Health systems are increasingly reliant on travel nurses, more flexible hours for nurses and simply making do with less as the nurse shortage has only grown worse since the pandemic began.
Delaware-based ChristianaCare, and other systems across the country, have grappled with how to maintain quality when a flux of new nurses face a steep learning curve that could affect patient care.
"Imagine you're a nurse and you have you have a skill set that theoretically translates across care areas, but there are potentially over fifty central lines offerings in the U.S., the dressing [at an individual hospital] might be different, the technique of maintaining it might have slight variation and the regimented steps around how often you should clean the line before and after you stick a needle to give medication might be different: all these steps go toward preventing a central line bloodstream infection" said Dr. Kert Anzilotti, ChristianaCare's chief medical officer who oversees quality and safety.
Nurses who would normally start with a weeks-long training course in a particular unit were thrown into immediate bedside care.
"The traveling nurses and the people that we've redeployed have done an outstanding job for us, but it was tough learning a new environment and quite honestly doing it while you were scared and worried about your own health and the health of your family," Anzilotti said.
When all the individual steps that go into preventing a type of infection are unknown, or done a little differently, it can lead to increases in adverse outcomes. Anzilotti said they have not seen these increases in their data. But it has happened at least one hospital system, according to a recent study in the American Journal of Infection Control.
Researchers from Northwestern Medicine in Illinois charted healthcare-acquired infections at two hospitals with combined 1,000 beds over a three-year period ending Dec. 2020. They found a correlation between increased infection rates and the use of agency nursing and overtime hours during the pandemic.
"Increased attention to adherence of device bundle elements, device necessity and observations of [hospital] practices including hand hygiene and cleaning should occur, particularly during a pandemic surge when staff are flexed to work in alternate locations or when increase in agency staff are utilized," the authors wrote.
Earlier this month, ECRI also recognized staff shortages as the top risk to patient safety for 2022, a notable move considering previous reports have focused on issues like diagnostic errors or cybersecurity attacks.
"Adverse events that we found were happening because the staff they did have were exhausted, and that contributes to contributes to human error" said Sheila Rossi, director of the watchdog's patient safety organization, the Institute for Safe Medication Practices, which collects hospital adverse event reports. "You can't think clearly you have too many tasks to do, and that's a common theme that we were seeing."
Hospitals also redeployed administrative nursing staff that had moved into leadership roles that were still licensed to practice, throwing another layer of workers in who lack in-depth training on specific units.
While there is robust research on what happens to patient safety when there are not enough nurses to properly care for patients, there is a deficit of data on the impact of travel nurses to patient safety and quality.
That's in large part because there's no main database of how many agency nurses a hospital is using at any given time. Dr. Ying Xue, associate professor at the University of Rochester School of Nursing, said most studies on this are small scale and come from individual hospitals that can pull their own data on agency nurses to cross reference with quality outcomes. Xue published a study in 2012 based on her institutions' data that found no correlation between travel nurses and quality.
"I was very fortunate to gather data from our medical center to study that topic, but that's why my study has a limitation, because the result was based on one medical center," Xue said.
But there won't be a more definitive answer to how travel nurses impact quality without larger studies with data across multiple hospitals. The renewed focus on travel nurses and their monetary cost may lead to more research as hospitals look to collaborate more due to the pandemic.
For now, hospital leaders can focus on specific procedures and create short, how-to videos with a QR code for nurses to scan and watch on their phones at the bedside. Or the hospital could place signs next to medical supplies with the order they're used and instructions on how to use them. Medical supply manufacturer Medline's director of clinical services Angela Zuick is starting to work with hospitals on these solutions.
"We need to be more proactive and think about what our needs will be when we have to use travelers, and put together some solutions, almost like a first aid kit," Zuick said, who is also a former critical care nurse manager. "This just-in-time education is something we should continue to focus on to prepare ourselves to provide success for our travelers or outside staff."