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Why travel nursing will likely outlast the pandemic

Amid staffing shortages and rising hospitalization rates during the pandemic, many hospitals have relied on travel nurses to keep up with patient volumes—and while this practice is straining many hospitals' budgets, it's a trend experts believe will last beyond Covid-19.

The nursing shortage, discussed: A conversation with Advisory Board's top nursing experts

Hospitals are increasingly relying on travel nurses

Currently, there are more than 5 million nurses in the United States, including about 4.2 million RNs, according to the National Council of State Boards of Nursing . However, exhaustion, burnout, and other issues have led many to leave their full-time staff jobs to pursue less stressful careers during the pandemic. In addition, many have transitioned from full-time staff positions to travel nursing because of the increased pay and scheduling flexibility. 

Notably, the United States has enough nurses to fill the necessary full-time positions, according to Linda Aiken, a nursing and psychology professor at the University of Pennsylvania who researches workforce issues, but the issue stems from the harsh working conditions and inadequate pay that existed in full-time nursing since before the Covid-19 pandemic.

"This is not a failure of our supply of nursing," said Aiken. "It's really a failure of hospitals to invest enough of their resources, to have enough nurses working for them."

However, data from Indeed shows that interest in travel nursing continues to climb, with job searches now at more than five times the levels of pre-pandemic searches.

Zachary Shepherd, a 36-year-old ICU nurse, has worked as a travel nurse for the past four years. He has worked in ICUs in Covid-19 hot spots, including Newark, N.J. and Long Beach, Calif. Shepherd said he doesn't mind the uncertainty surrounding his work since he enjoys the flexibility associated with working as a travel nurse.

"I like the empowerment that I feel from being a traveler and having a lot more control over the direction of my career," said Shepherd.  

Meanwhile, hiring for staff nurses declined 3.2% in February 2022 compared with a year earlier, according to the U.S. Department of Labor .

"Everybody is searching for more staff, asking your staff to take on longer shifts," said Troy Clark, CEO of the  New Mexico Hospital Association . "That encourages them to go, 'If I'm going to do all this work, I might as well go become a traveler and get paid a heck of a lot more.'"  

The rise of travel nursing brings budget concerns and wage gaps

In 2021, travel nursing revenue tripled to an estimated $11.8 billion, up from $3.9 billion in 2015, according to  Staffing Industry Analysts . As a result, hospitals and health systems around the country have taken a financial hit from having to rely on highly paid travel nurses—with no clear fix in sight.  

According to ZipRecruiter , during the Covid-19 pandemic, wages for travel nurses surged as high as 3.4 times the wages of regular full-time nurses in January 2021.

In addition, ZipRecruiter in January reported a 15% increase in average monthly postings for open travel nursing jobs. According to Sinem Buber, ZipRecruiter's lead economist, the increase will likely continue as the backlog of patients who need elective procedures return to hospitals and the population continues to age.

"I don't see the trend going down or getting flat anytime soon, even if the pandemic wanes," Buber said. 

Before the Covid-19 pandemic, the  University of New Mexico Sandoval Regional Medical Center  (SRMC) never had to rely on travel nurses. Now, their monthly payroll ranges up to roughly $1.5 million for around 60 travel nurses—almost half as much as the payroll for its full-time staff of 580, who receive around $3.3 million.

During the pandemic, SRMC lost almost a third of its 200 nurses to traveling positions, forcing them to increase staffing levels further to meet the increased demand of Covid-19 patients, said CEO Jamie Silva-Steele. With potential travel nursing costs of $18 million in 2023, Silva-Steele plans to replace 40% of the center's travel nurses with full-time staff by the end of June.

"We are not budgeted for another $18 million in compensation, so we have to have those strategies to gradually reduce those types of staff in the organization," Silva-Steele said. 

To reduce the financial strain brought on by travel nursing, many hospital administrators are making efforts to reduce the number of travelers—and some are considering not renewing travel contracts, Bloomberg reports.

Ultimately, "[w]e want our nurses and all of our clinical staff to be paid fairly, but we have to be able to keep the doors open," Clark said. (Gooch, Becker's Hospital Review , 3/16; Adegbesan, Bloomberg , 3/15)

Workers are feeling overwhelmed by the demands of Covid-19 and are increasingly concerned about pay and staffing shortages. With resignations and even labor strikes on the rise, what can you do to recruit, support, and retain your workforce? We've uncovered the most important insights and turned them into actionable items for you. Whether you are trying to recruit a nursing workforce amid a shortage or simply trying to keep your existing staff, we have curated multiple pieces of expert guidance.

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Posted on March 18, 2022

Updated on March 18, 2023

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How the era of travel nursing has changed health care

Travel nursing is a short-term and unsustainable solution for medical understaffing.

by Miranda Dixon-Luinenburg

In 2016, I was working as an ICU nurse in Reno, Nevada. But I didn’t live in Reno. In fact, I hadn’t trained as a nurse in the US at all; I’m from Canada and went to nursing school there. My initial contract was for just 13 weeks. I was what was called a travel nurse — someone who was brought in from a different city, and sometimes even from a different country — to meet a hospital’s temporary staffing needs.

At the start of my contract, we had a couple of days of onboarding and were then expected to hit the ground running. Every morning, I would report to the trauma ICU, one of four ICU units in the hospital, and only then find out where I was assigned, which was sometimes outside the ICU entirely.

Six years ago, travel nursing jobs like my Reno gig were a fringe part of the nursing landscape. But that’s changed. During the pandemic, the need for travel nurses has soared, and so have the wages paid them. Because I was a former ICU and travel nurse, I received frequent emails from travel nursing agencies when the pandemic first erupted, offering upward of $6,000 per week and occasionally as high as $10,000, if I were willing to relocate on as little as 48 hours notice to one of the cities experiencing a Covid-19 surge.

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This was a steep increase from the average US ICU travel nurse’s salary of $1,800 per week, per this 2019 report . (I didn’t accept any of them, but I have to admit it was tempting.)

The rise of the travel nurse in the time of Covid-19 isn’t that surprising. From the earliest days of the pandemic, registered nurses bore the brunt of the increased strain on the health care system. With ICUs across the country overflowing, hospitals were forced to open specialized Covid-19 wards and staffing was strained. Nurses were often required to work grueling hours with heavy patient loads, a shortage of personal protective equipment (PPE), and limited access to Covid-19 testing.

As we enter the third year of Covid-19, the staffing shortage is only getting worse . Many nurses are facing burnout, choosing less arduous roles in non-hospital settings, or retiring from the profession altogether. Others are staying in the profession, but leaving the hospitals that employ them for travel nursing agencies, which offer them better-paying, short-term contracts.

In travel nursing, rather than working directly for a hospital as permanent employees, nurses are hired by a staffing agency, which then arranges time-limited contracts with hospitals to meet temporary or seasonal staffing needs. Over the course of the pandemic, crisis demand for additional staff sent travel nursing wages skyrocketing, and thousands of nurses across the country accepted these offers. While travel nurses previously represented 3-4 percent of all nursing staff across the nation, the figure has risen to 8-10 percent.

Travel nurses are extremely valuable to hospitals, rapidly and flexibly providing critical staff during case surges. But relying so heavily on temporary staff brings disruption. With many of their permanent nurses leaving for lucrative travel gigs, hospitals are increasingly being forced to bring in travel nurses from elsewhere to make up the deficit, leaving teams fragmented. This is especially hard on small rural hospitals, which lack the resources to compete with larger hospital networks.

The massive pay discrepancy is likely a temporary side effect of the crisis and various economic and funding constraints, but the underlying situation is not about to disappear. Covid-19 has taken a nurse shortage that predated the pandemic and dramatically worsened it.

Relying on temporary staff weakens hospital teams, drawing away the best and most experienced nurses and making it that much harder to onboard new staff, train students, and provide high-quality care. With more and more nurses burning out and quitting by the day, hospitals and the federal and state governments have yet to address the factors that would help frontline health care workers stay in the profession. Travel nurses are at best a temporary fix, and the long-term cost is unsustainable.

How travel nursing works

Travel nursing didn’t begin with the Covid-19 pandemic. The idea originated in New Orleans in 1978, as a response to the annual influx of patients during Mardi Gras. The practice became more prevalent over the next decade; by the late 1980s, travel positions had become widely available.

Travel nurses are hired by a staffing agency, rather than a hospital; the agency then arranges contracts with hospitals to provide nurses during periods of temporarily high demand and usually arranges housing for the nurses in their destination city. The standard contract is 13 weeks long, though nurses can sometimes choose to extend it to six months or longer.

In the past, travel nursing wages varied widely by state and region and were often higher than permanent staff salaries (though some of that difference came from the free housing or housing stipend and other incidentals that were often included). Since the start of the Covid-19 pandemic, though, the pay for travel nurses has increased dramatically, and much faster than permanent salaries.

“When I worked as a travel nurse, there wasn’t that much of a discrepancy between my wage and permanent staff,” said Mary Jorgensen, an operating room nurse at UW Health in Madison, Wisconsin, and a former travel nurse. “We were more attracted to travel nursing for the lifestyle of going to different locations. But now that hospitals have this over-reliance on travel nurses to try to make up for the nursing shortage crisis, the amount they’re spending on travelers is astronomical.”

Over the past 18 months, it has become common for many nurses to double their paycheck by choosing the travel route. It’s not for everyone. It requires high levels of adaptability, independence, and tolerance for uncertainty, not to mention the personal freedom to pick up stakes and move temporarily, but for nurses who can take advantage of the opportunity, travel nursing can provide a financial windfall.

Lydia Mobley, a travel nurse with the major travel nursing agency Fastaff, believes that health care workers deserve more pay, and that travel nursing offers a route toward that end. “I know two amazing nurses who are some of my best friends, who are travel nurses and they are single mothers, but they still make travel work because they just want to give their kids the best life possible,” Mobley told me. Thirteen-week contracts also mean that nurses can choose to take breaks to recover in between periods of intense workload.

Mobley also sees the novelty with each contract as a perk, offering nurses (and by extension the hospitals they normally work for, and in the past at least, usually returned to) the chance to learn how other hospitals operate. “Even if a hospital happens to have maybe some older, outdated policies, at least you learned, ‘Hey, that’s a way that that probably should be done,’” she said.

In my case, the experience was very positive. It felt good to be where I was most needed, and to bring my own background and experience to an understaffed unit. By the end of my initial 13-week contract, which I chose to extend for a total of six months, I was familiar with the hospital’s processes, and actually able to provide support and mentoring to the many recently-graduated nurses on the permanent staff.

For hospitals, travel nurses provide a huge advantage in flexibility and response time in a crisis. It’s extremely difficult to hire and fully train a cohort of permanent nursing staff fast enough to respond to a surge in case numbers, which can happen in weeks or even days. Hiring travelers also means that when local case numbers begin to drop, a travel agency can send its nurses on to other states with the highest needs.

Bart Valdez, CEO of Ingenovis Health (which owns Fastaff as well as several other travel nursing agencies), told me how his company was among the first agencies to send nurses to early Covid-19 hotspots like Washington and New York. These staff became early “veterans of Covid,” he said, bringing their experience of the challenges of Covid-19 patients to other facilities.

“A less stable ecosystem”

But there are real downsides to taking this model too far, which are apparent to travel nurses as well as the permanent staff.

For one thing, hospitals end up paying far more in hourly wages for staff who are less familiar with local conditions, which can erode nurses’ teamwork and the quality of care for patients.

Kelly O’Connor, another registered nurse from UW Health, mentioned a colleague of hers left Madison, Wisconsin, for a travel position in Milwaukee the very same week that O’Connor’s unit resorted to hiring a travel nurse from Milwaukee to fill the vacancy at a much higher cost to her hospital. Travel nurses are not only paid a higher hourly wage, but the agencies generally mark up the bill by 32 to 65 percent to turn a profit. (Texas has recently resorted to banning nurses currently in permanent positions from accepting contracts in-state in an attempt to circumvent this dynamic.)

Increasingly relying on travel nurses more often can also warp the inner workings of a hospital. “There was a time when travel nurses were used appropriately, as a ‘Band-Aid,’ but this is beyond that,” O’Connor says. “There’s so much that goes into a hospital running smoothly, and historically if a travel nurse was needed, they were able to pop in, understand the ecosystem quickly, and everything would function as normal.”

But now, she notes, “we’re relying on them too much, and they’re thrown into a less stable ecosystem without the support to figure it out.”

The delicate “ecosystem” of a well-run hospital unit is made up of all the staff needed to keep a medical center running: doctors, pharmacists, lab techs, respiratory therapists, and of course, nurses. To mentor new staff and train travel nurses, the unit needs a certain base of experienced nurses, with years of commitment and investment in the local hospital and community. But with high levels of staff turnover — and many experienced nurses shifting away from bedside care or choosing early retirement due to burnout — this essential resource is in jeopardy.

When the nursing ranks are chronically understaffed and overstrained, even the best nurses can’t spare the time to properly mentor a new staff member, and instead have to tag-team just to cover all the basic tasks.

O’Connor described a revealing situation she found herself in: She realized only in the final few days of a new nurse’s multi-week orientation that she had never found time to show her trainee where the wheelchairs were kept. That’s a basic if important piece of information that would usually have been covered in week one.

“I used to feel that I helped the new nurse grow, and now more often than not we’re having to rely on each other just to get through the workload,” she says. “Nursing is already so hard. This is only making it harder than it needs to be.”

The cost of good care

If experienced, committed permanent nurses are so essential to a hospital’s functioning, providing value that no temporary travel nurse can replace, why aren’t they compensated accordingly?

One contributing factor may be that during the pandemic, crisis funding from government institutions such as the Federal Emergency Management Agency (FEMA) couldn’t easily be allocated to hiring more permanent staff, or toward efforts to retain existing experienced staff via retention bonuses, hazard pay, or other support.

But there are systemic issues at work as well. The National Nurses United is the largest professional association of registered nurses, with more than 175,000 members working at the bedside in nearly every state. Its latest report — titled “Protecting Our Front Line: Ending the Shortage of Good Nursing Jobs and the Industry-Created Unsafe Staffing Crisis” — explores the background of the nursing shortage and the worsening conditions during Covid-19. It lists a number of specific policy recommendations, such as mandated staffing ratios and better workplace safety regulations, that they believe will help create sustainable, rewarding jobs and keep nurses in the field. (On a more local level, Mary Jorgensen and Kelly O’Connor are working with other nurses to form a union with SEIU Healthcare Wisconsin, in hopes of addressing the short-staffing and other challenges that have plagued UW Health during the pandemic.)

Such reforms were needed before the pandemic, and are even more necessary now. The spike in travel nursing demand and pay shows that the system as it exists now is not equipped to respond to a major crisis without significant disruptions that will have serious consequences down the line. The worsening personnel shortage, with many nurses retiring and leaving the profession entirely, is a symptom of a system that prioritizes the short term at the expense of sustainability.

Travel nurses have been a part of the nursing workforce for decades, and as a supplement for temporary needs, they are very valuable. But it’s not fair to either travel nurses, or the patients they care for, to ask them to take on so much of the ongoing essential duties of running a hospital unit.

A hospital relying too heavily on travel nurses will lose institutional knowledge, be less able to fit in new hires or provide nursing students with a strong education, and will end up being a frustrating and draining work environment, leading to more burned-out nurses and a worsening staff shortage at a time when the US can least afford it.

Clarification, March 3, 3:40 pm: This story has been updated to clarify the role of Mary Jorgensen and Kelly O’Connor in the effort to form a nurses union with SEIU Healthcare Wisconsin.

Correction, March 4, 3 pm: Due to a copy-paste error, an update to this article previously transposed the last names of Mary Jorgensen and Kelly O’Connor.

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Travel nurses took high-paying jobs during Covid. But then their pay was slashed, sometimes in half.

In early 2022, Jordyn Bashford thought things were as good as they could be for a nurse amid the Covid pandemic.

A few months earlier, she had signed an agreement with a travel nurse agency called Aya Healthcare and left Canada to work at a hospital in Vancouver, Washington.

Before the end of her first shift at PeaceHealth Southwest Medical Center, she said she realized other travel nurses there were earning even more than she was and asked for more money. Aya quickly amended her agreement and raised her hourly pay from $57 to $96. 

In January, her rate increased again to $105 as part of a new agreement. She thought that the high pay — and a generous living stipend of nearly $1,300 per month — meant she and her fiancé could finally make plans to buy a house. 

But two months later, when her assignment was renewed, Aya slashed her hourly pay back down to $56, and then cut it still more to $43.80 — less than her initial rate.

“I do know that travel nursing is fluid, and you can lose your job at any time, but I wasn’t expecting [my hourly pay] to fall 50%,” Bashford said.

The boom in travel nursing during Covid exposed a practice that has existed since the industry’s birth 50 years ago, according to experts. Nurses attracted by talk of high wages found themselves far from home with their salaries slashed at renewal time, and only then grasped the wiggle room in their signed contracts, which were really “at-will” work agreements. But the sheer number of nurses working travel jobs, and the difference between what they thought was promised and what they pocketed, has led to a substantial legal pushback by travel nurses around the country on the issue. 

This summer, Stueve Siegel Hanson, a Kansas City, Missouri, law firm, filed class-action lawsuits against four travel nurse agencies: Aya, Maxim, NuWest and Cross Country. As of Dec. 27, all were still pending. Austin Moore, the lead attorney, said the suits allege the companies pulled a “bait-and-switch,” offering nurses agreements at high rates and then slashing their pay after they’ve signed. Many of the alleged incidents occurred in March and April when, as NBC News has previously reported, the demand for travel nurses, which soared during the pandemic, began to drop.

“To go take a travel assignment is a really big deal, and to get there to have the rug pulled out from under you, for someone to collapse your pay, I just think it’s unconscionable,” Moore said. “They’re on the hook for a lease, and they’re scrambling trying to find another job, and it’s a really terrible set of circumstances.”

Maxim, Cross Country and NuWest said they could not comment on pending litigation.

In a statement, Aya said allegations of bait-and-switch “are demonstrably false. ”

“ Travel nurse companies contract with hospitals to provide temporary staffing to help them support their communities. Nurses are the heart of healthcare and we value the nurses who work for Aya, and go above and beyond to ensure they have an exceptional experience with us.”

“As is evidenced by Ms. Bashford’s employment with Aya," the statement said, "nurses also received mid-assignment pay increases at various times during the pandemic. Further, we understand when the government reduced subsidies to hospitals following the height of the pandemic, they in turn reduced pay to travel nurses.” 

$5,000 per week

Even in the industry’s earliest days, the 1970s, nurses could find themselves earning less than they expected. Advertisements touted an hourly rate of $8 to $11, but many nurses wound up making less than $6, according to Pan Travelers, a professional association of travel nurses.

Back then, there were no written agreements for the travel nurses, according to Pan Travelers. That began to change in the mid-1980s. At the same time, the number of agencies multiplied, fed by the hefty commissions that hospitals paid them.

Travel nursing became even more prevalent during Covid. Prior to the pandemic, there had already been a growing shortage of nurses nationwide, and the virus made the shortage worse. Agencies started offering nurses work agreements and renewals that extended far beyond the typical 13 weeks, according to six nurses who spoke to NBC News.

In January 2020, right before the pandemic, there were about 50,000 travel nurses nationwide, or about 1.5% of the nation’s registered nurses, according to Staffing Industry Analysts (SIA), an industry research firm. That number doubled to at least 100,000 as Covid spread, but according to SIA, the actual number at the peak of the pandemic may have been much higher. 

When the pandemic was at its worst, some travel nurses were earning $5,000 or more weekly,  as NBC News previously reported .

Erin Detzel never earned that much. But in November 2021, at $78 per hour, she said the money was enough to get her to move with her husband and two kids to Florida for her first-ever travel assignment.

Detzel’s 4-month-old daughter had respiratory distress syndrome and had also been hospitalized with respiratory syncytial virus, or RSV. That Detzel’s mother-in-law was in Florida was another inducement to move.

“We needed help,” Detzel said. “I didn’t want to put my baby in day care, so that’s kind of why we did this. My mother-in-law’s the only family member that could watch them.”

Detzel rented a house. But by February, after her first 13-week contract, Covid hospitalizations had waned and the demand for travel nurses had fallen. Her hourly pay was decreased to $62. Then it dropped again, to $32.50.

Travel nurses are typically hired by recruiters via phone calls or posts on social media and in online forums, and according to the 11 nurses NBC News spoke to around the country, the recruiters often use words like “contract.” All but one said it’s the norm for the recruiter to name a price.

Bashford said she found her recruiter through an online travel nursing forum. She said she sought out Aya’s job postings, with advertised payment amounts, on its website after a recruiter started corresponding with her.

Detzel said she agreed to go on an initial 13-week assignment from AB Staffing, an agency that is not named in the lawsuits, after a recruiter cold-called her and told her what she’d be making.

In a sample of four recruiting posts in a nursing Facebook group from 2022 from three of the agencies that are being sued, two from Maxim and Cross Country used the word contract, while two from Maxim and NuWest didn’t. The posts gave specific terms for how long the nurses were needed, as well as pay, hours, and room-and-board stipend. The two that mentioned contracts, however, used that word generally or in connection with the duration of the job, not the rate of pay. There were no Aya recruiting posts in the forum in the timespan sampled.

In the travel nurse industry, hospitals have the leverage to push the agencies for pay cuts when their demand dips, said Robert Longyear, vice president of digital health and innovation at Wanderly, a health care technology firm for staffing.

Hospitals and agencies have written agreements that allow for fluctuation, Longyear said. On top of the nurse’s agreed salary, the hospitals are also paying the agencies commissions that can reach  40% , according to a spokesperson for the  American Health Care Association , which represents long-term care providers.

Given the costs, when there are fewer patients, or less demand, hospitals will go back to travel agencies and tell them they’re exercising their option to decrease nurses’ pay, and then agencies will tell the nurses their pay has been reduced. 

The recruiters were the first to deliver the news about pay cuts to Bashford and Detzel. 

Bashford said she got the news about her second cut the same way. “I received a text from my recruiter saying, you know, your rate got decreased even lower,” she recalled.

If a nurse balks, Longyear said, “The agency can say, ‘Hey, look, I’m going to cancel this job. If you want to keep working, this is the new rate.’”  

He said this is a long-established practice, but that the pay cuts are just more noticeable now that travel nurses are promised more and paid more. And he said that because so many nurses are pursuing more lucrative assignments, it might be more common for agencies to start someone off high and then slash their pay mid-assignment.

When a travel nurse takes a job, the contract the nurse signs is an “at-will” work agreement.

NBC News reviewed Detzel’s AB Staffing work agreement, Aya agreements for three nurses, including Bashford’s, as well as versions of Cross Country and NuWest work agreements and the August 2021 Cross Country terms and conditions handbook. All mention the adjustable nature of work conditions. Cross Country and Aya explicitly mention “at-will” employment, which means an employer may terminate, and an employee may leave, a position at any time. The NuWest agreement explains the employee can be terminated at any time without saying “at-will.”

Bashford received emails saying, “Congratulations! Your contract was extended” from her recruiter each time she was approved for another 13 weeks, but she also had to sign new agreements with changed rates, including the cut to $43.80.

Moore, who is representing the nurses, said, “I doubt a nurse has ever successfully negotiated [the at-will provisions of] one of these contracts. They are form agreements and the agencies don’t change their terms.”

Richard Brooks, a visiting professor at Yale Law School, said some courts might view a company presenting the option ​between a sudden pay decrease or termination as within the realm of legality ​for at-will employment, depending on state contract laws. 

Brooks and other legal experts said the nurses still have some avenues of redress to pursue, however.

Sachin Pandya, a law professor at University of Connecticut School of Law, said that an at-will clause affects “the probability that the employer can change terms and conditions without violating state contract law.” He said the clause might not matter for legal claims that, by their change in pay, the employer violated some other source of law like fraud or wage-and-hour statutes. 

Avery Katz, a professor at Columbia Law School, adds that the language in a contract “is not the end of the story.”

“Even if there’s a contract, even if the contract says I have no right to recover, you made me these promises,” Katz said. “And then I relied on them by picking up and moving to another state and renting an apartment.”

Aya said that Bashford’s experience shows that nurses are able to negotiate the terms of their employment, and that “the harmful gist of [Bashford’s] accusations — that the company greatly lowered her pay below what she reasonably expected from the outset — is simply not true.” 

‘You can’t afford to lose me’

Jordyn Bashford and Erin Detzel are both former travel nurses now.

Detzel moved her family back to Ohio. She said the hospital and travel agency treated her like the equipment in hospital stockrooms. “It’s almost like I was a supply,” she said.

AB Staffing did not respond to a request for comment.

Bashford, now a staff nurse at a different hospital in Washington, recalls bonding with her teammates during the most challenging days of the pandemic, but also the long hours and how she was effectively training newcomers on the job. With six years of nursing experience, two of them in the ICU, she said she was one of the most experienced nurses on her floor some days, which she found shocking. 

But what most bothered her, like Detzel, was being made to feel disposable.

“The part that really just blew me away was like, ‘You can’t afford to lose me,’” Bashford said, referring to the ongoing national shortage of nurses. “That just felt very, very true. And somehow they thought that they could just dispose of us, and I don’t understand.”

Jean Lee is an associate reporter with NBC News’ Social Newsgathering team in Los Angeles. She previously reported for the NBC News consumer investigative unit.

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Health Care

Nurses can earn much more as traveling nurses. but the job comes at another cost.

Blake Farmer

A nurse who left her hospital job for much higher wages as a traveling nurse found the lifestyle hard on her family. But permanent jobs but those don't pay much better than they did pre-pandemic.

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As covid persists, nurses are leaving staff jobs — and tripling their salaries as travelers

The American Hospital Association represents a wide variety of hospitals, including nonprofit, for-profit, government and others. A previous version of this article said the group represents only nonprofit hospitals. The article has been corrected.

Wanderlust, and the money to fund it, made Alex Stow’s decision easy. After working a couple of years in an intensive care unit, he signed up to be a travel nurse, tripling his pay to about $95 an hour by agreeing to help short-staffed hospitals around the country for 13 weeks at a time.

“Travel” proved a bit of a misnomer. His current assignment is in Traverse City, Mich., only a few hours from his old full-time job in Lansing — close enough that he still works per-diem shifts at his previous hospital.

Now Stow, 25, is buying a truck and a camper and preparing to hit the road. He’ll work where he wants and take time off to see the country between nursing assignments.

“As soon as I found out that was a thing, I thought, ‘That’s got my name written all over it,’ ” said Stow, who agreed to discuss his new work life if the hospitals were not named.

If 2020 was the year travel nursing took off , with 35 percent growth over the pre-pandemic year of 2019, this year has propelled it to new heights, with an additional 40 percent growth expected, according to an independent analyst of the health-care workforce.

The continued pandemic; an aging, burned-out and retiring nurse workforce; the return of hospital services that were shut down last year; and a shortage of foreign recruits and nursing students have combined to make travel nursing one of the most critical and sensitive issues in health care.

“Of all the things that keep CEOs of hospitals up at night, this is the key one,” said Chip Kahn, president and chief executive of the Federation of American Hospitals, which represents about 1,000 for-profit facilities.

Hospitals accuse the travel companies of price gouging. The companies say they are responding to the laws of supply and demand in an increasingly mobile work environment. Nurses’ unions say there would be no shortage if nurses were adequately paid and afforded better working conditions.

The one area of agreement is that health-care staffing is suffering from fundamental problems that must be addressed for some measure of balance and efficiency to return.

“We need a better way to think about how we oversee and distribute and monitor the supply of our health-care workforce,” said Bianca K. Frogner, director of the Center for Health Workforce Studies at the University of Washington School of Medicine. “We don’t have any kind of centralized workforce commission in this country.”

Stow’s hourly pay is near the median of $99 an hour for critical-care travel nurses at the moment, according to Barry Asin, president of Staffing Industry Analysts, a research firm that focuses on the contingent workforce.

But a quick search turns up ads for even higher pay: $9,486 per week for ICU nurses, posted by Aya Healthcare , one of the industry leaders; nurses with cardiovascular experience can make even more. Travel companies also may offer a full slate of benefits, and some pay nurses a bonus to refer other nurses to them.

The highest pay is going to nurses with experience in specialized hospital units such as the various types of ICUs , those willing to move to remote locations for weeks or months and those willing to respond immediately to emergency needs, people in the industry said. Demand for other health-care workers such as respiratory technicians also continues unabated.

In contrast, a full-time registered staff nurse earns an average of just less than $74,000 per year, according to a 2018 report from the Department of Health and Human Services. About 2.6 million nurses worked in hospital settings in 2018, according to the government.

The travel-nurse market, which Asin said could accommodate well over 100,000 such staffers this year, had more than 40,000 vacancies in October, according to his data. Companies continue to recruit staff nurses to become travelers. Especially for younger and older nurses who aren’t tied to homes or families, the money and travel can be an attractive proposition.

“If people can go somewhere else and earn a year’s salary in three or four months, they will,” said Karen Donelan, a professor of health policy at Brandeis University who follows nurse staffing issues. “But they’re walking into high-covid zones. So this is a risk-reward scenario.”

Tracking the coronavirus

U.S. hospitals have faced periodic nurse shortages for years , and demand was high even before the pandemic, fueled by aging patients and more people with insurance, said Bart Valdez, chief executive of Ingenovis Health, which has 6,000 travel nurses, including Stow, at hospitals across the country. The arrival of the omicron variant may put more people in U.S. hospitals with covid-19.

The average age of a nurse is 50, and ICU nurses are older — an aging workforce edging toward retirement. The number of nurses needed to replace them has been limited by a shortage of faculty members in nursing schools, said Akin Demehin, director of policy for the American Hospital Association, which represents a wide variety of hospitals.

Hospitals are again offering elective surgeries and procedures that were canceled during the first year of the pandemic, putting more pressure on nursing staffs. The flow of foreign nurses into the United States was all but shut off by the pandemic and is not close to normal, said Kahn, of the Federation of American Hospitals.

Then came the pandemic-fueled “great resignation” that has created labor shortages across the United States. In health care alone, 534,000 people left their jobs in August, according to the Bureau of Labor Statistics. Some left for other jobs, but others simply quit or retired. In long-term care such as nursing homes and assisted-living facilities, 400,000 health-care workers have left since the pandemic began, said Frogner, of the University of Washington.

Asin said that “2020 was the year of, ‘Everyone to the barricades — let’s solve this national problem.’ And 2021 is the year of, ‘If this is what it’s going to be like, I’ve got to reevaluate my life.’ ”

Burned out by the pandemic, 3 in 10 health-care workers consider leaving the profession

As coronavirus cases spiked in their areas, hospitals also have hired per-diem nurses and retired nurses. In some particularly dire cases, the government sent in military and public health personnel. Massachusetts announced last month that hospitals there will reduce non-urgent procedures because of rising covid-19 cases and staff shortages.

The nation’s largest nurse union maintains that hospitals are suffering the consequences of the just-in-time staffing model they created to cut costs by keeping the number of full-time staff nurses as small as possible.

“This current staffing crisis is one of the hospital industry’s making,” Deborah Burger, president of National Nurses United, said in a written statement. “They need to take a long hard look at how their treatment of permanent staff and exploitation of the nursing ethos has inevitably led to this unsustainable model of staffing hospitals.”

In the current crisis, these conditions have led to charges that travel companies are gouging hospitals. If there are staff shortages , hospitals must close beds. Four members of Congress last month asked Jeff Zients, the White House’s coronavirus coordinator, to look at the issue, and in February the American Hospital Association complained to the Federal Trade Commission.

“The rates that are being paid and the amounts the nurses are making are frequently out of line with physicians,” Kahn said. “Those companies that have those nurses are in a position to gouge and leverage. I don’t think that can continue forever.”

Hospitals have been able to use government coronavirus relief funds to pay some of their expenses, but that may not always be the case, said the American Hospital Association’s Demehin.

Valdez, of Ingenovis Health, said that “if you need the nurses to support patients and you need them there immediately, you’re going to have to pay to get them there, because they have so many different opportunities. It’s a high number — I recognize that. But it’s a higher cost not to get the services to the patients.”

Stow said he occasionally sees the conflict firsthand when he is working side by side with staff nurses, performing the same tasks for vastly greater pay.

“With any population of people you’ll get a couple here and there. . . . They might show it a little bit, and they might treat you a little differently,” he said. “I think most of the nurses that you work with, they realize we’re not what caused this. We’re, as of right now, kind of a Band-Aid for the situation.”

Coronavirus: What you need to know

The latest: The Food and Drug Administration approved new mRNA coronavirus vaccines. Here’s what you need to know about the vaccines .

Summer covid uptick: A summer covid wave continues to wash over the Americas and parts of Asia and Europe, with the World Health Organization saying the virus is increasing in at least 84 countries.

Combined coronavirus and flu vaccine: A combined coronavirus-influenza vaccine may be on the horizon after Moderna’s shot produced a higher immune response in older adults than separate vaccines for those viruses administered together. Moderna officials say the earliest that the combined vaccine could hit the market is the fall of 2025, pending regulatory approval.

Covid isolation guidelines: Americans who test positive for the coronavirus no longer need to routinely stay home from work and school for five days under new guidance from the Centers for Disease Control and Prevention. Here are the latest guidelines .

Contract Nurse Agencies Are Making Big Money in the Age of COVID-19. Are They ‘Exploiting’ the Pandemic?

I n the 40 years that Jennie Kahn has worked as a registered nurse, the last two have been by far the most grueling.

A lot of that is due to COVID-19, which transformed health care facilities, including Thomas Health’s hospital system in Charleston, West Virginia, where Kahn works, into triage centers and forced nurses to take on an extraordinary amount of personal risk and heartache. It’s no mystery why some 18% of health care workers quit their jobs between Feb 2020 and Sept 2021, according to a Morning Consult poll.

But another reason these past two years have been so punishing, Kahn says, is that hospital nursing staffs have been subject to extraordinary churn as thousands of nurses have quit their staff positions to become contract travel nurses, where the pay is often two to four times higher. This rapid turnover has triggered a costly feedback loop: hospital administrators, facing shortages in staff nurses, spend a mint hiring contract nurses, which makes them less able or willing to increase their staff nurses’ pay. So more staff nurses quit to become contract nurses, thus further lowering nurse supply and driving demand for contract nurses. “It is a vicious cycle,” says Kahn, the hospital system’s chief nursing officer.

Meanwhile, contract nursing agencies have increased their prices. The advertised pay rate for travel nurses has surged 67% from January 2020 to January 2022, according to Prolucent Health, a workforce management tool for healthcare companies, while some staffing agencies such as AMN Healthcare, told TIME that pay rates for travel nurses at facilities they work with rose by 164% from the fourth quarter of 2019 to the fourth quarter of 2021. Some of these agencies’ profit margins top 20%.

Some hospital administrators, many of which saw their facilities’ profits shrivel during COVID, say they’ve reached a crisis point and are calling on Congress and the Biden Administration to step in. They argue that contract nursing agencies are exploiting circumstances resulting from COVID-19 to pad their own pockets. The agencies say their prices are merely a reflection of growing demand. Nurses, meanwhile, argue that hospital administrators, who are somehow finding a way to pay premium rates for contract nurses, could have avoided the mass nurse exodus by paying their staff nurses better and improving working conditions from the start, and that a fragmented nursing force with quick turnover is bad for patients’ health.

The solution is not straight-forward. Health care facilities, desperate to keep nurses on staff, may have to improve salaries and working conditions, but at many facilities, that’s easier said than done. At long-term care centers, bottom lines are dictated by Medicare and Medicaid reimbursement, and at many small and medium-sized hospitals, the cost of personal protective equipment and patient loads have fluctuated dramatically since March 2020.

“This is not anything that any health system can sustain for a long period of time,” says Kahn. “If the rates do not decrease or if travel nursing is not reduced somewhat, hospital systems are going to have to find alternative ways to provide patient care.”

An explosion of temporary staffing

Travel nurses have been around for decades and became more widespread in the 1980s, as nursing shortages grew, but it’s really the pandemic that changed the landscape of the profession. In some healthcare settings, contract nurses are now almost as prevalent as staff nurses.

Jeffrey Tieman, president and CEO of Vermont Association of Hospitals and Health Systems (VAHHS), says that prior to COVID-19, his system used travel nurses “as a stop gap”; now he says they’re “in every department of the hospital every day of the week.” The same is true of Thomas Health, Kahn says. When she first became the hospital system’s chief nursing officer in 2019, the acute care team didn’t rely on traveling nurses at all; these days, about 40% of her acute care nurses are on temporary contracts.

The financial fallout of this trend for hospitals’ and nursing homes is staggering. Due largely to the increase in contract nurses, Thomas Health is now roughly 100% over its previous staffing budget, the hospital system tells TIME. Between Fiscal Years 2020 and 2021, VAHHS’s outlay for contract nurses increased $29 million, or 35%, the group says. “As the pandemic picked up and dragged on, the need for nurses intensified when the supply of nurses diminished,” Tieman says.

Depending on contract nurses also creates logistical problems, says Deb Snell, a registered nurse and the president of the Vermont Federation of Nurses & Health Professionals. “It is difficult when you have new people coming in every 12-13 weeks, and orienting them to your floor, making sure they know where equipment is, where meds are, who to call for a problem,” she says. “It’s constant turnover.”

Struggling to fill empty roles and way over budget on staffing, VAHHS reached out to Vermont Congressman Peter Welch for help coming up with a solution, and on Jan. 24, Welch and Morgan Griffith of Virginia wrote a letter to the White House, cosigned by nearly 200 other members of Congress. The letter urges the Biden Administration to investigate the extent to which contract nursing agencies are exploiting the pandemic to drive their profits by engaging in anticompetitive activity. “We are writing because of our concerns that certain nurse-staffing agencies are taking advantage of these difficult circumstances to increase their profits at the expense of patients and the hospitals that treat them,” the letter says.

Days later, the American Hospital Association and the American Health Care Association/National Center for Assisted Living, the major nursing home trade group, threw their support behind Welch and Griffith, calling on the Administration to help prevent the travel agencies “from exploiting our organizations’ desperate need for health care personnel.”

Travel nurses, meanwhile, were incensed. On social media and message boards, they begged supporters to call their members of Congress to defend them and their pay schedules. “Wait, what? They want to cap travel nurse pay but they won’t cap CEO and executive pay? Well… I guess they know who their true masters are, and it sure as hell ain’t the voters,” wrote one Reddit user.

“It’s just because they can get away with it”

Welch says capping contract nurses’ take-home pay was never the intention of his letter. “I never have and never would propose a cap on nursing pay,” he says. “Nurses are the frontline, and they’re overworked, they’re underpaid, and they legitimately point out how the executives get fat salaries while they have to do all this work.”

Instead, he says, one big reason for the financial burden on hospitals is the fees that nurse staffing agencies charge to assign travel nurses to health care settings that need them. Proculent Health, the workforce management tool used by healthcare companies, estimates that hospitals and other healthcare facilities are billed an additional 28% to 32% above the wages the agencies pay contract nurses.

Welch argues these agencies may be exploiting the pandemic’s circumstances at the expense of hospitals, health centers, and the patients who seek care at them. “The fee that the agency charges is not related to any additional work they do, or any value added,” Welch tells TIME. “It’s just because they can get away with it.”

AMN Healthcare Services reported its gross profits were $434 million in the fourth quarter of 2021, up 109% from a year prior, according to an annual earnings report . Its net income, which takes into account all business related expenses and taxes it had to pay, was $116 million, an 1100% increase. Another healthcare staffing agency, Cross Country Healthcare, saw its revenue increase 93% between the third quarters of 2020 and 2021. It also reached $1 billion in annual revenue for the first time in the company’s history in 2021.

In recent months, private equity firms have begun acquiring contract healthcare staff agencies at a rapid clip, signaling to Welch that investors believe there is even more money to be made off the travel nurse industry in years to come—which would put hospitals under even greater strain. One of the largest healthcare staffing agencies, Medical Solutions, was purchased by two private investment firms in August. Favorite Healthcare, another large staffing group, was bought by a private equity-owned staffing firm in January.

“Three of the 10 largest staffing agencies—and probably more—were purchased by private equity right around the time that the pandemic began,” Welch says.

Staffing agencies argue that the higher prices health care facilities are paying are driven primarily by the higher wages the agencies pay nurses to meet the demand. In 2020, 75% of revenue nurse staffing agencies made went to wages and the costs of employing nurses, including payroll taxes, worker’s compensation and unemployment insurance payments, and other benefits, says Toby Malara, vice president of government relations for the American Staffing Association (ASA), a trade group for the staffing industry. He adds that most of the association’s nurse staffing agencies have seen their profits remain “relatively stable” during the pandemic.

Nurses worry about pay cuts — for good reason

Many nurses are worried that heightened government scrutiny will result in lower take-home pay for them — and that anxiety is not necessarily unfounded. Some states already cap nurse pay under certain situations, or are considering legislative action to do so. Minnesota, for example, caps contract nurses who work in nursing homes. The most that an RN can earn per hour during non-holidays is $62.36, according to documentation provided by the state’s Department of Health. Massachusetts caps pay for RNs at hospitals around $120 per hour. At nursing home facilities, the state caps an RN’s pay around $79 per hour, the state’s Executive Office of Health and Human Services says .

Other states including Kansas, Ohio, Oregon, Illinois and Pennsylvania are now considering legislation to cap nurse pay in some cases. Pennsylvania state Rep. Timothy Bonner has introduced a bill to establish maximum rates for employees of travel nursing agencies in his state that would be no higher than 150% of the average statewide pay rate for similar jobs. “[Staffing] agencies have seized on the pandemic and the critical need for workers,” he wrote in a letter to his statehouse colleagues, according to the Lewistown Sentinel , “and have raised their hourly rates to 100 percent, 200 percent or even 400 percent above the current median wage rate.”

The White House referred TIME’s questions about how regulatory action against the contract nursing industry would work to the Federal Trade Commission, which did not return a request for comment.

Many nurses say arbitrary pay caps are unfair. The problem is not high pay, they say; it is that there aren’t enough nurses to do an increasingly challenging job for relatively low wages. And while the pandemic exacerbated nurse shortages nationwide, the problem long preceded COVID-19’s added pressures. “Things were already getting tight even prior to the pandemic,” says Snell in Vermont. “Nurses have known and seen this coming for a while. We just couldn’t get people to listen.”

Part of the issue is demographics. The median age of RNs in 2020 was 52, according to a recent survey from the National Council of State Boards of Nursing, and with baby boomers retiring, more nurses will need replacing. But there’s no lack of interest. Enrollment in baccalaureate and higher-degree nursing programs increased in 2020, according to the American Association of Colleges of Nursing, and nurse practitioner graduates have swelled in recent years too. Nursing schools could be training even more graduates, experts say, but the cost of nursing school can be a barrier for students, and schools are also experiencing a shortage of nursing instructors.

But the largest factor, according to nurses unions and professional groups, is how low the pay is compared to how difficult the work environment is. “There is no nursing shortage in the United States. There is a shortage of nurses who are willing to work in these conditions,” says Michelle Mahon, a registered nurse who is assistant director of nursing practice at National Nurses United (NNU), the largest nurses union in the country. “This is something that’s been created by health care employers over a very long period of time.”

NNU has frequently criticized hospitals for adopting what it says are policies of chronic understaffing in order to help their bottom line. High patient-to-nurse ratios deteriorated patient care and put nurses at increased risk of workplace injuries and infections before COVID-19, Mahon says. Then when the pandemic swept in, hospitals that had prioritized cutting costs were unprepared.

Health care doesn’t operate like a free market

While some nurse unions have been able to demand raises from large hospital systems during the pandemic, health facilities that see primarily patients who have government health insurance are often more limited in what they can pay. Nursing homes are overwhelmingly paid by Medicaid and Medicare, so they say the rates they can pay nursing staff are largely determined by how much the government programs reimburse per patient, and hospitals in low-income areas can face similar situations.

About 70% of the costs of operating a nursing home are related to labor, according to Clif Porter, senior vice president of government relations at AHCA/NCAL. But even as facilities have had to pay two to three times normal wages to hire temporary nurses during the pandemic, their reimbursement rates have not kept pace. “I can’t pass on inflation to my customer,” he says. “This creates a situation where our expenses exceed our revenue. It’s just that simple. And that’s just not sustainable.”

Porter says that he doesn’t want maximums for what nurses can make, but floats the idea of a cap on agency profits or regulations that stipulate how much of what a staffing agency charges it must pass on to its workers.

“If the legislation were to directly impact the [agency] overhead, we don’t believe that nurses salaries would be impacted,” says Ernest Grant, president of the American Nurses Association. But the ANA does not support any effort to lower nurse wages, and Grant added that the concern over price gouging has “become quite a distraction.”

Mahon agrees, saying the idea of investigating these staffing agencies will not solve the staffing crisis. Even if the health care facilities are not happy about the rates these staffing agencies are charging, she notes, they have found the money to pay them. “If there was serious reflection and introspection and desire to solve [the nursing shortage], it would be focused inward by this industry,” Mahon says.

More nurses, better treatment

Nurses groups’ say there are other solutions that could retain and attract a larger workforce. NNU would like to see minimum staffing ratios, enhanced workplace safety measures, and increased funding for nursing education, for example. The ANA has also promoted ideas including improving nurse hours and mental health support, adjusting the Centers for Medicare and Medicaid Services payment methods, and removing barriers that make it difficult for nurses to practice. “We really need to address it once and for all, and not just cap it off at this particular time,” Grant says.

Desperate to retain staff, Thomas Health, where Jennie Kahn works, has increased bonus pay, instituted recruitment bonuses, expanded its tuition repayment programs and started offering its staff free meals at hospital cafeterias.

The University of Vermont Medical Center, meanwhile, just agreed to raise its nurse’s wages by 20% over two years, with 10% being implemented now and an additional 5% coming in October 2022 and an additional 5% coming in October 2023.

Though Snell says the raises are a positive step toward retaining staff, she’s not certain it is sufficient to stop the bleeding. A study released in October by the American Nurses Foundation reports 21% of nurses nationwide said they planned to resign from their jobs within the next six months. Another 29% said they were considering leaving. University of Vermont Medical Center is not immune.

“We have a lot of nurses leaving our hospital to go travel,” she says. “I’m hoping the 10% right now will be enough to maybe keep some of them in place.”

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Write to Abby Vesoulis at [email protected] and Abigail Abrams at [email protected]

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