For the last two years, hospitals have been reliant on travel nurses, with the demand for travel nurses skyrocketing. However, turnover has recently begun to increase, and hospitals and health systems are facing a turning point in addressing the staffing shortage crisis.
Minority Nurse chatted with Beth Brooks, Ph.D., RN, FACHE, and Clinical Advisor to Vivian Health, about how travel nursing is changing the nursing workforce and what hospitals can do to reconfigure the work environment to optimize the existing workforce.
Beth A. Brooks, Ph.D., RN, FACHE, and Clinical Advisor to Vivian Health
How is travel nursing changing the nursing workforce?
There have been travel nurses in the 30 years I’ve been a nurse. Of course, there have always been nurses who have chosen a full-time travel career path because they either wanted to travel the country or wanted the challenge of building robust clinical skills in a particular specialty. But for the most part, these travel nurses primarily filled temporary vacancies during past nursing shortages or labor strikes.
There are currently 4.4 million RNs in the U.S. nursing workforce. Between 2020 and 2021, the Bureau of Labor Statistics reported a 55% increase in travel nursing (from 43,160 to 66,790 RNs), representing 2.34% of the RN profession. Because travel nurses were all over the country working for different health systems during COVID, they are in a unique position to speak to how prepared (or unprepared) employers are to support nurses in their careers and mental health. As travel RNs consider permanent work, they are looking for employers to prioritize their mental health and well-being and provide flexibility, autonomy, career progression opportunities, and higher compensation to feel supported and respected.
Hospitals and health systems face a turning point in addressing the staffing shortage crisis. So what can we do to bring nurses back to nursing?
The industry has been facing many challenges. Recent research reveals that 600,000 Boomer RNs are expected to retire by 2030. The latest American Nurses Foundation (ANF) Workplace Pulse survey revealed that nearly half (49%) of direct patient care nurses intend to leave their position, 19% intend on leaving in the next six months.
That said, there’s some good news: 18-29-year olds remain interested in nursing careers. The National Nurse Work Environment study by the American Association of Critical-Care Nurses indicated that 75% would recommend nursing as a career, and interest in nursing school remains high. Rebuilding the workforce with these nurses is crucial, but the need to reconfigure the nursing workforce is equally important. This means adjusting how hospitals address staff churn and changing the care delivery model to ensure nurses are working at the top of their licenses. In addition, increasing the focus on mental health and well-being support, improving compensation, and reducing the complexity gap as more veteran nurses leave the profession and are replaced by newer, less experienced RNs.
Another interesting trend we’re watching is the new careers available to nurses. ANF’s Workplace survey indicates that 18% of RNs intend to find a nursing position outside the hospital setting, showing a growing interest in career pathing among nurses to build their career so it’s tailored to their specific lifestyle and interests.
During the pandemic, travel nurses tripled their pay by moving from job to job. But many see the short-lived boom as a temporary fix for a long-term decline in the nursing profession. So, do you think the travel nurse gold rush is over?
Travel nursing is not for everyone. It is its specialty, like pediatrics, critical care, peri-operative, medical/surgical nursing, or nursing leadership. Every nurse chooses a specialty area to focus on at some point in their career. Travel nurses feel that a higher salary compensates them for ever-changing patient assignments and adapting quickly to new organizations, making travel nursing their specialty. Some generational cohorts, such as millennials, are also drawn to travel nursing, but typically for a finite period.
Nurses attracted to travel nursing for the first time did so because early in the pandemic, they wanted to assist in regional COVID “hot spots.” Certainly, the salaries were a big draw. Still, these new travel nurses enjoyed control over their schedules, more autonomy, and flexibility, but whether these factors outweigh what they gave up – being part of a team, knowing the system, and professional development opportunities – remains to be seen.
We don’t know how many RNs will return to permanent roles or choose travel nursing as their specialty.
What has been the impact of travel nurses treating COVID patients for two traumatic years?
The pandemic has impacted every nurse – research studies of stress, fatigue, anxiety, moral distress, burnout, and some post-traumatic stress disorder reveal these findings. And let’s not forget that most of the 100,000 RNs who left the workforce during the pandemic were 49 years old or younger – not retirement age, as many assumed. What has been interesting is looking at the years of experience of travel nurses data: RNs who decided to travel for the first time during the pandemic report slightly higher stress, fatigue, and burnout levels than experienced travel RNs.
Do travel nurses feel like they answered the call and raced to help COVID patients, and now they’re being cut? Are the cuts attributed to federal and state funding drying up or something else?
During the early phases of the pandemic, permanent staff nurses were less tolerant of the initial drastic nurse staffing cuts when elective procedures were canceled. Then, during COVID surges, it was all hands on deck. This was hugely unsatisfying and may have fueled the interest in travel nursing (in addition to high salaries).
Nurses understand that when patient census decreases, there is less need for RNs, so their unit assignment or work schedule may change. This is true of permanent RN and travel RN staff. A lower patient census for RNs on travel contracts has led to a flurry of travel contract re-negotiations with hospitals. Negotiations to either end a contract early happened because patient census has decreased, or, where travel RN agencies benefited from federal and state funding by drastically increasing their billing rates, hospitals have been re-negotiating contract rates.
What can hospitals do to reconfigure the work environment to optimize the existing nursing workforce?
There are two areas to highlight: The first one is toxic cultures. Bullying, incivility, and violence perpetrated by patients and families towards nurses and hospital staff occurred at alarming rates. In acute care settings, 65% of RNs reported bullying or incivility, and 40% of RNs experienced violence. Nurses must have safer and more secure workplaces to provide the best care.
The second is to use more sophisticated math for nurse staffing and scheduling. Some savvy hospitals now view nurse staffing and scheduling as a logistics problem. Using a logistics management approach enables hospitals to use the science of operations research and more powerful math like linear programming. Predictive modeling is used to deploy the right number of staff with the right skills, at the right location, at the right time, with the appropriate patient assignment, and factor in the lowest cost with the best patient outcomes. This complex problem requires big data and sophisticated math, which is different from how nurse staffing and scheduling is typically done today. Nursing staff budgets are based on the “flaw of averages,” using rudimentary math to base nurse staffing on the census at midnight (Average Daily Census) and Nursing Care Hours per Patient Day (HPPD). This inevitably leads to some shifts being overstaffed (a nurse is sent home or floated to another unit) and some understaffed (not enough nurses during the day when the patient census is higher than at midnight). It is very dissatisfying for nurses.
Nurses are looking for scheduling flexibility and control. Health systems should consider creating different scheduling options like 8- or 10-hour shifts. Since nurses are familiar with gig economy-type jobs or travel nurse positions, they should also consider implementing these or similar options, which will be particularly attractive within large, geographically dispersed health systems.
Please discuss Vivian Health’s State of the Healthcare Workforce Survey findings. For example, why are nurses willing to trade the higher pay of travel nursing for a stable job with a strong employer?
Travel nurses learned to enjoy the sense of control and greater flexibility they had over their schedule while traveling during the pandemic. As a result, some want to continue traveling to see the country or build a robust clinical skill set. In addition, the pandemic created numerous work-at-home options. Those nurses with a partner who can “work from home” may choose to remain a travel nurse to continue enjoying greater control and autonomy regarding where and when they work.
It is becoming clear that while some first-time travel nurses want to return to permanent positions, they are demanding healthier work environments, flexible schedules, a sense of control, better staffing, more autonomy, and more significant compensation. Vivian Health’s recent survey asked travel nurses about their future career plans. Fifty-five percent were seeking a permanent position with a median salary of $65 per hour and being part of a team.
Why are nurses willing to trade the higher pay of travel nursing for a stable job with a strong employer?
Travel nurses learned to enjoy the sense of control and greater flexibility they had over their schedule while traveling during the pandemic. As a result, some want to continue traveling to see the country or build a robust clinical skill set. In addition, the pandemic created numerous work-at-home options, so those nurses with a partner who can “work from home” may choose to remain a travel nurse to continue enjoying greater control and autonomy as to where and when they work.
It is becoming clear that while some first-time travel nurses want to return to permanent positions, they demand healthier work environments, flexible schedules, a sense of control, better staffing, more autonomy, and greater compensation. Vivian Health’s recent survey asked travel nurses about their future career plans. Fifty-five percent were seeking a permanent position with a median salary of $65 per hour to be part of a team.
What about global nursing? What is the value of an American nursing degree internationally? What role do travel nurses play abroad?
First, there is a global nursing shortage. While we usually see nurses from abroad coming to the U.S. to work, many U.S. RNs travel abroad to work. There are a few interesting differences: First, travel contracts are for 1-2 years, not 13 weeks. Second, RNs traveling overseas need a U.S. Passport, an active, unencumbered RN license from a U.S. state, vaccines, and perhaps a work visa. Third, a language proficiency exam and board certification in a nursing specialty may be required. Finally, RNs who want to travel overseas must check each country’s regulations since they differ.
And yes, the value of an American BSN degree is significant. Unlike the U.S., where the minimum requirement for nursing is an AS degree, the BSN degree is the minimum requirement to be licensed in European countries.
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According to NC Nursecast, a shortage of 20,000 nurses in the state could happen over the next decade–even beginning in the next few years.
The predicted shortage isn’t for lack of interest in a nursing career, says Debra Barksdale PhD, RN, FNP-BC, CNE, FAANP, ANEF, FAAN, and dean of UNC Greensboro’s School of Nursing. Instead, nurses are leaving the field in greater numbers leaving a gap in their wake that UNC Greensboro is paying particular attention to.
Interest in attending nursing school is high, she says, and even with students weeded out through prerequisites, rigor, or attrition, there are still more nursing students than the university can take. Factors hindering enrollment mirror what’s happening on a national level including a shortage of faculty and enough adequate and sufficient clinical sites to educate the nursing students, she says.
Even if enrolling 30 additional students doesn’t sound like a lot, Barksdale says it is. “Every nurse counts,” she says. The COVID-19 pandemic, while it has worn out many healthcare workers, is also highlighting the work nurses do every day. The high-level, complex medical care nurses provide with skill and compassion has been on full display for the past two years and has sparked a renewed interest that kind of meaningful and challenging work. “People have seen the combined art and science of nursing,” says Barksdale.
The university shares clinical sites with other institutions in the area and so building on and strengthening relationships with those partners will benefit both sides. As nursing students work on clinicals in the facilities, they are also building a workforce pipeline of qualified and well-trained nurses who are familiar with the organization and its patient population.
And the nursing industry is also experiencing change in the way it is practiced. Technology, for instance, offers excellent tools for diagnostics and care. With simulation technology, student nurses can become adept at providing care and considering different outcomes before they even graduate.
“Students are more prepared,” says Barksdale. The experiences students have when learning a skill or when exercising clinical judgment and critical thinking to give the proper care are especially practical when performed in an environment like the simulated hospital suites or living quarters UNC Greensboro has. Student nurses are able to practice acute care and home care, says Barksdale. The university also has nursing simulation specialists who are able to help students debrief from the experience and add additional practical skills to the training.
Barksdale says looking at the faculty shortage requires a progressive perspective. There are ways to rethink academics to have the most efficient and high-quality educational experience, she says. There’s also new technology that can be implemented and that requires training and some getting used to. Faculty, for instance, need to learn about new approaches and stay current to offer students the most up-to-date training and knowledge. That takes time from their schedules as well.
And as the nursing industry changes, so too should the face of nursing. Barksdale says diversity in nursing is essential and must encompass more than race and ethnic diversity. It needs to include nurses of varying mobilities, so that nurses who use wheelchairs can find a place in the nursing field where they can also provide needed and critical care. Barksdale says fast tracking veterans and those who were military medics into nursing programs is another pathway to help with the nursing shortage while also tapping a highly qualified workforce.
“I’m really excited to see nurses step up and take their place as leaders and innovators on the front lines,” says Barksdale. “I’m excited as the status of nurses has been elevated through the pandemic. Others recognize what nurses bring to the table, and nurses have a place at the table where they didn’t have one before.”
There’s a nursing shortage that is not only affecting the United States, but the entire world. And research is showing that it could to get worse.
That’s why it’s crucial for nurses to stay happy and not completely burnout. And it’s not only up to them to stay that way, but for their employers to keep them pleased and working as well.
Anne Dabrow Woods, DNP, RN, CRNP, ANP-BC, AGACNP-BC, FAAN, Chief Nurse of Health Learning, Research & Practice at Wolters Kluwer, an acute care/critical care nurse practitioner at Penn Medicine, Chester County Hospital; a clinical adjunct faculty member in the graduate nursing program at Drexel University, and author of COVID-19: Transforming the Nursing Workforce in the New Paradigm of Care took the time to answer our questions.
What could the current nursing shortage mean for hospital care quality?
The nursing shortage is actually a global issue. According to the latest research, it is estimated that the world will need an additional 13 million nurses by 2030; in the U.S., the need is projected to be 1.1 million (International Council of Nurses). There are several reasons for the nursing shortage. As the population of the world increases and Baby Boomers continue to age, the need for care will increase. This is compounded by the fact that nursing schools around the country are struggling to meet the rising demand for nursing education due to limited faculty, resources, and clinical sites; they turn away an estimated 80,000 qualified applicants each year in the U.S. due to this supply and demand issue (American Association of Colleges of Nursing). A large portion of the nursing workforce was set to retire in the next 10 years. However, the pandemic has accelerated this event, and nurses are leaving sooner than expected due to widespread burnout and exhaustion.
If nursing staff are feeling overworked and undervalued, they will more readily leave their institution, and perhaps the nursing profession altogether. This, in turn, increases the current nurse shortage, and the problem continues to worsen. Hospital care quality suffers if nurses are burnt out and overwhelmed, just as it suffers if nurses are missing. Patient wait times increase, and bedside care suffers. For hospital care quality to improve, there needs to be a concentrated effort to fix the supply and demand issue in nursing education, and there needs to be a concentrated effort on workforce well-being and fostering resilience—that is the bottom line.
What can hospitals/medical centers do to increase resilience among their existing nursing staff, while making sure that they don’t burnout and leave?
To foster resilience among the workforce, organizations need to acknowledge there is an issue and focus on workforce well-being. This means providing a safe environment in which to practice and provide patient care. Providing adequate staffing based on acuity/severity of illness and competency not just on numbers is the first step. Building up float pools that are cross-trained to work across adjacent specialties and move from one area to another is essential. While nurses do not like to float outside of their units, in an emergency or disaster situation, having the staff cross-trained to work in adjacent specialties helps to create an agile, efficient workforce.
Health care institutions need to invest in their workforce. Providing adequate breaks, healthy meals, self-scheduling, shorter shifts, and being able to take time off is crucial to preventing burnout. Nurses want to feel valued—providing continuing professional development activities and having the ability to meet career goals with lateral or vertical moves can make the difference between keeping the talent and losing it.
Health care systems must recognize when burnout and moral distress are occurring. That means having trained personnel up on the units evaluating what is really happening and then providing mental health support through employee assistance programs. Often nurses are worried about their families; health care institutions need to provide alternative child or family care or even financial planning. Burnout can be prevented or at least minimized if health care institutions are actively on the lookout for it, address the issues that cause it and invest in their workforce well-being.
How can nurses prevent their own burnout? Especially when hospitals, etc. are understaffed?
Preventing burnout is no small task, but nurses can certainly take steps to reduce their stress and prioritize self-care when they feel overwhelmed in the workplace. It’s important for nurses to know how to evaluate their own well-being, recognize their limitations, and be able to advocate for themselves when something is beyond their bandwidth.
Learn to be comfortable with saying, “No.”
Saying no is one of the hardest things for nurses to do; we are a caring profession and we often sacrifice our own self-care to care for others. We need to understand that if we don’t care for ourselves and find our own inner peace, there will be no one left to care for others.
Personally, I recharge by finding my inner peace and joy by reading, enjoying the outdoors, and sitting by water. Reclaiming “me time” within my day to recharge allows me to show up fully ready for my next day of work.
What are some proven strategies for creating a more agile workforce that both addresses the nursing shortage as well as avoids reliance on traveling or temp nurses?
The agile care model is based on patient acuity, competency of the workforce, and alternative care delivery models. It provides agility that allows hospitals to move their nursing workforce when and where they are needed and uses other members of the health care team to support patient care such as unlicensed assistive personnel, licensed practical nurses, and others. It also switches the care delivery model from a primary nurse model to a hybrid team model of care as needed.
The backbone of this model is cross-training the float pool to work across adjacent specialty areas and as a backup, having the full-time staff cross-trained to work across adjacent specialties in an emergency situation. This interdisciplinary team-based approach facilitates the rapid deployment of staff to areas most in need in a crisis, such as what we’ve experienced with COVID-19, and provides better care for a greater number of patients.
This addresses the nursing shortage by improving the quality-of-life nurses experience at their workplaces. With more nurses trained to work in adjacent areas, staff will be able to take time off and recharge. When nurses feel practice-ready, confident, and able, they are less likely to burn out because they will experience less overall stress at work. Health care institutions must also be on the lookout for early signs of burnout and encourage their nurses to take time off when it is needed.
What are the biggest mistakes that hospitals/medical centers can make with their current staff that could lead faster to burnout and them leaving?
Health care organizations need to understand that their biggest asset is their workforce. Without nurses and other medical professionals, hospitals and medical centers cease to function. Nurses need to be recognized for their value—their workplaces should support them by looking out for signs of burnout, offering mental health support, offering family/childcare support, and encouraging a healthy work-life integration. Without these basic acknowledgements, it is no surprise the burnout and shortage levels are what we are seeing today.
Nurses’ mental health matters! Nurses need to talk to their organization and be vocal about how they can better support their nursing teams. Whether that is more frequent review of their workforce policies, more transparency in the workplace, or more vacation time, nurses shouldn’t be afraid to speak up and stand up for themselves and for their fellow nurses.
Teaching in the field of nursing is a rewarding experience and an opportunity to give back to nursing. Education in the faculty role allows for providing insight into current practices based on lived experience and present evidence-based guidelines. Overall, Caucasians and Asians are overrepresented in nursing in comparison to African American and Hispanic nurses, according to a study published in the Journal of Cultural Diversity. As a result of this disparity, there are also problems with equal representation of minority nurse faculty. Those considered faculty of color have continued to represent less than 13% of nursing faculty. As a nurse educator, I have a direct impact on one’s future practice when caring for patients. I am concerned about these known truths and have a few questions for one to consider:
Why is there not an equal representation of minority faculty when compared to the majority?
Are individuals given a fair chance?
It is a tedious process to complete applications for faculty roles and often discouraging to obtain feedback from an automated email generated message about qualifications not matching. I encourage all minority potential faculty candidates to increase their visibility in becoming part of a nursing faculty and continue to be persistent. There does need to be interest in nursing research to be considered competitive for some positions. There are overwhelming amounts of candidates with clinical experience as registered nurses or nurse practitioners. Students more than ever need to see someone who “looks like me” at some point in their curriculum with whom they identify with. This is important in ensuring self-efficacy is present throughout their program.
Often, the hiring process is screened by human resources and not nursing departments. Specific to nursing may be the change of having administrative involvement with applications submitted for faculty roles. Anyone who knows me both personally and professionally understands my passion for nursing education. A majority of my close friends have been convinced to give back to nursing in becoming professors. As an African American female, I disproportionately represent a minority faculty. I am grateful for my opportunities. However, we have more work to do in the recruitment and retention of minority nurse faculty.
Colleges and universities must consider diversity within the workplace, particularly for nursing. This is an initiative for the American Association of College of Nursing (AACN). Their initiative involved the inclusion of a diversity of both students and faculty in schools of nursing across the country. An inclusive learning environment can be shaped by the active recruitment of minority faculty. Should there be a representation of diversity in the hiring process, such as within a search committee? This endorsement by AACN is a step in the right direction in the solution to improving a diverse workplace and learning environment for students. Recognition is the first step in making strides to consider those who are minorities from diverse backgrounds.
Employment projections are estimating that Registered Nurse (RN) needs will continue to grow rapidly—at the same time a shortage in nurses is expected. Due to this shortage, it is critical for health care organizations to implement a firm training program, have direct leadership relationships, and target minority populations. Doing this will assist in filling RN openings and help create an organization that truly invests and cares for their nurses, which will positively impact retention.
Nursing school enrollment is not advancing fast enough to meet the RN demand, and with nurse baby boomers aging there will be fewer nurses available as the health care sector continues to grow. For example, in the Orlando, Florida region specifically, there are over 1,600 current RN job openings available, with 191 direct employers competing to fill those open positions. Simply put, there are not enough nurses to fill all those critical needs in the market. This shortage is impacting the current nurses’ job satisfaction, increasing their stress, and even driving some nurses to leave the profession.
Without nurses we cannot run our health care organizations, which is why having a process in place to train and support them is essential. To invest, you must have
a proper training program to support the nurse and ensure they are demonstrating safe quality care to patients. Certain organizations, such as AdventHealth, implement this in their Graduate Nurse Residency Program in the Orlando region. The first two weeks of the program are focused strictly on modules, simulations, and computer training. During that time the new nurse goes through a three-day simulation lab to provide hands-on learning before they even enter the department. The following months are focused on individual preceptor training. The nurse is partnered with an experienced nurse for a certain amount of duration (8-16 weeks depending on the acuity of the unit) to train the new nurse and will be with them every single shift side by side so they have the resources and training to be successful. After the focused preceptor training, the new nurse continues to be provided educational courses and simulations as needed. This shows the nurse that the company is investing in their future.
Proper training programs and support for nurse staff is essential for the nurse to feel like they have more opportunity, and desire to stay and grow as part of the organization. With the shortage of nurses, you need to ensure the nurses that you do have feel supported and uplifted to reach their full potential. Providing this training will provide a higher percentage of nurses to feel valued enough to want to stay in that organization and to have the desire to give back full circle to the organization that invested in their learning and education.
Leadership involvement is also a direct way for organizations to increase retention. If a nurse is feeling overworked, they need to at least feel appreciated for all they do. Open communication is critical for retention—and to really understand where your employees are coming from. Nurse leaders need to uphold regular one-on-one meetings and gain a professional relationship with their employees to understand their struggles. During this meeting it is also important for the leader to ask intuitive questions, so they are aware of the things that motivates their nurse employees to continue being a nurse every day to help others. Remind them why they started this career, so even through the negative days they resort back to the positive reasons why they started their nursing career.
In today’s recruitment efforts, the candidate pool of nursing talent is getting smaller since nursing schools can’t accommodate the applicants. Even though the schools can’t accommodate the volume of applicants, the nursing programs still need to ensure their selection process is fair in diversity selection as well. Health care organizations also need to focus on out of the box recruitment efforts targeting different populations—specifically, minority nurses. Health care in the United States is seeing a high influx of minority patients. When the number of minority patients increase, so does the demand for minority nurses to care for those patients. It is very important for the team of nurses at an organization to be well-rounded and diversified to care for patients from a variety of cultural backgrounds.
Implementing training programs, leadership engagement, and targeting minority nurse nurses will not only help with recruitment and retention, but also project longevity amongst nurse employees. Nurses need to feel wanted and valued. Nursing is one of the toughest jobs, but when an employer makes them feel respected, appreciated, and gives them the proper tools to be successful, they will be more likely to continue to stay within an organization that supports them wholeheartedly. Every organization needs to focus on these areas to be able to retain their nursing staff and provide the utmost care to their patients every day.
