"Would You Like a Krabby Patty with That?"

March 17, 2006 -- Today The Baltimore Sun ran a long piece about travel nurses on the front page of its weekly Health & Science section. Dennis O'Brien's article was "Nurses to go: Traveling medical personnel command top dollar and, for some, follow-the-sun benefits as they relieve shortages in the nation's hospitals." On the whole the piece is a fairly standard travel nursing piece. It includes discussion of the short-term benefits to the traveling nurses and the hospitals at which they work, along with a little on the potential drawbacks to the travelers. Commendably, the piece quotes several nursing experts, and briefly suggests that nurses affect patient outcomes. But unlike other pieces that simply ignore the larger implications of the growth of travel nursing, this piece may leave readers with the sense that travel nurses are clinically superior to staff nurses, and that they are not necessarily more expensive. Based on this article, it would not be unreasonable to think that travel nursing should be promoted as a key way to address the critical nursing shortage. The piece does not convey that many feel that the growth in travel nursing during the current crisis may actually undermine nursing practice and threaten patient care. Finally, it's hard to love a headline that essentially compares nurses to fast food.

Most of the piece discusses the personal experience of several travel nurses from Maryland. We hear that the "footloose" adventurers winter in Florida and summer on the Vineyard, how they get top salaries and free housing, all while seeing America and "help[ing] ease a severe shortage in virtually every hospital in Maryland--and most other states." The piece says there are now an estimated 35,000 travel nurses in the U.S., which is more than one per cent of the total RN population. To its credit, the piece does outline some of the dimensions of the overall shortage, noting that the U.S. is now short an estimated 168,000 nurses, a number that is expected to exceed 800,000 by 2020. It also says that hospitals use travelers to fill in when staff nurses take vacations, or to help handle seasonal populations or illnesses like the flu. The piece also notes--at the very end--that there are some drawbacks for travelers, including potential loneliness, uncertainty, and fewer benefits such as sick leave and tuition reimbursement.

Toward the end, the piece addresses the larger implications of the travel nurse trend. "With more nurses expected to retire in the years ahead, experts say the shortage of regular staff nurses will get worse -- but the number of travelers is likely to increase, too." The piece then offers comment from several nursing experts about the effect of traveling nurses on patient outcomes and hospital costs. Vanderbilt nursing professor Peter Buerhaus is quoted as saying: "There's not a lot of risk when it comes to quality...These traveling nurses tend to be pretty good." University of Pennsylvania nursing professor Linda Aiken is quoted as going farther, saying that (in the reporter's words) "[u]sing travelers actually helps reduce problems with patient care, including medical errors, dispensing the wrong medication and the spread of infections." Then the piece starts a new section with the heading "Positive patient outcomes." It notes that Aiken says such care problems often result from (again in the reporter's words) "understaffing or poor work environments that stem from mismanagement." Then the piece quotes Aiken directly: "You have problems where the staff turnover rate is high, where productivity of the nurses is being undermined by a chaotic environment...But use of per diems or travelers seem to have a positive effect on patient outcomes."

As for the cost to hospitals, the piece says that "experts say" they "vary." Travelers tend to earn several dollars more per hour in Maryland, and their subsidized housing may add an additional $6 to $8 per hour. However, the piece then quotes Karen Haller, vice president of nursing at Johns Hopkins Hospital, as saying (in the story's words) that a "staff nurse with years of training and experience at Johns Hopkins can earn $100,000 a year...so if the hospital replaces a highly experienced nurse with a traveler it can actually save money." We assume it was not intended to come off this way, but the way the article presents this, it almost sounds like some nursing executives would be thrilled if they could get rid of their most experienced staff nurses and hire travel nurses for less money. However, the piece notes that Hopkins and most other hospitals "have rules about the use of travelers," and Haller assures readers that "[w]e always have a senior Hopkins nurse in charge" of a unit.

The piece never actually explains why a travel nurse would not be in charge of a unit. Indeed, if they're cheaper than many experienced staff nurses, and if they actually produce better patient outcomes, why not staff your unit completely with travelers? Of course, it's not really clear from the piece whether the quoted nursing scholars are suggesting that travelers as a class provide better care than staff nurses as a class, or simply that travelers can improve outcomes in specific situations, such as on troubled units. Of course, we assume the academics are actually comparing equal numbers of travelers and staff nurses. Obviously adding a traveler is likely to improve outcomes as compared to not adding a traveler, if the number of staff nurses remains constant. But is there really research suggesting that, all other things being equal, travel nurses produce better outcomes than staff nurses? We commend the piece for letting readers know that nurses do in fact affect patient outcomes, for the reasons Aiken cites. However, it seems likely that most readers will take the article to be saying that experts believe that travel nurses are simply better than staff nurses are.

It is difficult to accept that idea. Of course there are great travel nurses, and surely travel nurses must develop a great ability to adapt to new situations and gain valuable experience with many different care systems. But much of the work of nurses and other serious professionals in modern workplaces depends on site-specific things that cannot be learned in a fleeting orientation, or even in 13 weeks. That's why we are unlikely to read a piece about how hospital physicians who move around in 13-week stints provide better care than those who spend years practicing in a particular setting. Even the best new travel nurse may have difficulty negotiating an unfamiliar work environment, with all of the different colleagues, patient populations, care systems, equipment, and institutional practice. Is it likely that substituting travel nurses for staff nurses would lead to less chaos? Travel nurse orientations are often inadequate. In addition, as the piece notes, travel nurses tend to be young and therefore less experienced than average; the three nurses profiled in the piece apparently became travel nurses just three years, two years, and 18 months into their nursing careers. And even assuming there is a cadre of unusually competent travel nurses--the Special Forces of nursing, if you will--it's difficult to imagine that this could be a viable large scale care model to relieve the nursing shortage.

As we have explained in the past, in Nursing Against the Odds Suzanne Gordon describes the rise of travel and temporary nursing that has accompanied the nursing shortage. Gordon rightly casts no aspersions on travel nurses themselves, but she explains why the sharp growth in the use of travel agencies is worrisome. Potential problems include that it divides nurses in the workplace and creates resentment in regular staff nurses, who are often making less money; that it undermines unions and contributes to an atmosphere of shift work that decreases nurses' power and inclination to challenge the unsafe conditions that result from short-staffing; that it costs a lot of money that could be spent on adequate full time staffing and other critical needs; and that it may present inherent safety issues, because of the site-specific and increasingly complex hospital systems discussed above. At the same time, Gordon argues, the tempting perks of travel nursing--short contracts, nice housing, sign-on bonuses, ski jumping off the hospital roof or whatever--may do little to keep nurses in the profession long term. Travelers don't have to like their hospital; they can be gone in 13 weeks. When they get tired of that, and there is no hospital at which they can stand to work for long--what happens then? Of course, this article presents the growth in travel nursing simply as a helpful solution to the shortage, not a troubling result of it.

We thank the Baltimore Sun for this coverage of a trend in nursing, but we wish it had provided better context as to the full significance of the growth in travel nursing.

Please send a letter to the editor of The Baltimore Sun at letters@baltsun.com, copy author Dennis O'Brien at dennis.obrien@baltsun.com and please blind copy us at letters@truthaboutnursing.org

See the article "Nurses to go: Traveling medical personnel command top dollar and, for some, follow-the-sun benefits as they relieve shortages in the nation's hospitals" by Dennis O'Brien in the March 17, 2006 edition of The Baltimore Sun.