Quality and cost of travel nursing: Real-world studies refute common misconceptions

A common perception in the healthcare industry is that travel nurses’ quality of care is lower than staff nurses, while their costs are higher. This belief persists despite a growing body of research showing that it is inaccurate.

Why is it important to clarify the cost and quality of Travel Nurses?
Travel nursing is a fast-growing option for healthcare organizations, particularly due to the growing shortage of nurses overall. Growth in travel nursing was projected at 7% for 2018, which is slower than the torrid growth of recent years but still at a record high in terms of market size, according to Staffing Industry Analysts. Continued high demand for nurses, particularly experienced and specialty nurses, is expected to sustain growth in utilization of travel nurses at healthcare facilities for the foreseeable future.

Considering that patient-care quality and cost-containment are the top priorities in the healthcare industry, an accurate understanding of the quality and cost of travel nurses could be valuable to clinical and executive leaders at healthcare organizations.

Evidence on Supplemental Nurses
• Survey data from 40,356 registered nurses at 665 hospitals and inpatient mortality data for approximately 1.3 million patients was examined among supplemental nurses and staff nurses in a 2013 study of fail-to-rescue events. It concluded that higher use of supplemental nurses does not affect patient mortality “and may alleviate nurse staffing problems that could produce higher mortality.”

• A 2011 study on quality issues of supplemental nurse staffing in the United Kingdom, using data gathered from hospital throughout the country, found that overall quality scores were no different between units that employed only permanent staff and units that employed both permanent and supplemental staff.

• On average, supplemental nurses and permanent nurses have similar levels of education and experience, according to a 2012 study. The supplemental workforce is more racially and ethnically diverse. The study concluded that supplemental nurses can help meet the challenges of an aging nurse workforce, continued nurse shortages, and an increasingly diverse patient population.

• Employment of supplemental nurses does not detract from patient satisfaction, according to a 2015 study of survey data from 427 hospitals. It determined that the use of supplemental nurses “is safe and satisfactory to patients...”

• A 2017 survey of 100 senior hospital executives from across the country found that the hourly cost of a full-time, permanent nurses is approximately $6 more than a travel nurse.

• A 2015 study of patient-care units in a large academic medical center found no statistical difference between the hourly cost of supplemental nurses and overtime pay for permanent nurses. The study concluded that use of overtime by permanent nurses “might not be a cost-effective strategy compared with supplemental nurse use.”

Single-Hospital Studies on Travel Nurses
Most research reports on these topics are based on analysis of large data sets covering numerous hospitals or are nationwide surveys of nurses or healthcare leaders. Some cover the entire range of supplemental nurses, but until now, none have studied travel nurses at a specific hospital.

Two single-hospital travel nurse studies, comparing quality and cost in specific patient care units with changing levels of travel nurses, are based on data extracted from 2013 to 2015 from patient-care units at a moderately large community hospital in a fast-growing region of the southern United States.

• Quality of Travel Nurses
• As travel nurse coverage fluctuated in five units over the two-year period, there were no significant differences in the quality of patient care in 55 of 60 quarterly tests of HCAHPS scores and NDNQI.

• In the five tests where significant differences were shown, there were no consistent patterns to demonstrate a relationship between changing travel nurse coverage and HCAHPS and NDNQI scores.

• Cost of Travel Nurses
o Employer costs paid by the healthcare organization were included with the staff nurse payroll data, resulting in full staff nurse costs comprised of pay, benefits, Medicare taxes and Social Security taxes. The applied benefit and tax load for this hospital was 27.28%. For travel nurses, these additional costs are entirely covered by agencies.

o Full-cost staff overtime costs were higher in three of the four units when compared to travel nursing bill rates. In two units, staff costs were nearly 10% higher. In one unit, travel nursing bill rates were higher.

Conclusion
A significant and growing body of research, ranging from analyses of national datasets to studies of patient-care units at a single hospital, establishes that the quality and costs of supplemental nurses, including travel nurses, are equivalent to staff nurses. Healthcare leaders and managers should reconsider past assumptions about the quality and costs of travel nurses in strategic staff planning and when filling staffing gaps.

References:

Karp, M.; Gregoire, T. (2018). US Healthcare Staffing Market Assessment. Staffing Industry Analysts. Crain Communications, Inc.
Aiken, L. H., Shang, J., Xue, Y., & Sloane, D. M. (2013). Hospital Use of Agency-Employed Supplemental Nurses and Patient Mortality and Failure to Rescue. Health Services Research, 931-948.
Hurst, K., & Smith, A. (2011). Temporary nursing staff – cost and quality issues. Journal of Advanced Nursing, 287–296.
Xue, Y.; Smith, J.; Freund, D., Aiken, L. (2012) Supplemental Nurses Are Just As Educated, Slightly Less Experienced, And More Diverse Compared To Permanent Nurses. Health Affairs, Vol. 31, No. 11.
Lasater, K.; Sloane, D.; Aiken, L. (2015). Hospital Employment of Supplemental Registered Nurses and Patients’ Satisfaction With Care. Journal of Nursing Administration, 2015 Mar; 45(3): 145–151.
Gregg, T.; Hottle, R.; Lo, A.; Elmblad, D. (2017). KPMG’s 2017 U.S. Hospital Nursing Labor Costs Study. KPMG LLP.
Xue, Y.; Chappel, A.; Freund, D.; Aiken, L.; Noyes, K. (2015). Cost Outcomes of Supplemental Nurse Staffing in a Large Medical Center. Journal of Nursing Care Quality, Volume 30 - Issue 2, p 130–137.
Faller, M.; Dent, B.; Gogek, J. (2017). A Single-Hospital Study of Travel Nurses and Quality: What Is Their Impact on the Patient Experience? Nurse Leader, Volume 15, Issue 4, August 2017.
Faller, M.; Dent, B.; Gogek, J. (2018). The ROI of Travel Nursing: A Full-Cost Comparison of Core Staff Pay Rates to Travel Nurse Bill Rates. Nursing Economic$, Volume 36, Number 4,July/August 2018.

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