Can contracted nursing transform health care?

FigureWHAT DO WE KNOW about travel nurses? More important, what should we know to better understand the value travel nurses provide to health care organizations and the health care of those we serve? Travel nurses (TNs) are contracted employees, usually employed by an agency that contracts services with a health care organization. TNs are also referred to as temporary nurses, agency nurses, or contract nurses. TNs were in the headlines during the COVID-19 pandemic, as the demand surged. Health care organizations were desperate for clinical nurses to meet the mounting demands for patient care. Prices soared and many nurses left their regular positions to join the ranks of TNs. Contract staff aren't unique to nursing. Other industries such as information technology; financial services; federal, state, and local governments; marketing; and hospitality services use contract employees. The advantages of contracting for staff across all industries are that staffing can be based on needs, specialized skills, cost management, and “try before you buy” to evaluate the potential for engaging the individual in a permanent position. WHAT MAKES HEALTH CARE DIFFERENT? Many health care leaders argue against the use of TNs. Their opinion is that TNs, because they're not employees, aren't fully integrated into the organizational culture, ethics, and processes, and don't have loyalty to the institution. A minority opinion is one that welcomes TNs and leverages their experience in professional governance and clinical improvement activities. But what do we really know, beyond the opinions? WHAT DOES THE RESEARCH TELL US? Much of the recent research on TNs has been focused on their experiences during the COVID-19 pandemic, and the differences between TNs and non-TNs. Early in the pandemic, Hansen and Tuttas found similarities in happiness scores among veteran TNs (those who were travelers both prior to and during the pandemic) and permanent staff nurses, and differences between those groups and new TNs.1 These researchers also reported animosity growing between the TNs and the nontravel nurses. In a large-scale national study of TNs and non-TNs' perceptions of the work environment, Fiore-Lopez and colleagues found no meaningful differences between the two groups.2 In their systematic review of TNs and patient outcomes, Vander Weerdt and colleagues concluded that the literature failed to identify a consistent relationship between TNs and patient outcomes.3 Zhong and colleagues identified significant differences between TNs and non-TNs on key background variables garnered from the 2022 National Nursing Workforce Survey (NNWS).4 TNs were younger, reported higher pay, and held more multistate licenses. TNs also reported higher rates of work stress and burnout.4 The 2024 NNWS was recently published and comparisons regarding TNs and non-TNs in the 2022 and 2024 surveys will increase our knowledge of differences pre- and postpandemic.5 Nurse leaders are challenged in understanding how these temporary employees contribute to both patient and organizational outcomes. Future research should prioritize patient outcomes as well as explore organizational factors associated with TNs. There are opportunities for cross-sectional national and global studies. Also, there are opportunities for pilot programs aimed at addressing new organizational models for integrating TNs into the workforce, and new models of professional nursing practice in contractual relationships with health care organizations. WHAT IF? For years, the practice model for engaging physicians to provide clinical services in health care organizations has been through a formal legal arrangement with a professional practice corporation (PPC). These physician-led (and owned) organizations ensure that the clinical practice of medicine adheres to regulations, and, importantly, control over medical practice lies within the PPC. What if professional nursing services provided to health care organizations were contracted similarly? In a scenario where professional nurses controlled the work they do within health care organizations, would a significant portion of their time still be spent on nonnursing tasks? Many reasons are cited for why nurses perform nonnursing tasks, including staffing shortages of other personnel and organizational factors. Examples of nurses, particularly advanced practice nurses, contracting their services exist but this isn't the predominant organizational model for the provision of nursing care in health care organizations. Within PPCs, nurses could control all professional nursing. Although this isn't the current model underlying the TN industry, there are components within the organizational structure that are similar. Specifically, professional nurses wouldn't be employees of health care organizations and would contract only for professional nursing services. They wouldn't cover the work of ancillary personnel or assume responsibilities outside of the scope of practice of professional nursing. They also would set the standard for reimbursement of professional nursing services. No longer would the value of nursing be masked. Concomitant with the clarification of professional nursing practice would be the necessity to capture the work of nurses through use of specific professional nursing terminology embedded within clinical records. There are many opportunities for research; nurse leaders and researchers must seize these opportunities to guide health care and professional nursing practice in the future.