Supplemental nurses are a small but nontrivial group of RNs in hospitals. A high proportion of supplemental nurses works in critical care units, where the need for nurses with specialized skills is high. The analyses provided no indication that supplemental nurses were less qualified than permanent staff nurses; supplemental nurses were more likely to hold baccalaureate and higher degrees and were as experienced as permanent nurses. This is not altogether surprising, because supplemental nurses and staff nurses are not distinctly different groups. More than half of the supplemental nurses reported that their temporary nursing position was secondary to a primary job as a hospital staff nurse.
The Pennsylvania data analyzed here did not suggest that higher use of nonpermanent nurses caused safety and quality problems for nurses or their patients, nor that higher levels of nonpermanent nurses were linked to poor job satisfaction among permanent nurses. Rather, it was observed that more nonpermanent nurses were found in hospitals where staffing and the adequacy of other resources were rated lower, which seems logical because temporary nurses are brought in explicitly to compensate for shortfalls of permanent staff. Higher levels of nonpermanent nurses were not associated with events suggestive of quality problems in hospitals. After controlling for adequacy of staffing and resources, higher levels of nonpermanent staff were actually associated with lower levels of such events, suggesting that resource adequacy is the deeper underlying problem and that nonpermanent or supplemental nurses may mitigate or compensate for nurse staffing deficiencies. Especially with forecasts of a deepening shortage in the coming decades, judicious use of supplemental staff is likely to be one of several strategies that managers and executives will need to draw upon to ensure patient safety and quality care.
The data here indicating that having more supplemental nurses may, in some cases, have a positive impact on patient outcomes are consistent with a previous study that found better perioperative outcomes associated with the use of temporary nurses.25
One exception was that permanent nurses in hospitals with higher proportions of nonpermanent nurses were more likely to indicate intentions to leave their jobs within a year, even after controlling for staffing and resource adequacy. Intent to leave can reflect both local labor market conditions (nurses who believe they have many job opportunities may express greater willingness to leave their positions, all things being equal), as well as poor working conditions in specific hospitals. Consequently, this association may reflect common underlying causes of high use of temporary staff and weaker commitment of permanent nurses to their jobs rather than a negative impact of the temporary nurses themselves.
Several limitations should be noted. In our analysis of the characteristics of supplemental nurses, using the NSSRN, it was possible to identify nurses who worked in primary or secondary jobs for supplemental staffing firms. However, in the Pennsylvania hospital data, it was not possible to distinguish nonpermanent nurses employed by supplemental staffing companies from RN employees of the hospital who move or float to different units on a temporary basis. Also, in the Pennsylvania data set, the proportions of nonpermanent nurses were derived from nurses’ reports of all personnel assigned to their unit on their last shift. Although subject to reporting biases, to our knowledge, survey data currently provide the only means for making direct comparisons across the hospitals in an entire state on both the staffing and the outcomes measures we selected.
In conclusion, national data suggest that nurses employed by supplemental staffing agencies are as well educated (perhaps even more so) and as experienced as permanent nurses in hospitals. Our analyses of nurse-reported outcomes in 198 hospitals in Pennsylvania do not suggest a negative impact of temporary nurses on quality of work life or quality of patient care. On the contrary, our findings are consistent with the body of literature showing that, across many time periods and different states and countries, higher levels of RNs in direct patient care, whether permanent or nonpermanent nurses, are associated with lower rates of patient adverse events. Thus, the assumption that the use of temporarily assigned RNs has an adverse impact on quality of care, although widely held, may be more of a myth than reality. Further research exploring the patient outcomes associated with different staffing approaches is warranted. Executives and managers in hospitals need options in the face of a deepening nurse shortage and should be offered more evidence (and less speculation and conjecture), for making rational staffing decisions.