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Costly but critical: Nurses travel the nation to blunt staffing shortage
UI spent $42.3M last year as pandemic fallout persists
IOWA CITY — The mother-baby floor — famous for its infant coos and cries and first meetings and feedings — is supposed to be the “happy floor.” But even that unit at MercyOne Medical Center in Des Moines has been hit by one of biggest problems in health care: a critical nursing shortage and its fraught fallout.
“It’s a big floor,” said Jill Hayes, a longtime registered nurse who just turned 60 and has been a MercyOne mainstay in that popular unit since 1996. “We have 40 beds. And it’s a lot of running … you hurt.”
Even with all the rushing through long shifts over nights and on weekends, the mother-baby unit for decades was a popular destination for nurses.
“For years, you did not see anybody leave,” she said. “It was hard to get on the floor. There was never an opening unless somebody retired. I mean, they stayed forever.”
And then the pandemic arrived. And like a gust of wind toppling a house of cards, nurses near retirement, looking for better pay or smoldering toward burnout submitted two-week notices in droves.
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“A few left right before,” Hayes said. “And then COVID kind of just got them out the door.”
MercyOne is hardly unique in its new nursing normal, characterized by shortages and shift holes plugged by staffers on overtime and by “traveling nurses” — trained and educated nurses who contract with agencies to fill openings nationally for temporary stints that can last days, weeks, months or longer.
Those travelers face a conflicted reception from the staff nurses they work alongside. Some, overwhelmed by ballooning patient loads and medications to juggle, feel relief at the extra hands. Others harbor contempt for the higher wages that travelers make — costing their hospitals millions — even as the temporary nurses are less familiar with the facilities, processes and doctors.
Contradictions also characterize the larger hospital relationship with traveling-nurse staffing agencies — as facility executives plead with, praise and thank agencies behind the scenes while publicly bemoaning the need to use them.
“In order to maintain capacity, there's more reliance on agency,” University of Iowa Health Care Chief Financial Officer Mark Henrichs told the state Board of Regents in April about his system’s 35 percent expense spike in traveling nurses over the previous six-month span. “Hopefully that'll kind of change over time.”
But it hasn’t yet, and UIHC spending shows it.
In the 2020 budget year — which started in 2019, before the pandemic — UIHC paid a combined $10.2 million to seven temporary nurse staffing agencies, according to spending data The Gazette obtained through a public records request.
That jumped to $15.5 million in the 2021 budget year and then $42.3 million in the budget year that just ended — a fourfold spike over two years showing that even as COVID-19 concerns have waned, the costly fallout from its stress on nurses hasn’t.
“You see more absenteeism,” one UI Hospital and Clinics intensive care nurse said recently at a protest held outside the hospital over administrative warnings that nurse-patient loads could rise. “You see nurses leaving the industry altogether. Suicide rates are going up among nurses.”
UIHC officials told The Gazette that even as they race to recruit more staff, the campus remains reliant on temporary nurses — with payment to its traveling nurse providers topping $23.4 million just three months into the new budget year. That already is more than half of last year’s total, 52 percent more than UIHC spent in all of fiscal 2021 and 130 percent more than it spent in all of fiscal 2020.
Officials reported more than 250 traveling nurses working across its campus in September, up from about 100 in July 2021 and about 50 in July 2020. Nearly a decade ago, in 2014, UIHC had the full-time equivalent of just nine traveling nurses.
“Like most other health systems around the country, we have seen an increase in staff turnover during the pandemic, which has in turn led to an increase in the use of travel nurses — not only to fill open roles, but also to support our staff,” UIHC administrators said in a statement. “We are actively recruiting to fill hundreds of nursing roles in various units, and travel nurses are helping to bridge the gap until we fill roles permanently.”
In June, for example, UIHC held two large-scale “we’ll train you” nurse-recruiting events providing on-site interviews and same- or next-day job offers for all clinical care positions, including registered and licensed nurses and nursing assistants.
As of Friday, UIHC had about 340 open nursing jobs — equal to more than 10 percent of its 3,000-plus total nursing team — and 150 open clinical positions, including medical lab technicians, physical therapists, phlebotomists and psychiatric social workers. The hospital system has a total health care staff topping 11,000.
Like nurses in hospitals nationally — including in Wisconsin, where thousands recently planned a walkout over pay, safety and staffing issues, and in Michigan, where nurses voted to strike before reaching a tentative contract deal — UIHC nurses in late September protested their work conditions.
The protesters outside UIHC last month — waving signs with messages like, “Stop asking me to be less of a nurse” and “Safe staffing saves lives” — demanded UIHC do more to attract and retain not only staff nurses but their traveling counterparts.
“Our staffing … is going to be some of the most challenging that it has been,” a UIHC unit nurse manager told to her team in a Sept. 23 email obtained by The Gazette.
The manager warned of intensive care unit plans to “triple patients that have orders for the floor” and said some nurses could see a patient-load increase up to five at a time.
“Challenges will continue for the adult inpatient staffing through mid-November,” the manager wrote in the email. “This is really hard to hear for all of us, and I understand the feelings of being frustrated and nervous for what the future is going to bring.”
Half of nurses nationally who responded to an August survey by the American Nurses Foundation — 55 percent of them in acute care hospitals — said their units were short the registered nurses needed “with the right knowledge and skills” up to 49 percent of the time. About 66 percent of all nurses and 74 percent in acute care said they sometimes, seldom or never have the ancillary staff they need. Fewer than half — 42 percent — said they considered their work environment to be healthy or positive, and nearly half said they will or might leave direct patient care within six months.
Topping the list of things those nurses said employers could do to improve work satisfaction were increasing compensation and the number of nurses and support staff.
“Nurses are sounding the alarm that quality care is at risk and concerns are high over a healthy and safe work environment,” according to the American Nurses Foundation.
Although hospital administrators have said they’d prefer to meet staffing needs by hiring permanent workers, 75-year-old David Leitsch said he had mostly traveling nurses during his recent COVID-19 hospitalization at UIHC — and felt he had good care.
“I was really surprised,” Leitsch, of Iowa City, told The Gazette about learning so many caring for him weren’t on staff. “I haven't been in the hospital for 25 years, but I was just startled to discover that they were almost all traveling nurses.”
He wouldn’t have known had he not asked, adding, “I had no complaints about the care.”
Likewise, UIHC staff nurse Ashley Lynn said her cardiac unit has “quite a few travelers” and — though she views them as temporary — she wants them around until administrators make permanent hires “so that I can do my job in a quality way.”
“They do wonderful,” she said.
But the constant turnover and cycling in and out of new and different faces can be wearing and create meaningful relationship and knowledge gaps, said MercyOne nurse Hayes — worried not just about nurses who travel from other states but those who travel or float among different floors in the same hospital.
“I think the care has suffered tremendously from all this switching around,” she said. “I think it’s not having people familiar with our protocols, because they can be a little different in different areas. It's hard enough for us to keep up with how they change.”
UIHC — planning to add hundreds of thousands of square feet to its sprawling reach in the next few years, including a new campus in North Liberty and plans for a new inpatient tower in Iowa City — often reports its current 866 inpatient beds are at or near capacity.
Despite concerns about staffing ratios, though, administrators reiterated their commitment to “providing safe, high-quality care.”
“In health care, staffing is flexible and we safely match resources with constantly changing patient care needs,” said UI Hospitals and Clinics Interim Chief Executive Officer Kim Hunter, who also serves as chief nursing executive.
The hospital has earned three of five possible stars in a federal patient satisfaction rating — falling below state averages in all 10 categories and at or below national averages in all but two.
It scored the lowest on questions of whether patient rooms are quiet at night and whether patients get help when they want it, according to the U.S. Centers for Medicare & Medicaid Services, which annually conducts a hospital survey.
‘Altered health care altogether’
Even as more hands on deck would be helpful, among the reasons UIHC and others want to curtail temporary nurses is cost.
While the full-time average base salary for UIHC staff nurses is about $70,000 — a figure that varies depending on experience — travelers make more while also receiving benefits from their agencies. The average traveling nurse in Iowa makes $88,928, according to an Oct. 1 report from Nurse.org, a trade publication.
A majority of states report average annual traveling nurse pay over $90,000 — including six paying travelers an average over $100,000.
Iowa is tied for fourth lowest in staff nurse pay, with an average annual salary of $64,990 for registered nurses. That puts it nearly $20,000 below the national average of $82,750 and below most bordering states, like Minnesota’s $84,030.
UIHC uses seven “temporary nurse” agencies, according to payment data reviewed by The Gazette. It uses Aya Healthcare the most, paying that agency nearly $28 million in the just-completed budget year, compared with $4.2 million to the next closest agency.
The $28 million to Aya last year was more than four times the $6.6 million UIHC paid the agency in fiscal 2021 and more than nine times the about $3 million it paid Aya in fiscal 2020. Just a quarter into this budget year, UIHC has paid Aya $15.5 million — more than half last year’s total.
The onslaught of traveling nurse requests is a nationwide phenomenon, Aya Executive Vice President Chrystal Fugett said.
“We had hundreds and hundreds of hospitals coming to us. … One hospital said we need 2,000 nurses in a week,” Fugett said of her agency’s experience during the height of COVID-19. “To give you context, we were placing about 600 (nurses) a week all over the nation. So we had to do more than double that in just one location, while still helping all of our other hospitals nationwide.”
Most hospitals didn’t need 2,000 nurses, but rather 200, 100 or 50. They needed them urgently, though, bucking Aya’s norm of providing workers four weeks out.
“These hospitals are saying, half of our staff is sick, we do not have the patient ratios that we need to have, we’re not at a safe capacity, we need people here in a week,” she said. “So we had to figure out how to get through a lot of the red tape and how to be very thoughtful with getting people in there that were still qualified.”
Pre-pandemic, Aya had between 10,000 and 11,000 clinicians placed at any given time. At COVID-19’s peak, the agency had nearly 50,000 placed. Aya today has more than 45,000 working clinicians on assignment, and Fugett doesn’t expect that will fall back to pre-pandemic levels soon — if ever.
“I really do think that there were so many monumental things that happened during the pandemic that have altered health care altogether,” she said.
While the entire American workforce experienced a “turnover tsunami” during the pandemic, she said, “It was further exacerbated in health care because of those challenging working conditions.”
Health care workers experienced an amplified fear of their own mortality, saw unprecedented death and had to make excruciating decisions — while working 36 hours at a time, Fugett said.
“We’re talking a real wartime effort,” she said. “And so now we are seeing a ton of burnout where people are like, ‘You know what, I'm not leaving health care altogether, but I'm taking three months off.’ Or they take the whole summer off, and the hospital has to fill that position.”
Before COVID-19, according to Fugett, the concept of becoming a traveling nurse “was a puzzle piece that had to fit directly into their lives.” Having kids or a working spouse, for example, often made the prospect unreasonable.
Today, though, COVID-19 has expanded the jobs and schooling people can do remotely. More nurse spouses, for example, can continue doing their jobs from new communities — allowing families to increase their income while experiencing other parts of the country. That travelers can take off more time between assignments is a perk.
“It gives people this different type of fortified mental, emotional, and physical awareness and alertness that they need to go back and do the job two weeks later,” Fugett said.
Traveling nurses historically have made more than their staff counterparts — a reality the pandemic exacerbated. Aya recruiters found it hard to persuade nurses to go to high-risk places like New York, where they had to reuse their protective gear and work long hours to care for patients dying from a highly contractible virus.
“But it's always been true that travelers need a little bit more than staff just because of the fact that they have to go somewhere new every 13 weeks,” Fugett said.
The agencies provide benefits such as health insurance and 401Ks. And hospitals and providers typically pay the agencies a flat, hourly fee for the nurses — covering associated costs like background checks, drug screening, overtime pay, housing, transportation, parking and bonuses.
UIHC officials said agencies determine how much to pay the traveling nurses from that flat fee. The university recently extended its agency contracts through December 2023, but didn’t provide The Gazette with contracts showing whether rates have changed.
The Aya agency — like its nurses on the ground — has gotten used to the mixed messages and receptions they receive from hospital administrators who need them, but wish they didn’t.
As executives aired hopes to move away from using travelers, Fugett said, “We were on the phone with CEOs of hospitals that were in tears, saying we need help.”
‘My country needs me’
Although the money is nice, 52-year-old Wesley Fish, of Poplar Bluff, Mo., said he rejoined the traveling nurse ranks at the start of COVID-19 to help. Years earlier, he served as a Navy ship repairman and then in military law enforcement before pursuing a nursing degree when a friend suggested he become a different kind of first responder.
With a new nursing degree in 2013, Fish landed a staff job for four years before testing his traveler chops. That lasted a little over a year before he snagged another staff job closer to his seven kids and wife. And then COVID-19 hit, and his military roots motivated him to pack his bags.
“That’s when I said, I’m a vet, I served my country, and my country needs me again,” he said. “I have a skill set that they need desperately. And so I was back on the road traveling for COVID.”
Fish started in New Jersey in April 2020 for an eight-week stint, and then took several weeks off before heading to southern California for six months. “I’ve been working these crisis contracts,” he said.
Fish has served stints in St. Louis, Miami, Portland and then Iowa City — spending 13 weeks at the UIHC in the cardiovascular ICU, wrapping up his time at the end of June. He likes the service piece and that he gets to learn new skills and see new places.
“And, very honestly, the money — it makes it worth me leaving my family for three months to six months at a time,” he said. “As a travel nurse, we make two and a half to three times more than a staff nurse.”
Registered nurses nationally earn on average $39.78 an hour, according to the U.S. Bureau of Labor Statistics, which reports Iowa pays an average of $31.25 an hour.
“A travel nurse makes on average $80-plus an hour,” Fish said. “My average pay right now is about $3,500 a week.”
Though Fish expected animosity from staff nurses he joins for monthslong stretches, most have been welcoming — and, on occasion, so understanding they later join him on the “other side.”
“I can't tell you how many nurses I know that are staff nurses and talk to a few travel nurses and the next thing you know they're going to go travel, too,” Fish said.
MercyOne nurse Hayes said even she considered swapping her stable staff job for one taking her across the country — and might have made the move if she were younger.
But with fewer and fewer resources and more work, Hayes, like many of her peers, is facing the internal conflict of whether to stay.
“We’re just not getting any of that benefit of staying,” she said. “There’s no incentive.”
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