Critical Care Plus: Using Travelers’ to Meet Staffing Needs is Harder in ICUs 

Reasons for Hiring Temporary Staff Determine Success, Administrator Says 

By Julie Crawshaw, Critical Care Plus Editor

Travelers—those icu nurses, respiratory therapists, radiology techs, and critical care personnel who are not permanent staff members—are a hot topic in critical care circles these days, and hospitals face tough questions about whether and how many of these people to use.

The problem is especially significant in ICUs where the hospital’s sickest patients make a high degree of smooth staff interaction an absolute necessity.

On paper, travelers offer the necessary qualifications, says Max Harry Weil MD, PhD, MACP, Master FCCP, FACC, Distinguished University Professor and president of the Institute of Critical Care Medicine in Palm Springs, CA. But in practice, Weil says, travelers are not likely to function as competently in the environment over the short run because it takes time to learn how to respond to other personnel, patients and the culture of the hospital.

"The staffing turnstile we now face is hardly an ideal system," he adds. Hospitals, Weil observes, can’t keep their doors open if they fail to provide accredited staff and will use whatever means they have to recruit those staff from agencies, even those located as far away as Canada and the Philippines.

The underlying problem is macro-economic, Weil says, because medicine is now a marketplace in which well-industrialized HMOs and for-profit hospitals are giving philanthropic organizations and non-profit hospitals a run for their money.

"The only response to a personnel shortage in an industrialized environment is to make the position more competitive," he adds, noting that in many places registry personnel are better paid than permanent personnel. "More competitive means that the incentives for becoming a critical care nurse attract an increasing number of entry-level personnel."

Weil, who was the first president of the Society of Critical Care Medicine, says the problem is exacerbated because modern hospitals are turning into one large intensive care unit due to the large volume of patients who now receive care as outpatients.

"What’s left in the hospital is more severe disease," Weil says, "What appears to be more intense need and sicker patients actually has to do with shorter hospital stays, more outpatient-delivered care, and more elaborate and invasive procedures."

Reasons Affect Success

No matter the reason, hospitals must hire some temporary labor or risk longer hours for existing staff and fewer resources for patients. But Paul Ocon, RN, MPA, administrator of Critical Care Service at Children’s Memorial Hospital in Chicago, says the reasons hospitals use travelers determine how much benefit they receive.

Planned back-filling around unavoidable staff fluctuations, such as when a temporary nurse comes on board for a permanent staff nurse’s maternity leave, enjoys much more success than using travelers because the hospital can’t keep regular staff on board, Ocon says. "The impact of today’s nursing shortage tests what I learned in nursing school, namely that there is no shortage of nurses, only a shortage of places where nurses want to work," he adds.

Solving the problem goes beyond being a good employer. Ocon believes that hospital personnel must share a strong sense of mission and commitment throughout the personnel ranks.

"We’re a magnet hospital and are very proud of the things we do to help retain our team," Ocon says. He adds that the American Nurses Association made Children’s the first hospital in the country to receive its prestigious Nursing Excellence Magnet Award. "It means we as health care leaders and clinicians need to promote opportunities in our professions versus discouraging the next generation from joining our ranks."

The positive side of temporary labor, Ocon notes, is that it attempts to provide the right number of caregivers to provide appropriate care. Using travelers may also help a hospital implement retention strategies by allowing clinicians to work every third weekend instead of every other weekend.

The downside factors of travelers are that their costs are extremely high, the team dynamics between temporary and core staff become complicated because the traveler must learn new systems, and hospital administrators must expend additional time and energy making sure traveling staff are competent.

As the pediatric teaching facility of Northwestern University’s Feinberg School of Medicine, Children’s Memorial faculty includes specialists in every known pediatric specialty. Ocon says this translates to patients with a higher acuity level and that translates to a greater demand for experienced clinicians at the bedside.

The best results occur when travelers become committed to the hospital’s mission, Ocon says, a feat much easier said than done. Some travelers apply because they want to live in a particular city or climate. Many seek temporary work only because the pay is better than a permanent position in the area they left.

"It’s hard to align temporary labor’s motivation beyond the dollars and that sometimes reflects in the type of care they provide," Ocon says, adding that it’s much easier for a hospital to train and measure competence in permanent staff. With a temporary agency, administrators really have to ask some probing questions about the type of training travelers have had and what equipment they know how to use.

(For more information contact Max Weil, MD, at [760] 323-6867; and Paul Ocon [773] 880-3947.)