Hospitals around the U.S., including large academic medical centers like Vanderbilt University's in Nashville, Tenn., have been forced to rely on traveling nurses to keep their intensive care units fully staffed. The demand for travel nurses has driven up their hourly rates, which then motivates more staff nurses to leave in pursuit of a traveling gig. Blake Farmer/WPLN
Nearly two years into the coronavirus pandemic, there's some truth in a joke circulating among frustrated ICU nurses: They ask their hospitals to appropriately pay them for the hazards they've endured. And the nurses are rewarded with a pizza party instead.
That's what happened at Theresa Adams' hospital in Ohio. The facility across town was offering bonuses to keep its nurses from leaving. But not hers. They got ... a pizza party.
"I heard a lot of noise about 'Well, this is what you signed up for.' No, I did not sign up for this," she says of the unparalleled stress brought on by the pandemic.
Adams is an ICU nurse who helped build and staff COVID-19 units in one of Ohio's largest hospitals. She recently left for a lucrative stint of travel nursing in California.
Travel nurses take on temporary assignments in hospitals or other health care facilities that have staffing shortages. The contracts typically last a few months, and though the assignments pay more than staff positions, there can be trade-offs, such as predictable benefits or stable professional relationships.
Adams hopes to return to her home hospital eventually, though she's a little irritated at management at the moment.
"I did not sign up for the facility taking advantage of the fact that I have a calling," she says. "There is a difference between knowing my calling and knowing my worth."
In parts of the U.S. where hospitals are full of COVID-19 patients, the only thing keeping intensive care units fully staffed is a rotating cast of traveling nurses. And hospitals are having to pay them so much that those hospitals' staff nurses may be tempted to hit the road too.
A reckoning may be on its way as hospitals try to stabilize a worn-out workforce.
Reliance on travel nurses creates a vicious cycle of turnover
The use of traveling nurses took off in the 1980s in response to nursing shortages. Although they've always been paid more for their flexibility, some traveling ICU nurses can now pull in as much as $10,000 a week, which can be several times more than what staff nurses earn.
And while some hospitals have been offering retention bonuses and upping pay for staff nurses, they say it doesn't compare with the financial bonanza of traveling.
Some hospitals are facing a vicious cycle as nurses leave their staff jobs to make more money at other hospitals as traveling nurses. Training nurses in critical-care skills has become a fraught gamble, says Jonathan Emling, a nurse and the ECMO director at Ascension Saint Thomas in Nashville: "We will train these people, and then six months later they will be gone and traveling." Blake Farmer/WPLN News
But hospital managers now find themselves trapped in a vicious hiring cycle — especially for the most highly trained critical-care nurses who can monitor COVID-19 patients on the advanced life support machines known as ECMO, for extracorporeal membrane oxygenation.
"Our turnover for ECMO nurses is incredible, because they're the most seasoned nurses. And this is what all my colleagues are facing too," says Jonathan Emling, a nurse and the ECMO director at Ascension Saint Thomas in Nashville.
The shortage of ECMO nurses has prevented the hospital from admitting additional COVID-19 patients who need their blood oxygenated outside their body, he says. There are no more staff nurses with enough experience to start the training.
"We will train these people, and then six months later they will be gone and traveling," Emling says. "So it's hard to invest so much in them training-wise and time-wise to see them leave."
And when they leave, hospitals are often forced to fill the spot with a traveler.
"It's like a band-aid," says Dr. Iman Abuzeid, founder of a San Francisco-based nurse-recruiting company called Incredible Health. "We need it now, but it is temporary."
Hospitals try bonuses, perks and hiring outside U.S.
Incredible Health helps to quickly place permanent, full-time staff nurses in some of the country's largest health systems. On the company's platform, the number of listings that seek permanent, full-time nurses has shot up by 200% in the last year.
To help hospitals, some states are chipping in to help hire traveling nurses. But for many hospitals, the higher costs are straining their budgets, which is especially difficult for those that have suspended elective surgeries, through which hospitals make most of their money.
"Every executive we interact with is under pressure to reduce the number of traveler nurses on their teams, not just from a cost standpoint but also from a quality-of-care standpoint as well," Abuzeid says.
It's hard on morale as well: Team camaraderie suffers when the newcomers need help finding syringes or other medical supplies but may be earning two or three times more than the staff nurses showing them the ropes.
Some hospitals are proactively trying to stop the turnover. Some are offering big signing bonuses to permanent nurses, as well as loan forgiveness or tuition assistance for those getting further education. Hospitals have also hiked pay for nurses as they earn new certifications, especially in critical care.
Other medical centers are even looking outside the U.S. to fill their nursing needs.
Henry Ford Health System in Michigan announced plans to bring in hundreds of nurses from the Philippines. Smaller community hospitals are looking internationally too. Cookeville Regional Medical Center, in a Tennessee town of 33,000, is a city-owned hospital that is now recruiting its first nurses from overseas.
"The cost for what we pay for a local recruiter to bring us one full-time staff member is more expensive for what we're going to be spending to bring one foreign nurse," says Scott Lethi, the chief nursing officer at Cookeville Regional.
Lethi hopes the staffers from overseas will decide to stay more than a year or two. He says even new nurses can't be relied on not to leave or burn out: Cookeville hired a few recent graduates from U.S. nursing programs, but they quit after just a few months.
Nurses say high turnover increases burnout and affects patient care
Among ICU nurses of all ages, two-thirds have considered leaving the profession entirely because of the pandemic, according to a survey published in September by the American Association of Critical-Care Nurses.
When a nurse leaves — whether to retire, work as a travel nurse or leave the profession — the remaining nurses can be stretched dangerously thin, caring for more patients at once. COVID-19 patients are particularly demanding, especially those on ventilators or ECMO machines who may require one-on-one care around the clock. COVID-19 patients may also be hospitalized for weeks or even months.
"My ability to care for people has suffered. I know that I have missed things otherwise I would not have missed had I had the time to spend," says Kevin Cho Tipton, an advanced practice nurse in the South Florida public health system. "Many of us feel like we're becoming worse at our jobs."
The worry about providing substandard care weighs heavily on nurses. But in the end, Tipton says, it's the patients who suffer.
This story was produced in partnership with Kaiser Health News (KHN) and Nashville Public Radio.
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