Travel nurses make headlines today in Maine because without them many of our hospitals and nursing homes would fail to care for us. But we must ask: Why does our health care system rely on them?
Travel nurses are not the problem. Nurses have traveled for a long time. They have wanted to see the world, teach others their skills and bring their knowledge and compassion to bear in places with need.
COVID is one problem, but the need for nurses is a symptom of a more troubling illness. For the last 20 to 30 years, our health care system has increasingly organized itself around making money. It is now like a garden overrun with noxious weeds choking nurses and others on the front lines who actually care for patients. Our health care system has misallocated our health care resources. It has left our communities vulnerable to the pandemic.
My grandnephew’s wife — I’ll call her Florence — told me that she always wanted to travel. She comes from a small mountain town in western Pennsylvania, is very bright and worked in the intensive care unit of a major New England hospital for five years. The relentless stress of her job pushed her to look elsewhere. She signed up for a 90-day stint with a travel nurse agency and went off with her husband, who works remotely, to a hospital in Miami.
It was a devastating experience, a broken and neglected hospital in a broken and neglected neighborhood — a community with untreated HIV, diabetes, hypertension and rampant COVID, all the consequences of long-term deprivation. After a single day of orientation, she was on her own in an overcrowded ICU — sick patients, new protocols, no nurses’ aides or respiratory therapists, broken equipment that she had to fix herself, a distant medical staff and worse.
This was no vacation in sunny Florida. She worked three to four 12-hour shifts per week and then slept, worked, slept, worked and slept again. She couldn’t wait until her contract ended.
She recovered at home and then signed up with a rural Idaho hospital.
It was quite different — a fundamentally healthy population, a hospital that needed only temporary help to cover for staff vacations. She had primary responsibility for two, not three, ICU patients and a chance to breathe healthy air. Now in the middle of her contract, she said that she would like to extend her stay through the summer to spend time in the great outdoors. Then perhaps to California or Alaska and after that to settle down.
Working in an ICU has always been high stress but is now worse. COVID has tipped the scales. The emotional toll is exhausting.
Florence loves the challenge and intensity of her work but over the last eight months she has had many — too many — patients die of COVID. Not one has been vaccinated. Those with COVID complications have made the care of other sick patients more difficult. ICU beds are filled and a patient with a heart attack, out-of-control diabetes or a stroke must often wait. Death — all too often avoidable — has been her constant companion.
Travel nurses are paid two to three times as much as the local staff nurses with whom they work side by side. Pay is a major incentive. In Idaho, Florence receives $95 per hour, with $190 per hour for overtime (about $4,000 a week).
Pay is high because hospitals see no alternative — they must either pay what a travel nurse agency demands or not deliver care. Travel nurses can make the difference between a functional or a failing ICU, keeping an endoscopy suite open and generating revenue for the hospital or closing it down.
Here in Maine, Northern Light Health has about 3,000 nurses across its 10 hospitals, 150 of whom are travelers, according to Deb Sanford, vice president of nursing and patient care services at Northern Light’s flagship hospital, Eastern Maine Medical Center in Bangor. The latter costs the hospital system $150 to $200 per hour, “with a large portion of that fee going directly to the agency,” Sanford told me.
The median hourly wage for a registered nurse in Maine is $33.14, according to the state Department of Labor. The entry-level wage for an RN is $26.35.
“The total compensation of our nurses is in line with the regional market, but below the unsustainable rates we are being charged by traveling agencies,” Sanford said.
Overhead makes a direct comparison between pay of staff nurses and travelers complicated. But there is no question that travel nurses are a very expensive bandage on a broken health care system, one that inflates pay for administrators while limiting it for nurses on the front lines providing care. The publicly available 990 tax form for EMMC, for example, shows that senior vice presidents in charge of various departments at the Bangor hospital earn at least $300,000. That’s more than four times the median pay of an ICU nurse who lives daily with patients facing life or death situations.
Into this system step firms that employ traveling nurses, charging high rates to big hospitals as well as poorer players such as nursing homes, clinics and small hospitals with limited financial resources. For the latter, the high cost of traveling nurses is another step on the path to insolvency.
Adding to the problem, the agencies that provide traveling nurses are increasing the fees they charge by two to three times over their pre-pandemic rates. Their greed has prompted the American Hospital Association to ask the White House and the Federal Trade Commission to investigate possible price gouging.
Agencies have hospitals and other providers in an impossible bind: without nurses, hospital units and nursing homes will close; with expensive agency nurses they also risk closure.
As a physician, I look for the underlying cause of symptoms. The increasing number of travel nurses here in Maine are a symptom of a profound illness: The organization of our health care system is sick. Nurses on the front line are responding with their feet.
We all will continue to bear the expense of treating symptoms until we begin to put patients over profits and rethink the way we deliver health care.