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Special Report: Temporary Nurses Bad for Quality? Not So, Studies Find

Sorelle, Ruth MPH

doi: 10.1097/01.EEM.0000475556.32988.01
Special Report
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Like waves in the ocean, the pool of available registered nurses worldwide fluctuates, sometimes overflowing and sometimes withdrawing. That ebb and flow in hospitals is largely managed with “temporary” nurses who fill roles left vacant when nurses resign or retire and when new programs require more nursing power than currently exists.

An estimated 88,495 (3.4%) registered nurses occupy so-called “temp” positions, most of them employed through temporary agencies in hospital settings, according to the most recent survey from the U.S. Department of Health and Human Services. (“The Registered Nurse Population,” September 2010; http://1.usa.gov/1jZn942.) Other studies have estimated the percentages even higher. Some have principal employment through temporary services, and an estimated one percent have a principal full-time nursing position but also work part-time as a temp. Still others are travel nurses, whose contracts can result in spending their time at the same job for anywhere from three months to one year.

AnnMarie Papa, DNP, RN, CEN, the vice president and chief nursing officer at Einstein Medical Center Montgomery in East Norriton, PA, and a past president of the Emergency Nurses Association, said the organization takes no position on the use of temporary nurses in the emergency department. “Our question is, ‘Do they have the credentials and experience needed for the population they are serving?’ You cannot put a community emergency nurse in a trauma unit. Sometimes you cannot put a trauma unit nurse in a rural hospital where they don't understand the community or the institution.”

Not all nurses are what they advertise, she said, but these are exceptions. “I think what's most important from my perspective is that people do their due diligence. Make sure that you have checked their competency and skillset. Verify and validate. Maybe I say I can assist with trauma or chest tube insertion. You ask me what to do.”

One set of experts found — before controlling for multiple nurse characteristics — higher proportions of agency-employed supplemental registered nurses appeared to be associated with higher mortality (odds ratio = 1.06) and failure to rescue (OR=1.05). (Health Serv Res 2013;48[3]:931.) The authors noted that hospitals with higher ratios of supplemental registered nurses tend to have poorer work environments, and mortality outcomes were insignificant when that was taken into account.

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The Cost Myth

Linda Aitken, PhD, RN, the Claire M. Fagin Leadership Professor in Nursing and the director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Philadelphia, led the study that analyzed cross-sectional data from California, Florida, New Jersey, and Pennsylvania to determine the effect of hospital-level employment of supplemental registered nurses and general patient outcomes before and after taking into account other hospital characteristics.

“It doesn't cost any more to use them moderately than to hire people, bringing them on staff. There are a lot of myths in health care. One is the myth that temporary nurses are bad for quality. That is really not true. We have not found that at any level,” she said.

Dr. Aitken said temporary nurses are actually travel nurses who have contracts that last three to six months or even longer. “They are very experienced, often more experienced than the average nurse. They are older and have worked in different kinds of hospitals. They are not coming into the hospital for the day, she said. “More than half of the nurses working for an agency are also working full time for a hospital as well — and often the same hospital. The world has changed, and nursing schools have doubled their output. Now there is a problem with nurses getting employment. Hospitals now would be loath to bring in someone for one day whom they did know. There is a huge investment in orientation. The pattern of use is for longer periods.”

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The image of the unskilled temporary nurse was buttressed in 2009 when the Los Angeles Times and the investigative group ProPublica published an exposé of the practices of temporary agencies, finding that they skimp on background checks and “become a haven for nurses who hopscotch from place to place to avoid the consequences of their misconduct.” (ProPublica Dec 5, 2009; http://bit.ly/1jsWbRA.)

“Failings in the temp industry are magnified in states like California, where nurses are in particularly short supply,” the report said, citing that nearly six percent of California nurses are temps. A Johns Hopkins study found that medication errors by temporary workers were more likely to reach the patient, resulting in temporary or even life-threatening harm. (J Healthc Qual 2011;33[4]:9.)

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A Sea Change

But Dr. Papa said hospitals must embrace supplemental nurses and give them the same consideration and training they would offer permanent staff. Dr. Aitken agreed, noting that supplemental nurses are a good way for hospitals to ensure that they have enough nurses without overspending on human resources. “There is a huge sea change in who can be a nurse in a hospital,” she said. “It is hard for the brand-new nurse. The health care organizations are leery of new people. More and more of them require a full-year residency.

“The myth persists because of people who are not involved in the day-to-day aspects of hospitals. Now nurses are involved in hiring and who is working at their hospitals. It is different from decades ago when human resources was doing the hiring,” she said. “There is no adverse impact we can measure in big studies in hundreds of hospitals. Our results show that the outcomes are better than they would be without the supplemental nurses. If they had not been there, the mortality rate would have been higher.”

A group of researchers led by Ying Xue, DNSc, RN, of the University of Rochester School of Nursing in New York, found that the use of agency-employed supplemental nurses on 19 patient care units in a large academic medical center were cost efficient when used moderately but not when there was heavy reliance on them, according to the study published in Journal of Nursing Care Quality. (2015;30[2]:130; http://bit.ly/1N9ld2u.)

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Use of Supplemental RNs

The use of supplemental nurses ranged between 0 and 56 percent in 2005-2006, with 60 percent of hospitals employing more than five percent supplemental nurses, according to the study. Dr. Ying said the use of supplemental nurses rises and falls, with those in academic settings having good experience and qualifications that match the units on which they work. “Some nurse managers are actually complimentary of supplemental nurses because they have varied experience working with other hospital systems. They bring in a lot of quality and make suggestions for quality improvement,” she said. “On the negative side, there are some scenarios where supplemental nurses do not function well. The question to ask is, ‘What is the validating process?’ Each hospital has its own recruitment process so they have different criteria they use to determine qualifications.”

A KPMG study found that 90 percent full-time employed nurses to 10 percent supplemental nurses was an ideal ratio. (“KPMG's 2011 U.S. Hospital Nursing Labor Costs Study,” 2011; http://bit.ly/1PCz2tx.) Another study put the upper limit of supplemental nurses at 15 percent. (Health Care Manage Rev 2010;35[4]:333.)

“Ideally, you staff for what the facility needs,” said Dr. Papa. “For example, a hospital in a small beach town might find that nothing is going on during the winter and that the census triples in the summer. Many of the nurses leave for the winter and are paid part-time to work in the summer. Have some travel nurses come in.

“There is no [other] choice. An absolute panacea — nirvana — would be to have every nursing position filled. The team is always there, including every nurse you need. But life is not like that. Nurses get sick. They have days off. Patients have different needs. How do you manage that?”

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