Use of Temporary Nurses Shown to Help Save Lives

By Jennifer Larson, contributor

January 24, 2013 - If your healthcare staffing plan includes the use of temporary or agency nurses, there is new evidence that they can do much more than supplement your workforce--they can help save lives.

A new study at the University of Pennsylvania School of Nursing for Health Services Research has found that using supplemental registered nurses, or SRNs, doesn’t have a negative impact on patient mortality. In fact, the use of temporary nurses can help alleviate the problems that may lead to a higher mortality rate. 

This should be welcome news for the many hospitals that rely on supplemental nurses for various reasons, noted BJ Bartleson, RN, MS, vice president of nursing and clinical services for the California Hospital Association.

“I was happy to see the study,” she said. “It helps reinforce the fact that hospitals strive to provide the very best quality that they can to the public.”

The new study examined data from four states, including 600 hospitals, 40,000 nurses and approximately 1.3 million patients. It was funded by the National Institute of Nursing Research, the National Institutes of Health, the American Nurses Foundation and the American Staffing Association Foundation.

Bartleson was also glad to see the study address the perception of a disparity between the temporary nursing workforce and the permanent hospital nurse workforce.

“It helps us change the perception that the quality of temporary staff is not up to snuff,” she said.

The study’s lead author, Linda Aiken, PhD, FAAN, FRCN, RN, professor of sociology and nursing and director of the Center for Health Outcomes and Policy Research (CHOPR), and her co-authors wrote, “Considering that supplemental nurse staffing is a $3.6 billion per year market, there is remarkably little rigorous research on the outcomes or cost of supplemental nurse use.”

The authors also noted that while some past studies may have influenced perceptions of quality issues, they concluded that poor patient outcomes thought associated with hiring of temporary nurses are more likely the result of poor working conditions. They explained, “[t]he findings from our study suggest that the seemingly negative effect of greater use of agency-employed supplemental registered nurses on patient mortality and failure to rescue may have less to do with the characteristics of the supplemental nurse than the characteristics of the work environments in the hospitals in which they are employed.”

Many hospitals now use temporary nurses as a strategic part of their staffing plan, but the researchers called for hospital executives who must continually employ a large number of supplemental nurses to fill vacancies to “evaluate whether deficiencies in work environments in their institutions are adversely impacting their success in attracting and retaining qualified permanent nurses, as well as possibly adversely affecting patient outcomes.” Their premise: improvements in the nursing work environment will likely improve the quality and safety of care.

This study helped reinforce findings from a recent study published in Health Affairs that found the education, experience and characteristics of temporary nurses are very similar to permanent nurses, and a 2007 study published in the Journal of Nursing Administration by Aiken’s team at CHOPR that found temporary nurses have similar qualifications and their use was associated with lower levels of adverse events. The 2007 researchers also concluded that poor hospital working environments were more likely to cause poor outcomes. “Supplemental nurses obviously can't change these factors but they can help diminish risk factors by improving staffing levels and continuity of care," they wrote.

And work environment is something that hospital leaders can change. For example, a growing number of hospitals have worked to achieve the prestigious Magnet designation from the American Nurses Credentialing Center (ANCC)--a designation that rewards and promotes nursing excellence. Of course, not all hospitals have the resources to complete the Magnet process, Bartleson said, but they can still adopt some of the overarching principles that would show their commitment to having a positive work environment. For example, they might incorporate shared governance models in which clinical nurses have a voice in the decision-making process.

Hospitals are likely to rely on the supplemental nursing workforce even more in the future, especially since the nursing shortage, which had eased during the recession, is expected to rebound to previous levels later this decade.

“My understanding is that this is a temporary state of affairs,” said Alwyn Cassil, director of public affairs for the Center for Studying Health System Change. 

“Nurse shortages in the future seem likely despite recent increases in graduation of younger nurses nationally,” wrote Aiken and her co-authors, adding that the shortages are a concern because “inadequate nurse staffing has been linked to poor quality of care and adverse patient outcomes.”

Factors contributing to the nursing shortage include the millions of additional patients who are joining the ranks of the medically insured because of the Affordable Care Act and the aging of the baby boomer generation--which will cause more retirements of nurse faculty and the most experienced nurses in the workforce, along with the increasing needs of an aging population.

Cassil noted that temporary staffing does incur costs that show up on the balance sheet, and the struggle to be more efficient will continue to challenge healthcare organizations in the future.

But cost containment and efficiency efforts require more than just a comparison of hourly cost differences between permanent and temporary nurses, noted Marcia Faller, chief clinical officer for AMN Healthcare. “Employers need to consider the overhead costs of having too many permanent clinicians throughout the year, as well as the potential problems for their patients and financial fallout that can occur from not having enough staff to handle the patient load. Experienced staffing companies like AMN can help hospitals be sure that they have the right amount of qualified nurses at the right time.”

In today’s healthcare environment, healthcare providers need to be flexible--for example, bringing in nurses to cope with a spike in admissions during a bad flu season.

“Being able to creatively meet that [type of] challenge is going to be a priority for all healthcare leaders,” said Cassil.

Co-author Ying Xue, DNSc, RN, associate professor, University of Rochester School of Nursing, who headed the 2012 Health Affairs study, noted that more evidence on the impact of the supplemental nursing workforce on the quality and cost of patient care is needed.

“The multi-state study led by Dr. Aiken really explores this topic further by looking closely at the impact on supplemental nurses on two important patient outcomes--in-hospital mortality and in-hospital failure-to-rescue--and provides very useful evidence,” Xue said. “It represents another step to inform future studies and discussion on this topic.”

As Aiken said in a statement, “Our study showed these nurses could be lifesavers.”

Related articles:
Temporary Nurses Have Similar Education and Experience, More Diversity than Permanent RNs
Creating a Great Nurse Work Environment to Improve the Bottom Line
New Online Tool Helps Facilities Compare Nurse Labor Costs
National Study Shows Temporary Nurses Deliver Quality Care

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