Travel Nursing and the Demise of the Virtue-Script: Steps to a New Beginning

Since the onset of the COVID-19 pandemic, travel nursing is transforming the nursing workforce in a myriad of ways that are positive and negative. Evidence suggests that the nursing shortage, which predated the pandemic, was heightened during this period and is expected to escalate in the years to come (Lee, 2022). During the pandemic, travel nurses filled the gap, increasing from 3–4% of all nurses to 8–10% (Dixon-Liunenberg, 2022). The use of travel nurses is not new, however, for example, a 2012 study reported that 75% of hospitals used “travelers” in 2006 and found no difference in patient outcomes related to such supplemental staffing in the years of the study, 2003–2006 (Xue et al., 2012). Moreover, a pre-COVID 2017 analysis suggested the optimal percentage of travelers to be 6%, however 11% of nurses were travelers (KPMG, 2017). This figure is not out of line with estimates during the COVID travel nurse surge. What is new this time, however, is the enormous stress of COVID caring; the whiplash of being discarded then sought after and, in “stayers,” working side-by-side with much higher paid travelers, many who recently had been hospital employees. What is the effect of this dramatic change in nurse-to-nurse relationships as well as nurse-to-employer dynamics? How do we capitalize on the gains and learn from the negatives to better serve society, stabilize the workforce, and promote nurse well-being and career satisfaction?

Gains

Hilgers’s 2022 New York Times article titled, “Nurses have finally learned what they’re worth” seemed to zero in on the heart of the issue. Our view is that nurses knew their worth, yet systems did not always recognize this in tangible ways. Once nurses were worth-affirmed during this crisis, they could not return to where they were pre COVID. For example, before the pandemic New York City registered nurses made, on average, $1672 per week; at the height of COVID-19 travel nurses made $10,000/week or $100,000 for a 13 week assignment (Perry, 2020; Wainer, 2022; Walker, 2020). These disparities in wages were magnified, in part, by federal subsidies used to pay travel nurses and had the effect of distorting wages relative to non-travelers. Travel-nursing revenue on average tripled in the past 6 years, to about $12 billion (Wainer, 2022). Some, including members of Congress, have accused the industry of price gouging in the COVID-19 era (Perry, 2020; Welsh, 2022; Yang & Mason, 2022).

Yet nurses took extraordinary responsibility during the pandemic; they were initially seen as heroes and lauded for their service. Yet recently, the sheen wore off and increased violence, bullying and burnout began to dominate the workplace (Proctor & Levine, 2022). The monetary gains were comparatively high for travel nurses, but unequal across the different types of nurses, creating immense salary differentials. Many health care facilities are still dependent on travel nurses and have been trying to even the playing field by providing non-travelers with monetary incentives to stay employed. One example was a $30,000 retention bonus to stay 18 months at one hospital in Maryland.

Has travel nursing reached its peak? HCA Healthcare Chief Executive Officer, Sam Hazen noted that expenses for temporary staff were down about 22% in June compared with April 2022 (Wainer, 2022) and the American Hospital Association (AHA) has called hospital cost growth “unsustainable” (AHA, 2022, p. 8). Many facilities continue to employ travelers; however, the market is unequal. In summary, some organizations have now reduced their reliance on travel nurses and offer them lower wages (Gooch, 2022a).

Negatives

At the beginning of the pandemic, the reduction in elective procedures created a revenue reduction that resulted in many nurses, who were not working with COVID-19 patients, being laid off or furloughed (Anderson, 2020; Winslow et al., 2022). This action eroded both employee embeddedness and organizational loyalty. The perception that some travelers had little loyalty to the hospitals in which they worked further eroded the nursing workforce morale, given that many nurses saw travelers making significantly more money than they did and even receiving preference in assignments. As the work environment became more toxic, burnout and disillusionment among nurses increased, especially among newer nurses (Proctor & Levine, 2022; Winslow et al., 2022; Yang & Mason, 2022).

Nurses new to the organization often became the majority in hospital units as older nurses and others with longer tenure resigned or retired (Thayer et al., 2022). The new nurses were confronted with a work environment in which loyalty to the organization typically had few monetary rewards. The criminal prosecution of a nurse in Tennessee for a medication error that resulted in the patient's death also had a chilling effect on all nurses, but particularly on new nurses. In addition to suffering disillusionment with the job, new nurses were faced with poor staffing ratios and increasing violence in the workplace. Unequal compensation, violence, poor staffing ratios and burnout has led to a perfect storm in the health care environment for nurses (Proctor & Levine, 2022; Yang & Mason, 2022).

A recent survey by the American Association of Critical Care Nurses offers evidence that that health of the workplace has substantially declined (Ulrich et al., 2022). While we do not have specific data on overall patient outcomes across settings during the workforce fluxes of COVID-19, this study offers important clues. Responding critical care nurses reported declines in all categories: appropriate staffing, skilled communication and collaboration, meaningful recognition of nurses, effective decision making, authentic leadership, physical and psychological safety, and quality of care between 2018 to 2021.

Finally, in September of 2022 Lee reported that the “travel nurses’ gold rush is over” (para 1) but that many nurses are not returning to nursing and instead will leave the profession altogether. A recent survey found that 67% of respondents plan to leave their position within three years (Carbajal, 2022). This, coupled with “quiet quitting”--a widely reported phenomenon in which people remain employed but do as little as possible yet feel positive about this level of contribution (Gooch, 2022b; Telford, 2022), places our nation's health care future on a fractured foundation, leaving it ill-equipped for what lies ahead. The historically dominant “virtue script” (Gordon & Nelson, 2006, p 13) in which nurses are socialized and accept service at any and all cost to themselves is out-of-touch with today's realities. Bold action is necessary.

Policy Solutions

Now that the pandemic is leveling off, what will the nursing environment look like in acute care hospitals? Will we regress to old patterns or increase compensation and rewards for nurses who stay? Many models to improve the work environment exist, for example, Magnet (American Nurses Credentialing Center, nd) and Beacon (American Association of Critical Care Nurses, nd) designations, but did these models serve us well in this crisis situation? More research to determine their efficacy in such crisis situations is warranted.

How will we continue to recruit and retain young and new nurses as they replace the aging nurse workforce, many of whom have retired or changed positions? New types of incentives are needed, and longstanding problems must be resolved. Inclusive models that engage nurses and incorporate innovative solutions are essential (Nyhus, 2022).

We need to strongly push back on criminalization of patient care errors made by nurses; this cannot become the norm if we hope to make improvements in patient care. Only when we reach the root causes can we truly decrease medical errors and effect systemic change. This approach, rather than penalizing nurses for errors, is effective (TAANA.org, 2011) and consistent with the “just culture” movement recognizing that most errors are the result of faulty systems rather than deficient individuals (Boysen, 2013, p 400).

We also need real solutions for violence and bullying in the workplace, which has only escalated since the pandemic (Ulrich et al., 2022). Advocacy for the federal legislation proposed in the 117^th Congress, H.R.1195, the Workplace Violence Prevention for Health Care and Social Service Workers Act, is time well spent and a beginning solution.

As a new generation takes command of the nursing workforce, fresh compensation and work environment enhancement strategies are also needed. One approach would be to use tools of behavioral economics to understand what the remaining and emerging workforce desires and will demand. Such an approach has been proffered to design physician incentives that drive high-value care (Emanuel et al., 2016). Unfortunately, previous studies have found that when hospitals have additional revenue, it is not allocated to expenditures that directly impact patients, such as nurse staffing (Wang & Anderson, 2022). Antecedent to this troubling situation are most current reimbursement models, in which nursing care remains a labor cost while physician care is a revenue generator. In this reimbursement schema, the inherent incentive is to keep the nursing care “costs” as low as possible, and physician care “revenue” as high as possible, even though both are borne by society as cost. This payment model has created many of today's healthcare challenges, including inadequate nurse staffing and uncompetitive compensation, particularly for the lowest wage workers.

As early as 1987 Claire Fagin argued for dramatically reformed reimbursement models such that “nursing cost and revenues [are] explicitly identified in all health facilities” (Fagin, 1987, p 120, emphasis added). An option that is likely more palatable in the current shift toward value-based care would be fixed-revenue global budgets, provided that organizations don't nevertheless lay-off or furlough nurses just because they can. An intermediate strategy is to employ “wage-pass throughs” or minimum spending limits that ensure the revenue consistently goes to those providing the care. These have had limited use in the US, but still have led to some notable successes (Baughman & Smith, 2010; Feng et al., 2010; Foster & Lee, 2015; Jaffee, 2021, 2022; Miller et al., 2012). Such efforts may be particularly critical given profit-oriented private equity's growing footprint in healthcare, despite oft questionable quality (Private Equity Stakeholder Project, 2022). Finally, organizations should be very cautious about token demonstrations of value that paternalize nurses’ contributions. As one nurse confidentially shared with one of the authors: “Forget the free pizza and popcorn. I am not a child to be placated with snacks. Give me enough talent to work with and compensation that reflects my risk-taking, education, and skills. I’ll buy my own xxx-xxxx pizza.”

Changing nurse compensation models is only one thread in what must be a comprehensive approach toward improved working conditions and adequate staffing. Staffing levels and staff skill mix may be even more critical than compensation to many nurses. Yet one lesson from COVID is that the money, indeed, does matter. Travelers have long been among us and will continue at some level into the future. Fresh approaches, and answers to the research questions posed above, are needed to revitalize the workplace and prevent schisms among various nurse factions, nurse employment models, and age cohorts. Nurses, once the invisible profession (Fagin) are now “seen” in heretofore unprecedented ways. The critical role of nurse job satisfaction and career satisfaction in our nation's health is now on full display to healthcare organizations, payers, trade groups, and policymakers at all levels. Our fervent hope is that this visibility translates into the palpable changes that only they can make.