Jesse Mogler had been working as an emergency room nurse for less than a year when the pandemic started. During that time, he says, he worked with travel nurses—maybe one or two per shift—in the busy ER of San Juan Regional Medical Center in Farmington, N.M. They were often less experienced than staff nurses, he says, and helping to orient them to the practices of the specific ER took time from more senior nurses on the floor. Still, the travel nurses were helpful, especially on the unpopular late shifts.
By the time he left, over a year later, the COVID-19 pandemic was in full swing, and the floor was primarily staffed by travel nurses—especially during the evening and overnight shifts. By midnight, he says, sometimes even the nurse in charge of running everything—known, appropriately, as the charge nurse—was a “traveler.”
Mogler, who finished nursing school in 2018, found that he was rapidly becoming one of the most experienced nurses on the floor. He was charged with looking after a higher number of patients than ever before, sometimes overseeing six to 10 emergency cases, he says.
In school, he says, teachers constantly reinforce that preventable accidents or deaths among the patients a nurse is assigned to can result in an inquest and the loss of your nursing license—to say nothing of the trauma of knowing you had a role in unnecessary suffering. “It increasingly felt like every shift, we [were] about one traumatic accident, one trauma or critical patient away from unnecessary deaths,” he says. “It was risky to be a patient. It was risky to be a nurse.”
Looking for higher compensation for an increasingly draining job (as well as the ability to move on quickly from an environment that felt unsafe), he posted on a travel nurse job board and got a rush of text messages and voicemails from recruiters. He started his first contact in October and will be working in Durango, N.M., until the end of 2021—making four times the hourly rate he made as a staff nurse.
COVID has transformed many aspects of health care—from early ventilator shortages to endlessly delayed routine procedures. But one of the most striking effects the virus has had is on the career market for the people that care for you. The explosion of travel nurses has massively increased pay for those willing to work for the highest bidder. Healthcare job board Vivian estimates that the average travel RN salary in the U.S. is presently almost $3,200 per week, based on 59,000 active job listings in the past 90 days. That works out to almost $90 per hour for the average 36-hour travel nursing week, according to Vivian. It’s also more than twice the median hourly pay of a staff nurse in the United States in 2020, according to the Bureau of Labor Statistics. But a rotating cast of for-hire staffers has also, some say, destabilized hospitals where employees soon entering year three of the pandemic were already at a breaking point. As ICUs begin to fill up again with a winter COVID-19 surge and the Omicron variant, as well as flu season, this shaky system keeping hospitals afloat will be put to the test.
Becoming a “traveler”
Travel nurses were around as far back as the 1970s, says Peter Buerhaus, a nursing policy expert from Montana State University. “They have never been a large component of the nursing workforce,” he says. The field, once used to bridge brief localized nursing shortages, started growing pre-pandemic: A market report from Grand View Research published in early 2020 found that in 2019 alone the market for travel nurses grew by 7%, driven in part by hospitals’ ongoing attempts to cut permanent-staffing costs.
The market has ballooned in size since the pandemic began. Staffing Industry Analysts (SIA) estimates that the U.S. travel nurse staffing industry grew 35% in 2020, from $6.2 billion in 2019 to $8.4 billion. By the end of 2021, SIA predicts a further 40% expansion, to $11.8 billion.
“While the volume of travel nurses on assignment grew in 2020 and 2021, much of the market size growth has been due to large increases in pay rates due to the imbalance of demand with supply,” notes Timothy Landhuis, North America director of research at SIA.
The active Facebook group “Traveling Nurse Jobs $5,000 a week and up” has more than 100,000 members and is peppered with listings and posts from recruiters. Job boards and groups like the Facebook group are the main ways that travel nurses find work. The business of AMN Healthcare, one of the largest health care staffing firms, is driven predominantly by word of mouth, CEO Susan Salka told a Bank of America virtual conference on the state of health care in May.
Health care staffing firms have posted impressive returns during the pandemic. AMN reported a whopping 60% bump in revenue over 2020 in its third quarter 2021. Cross Country Healthcare, another prominent firm, was even higher, with a 93% year-over-year increase in Q3 2021.
Usually, travel nurses are restricted to the specific states or regions where their nursing licenses are valid. During the first wave of the pandemic, those restrictions were waived by state governments, and travel nursing provided a framework to move people across state lines to where they were needed most, says Polly Pittman, director of the Health Workforce Research Center at George Washington University. By the time of the third wave, when COVID-19 was ubiquitous, nurses could still work almost anywhere. A bidding war ensued.
“I think travel nurses have an important function, in moderation,” says Pittman. But a large body of research shows that overuse of travel nurses isn’t good—for hospital bottom lines, for staff morale, or for patients.
During the pandemic, big hospital systems that can afford to pay have been able to hire the nurses they needed, says Pittman. Smaller health care facilities that provide care to some of those most vulnerable to COVID-19—like San Juan Regional, a community hospital with about 250 beds—have struggled to maintain staff and find the funds to pay for travelers.
Paying travel nurses has a serious effect on hospital bottom lines, which also impacts quality of care. NSI Nursing Solutions, a national health care staffing and retention agency, conducted a survey of over 3,000 hospitals in 2021 and estimated that hospitals could save an average of $3 million for every 20 travel nurse positions eliminated.
And it hurts relationships with the regular workforce. The widespread use of travel nurses during this pandemic has left staff nurses asking why hospitals can’t find the money to pay them better and hire more staff nurses to reduce their load, multiple sources including Pittman told Fortune. “It creates this downward spiral of low morale,” Pittman says.
Exhausted and overburdened, many staff nurses are leaving the profession altogether or, like Mogler, turning to travel nursing. “If you have a regular nurse making $50 an hour and a travel nurse making $150 an hour, that’s a big gap,” says Martha Dawson, president of the National Black Nurses Association. “I can’t hold that against the nurse, because for them that’s the current system that provides them with earning power.”
“A smoldering fire”
Jewel Scott, a postdoctoral nursing scholar at the University of Pittsburgh, compares nursing before the pandemic to a smoldering fire. If you were right beside the profession, you could see the heat of issues like low staffing ratios, ever-increasing responsibilities, and lack of institutional support flickering. Farther away, though, they were invisible. “Then COVID-19 hit, and [it was like] somebody poured a gallon of gasoline on the fire,” Scott says.
Once upon a time, nearly all nurses got a single one-year qualification—known as the LPN, or licensed practical nurse—and spent their entire career at one or two facilities. Nursing has professionalized significantly in the past 40 years, as health care generally has become more high-tech and specialized. Today, most American nurses get a three-year degree, which makes them RNs, or registered nurses, and many go on to further qualifications. They can become nurse practitioners, who work without the supervision of a doctor, go into more specialized positions like nurse anesthetist, and some even get Ph.D.s and go into academia.
All of those factors mean that acute care RNs, the mainstay of hospital and nursing home staffing, are in much shorter supply than they used to be. “There are always background shortages of nurses,” says Buerhaus. Local shortages can result from factors like several nurses on a ward all going on parental leave at the same time, or poaching by a competitor hospital, he says.
But trends in the past few decades have exacerbated structural shortages—and made the national workforce more vulnerable. The baby boomers who make up the bulk of the RN workforce have been retiring in large numbers since their generational workforce peaked in 2000. Pre-pandemic, about 70,000 of these nurses retired per year.
As a fraction of the total workforce, that’s not a huge percentage. “But when you think about the 20 and 30 years of experience that are leaving the workforce, that’s a big number to replace,” Buerhaus says. For the past few years, he and his colleagues have been hearing from hospitals that experienced nurses in complicated, demanding areas like intensive care and emergency care have been difficult to hire.
At present, about 3.08 million registered nurses are employed around the country, according to the Bureau of Labor Statistics. Demand is predicted to grow by 9% by 2030—that means almost 300,000 nurses. But even though the mainstay of the labor force is retiring and demand for nurses is growing, nursing schools around the country are turning away qualified applicants—over 60,000 last year, the American Association of Colleges of Nursing reported in April.
There just aren’t enough faculty available to staff nursing schools—especially faculty who are people of color. They make up less than 10% of full nursing professors, Scott notes. About one-quarter of nurses identify as people of color. Studies show that outcomes are better for students who learn from people with a mix of ethnocultural backgrounds, regardless of the student’s race. Students who are people of color especially benefit because they have the opportunity to be mentored by people who share their lived experiences and feel more like they belong.
In her case, Scott says having a Black nursing professor, Marva Price, reach out to talk to her about pursuing graduate studies led her to seek out further qualifications and eventually become a nursing professor herself. “Without a doubt, representation matters,” she says.
And training nurses isn’t just about what happens in the classroom. Few hospitals have invested in nurse training on the job, says Joanne Spetz, director of the UCSF Institute for Health Policy studies. Now that the older nurses who were carrying so much weight are leaving, she says, there’s nobody who can do that vital teaching.
When the pandemic hit, these background issues became an urgent problem. “Hospitals were hit by this very fast, overwhelming demand for this very narrow specialty,” Buerhaus says. Trainee nurses and novice nurses were pressed into service in critical care, alongside the experienced nurses who remained. It’s a vicious cycle. “Poor staffing causes nurse attrition, and nurse attrition sustains poor staffing,” reads a recent commentary from the American Association of Critical-Care Nurses. This cycle has become more intractable during COVID-19. A recent McKinsey & Company survey suggests that as many as 22% of the country’s nurses may plan to leave direct patient care in the next two years. The top issue for the survey’s more than 300 respondents: insufficient staffing. “During the pandemic, what is considered to be a safe number of patients to care for has been stretched to the absolute limit,” says Sue Anne Bell, a University of Michigan nursing professor who specializes in disaster preparedness and has been deployed to communities for four months during the pandemic.
In addition to lowering nurse job satisfaction, turnover dramatically increases labor force costs. Each RN lost to a hospital costs on average $40,038 in 2021, the NSI report finds. Those individual losses add up quickly: With each percentage point a hospital improves its turnover rate, it saves an average of $270,800 annually. Nurse turnover also detracts from quality of care, a team of researchers wrote in a recent quantitative study, “with potentially increased rates of medication errors, falls, or other nurse-sensitive outcomes including health care–associated infections.”
A “national crisis”
In that sense, travel nursing has created a tricky problem: While it elevates and provides relief for a small subset of burned-out nurses, it magnifies the issues making the job so hard in the first place. The long-standing issues that paved the way for the current crisis also aren’t going away anytime soon, says Georges Benjamin, president of the American Public Health Association. They could be solved over time, he says, although it would take sustained effort.
But the first step in solving a problem is acknowledging that it exists. On Sept.1, the American Nurses Association submitted a letter to the Department of Health and Human Services Secretary Xavier Becerra. The association asked him to declare “a national nurse staffing crisis and take immediate steps to develop and implement both short- and long-term solutions.”
“We do hope to hear from Secretary Becerra soon,” ANA president Ernest Grant told Fortune a week after the letter was submitted As of this article’s publication in December, the ANA had received no response.
As for Mogler, the nurse that left his staff job for a travel position, he struggles with his choice. “I don’t feel great having left a very sick and needy population in a very understaffed hospital and coworkers who…were not able to take the same transition I did,” he says.
But the risk of handling a too-big workload and the feeling that his hospital wasn’t supporting him or his colleagues were too big an incentive to leave. As it is, he says, “I’m going to transition from one contract to the next until either the money is no longer worthwhile or situations start to improve and staff nursing becomes more appealing.”
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