Reliance on 'traveling' nurses soars at University of Iowa

Use of contractors to cope with nursing shortage comes with costs

Annmarie Carter, who has worked for 20 years as a staff nurse at the University of Iowa Hospitals and Clinics, said she
Annmarie Carter, who has worked for 20 years as a staff nurse at the University of Iowa Hospitals and Clinics, said she has no plans to become a traveling nurse, but can see the appeal some of her colleagues do. “We are losing some great experience because they’re figuring out, ‘Hey I can make a lot more money on the outside,’” she said. Carter stands outside the hospital Friday. (Rebecca F. Miller/The Gazette)

IOWA CITY — Facing a national nursing shortage that’s particularly taxing for the state’s largest hospital system, the growing University of Iowa Hospitals and Clinics increasingly is relying on “traveling nurses” to fill the gaps — paying a premium that can be double or more of what a staff nurse earns.

Their use can swell hospital costs, affect morale and propel turnover, aggravating the very nurse recruitment and retention problem that’s driving the increasing need for travelers.

“Sometimes you’ll see a traveler that’s maybe from an institution that doesn’t see the acuity that the U does, and so it’s a nurse that’s not necessarily prepared for the role that she is filling,” said Alexis Carson, who’s been a UIHC staff nurse for more than four years but is leaving next month for a better-paying traveling gig.

“That can definitely cause some negative feelings — regarding the fact that you know this person that you’re having to carry for 12 hours at a time is making more than you,” Carson, 27, said. “That can be very frustrating.”

Since the 2014 budget year, UIHC’s use of traveling nurses has soared from the full-time equivalent of nine to 216 currently, according to documents obtained by The Gazette.

The university currently employs 2,648 staff registered nurses, meaning travelers account for about 8 percent of its nurse workforce.

With many of the university’s travelers earning a starting hourly rate of $59, the university could spend more than $26 million a year on the contractors — if 216 work the standard 2,080 hours a year. Several of the university’s recent contracts with traveling nurse agencies pay far more, showing rates up to $110 an hour, according to those documents.


At the same time, the minimum starting salary for an inpatient staff nurse is $54,679 — not including additional premium pay and other differentials. That equates to $26.29 an hour, based on 2,080 work hours a year. The average total base compensation for a staff nurse — including benefits — is $89,865, or about $43.20 an hour, still below base pay for travelers.

Ken Fisher, then UIHC’s chief financial officer, reported the university’s rise in traveling nurse use to the Board of Regents earlier this month, noting the hospital is having “great difficulty” recruiting all the staff nurses it needs.

“That comes at a premium, which is probably twice — at best — the cost of hiring a full-time nurse in our organization,” said Fischer, who has since retired. “It adds about $1.5 million a month in incremental operating costs, and that’s been the truth since the beginning of this current fiscal year.”

Recruitment and retention

The UIHC nurse shortage is hardly unique. U.S. Bureau of Labor Statistics project 1.09 million registered nurse job openings by 2024, UI officials point out.

Compounding the university’s need for more nurses was its recent opening of the new $360 million, 14-floor Stead Family Children’s Hospital, which added 134 patient beds.

UIHC said that “maintaining appropriate staffing levels for nurses is critical for providing excellent care to our patients, which is why UI Health Care has an ongoing robust recruitment effort.”

This year, the university has added social media, digital advertisement and job fairs to its nurse recruiting toolbox. Since January, UIHC has filled 733 “nursing and related positions.”

Compared with the national nurse vacancy rate topping 10 percent, UIHC’s is lower — about 8.35 percent. The university also reports improvement in key patient care areas, such as adult critical care medicine, where the rate has been cut in half since March 1, and UI adult medical surgical services, which has seen a decrease in its vacancy rate of 35 percent.


In terms of retention, the university — despite being locked in litigation over a new contract with its nurses’ union — plans on giving all staff nurses a 2 percent base salary raise effective July 1, according to UI Health Care spokeswoman Jennifer Brown.

Additionally, all inpatient staff nurses will get another $1,500 — meaning, essentially, they’re in line for a greater than 4 percent increase.

UI Health Care is self-supporting, meaning its budget is not dependent on state appropriations.

‘We need more faculty’

Entangled with the national nurse shortage — and contributing to it — is the struggle to educate and train new nurses.

The UI College of Nursing is on the front line of that battle, as it vies for top faculty in hopes of upping its capacity for students.

“People would think, ‘Well, why don’t you just admit more people?’” said Anita Stineman, a registered nurse, associate professor and UI interim associate dean for academic affairs. “For us, that has a trickle effect. Because what happens when we admit more students, we need more faculty. And that’s how the nursing shortage hits us — is in faculty.”

The university also is bound by Iowa Board of Nursing regulations that limit ratios for clinical experiences. Thus the university admits only 72 undergraduate students to its bachelor of science in nursing program in both the fall and the spring.

“That’s really the maximum that our clinical facilities can meet,” Stineman said. “We can only admit enough students that we can cover the full range of clinical experiences for them.”

Behind the university’s struggle to bolster its nursing faculty are budget constraints. The largest percentage of the College of Nursing budget goes toward faculty salaries and “we don’t have a bottomless pit,” Stineman said.


The university has made some progress. In the last four years, the college has received 161 nursing faculty applications, 67 of whom interviewed for jobs. The university made offers to 50, and 40 new nursing faculty accepted.

But the university has four distinguished scholar positions — made possible through an endowment — that have never been filled.

“We have been recruiting for two years to fill those positions,” Stineman said. “One of the things that inhibits us is huge competition nationally for senior faculty.”

Negotiations over pay can stymie potential hires. “One of the reasons that people sometimes decline coming to Iowa is that other schools can offer them a higher salary,” she said.

With about 40 percent of the university’s 53 full-time nursing faculty at retirement age, Stineman said, she expects the challenges to continue.

“We know in the next few years we’re going to be losing a lot of years of experience,” she said. “It would be nice to say we are hiring on new junior faculty to replace the senior … but with budgetary moneys the way they are, we don’t have the funds to be able to do that.”

UI President Bruce Harreld has been pushing to improve faculty pay, and he announced last week the university is committing nearly $5 million toward that goal. The College of Nursing is getting $149,583 of that chunk, which Stineman said her college will use to boost existing faculty pay and recruit.

‘They are making double’

Although Carson, the UI nurse about to embark as a traveler, has enjoyed her time at Iowa, she has aspirations to pursue a graduate degree and become a nurse practitioner. And she can’t afford to do that.


“It’s super expensive, so I’m planning to travel for probably a 1.5 to 2 years and try to save up as much money as possible,” she said. “That way, hopefully, when I’m kind of hitting the number I need to be at, I can come back.”

Carson’s last day here is July 4. She starts her first travel assignment July 20 in Maine. Because she’s not tied down, Carson said this also allows her the chance to see the country. But, she stressed, her decision is “absolutely financial.”

Annemarie Carter, 52, said she’s not in a place in life that allows her to travel — but she sees the appeal.

“They are making double, and one of the things that’s happened to our unit is because we’ve had all these travelers, and people have inquired, we are losing permanent staff to traveling,” she said. “We are losing some great experience because they’re figuring out, ‘Hey I can make a lot more money on the outside.’”

On the inside, Carter said, she and many of her colleagues often are thankful for travelers — in that they’re another set of hands to help care for a constant flow of patients.

“I think we’re just grateful to have safe staffing levels,” Carter said. “But I think the hospital needs to be careful who they hire because we are such a high level facility.”

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