresh meaning in nursing because the more recent generations of nurses are less likely to remain with 1 employer for an extended period.1 A broader array of stepwise opportunities abounds, for nurses to progressively advance in self-directed career trajectories. Travel nursing continues to be a popular option.
At the end of each contract cycle (typically 13 weeks), if not renewing, extending, or returning to a permanent staff position, a travel nurse must secure a new contract, relocate to a different city, and speedily adapt to a new locale and practice environment. Although the pay is higher than a permanent staff position, usually only a small cohort of the nursing population is willing to adjust to the pace of this mobile lifestyle. Bureau of Labor Statistics (BLS) data expose that in 2019, only about 43,000 of the 2,982,280 registered nurses in the United States were employed as travel RNs.2 This translates to less than 2% of the total nursing workforce supplementing the needs of hospitals, which were experiencing an average RN vacancy rate of 8% at that time.
Rising Interest in Travel Nursing
Although higher pay is commonly assumed to be the main attractor, multiple factors motivate nurses to transition to a travel work arrangement. Travel nursing grew in popularity over the course of the pandemic. Notwithstanding incentives or inspiration, these nurses’ decisions to travel catalyzed a shift that interacted with an existing complex and fragmented supply versus demand situation. Individually, the choice to travel generated a sense of control amidst an environment of mounting uncertainty. Collectively, the nursing workforce gained fluidity to counter the ill effects of maldistribution, funneling much needed expertise to practice settings in greatest need during census surges.
Pandemic-boosted Shift
As censuses surged during the pandemic, the demand for supplemental nursing staff increased substantively. In essence, travel nurses executed a national rapid response by mobilizing from one pandemic hotspot to the next, where nursing resources were most urgently needed. Over the course of their travel assignments, these nurses progressively acquired a suite of valuable pandemic management knowledge and experience. Hospital administrators raced to tap into the finite supply of travel nurses to bolster their staffing resources. Imagine, how less than 2% of the nation’s nurses comprising the main supplementary pipeline were relied on to meet hospital RN vacancy rates, which had already risen to 9% to 10% or more.
Change Motivators and Benefits
In addition to the pay differential, a benefit of this work arrangement cited by travel nurses is the sense of increased flexibility and freedom to schedule breaks between contracts. The nurse has more control to structure opportunities for self-care and, by extension, avoid burnout. Beyond these reasons, a mission-centered urge beckoned nurses to help during the pandemic. Like prior wartimes, for some nurses the war on COVID-19 generated a nudge to take on an adventurous and meaningful new career experience. A similar movement was seen in World War II, where 1,000 nurses listed on the Army Nurse Corps roll increased to 12,000 soon after the attack on Pearl Harbor.3
Some nurses were already contemplating the travel work arrangement on a back burner. The pandemic inspired them to act and go where the need was most urgent. First-time travel nurses were bursting with intellectual curiosity, eager to enhance their skills by gaining exposure to new settings and learning from different hospitals’ responses to the crisis. As travel nurses accumulated knowledge and experience at each assignment, they synthesized and disseminated what they learned to add value at new locations. This cross pollination of knowledge and experience was particularly beneficial in the early pandemic period during the evolution of a best-practice model for treating patients hospitalized with the novel virus. Further, travel nursing opportunities evolved and diversified as new pandemic-related needs emerged, such as staffing for mass testing and vaccination initiatives.
Nurse Vacancies on the Pandemic Timeline
The combination graph in Figure 1 overlays the demand for travel RNs on the backdrop of hospital census volumes in the United States4 from January 2020 through October 2021. For this discussion, the full timeline is segmented into 3 consecutive phases. Figure 2 presents a summary of the descriptive narrative that follows.
Figure 1.
Census and Travel Nurse Demand
Figure 2.
Travel Nurse Demand Timeline
Phase 1: January–September 2020
The first phase begins with a typical (pre-pandemic) level of travel nurse demand, followed by a temporary reduction in demand during the M-shaped curve of COVID-19 hospital censuses. For a limited time, staffing needs were managed through strategic reassignment of internal staffing resources. For example, the halt on elective surgeries enabled hospitals to bolster staffing in other areas of need by mobilizing internal staff. However, by July/August 2020, the demand for travel nurses crept upward and normalized.
Phase 2: October 2020–April 2021
During the second phase of the timeline, travel nurse demand generally occurred in lockstep with the peak and taper of hospital censuses, as would be expected.
Phase 3: May–October 2021
Interestingly, in May/June 2021 an inverse relationship developed as travel nurse demand continued to rise despite a downward trend in hospital censuses. Patient volumes increased again in August/September 2021 but peaked at a much lower volume than in Phase 2. Nevertheless, travel nurse demand maintained a steady upward trend throughout Phase 3, no longer in unison with COVID-19 hospital census levels, and reached a record high plateau, all while consistently exceeding proportions of the first 2 phases. By September 2021, a watershed moment occurred when COVID-19 hospital volumes plunged despite reinstituting “on-hold” services, whereas record-high travel nurse demand continued in steady growth mode. Although the pandemic crisis appeared to be simmering down, the staffing crisis was clearly still in full swing. Indeed, as the “new normal” began to manifest amidst the post-acute ravages of the pandemic, intense demand for travel nurses continued.
Where Are the Nurses?
Staffing resource demand was affected when record numbers of nurses pursued travel opportunities and again when reinstated hospital service lines opened more jobs. However, additional factors weighed heavy on nursing workforce capacity. Scale-tipping trauma endured by nurses during the height of the pandemic influenced many to retire or quit, move into non-direct care roles, head back to school, or even leave the profession entirely to pursue non-nursing career paths. Phase 3 of Figure 1 symbolizes the fallout that occurred because of the extended period of traumatic stress at an intensity and duration that most health care professionals were never educated or equipped to withstand.
In conjunction with volatile changes in nursing supply and demand, an interesting overlay of employment behavior occurred across US work sectors at large. Described in the literature as “The Great Resignation,” the number of US workers who quit their jobs reached record highs in the summer of 2021.5 According to the Job Openings and Labor Turnover Survey put forth by the US Bureau of Labor Statistics, 4.3 million Americans quit their jobs in August, and of those, 534,000 were health care workers.2 As of November 1, 2021, Liquid Compass data (accessed per subscription) showed 182,100 open RN direct hire jobs nationally, representing an 85% increase over pre-COVID average demand for this time of year. In a May 2021 McKinsey report, 22% of 314 nurses surveyed indicated they may leave their current direct care positions, and 60% of those said they became more likely to leave since the pandemic began.6 Insufficient staffing, unmanageable workloads, and emotional toll were cited as the major contributing factors.
Figure 3 illustrates how both RN staff job openings and RN travel job openings continued an upward trajectory throughout the fall of 2021 at higher levels than any prior period, despite hospital censuses that were proportionately lower and on a decline.
Figure 3.
Permanent Staff and Travel Nurse Job Opening Trends
Leverage Points for Nurse Leaders
Nurses’ decisions to start travel nursing in response to the pandemic manifested benefit nationally by assuaging the impact of nursing resource maldistribution. However, the consequences imposed when nurses decided to leave direct care roles or leave the profesison altogether, signal leaders to take pause.
The “Great Resignation” era calls for new approaches and fresh applications of existing approaches to navigate the radically changed landscape experienced by nearly every workforce sector. Table 1 summarizes the following suggestions in a manager reference tool.
Table 1.
Six Suggestions for an Actionable Approach
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Ensure consistency and adequacy of non-RN support staff.∗ Utilize these important team members to the full scope of their roles, making it feasible to allow/expect RNs to practice at the top of their education, competence, and regulatory scope of practice. A promoter. Absence of sufficient support staff generates a perceived need for more RNs because RN HPPD are absorbed by delegable tasks and functions. This non-lean approach is budget-unfriendly and dissatisfying to RNs. A detractor. ∗Nursing assistants, patient care techs, clerical staff, monitor techs, patient/specimen transport staff, turning teams, safety observer (“sitter”) staff, etc. |
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Current career path trends are veering away from traditional long-term employment models. Anticipate this and adopt a management paradigm to accommodate frequent turnover and onboarding as the “norm.” Streamline onboarding programs to consist of “need to know right now” launching content that dovetails into a developmental continuum for the working nurse. Form and visibly support networks of structured buddy systems that inspire team culture. Team pride and cohesion transform nurses into natural recruiters. Collaborate with staff nurses, travel nurses, and other nurse leaders to develop a mind map of fresh, innovative nursing resource management initiatives. Repurpose existing team optimization principles sourced within and outside of health care. Get and stay ahead of the knowledge curve about what conditions best attract nurses to your locale, facility, and/or unit, and capitalize on those. Carry out intermittent culture audits: Talk to staff nurses daily. Simply ask “Are you ok?” then listen. |
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Implement measures to calm sentiments that stir up permanent staff animosity toward travel staff. Educate permanent staff about the unique work–life arrangement that travel nurses must effectively adapt to and manage. Routinely include contingent staff in social and educational initiatives. |
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Actionable tips derived from the literature7,8
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Nurse leaders are already repurposing team and functional delivery models to gain traction in addressing increasing intensity of need. Leaders increase collective knowledge via channels such as AONL Open Forum discussions, where they share experiences and knowledge gained in the piloting and conversion process. Test the waters to identify a cohort of nurses willing to pilot and evaluate several 4-week cycles of 8-hour shifts/40-hour weeks, with leadership commitment to ensure consistent adequate non-RN support staff. |
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Be mindful that travel nurses often maintain a home based per diem or part-time job where they may return to fulltime status later. A senior client partner at Korn Ferry suggests forming alumni networks consisting of former rehirable employees.11 Maintain direct communication with rehirable former RN employees to keep them engaged and abreast of facility goings on, cultivating a “homing sense” and breadcrumb trail. |
HPPD, hours per patient day.
Increase the Presence and Adequacy of Support Roles
Florence Nightingale’s ageless wisdom lives on through her writings. For example, “Let whoever is in charge keep this simple question in her head (not how can I always do this right thing myself, but) how can I provide for this right thing to be always done?”12 RNs must take on delegable duties in the absence of support staff (nursing assistants, patient care techs, safety observers, patient/specimen transporters, monitor techs, unit clerical staff, lift teams, et al.). Doing so perpetuates a shortage syndrome by absorbing RN time at the expense of disruption to essential role functions that only RNs are educated, authorized and required to fulfill. Such disruption yields an assault on nurses' professional integrity when they attempt to adhere to the standard of care while simultaneously juggling delegable tasks in the absence of support staff. Pandemic urgency catalyzed openness to innovation. Hospitals succeeded in teaching nonclinical personnel, to assist proning teams, pass trays, observe patients as sitters, and respond to call lights, thereby facilitating nurses to focus on essential functions that only RNs can perform. Ensuring adequate support staff is cost effective, maintains a safer environment for patients, and facilitates RNs to practice at the top of their education, competence, and regulatory scope of practice.
Embrace a “Teaming” Mindset
Nurses are trending away from remaining in 1 role or with the same employer for more than a few years. Several factors drive this trend. The landmark 2010 Institute of Medicine Future of Nursing Report inspired nurses to continue their formal education.13 Predictably, a broad array of roles and advancement potential opened for nurses with advanced degrees. Today, nurses take an early, more targeted approach to design a stepwise career path in motion. In a recent blog, Sherman1 described how today’s nurse leaders can excel by developing the skill of “teaming,” which is a mindset for cultivating cohesive, high reliability nursing teams in an environment characterized by frequent turnover and evolution of composition. Can it be done? For context, consider capitalizing on principles of interprofessional practice to promote intraprofessional collaboration, or of aviation safety training designed for airline crews (often composed of individuals who have not worked together before) to ensure passenger safety in emergencies at 42,000 feet.
Enhance Collaboration Between Permanent Staff and Travelers
Sometimes animosity manifests among permanent staff toward travelers when it is perceived that travelers are being paid more to do the same job. This can disrupt the functional capacity of a team and impact patient outcomes. Educating permanent staff about what is expected of a travel nurse in addition to delivering direct patient care can mitigate negative sentiments. Travel nurses must develop and hone a suite of adaptive skills and techniques to operate with the degree of agility and critical thinking necessary to succeed in the role. These nurses work on a repeating cycle of change. Every few months travel nurses leave family and social networks behind; become familiarized with a new geographic community; live in temporary accommodations; receive minimal hospital orientation; navigate a new organizational culture; quickly earn trust and develop a working rapport with new peers, supervisors, and doctors; float as often as every shift (including mid-shift or to another system facility); comply with new policies and procedures; learn new or customized charting systems; navigate a new hospital physical plant; receive no paid vacation accrual; and work a schedule designed to accommodate permanent staff. Travel nurses are paid to adapt to a challenging mobile work–life arrangement as an employment-ready source of relief to bridge staffing gaps.
Harness the Power of Empathy
Researchers at EY (an Ernst & Young global organization), shared findings from the 2021 Empathy in Business Survey of 1,000 working Americans.14 Interestingly, 46% of the study participants perceived their employers’ attempts to show empathy was disingenuous. Being perceived as a leader who is authentically empathetic to employees’ struggles with work and personal lives was described as the possible “secret sauce” that, according to 88% of participants, generates employee trust and loyalty.14 During the pandemic, traditional gestures of appreciation made in good faith by hospital leaders were no longer effective to generate a sense of comfort for nurses, who were often on the brink of physical, mental, and spiritual exhaustion. This notion resonates with the sentiments of travel nurses surveyed by Aya Healthcare in the spring of 2021, who told us that during the peak phases of the pandemic, no one at the hospital simply asked if they were OK. Table 1 includes actionable suggestions sourced from the current literature to enhance empathy in leadership.
Consider Alternative Nursing Service Delivery Models
Pandemic conditions prompted nurse leaders to repurpose team and functional models. Teams consisting of an RN, licensed practical nurse, and certified nursing assistant/tech proved their worth in boosting care quality and reducing stress burden amid burgeoning patient volumes and acuities. Consider, too, the benefits of the 8-hour shift. Eliminating the last four (highest risk for error) hours of a 12-hour shift increases weekly fulltime coverage from 36 to 40 hours per nurse, while abating dangerous shift fatigue.
Reach Out to Former (Rehirable) Staff
Acknowledging the current trend of shorter employment tenure, global consulting firm Korn Ferry suggests that rather than trying to make employees stay, consider ways to maintain professional ties with former (rehirable) employees.11 It is not uncommon for a travel nurse to resume a prior permanent staff position after a series of travel assignments. Establish an alumni network of former nurse employees to facilitate a culture of belonging by streaming information to keep them up to date on the facility.11 Fresh opportunities may attract that talent back “home” or prompt them to refer a colleague.
Conclusion
The pandemic yielded more visibility into travel nursing as a career option. Nurses who joined the ranks of the contingent nursing workforce were paramount to achieving the best possible level of staffing adequacy during the pandemic through redistribution of expertise to locations in greatest need. Strain on the healthcare workforce will persist as the dynamics within the nursing community continue to shift. Meanwhile, the actionable suggestions offered in this article can be implemented to cultivate practice settings where all nurses (travel and permanent staff), are empowered to work more cohesively with a fulfilling sense of job satisfaction and team pride.
Biography
April Hansen, MSN, RN, is Group President, Workforce Solutions, at Aya Healthcare in San Diego California. Carol Tuttas, PhD, RN, is a Clinical Manager at Aya Healthcare. She can be reached at Carol.Tuttas@ayahealthcare.com.
Footnotes
Note: This work did not receive any specific grant from funding agencies in the public, commercial, of not-for-profit sectors. Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
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