A Traveler's Tale: Nursing shortage boosts demand for "gypsy" nurses
By Rebecca Vesely - STAFF WRITER
Sunday, July 06, 2003 -
It seems like a dream job.
Free luxury housing. Guaranteed overtime. Car allowances. $2,500 bonuses. Six months in Hawaii.
Plus, they're saving lives.
A relatively new breed of nurse has emerged out of the sustained national nursing shortage: the ``traveler.'' Travelers jump from city to city, working in hospitals that don't have enough staff nurses to meet patient demand. They contract through national staffing agencies for one month to 13 weeks per job. Essentially, they're the temp workers of the medical profession.
The Bay Area is a popular destination for travelers for the same reasons tourists love coming here. Even better, traveler pay in the Bay Area is the highest in the country. Local hospitals spend as much as $80 an hour per nurse to staffing agencies specializing in traveling nurses. And the nurses get a cut of between $35 and $50 an hour, plus guaranteed time-and-a-half for a portion of each shift and completion bonuses in the thousands of dollars for just a few months of work.
On the surface, it's a win-win. Hospitals in California, which ranks 49 out of 50 states in its share of registered nurses, need qualified, experienced health care workers. But underneath there's a quiet debate going on in Bay Area hospitals over travelers.
Critics - ranging from local staff nurses to national experts on the subject - contend that travelers contribute to nurse burnout instead of alleviating it because of the constant turnover. They also say travelers compromise patient care.
The steep fees commanded by agencies that supply travelers can add up to millions each year for hospitals. This, in particular, is causing Kaiser Permanente to phase them out this summer. And Alameda County Medical Center, which includes Highland and Fairmont hospitals, hired a nurse recruiter this spring to lure more permanent nursing staff so it could ween itself off the high-priced travelers.
Demand for travelers remains steady at Bay Area hospitals, though, and could increase in January of next year - when California becomes the first state to mandate nurse-to-patient ratios. On Tuesday, the state released its revised list of the maximum number patients that can be assigned to each nurse on duty. In response, the California Healthcare Association, representing hospitals in the state, said that hospitals would be forced to hire more travelers to meet the ratios.
That's great news for nurses longing for the open road. The perks don't hurt, either. ``We call it the fishbowl,'' said Debbie Jacobs, a 29-year-old nurse from Denver who is on assignment at Children's Hospital in Oakland, describing her free accommodations - a two-bedroom apartment in San Francisco's South Park, near Pac Bell Park, she shares with another traveler.
``It has 360 degree views of the Bay.''
Another traveler at Children's Hospital, Marijane Holjes, 26, from Harrisburg, Pa., explains her digs on Post Street in San Francisco in two quick words, ``It's awesome.''
Kurt Smudzinski, 26, a traveling nurse from Long Island now at Alta Bates Summit, has spent the past four years on the road. When he wasn't caring for patients, he was snowboarding in Boulder, Colo., laying on the beach in San Diego, and surfing in Hawaii. He owns three surfboards, at about $600 a pop.
``First I wanted to live in the mountains, then near the ocean,'' he said with a grin. The cream, or the concern of nursing?
For these nurses, and about 25,000 others like them nationwide, traveling has staved off the pitfalls for their chosen profession - burnout, repetition and mounting paperwork.
Of the six travelers interviewed at various area hospitals, most said they would have left the nursing profession by now, but travel has given them freedom, money and the opportunity to care for people without getting caught up in the administrative hassles that are part and parcel of the modern health care system.
``They represent the cream of nursing,'' said Nancy Shibata, director of nursing at Children's Hospital in Oakland, which employed 30 travelers this winter to meet the seasonal spike in patients. ``They are like sponges. They soak up information and then take it onto the next job.''
There's the rub. Travelers take their experience with them when they leave - and staff nurses are left to train yet another nurse who's just landed on their doorstep, so the complaint goes.
``Travelers aren't oriented to the facility and so they are a lot slower and they don't have the focus to be part of the team,'' said Regina Harrison, a nurse at Kaiser Permanente's Oakland Medical Center, echoing a common sentiment. ``More nurses are injured because they are lifting patients and moving them by themselves because travelers won't help.''
National surveys support this notion that high numbers of travelers compromise nurses - and patients.
Nancy Aiken is a leading researcher in nurse safety and burnout who directs the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing. In her research, she has found that needle stick injuries to staff and patients go up when permanent staff goes down, and the higher numbers of temporary staff affects patient outcome as well.
``Our primary concern about travelers is they don't know hospital staff and procedures,'' Aiken said. ``There's nothing wrong with the nurses themselves. Safety concerns have to do with nature of hospital care - it's so intensive and so fast-paced, that you need cohesion and a good relationship among the staff.''
Jan Rodolfo, an oncology nurse at Summit Hospital, said so many travelers are at Summit that working on a shift without them is ``a luxury,'' and high turnover is compromising patient safety. She said it is not unusual to go into a room where a traveler is on shift and find that basic things have not been taken care of, like changing IV sites to avoid infections and bathing patients.
``I have seen an increase in medical errors and medications missed - these errors are concentrated with the travelers,'' Rodolfo said. ``They are not being oriented properly. A number of them do an admirable job, but it is not an ideal situation.''
Nevertheless, the travelers interviewed for this article were trained at some of the leading hospitals in the country before they hit the road. Holjes, the one with the awesome apartment, spent several years as an ICU nurse at Children's Hospital of Philadelphia, one of the leading pediatric centers in the country. Smudzinski, the surfer, was at New York University Hospital before he started traveling. And 45-year-old Leslie Huff, a nurse at Summit Hospital, spent 13 years learning her craft in Austin, Texas.
Nurse managers and experts on travelers agree that the problem doesn't lie with the individual nurses, but rather the system.
``When it's not your own staff, maybe they (travelers) aren't as interested in customer service,'' said Viki Ardito, director of nursing at Alta Bates Summit, which employs 160 travelers out of a nursing staff of about 1,000. ``And teamwork is affected when you have turnover. ''
Staff nurses interviewed for this article said that complaints have been filed at their respective hospitals about travelers. But managers at Alta Bates Summit, Children's and Kaiser Permanente all said they had not heard of any concerns. Nurses at Children's Hospital in Oakland had suggested the hospital create a permanent position whose main task would be to orient travelers, but the idea was rejected because of costs. ''Endless questions''
On a recent spring morning at the cardiac care unit at Summit Hospital in Oakland, no bed was empty.
Patients here are admitted in the morning, usually for non-invasive heart surgery, like clearing a blocked artery. They are monitored overnight and released the next day. This unit opened in January as part of Summit's highly regarded cardiac surgery department - among the top 50 in the nation - and serves patients from all over the Bay Area. Ten patients have surgery every day here, adding up to about 3,000 by year-end.
On this particular shift, 14 patients shared four nurses - all travelers.
Nancy Brosnan, the critical care nurse manager who has 26 years experience, said travelers help with hospital flexibility, and that she carefully screens all the nurses who do a tour through here.
``I spend a lot of time making sure the new people understand the unit,'' Brosnan said.
Some of the travelers on shift this morning have been here a while. Smudzinski is one of them, and he has been ``traveling'' here since last November, so is well oriented to the facility.
Travelers typically get one day of orientation. During that first shift, they do their paperwork, get their ID cards, and are teamed up with a staff nurse, who shows the traveler the ropes on the first day. The next time the new traveler comes on a shift, they are usually assigned their own patients. Nurse managers said that travelers are used to moving around so they adapt quickly. Staff nurses said one day of orientation is not enough. Martha Kuhl, 51, who has worked as a nurse at Children's Oakland for 21 years and is a specialist in pediatric oncology, said it is up to staff to constantly train the travelers in everything from where to find equipment to how much of an unfamiliar medication to give a child.
``It's endless questions,'' Kuhl said. ``It's `Where do I find this?' And `How do you do that?'''
Holjes, the ICU traveler at Children's Oakland, agrees that orientation is an issue. ``Half the problem with being a traveler is not knowing where things are, who you need to talk to and what the protocols are,'' she said. ``Every hospital has different ventilators and monitors.''
Kuhl said she would never assign a very sick patient to a traveler for this reason. ``So the outcome is that a nurse like me who is an expert on a unit gets all the tough assignments,'' she said.
But travelers said that once their colleagues know that they can handle the most difficult patients, they are willing to hand them off to them. It is a matter of building trust quickly.
Travelers - often from the Southern states where nurse salaries are particularly low - typically must be trained on how to interact with the diverse needs of Bay Area patients.
Two staff nurses at separate hospitals cited the example of immigrant patients from China. Most Bay Area nurses know never to offer a Chinese patient something cold to drink or eat after surgery. In Chinese culture, only warm food or drink is considered tolerable to the human bodyMDBO MDNMwhen sick. A nurse who doesn't know this will offer something cold to a Cantonese-speaking patient, for instance, and the patient will refuse.
The nurse will then write in the patient's chart that the patient is not eating, and the patient will go without a meal, compromising their recovery, staff nurses said.
Charity McGriff, a 29-year-old traveling nurse from Birmingham, Ala., said she enjoys the diversity, and wants to know more. ``I had never taken care of a Cantonese patient before,'' she said. ``Now I am learning some Cantonese words, like the word for pain.''
It's the not knowing, though, staff nurses said, that creates a difficult situation for everyone - especially patients.
``We discover that a nurse isn't up to the task only after a mistake has been made, instead of being able to gauge the experience level of each nurse before mistakes,'' Rodolfo of Summit Hospital said, adding, ``I don't like the conditions we encounter daily. You need travelers, but the high numbers of them contribute to chaos on the floor.''
Another familiar complaint among staff is the amount of hours travelers work. To sweeten the deal, travelers are guaranteed 12-hour shifts every time they work, while staff nurses work eight-hour shifts. Travelers like the longer shifts because they get guaranteed overtime and can typically work three days in a row and then get four days off to sightsee around the Bay Area.
Staff nurses complain that the discrepencies between staff and traveler work schedules leave too many travelers and not enough staff on the floor during those four hours that travelers stay on and staff go home. So, for instance, staff nurses will work an eight-hour shift of 7 a.m. to 3 p.m., while travelers will work a longer shift of 7 a.m. to 7 p.m.
``You have a nightmare between three and seven,'' said Ardito, the nursing director at Alta Bates Summit. ``We try to get staff to match up as much as possible. Every day is a juggling act.''
Harrison of Kaiser Oakland said the 12-hour shifts can be tough on any nurse, but especially those who are learning a new facility. ``At the end of their shifts, they are wiped out.'' The hidden costs of travelers
Can consistent quality patient care be assured with temporary nurses?
Kaiser Permanente doesn't seem to think so. Kaiser employs about 500 travelers in its California hospitals - including Oakland, Walnut Creek and Vallejo - but management plans to phase out all of them by summer's end.
Despite state mandated nurse-to-patient ratios scheduled to go into effect in January, based on legislation passed in 1999, Kaiser said the high costs of travelers, combined with concerns about patient care, are putting an end to the practice.
``When you have travelers there is a lack of continuity of care,'' said Marylin Chow, vice president of patient care services at Kaiser Permanente of Northern California.
Hard numbers on how much travelers cost hospitals are hard to pin down. Hospitals nationwide spent an estimated $71 million on travelers in 2001, according to a study by First Consulting Group, a research firm. Of those hospitals that employ travelers, about 76 percent pay travelers more than 20 percent over what they pay regular staff, according to the study. Local nurse directors said travelers cost the same as staff because they don't pay their health benefits, vacation time and worker's compensation costs - the staffing agencies cover these expenses.
Alta Bates Summit and Children's Oakland would not release figures on how much they spend on travelers. Kaiser Permanente spent at least several million last year on travelers, Chow said - a major reason why they are phasing them out. The Alameda County Medical Center spent $1.3 million last fiscal year on non-permanent staff, including about 40 travelers, a spokeswoman said.
Full-time staffers at Highland Hospital are critical of the use of high-priced travelers - especially at a time when it is closing outpatient clinics and considering slashing more services to meet a $45.7 million budget deficit.
``I don't understand why you would provide double the wage for someone who doesn't have double the experience,'' Dolores Flanagan, a nurse at Highland, told Medical Center CEO Kenneth Cohen at a budget hearing in late June, to thunderous applause from her collegues. Nursing expert Aiken said that hospitals fail to account for costs to replace staff nurses because of burnout created, in part, by the traveler system. For every staff nurse who quits, hospitals must pay about $45,000 to recruit a replacement, and up to $65,000 to replace a specialty nurse.
Some travelers renew their contracts for a year or more - reaping the benefits of free housing and automatic overtime. Indeed, several staffing agencies said opportunities are fewer at Bay Area hospitals this year in part because travelers keep renewing their contracts, or they decide to stay on as permanent staff.
Taking a permanent staff job does have its advantages.
Kurt Smudzinski accepted a staff job at Summit Hospital this spring because he wants to improve his skills. ``When you are a traveler no one will teach you new things,'' he said. ``Like invasive cardiac procedures, they won't give that work to travelers.'' Traveling certainly isn't a cure all for the health care profession - or even for travelers themselves. While the opportunity to see the most beautiful cities in America has been grand, many travelers will ultimately leave nursing. Charity McGriff, from Alabama, is considering law school. Debbie Jacobs, with the 360-degree view, wants something ``more 9 to 5.'' Holjes is saving money in case she wants to go back to school.
Smudzinski complains though he isn't even 30 years old, he already has chronic back pain. He's considering taking classes to become a nurse anesthetist.
First, however, he may have do a bit more traveling, he said. ``I would like to go back to Hawaii.''
Contact Rebecca Vesely at firstname.lastname@example.org