Study: Temporary nurses not a threat to quality

Negative perceptions unfounded

Contrary to popular belief, negative perceptions of temporary nurses may be unfounded, say the authors of a new study in the Journal of Nursing Administration.1 In fact, they argue, temporary nurses have qualifications similar to those of permanent staff nurses, and while hospitals employing more temporary nurses do have poorer quality, other factors such as work environment are more likely to be the main cause.

"Our research center [The Center for Health Outcomes and Policy Research] prides itself on taking a hard look at widely held assumptions in health care that have not been sufficiently tested," explains Linda Aiken, PhD, FAAN, FRCN, RN, director of the center at the University of Pennsylvania School of Nursing in Philadelphia and lead author of the paper. "And when we look at them more seriously, they turn out not to be right."

This, apparently, pertains to commonly held perceptions about supplemental nurses. "We had done some of the defining work showing that hospitals with more nurses have better outcomes," she continues. "We thought about that, and about the general assumption often found that the use of supplemental nurse staffing adversely affects quality — that the use of supplemental nurses becomes a proxy for poor quality. That did not really line up behind the empirical information that having more nurses is better for quality."

For supplemental nurses to be associated with an adverse affect on outcomes "would require some terrible mismanagement in deployment of these nurses, or the fact that they had so little orientation that they were dangerous," Aiken asserts.

An objective look

In order to get a truly objective look at these hypotheses, Aiken and her team reviewed data from the 2000 National Sample Survey of Registered Nurses to determine whether the qualifications of supplemental nurses working in hospitals differed from those of permanent staff nurses. "This is the most comprehensive study of the national nursing labor force, conducted every four years by the federal government," Aiken explains. "In looking at education, we found that supplemental nurses were more likely than nurses, in general, to have a baccalaureate degree, and were more likely to be within 10 years of graduation — a positive factor given the rapidly changing science of nursing." In addition, she says, supplemental nurses are more likely to work in ICU settings — which implies they have sophisticated clinical skills.

"After confirming they were just as qualified, we looked more closely at [outcomes at] hospitals that employ supplemental nurses," she continues, adding that most hospitals in the United States do hire temporary nursing help — "even the best hospitals in America, and even the so-called 'magnet' hospitals."

Hospitals were categorized by the percentage of all supplemental staff — travelers, floaters, and so forth. "We found that those hospitals that employed the largest number of supplemental nurses as a proportion of their staff did have some poor outcomes based on the overall assessment by permanent nurses, as well as adverse events like falls with injury, infections, frequent medical errors, and family complaints," Aiken notes. "The outcomes tended to look worse in hospitals that used a lot of supplemental nurses, and that's why I think the association has developed."

Digging deeper

However, Aiken and her team moved on to the next step: "disentangling" the data.

"We were able to show in our paper that the outcomes in these hospitals were poor because they have a very deficient nurse worker environment, so they can't keep and attract enough of their own nurses," she explains. For example, she says, there is a maximum number of patients that a nurse feels comfortable taking care of, and once you go over that ratio you can't retain your staff. Other factors include poor relationships with top management, non-responsive management, the failure to invest in the education of the nursing workforce, and so on.

"In fact," says Aiken, "we concluded that by the very fact that they had temporary nurses, the outcomes at these hospitals were not as bad as they would have been."

Ensuring safety

Since the use of temporary nurses in and of itself does not seem to affect patient safety, what can be done to optimize patient safety when temporary nurses are used?

"Obviously, orientation is very important," says Aiken. "We interviewed the leadership in a number of staffing companies, and they all invest tremendously themselves in orientating their nurses at the hospitals where they work. They also try to send the same nurses to the same hospitals."

Orientation, however, is a joint process between the staffing firm and the hospital, Aiken continues. "New supplemental nurses should be working jointly in some mentored relationship with a current permanent nurse," she says. The time period for this preparation varies "dramatically" from hospital to hospital, she continues, "but you probably need to have a minimum of a week where there is some mentored relationship with a staff member."

It's also critical, Aiken says, for staff to be open to the idea of supplemental nurses — "to know these are qualified individuals, and be more open on how to deploy them as colleagues." Staff nurses, she notes, can often be hostile about having supplemental nurses come into the facility. They perceive that they make more money, which may or may not be true once benefits are factored in. "Try to debunk these myths within the organization," she advises quality managers.

Finally, she says, "one of my major recommendations to hospitals on the quality side is to really think about how to use supplemental nurses more strategically, rather than as substitutes for missing permanent staff."

For example, she says, at her own facility it was determined that patient/nurse ratios needed to improve. "We made a commitment to that staff that in order to retain these ratios, we would bring on enough nurses to effectively reduce the ratio in 'med/surg,' and there was no way we could do that immediately unless we used supplemental nurses," she explains. "We used a strategic plan that included beginning to recruit our own permanent nurses at the same time, and as we got more permanent nurses, we used the supplemental nurses on a declining basis."

In other words, she says, "explain to your staff that you are gaining something that they all value — in this case, overall long-term improvement in ratios. Everyone understood this would lead to the achievement of a strategic goal that they all valued."

Another strategy, she suggests, might be involving supplemental nurses while in pursuit of magnet status. "Many hospitals are working on magnet status, and that involves a lot of additional work for the nurses," she notes. "So, you could bring on additional supplemental nurses and be explicit with your own nurses that this is a resources investment in the successful achievement of magnet status."

Finally, she says, if you find you have to constantly use supplemental nurses, "something within your HR policies and clinical care setting needs to be fixed." For your permanent staff's sake, other than for seasonal swings or short-term shortages, these nurses should be only used for a justifiable strategic reason. "If you have to use them in a non-strategic manner, I suggest there should be a focus on improving the work environment for your nurses," she concludes.

[For more information, contact:

Linda Aiken, PhD, FAAN, FRCN, RN, Director, The Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Room 332 Fagin Hall, 418 Curie Blvd., Philadelphia, PA 19104-6096. Phone: (215) 898-9759. E-mail:]


  1. Aiken, LH, Xue Y, Clarke SP, Sloane DM. Supplemental Nurse Staffing in Hospitals and Quality of Care. J Nurs Adm 37(7):335-342, July/August 2007.