An increasing reliance on travel nurses is contributing to high turnover rates among nurses in Massachusetts, as health care remains strapped by labor shortages here and around the country, according to a Health Policy Commission report.
The issue has caught the attention of Health and Human Services Secretary Kate Walsh, who says the hospital industry has to "get rid of these usurious travel agency contracts that hurt everybody," and the attorney general has put temporary nursing agencies on warning of violating rate payment rules.
Registered nurse vacancy rates in Massachusetts hospitals doubled from 6.4% in 2019 to 13.6% in 2022, with especially high vacancy rates in community hospitals, the HPC report says .
The widespread industry shortage does not appear to be caused by fewer people wanting to become nurses, but rather nurses leaving the field after they had already begun working, the report shows. The number of people completing nursing programs did not change during the pandemic and, in fact, there was an increase in the number of people earning advanced nursing degrees in 2020.
When COVID-19 arrived in 2020, hospitals turned to traveling health care workers to fill gaps at facilities around the country that were overwhelmed.
As of 2021, these contracted workers represented about 5% of hospital patient care labor costs in the state, the report says. Across Massachusetts, health care facilities paid $1.5 billion to these workers in fiscal 2022 — a 154% increase over the previous year.
Travel nurses are not employed by a specific facility, but take temporary jobs in high-need areas. They are often paid more than their peers who are employed at hospitals or other care centers, and their wages spiked in 2020 and 2021, adding strain to health care facilities.
As of 2022, average wages for contracted nurses in Massachusetts were nearly double the average wage of employed nurses.
The increasing reliance on these traveling nurses affects incumbent employed nurses, said Sasha Albert, the commission's associate director of research and cost trends. They have to take on additional roles, including administrative and training tasks, and are paid less than contracted nurses doing the same work.
Albert said these facility-employed nurses, who usually have institutional knowledge, are being stretched too thin and are leaving their jobs — which then leads to more need for contract nurses.
"It just decimates morale," said Tara Gregorio, president and CEO of the Massachusetts Senior Care Association. "And for the patient it is wildly disruptive to patient care. Pre-pandemic we were very focused on the gold standard of consistent assignment. That's not possible when you have strangers taking care of strangers."
Vice president-at-large of 1199SEIU Filaine Deronnette echoed Gregorio's statements about the additional burdens placed on employed nurses.
Facility-employed nurses often also have to take on the role of training the temporary workers on how the systems in their care facility work, as well as teaching younger, early career nurses who are increasingly filling gaps where more experienced nurses worked previously, Deronnette said.
"Imagine working a shift, but having half of the staff be temporary and having the burden of showing and orienting every shift," she said.
Employed health care workers at acute care facilities are also having to take on additional overtime shifts, voluntarily or oftentimes mandated, Deronnette said, to fill vacancies.
"You can imagine the immense strain on families, physically and emotionally, for parents canceling your time with family," she said. "So the impact is on the patient, it's on the worker and I would say the community."
Many nurses have left patient care for administrative or research roles within health care, such as at insurers or on clinical trials, the report says.
"Under these conditions, experienced nurses may leave, new nursing grads who have not been able to be set up for success will also have high turnover, and the whole nursing unit faces a cycle of entrances and exits, a loss of institutional knowledge, a depletion of continuity of care and further strain for the nurses who remain, some of whom may then leave themselves," Albert said.
Community health centers have been among the most affected by the shortage. Nationwide, over two thirds of community health centers lost between five and 15% of their workforces during the pandemic.
The question of where traveling nurses fit into Massachusetts' health care system is on the minds of lawmakers, Gov. Maura Healey's administration, the attorney general, and the trade group that represents hospitals.
Massachusetts Health and Hospital Association President and CEO Steve Walsh said this month that the health care workforce market in Massachusetts "has been upended and it is unclear where the change is taking us." Travel agencies and temporary worker trends have "introduced a highly volatile variable in the budgeting and forecasting models hospitals use to remain financially stable and accessible to patients," he said. "Any state effort to analyze and constrain healthcare cost growth must recognize this dramatic workforce shift now occurring. This is a trend that demands our collective policy focus."
At a budget hearing on Monday, Rep. Matt Muratore of Plymouth asked Health and Human Services Secretary Walsh about her thoughts on capping the number of traveling nurses allowed to work in Massachusetts.
Walsh, the former president of Boston Medical Center, responded that fixing the problem is "more complicated" than just paying employed nurses more.
"The traveling conundrum is more complicated than just rate ... Oftentimes, nurses travel because we, or my former job at the hospital, couldn't give them the flexibility that they need for their life," she said.
She told lawmakers about a program through Boston College's nursing school that places graduate students in the surgical ICU at Boston Medical Center. This program attracts "the best and the brightest," she said, but all the students were going on to do an advanced nursing degree in specific disciplines, rather than working as a general RN in a hospital or community health center, because it allowed them more flexibility with telehealth.
"So I think the challenge to the hospital industry is to, yes, get rid of these usurious travel agency contracts that hurt everybody. But we also have to think differently about how we staff hospitals. People expect flexibility in their lives," Walsh said. "But I think that's, that's part of the answer to the traveling conundrum, which gets us to the supply, which is how can we get more more people into this profession."
Other than offering more flexibility, Walsh said another way to attract more nurses to salaried employment through a hospital is through creating a career ladder for them to advance without having to look to move to other facilities.
Healey proposed $10 million in a supplemental budget she filed earlier this month to create new career ladder incentives for licensed practical nurses. She wrote in her filing letter that these funds would "support nursing facilities and home- and community-based services providers in their efforts to retain direct care staff and upskill them to LPNs. The program would fund no-interest loans and grants to support the cost of attending an LPN certification program, as well as living expenses while attending."
Hours after the release of the HPC report, Attorney General Andrea Campbell issued an advisory on Wednesday afternoon "to notify temporary nursing agencies concerning the permissible rates that may be charged to long-term care facilities" in light of allegations that some temporary nursing agencies have attempted to demand additional fees.
These workers are not travel nurses. Travel nurses work based on contract assignments and often move to a new city for a short period of time to work at a facility before moving to a new assignment. Temporary nurses can pick up one-off shifts.
The advisory says the attorney general's office has received allegations that temporary nursing agencies have offered to contract with long-term care facilities at rates "well in excess of the maximum rates" set by the Executive Office of Health and Human Services, claimed that the maximum rates were suspended due to COVID-19 when they have not, and proposed excess rates during inclement weather, among other alleged violations.
"Affordability continues to be a major challenge for Massachusetts residents and their loved ones seeking long-term care, which is why temporary nurse staffing agencies need to adhere to state regulations," Campbell said in a statement. "Today's advisory serves as a resource to these agencies and a reminder that my office stands ready to act if temporary nursing agencies attempt to overcharge or mislead long-term care facilities in the Commonwealth."