Working dangerously short-staffed, many ED leaders are turning to travel nurses to solve the problem. “While it varies greatly across systems and geographies, we hear reports that fully half of the nurse staff are travel nurses in some EDs. We also hear that up to half of the open nursing positions are unfilled. I don’t think anybody has got a finger on just how acute the situation is,” observes Alan Lembitz, MD, chief medical officer at COPIC, a Denver-based medical professional liability insurance provider.
So far, there is no comparable shortage of EPs. “Physicians are paid more, are under contracts that are difficult to move from, and tend not to travel. But if that same thing that starts to happen where we start to have serious physician shortages in EDs, that would create additional challenges. I haven’t seen that,” Lembitz reports.
However, nursing shortages are acute, fueled in part by surging wages for travel ED nurses. “We are seeing people who are happy in their roles in a certain system. But if they can travel a short distance and get paid twice as much, that can be a strong incentive,” Lembitz says.
Unfortunately, travel nurses will not know the nuances of the EDs in which they are working. This hinders teamwork and communication. “It is an enormous aspect, in terms of burnout and in terms of quality of care,” Lembitz says. “Working with people you know who can anticipate what you want is a big deal for reducing your stress level.”
Thus, staffing EDs with travel nurses carries some potential risk management implications. It might take travel nurses more time to access resources, manage medications, and set up procedures. “We don’t know how these issues will play out in subsequent liability claims, but reduced communication, teamwork, and the appearance of not knowing where things are can make fertile ground for plaintiff attorneys to assert claims of substandard care,” Lembitz says.
It is not negligent for hospitals to staff EDs with whatever resources are available. “But failure to do so, and reaching critically low staffing ratios, generates long wait times and reduced patient experiences,” Lembitz warns.
When EPs and ED nurses work together regularly, there is a lot of unspoken communication. “Working with travel ED nurses reinforces the need for closed-loop communication,” Lembitz says. “EPs can prevent communication mishaps by routinely and politely asking ED nurses to repeat orders, directions, and patient care instructions back.”
A related concern is providers will vent frustration in the chart. “Those finger-pointing, opinion-based notes do not improve the defensibility of the physicians, the ED, or the hospital,” Lembitz says.
It can take years for EPs to know and trust their nursing partners. “A consistency in nurse staffing ensures open communication and confidence in nursing staff. Traveling nurses can cause a higher stress level for ED physicians,” says Susan Martin, Esq., executive vice president of litigation management and loss control in the Plano, TX, office of AMS Management Group, a medical professional liability insurer.
On the positive side, traveling nurses usually have experience, and can keep the hospital in compliance with nurse staffing ratios. However, in terms of liability, says Martin, “it can be a more risky decision. Traveling nurses, by definition, are temporary and more of a revolving door.”
If deposition testimony reveals the traveling nurse was a novice, was unaware of procedures, or could not respond promptly to a patient’s critical needs, “the hospital will bear this responsibility,” Martin warns.
In a fast-track setting, directing travel nurses to evaluate patients may not be as critical. “But with acutely ill patients, it is paramount to know that the ED nursing staff will quickly intervene, will get your attention if you are in another room, and will triage patients accordingly,” Martin says.
During a code, the traveling nurse might not know the location of the crash cart, equipment, or supplies. This could cause a delay in response for a critical patient. “ED nursing staff are also pulled in different directions in orienting the traveling nurses and getting them up to speed with policies, procedures, and standing protocols,” Martin says.
Martin suggests it may be more appropriate to use travel nurses on a nonacute side of the ED (e.g., a fast track) and to direct existing nurses to manage patients with more urgent needs. As a former ED nurse, Martin recalls starting in a new ED environment is highly stressful. ED nurses must know where medications and equipment are stored, but there also are some intangible factors. It is vital to gain the confidence of other providers. “That’s not something that develops on the first day. It may take many months to know the physician staff and other nursing staff. Travel nurses come and go, without that long-term benefit,” Martin says.
There is “tremendous concern” about the effect that a high proportion of travel nurses could have on patient outcomes, including in the ED, says Patricia Pittman, PhD, FAAN, professor of health workforce equity at George Washington University.
The authors of two U.K. studies learned higher levels of temporary nurses raised mortality rates and left care undone.1,2 There are few data on risks of travel nurses in the United States.
“We are currently conducting a study on this topic,” Pittman reports. “We will be assessing the effects of travel nurses on patient outcomes in different hospital units.”
Pittman says that to mitigate risks, administrators could require travel nurses to have at least one or two years experience in an ED. “Hospitals can also create their own internal supplemental nurses agency that they train and orient in ways that help ensure quality,” Pittman suggests.
REFERENCES
- Dall’Ora C, Maruotti A, Griffiths P. Temporary staffing and patient death in acute care hospitals: A retrospective longitudinal study. J Nurs Scholarsh 2020;52:210-216.
- Senek M, Robertson S, Ryan T, et al. The association between care left undone and temporary nursing staff ratios in acute settings: A cross-sectional survey of registered nurses. BMC Health Serv Res 2020;20:637.
Nursing shortages are acute, fueled in part by surging wages for travel ED nurses. Unfortunately, travel nurses will not know the nuances of the EDs in which they are working. This hinders teamwork and communication. Thus, staffing EDs with travel nurses carries some potential risk management implications.
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