Association of Travel Nursing With Quality Outcomes in Hospitalized Patients

ABSTRACT

Objective: To evaluate the impact of increased travel nursing on patient safety and infection outcomes.

Study Design: Retrospective analysis of staffing data from a large tertiary center (2019-2023).

Methods: We examined associations between nurse staffing ratios, agency nurse use, hospital-acquired infections, and patient safety indicators (PSIs) using Spearman correlations, analysis of variance, and regression analyses.

Results: Agency nursing shifts rose sharply from 70.9 per month (0.9% of shifts) in 2019 to 1206 per month (12.7%) in 2023 across inpatient units and the emergency department. Over that same period, PSI events increased from 7.1 to 9.3 per month, and total infections rose from 15.8 to 20.5 per month. Hospital-wide, greater reliance on agency nurses correlated with more pressure ulcers (PSI 03), postoperative acute kidney injury requiring dialysis (PSI 10), ventilator-associated pneumonia (VAP), total PSIs, and total infections. In critical care units, higher agency staffing was specifically linked to increased VAP, Clostridioides difficile infections, and overall infections. When agency nurses accounted for more than 10% of the workforce, there was an independent association with a higher number of PSIs, although not with infections.

Conclusions: Rising dependence on agency nurses coincided with increased patient safety events and selected infections. Although confounding factors may contribute to this association, these findings emphasize the need for structured integration, orientation, and monitoring of temporary staff to ensure patient safety while addressing workforce shortages.

Am J Manag Care. 2026;32(6):In Press

Takeaway Points

• Travel nurses are often unfamiliar with new health care systems, unit-based protocols, and unit-based competencies.
• There is a paucity of data on the impact of travel nurses on the quality of care and outcomes in hospitalized patients.
• A higher proportion of travel nursing was independently associated with more complications (patient safety indicators).
• This study highlights the need to understand the nature of the relationship between travel nurses and staffing indices with specific outcomes to establish preventive approaches.

In recent years, the number of traveling nurses in the US has risen sharply. Travel nursing, introduced in the 1980s to address nursing shortages, involves registered nurses (RNs) employed by staffing agencies and contracted to hospitals for short-term assignments (typically 13 weeks). Since the COVID-19 pandemic, many health systems have expanded their internal float pools, further broadening the definition of travel nursing.¹

During the pandemic, nurse vacancy rates increased due to retirements, resignations, burnout, and rising demand, leading to a heavy reliance on travel nurses.² The wage differential between staff and travel roles also made travel nursing a more appealing option.³ Studies on agency nurses’ impact, however, show mixed results: Some report no significant differences compared with staff nurses,^4-9 whereas others link agency use to higher complication rates, including pressure ulcers, bloodstream infections, and reduced efficiency.^10-16 A recent multihospital study found that excess agency nurse hours were associated with more pressure ulcers and perioperative hemorrhages or hematomas.¹⁷ One study suggested benefits, with supplemental nurses helping to alleviate shortages without compromising the quality of care.¹⁸ These discrepancies likely reflect variations in design, sample size, setting, outcomes, and whether staffing ratios were adequately controlled.¹⁹

Most published research predates the COVID-19 pandemic, which strained the workforce and sharply increased the use of agency nurses. During this period, many institutions loosened staffing restrictions, creating new workforce dynamics that may have influenced outcomes. Our study is novel in that it analyzes contemporary data from 2019 to 2023 and assesses hospital-wide outcomes, focusing on nursing-sensitive measures, such as hospital-acquired infections (HAIs) and patient safety indicators (PSIs).

METHODS

Study Design

We retrospectively analyzed hospital-wide data at Cooper University Health Care, a 630-bed tertiary, level I trauma center in Camden, New Jersey, from April 2019 to December 2023. Staffing sheets (2 per day) were reviewed to capture variables of interest. During this period, the hospital experienced nurse vacancy rates above the national average, necessitating reliance on agency nurses.

Inclusion Criteria

We collected data on inpatient units with nonpregnant adult patients as well as the emergency department (ED). We excluded the obstetrics, pediatric, and observation units. The observation unit had patients expected to remain in the hospital for a short time; therefore, they would not be subject to the outcomes of interest.

Variables Collected

Hospital staffing was divided into 3 areas: the critical care area (CCA), the medical-surgical area (MSA), and the ED. We collected data from staffing grids for both day shifts (7 am-7 pm) and night shifts (7 pm-7 am). We recorded the starting patient census (measured at the beginning of each shift) by hospital unit, including the number of nurses, agency nurses, and assignments with 6 patients per nurse on an MSA unit.^20,21 In the CCA, there were no instances of 1 nurse assigned to 6 patients; it is typically 1 nurse to 1 or 2 patients, depending on patient acuity, so a 6:1 ratio here was not included in our analysis. We also recorded the case-mix index (CMI) for the hospital and calculated the nursing ratio as the number of nurses per patient.

Outcomes

We gathered data from PSIs and HAIs during the same period. For the PSIs, we looked at pressure ulcers (PSI 03), hospital falls with hip fractures (PSI 08), postoperative bleeding (PSI 09), postoperative acute kidney injury requiring dialysis (PSI 10), postoperative respiratory failure (PSI 11), and perioperative pulmonary embolism or deep venous thrombosis (PSI 12).

For HAIs, we recorded the numbers and rates of ventilator-associated pneumonia (VAP), central line–associated bloodstream infections (CLABSIs), catheter-associated urinary tract infections (CAUTIs), nosocomial methicillin-resistant Staphylococcus aureus (MRSA) bloodstream infections, and nosocomial Clostridioides difficile infections.

Statistical Analysis

We present categorical variables as numbers (percentages) and continuous variables as means (SDs). We analyzed the associations between staffing indices and different PSIs and HAIs using Spearman correlations. We divided the variable of percentage of agency staffing into 3 groups: less than 5%, 5% to 10%, and more than 10%. We performed analysis of variance to compare the number of PSIs and HAIs between groups. We also conducted a multivariate linear regression analysis to evaluate the independent association between staffing indices and outcomes. We used a forward selection model and considered variables significant at a P value less than .05. All statistical analyses were performed using IBM SPSS Statistics 27.

RESULTS

Census and Nursing Staffing

Over the 57-month study period, the average starting daily census increased across all units (Table 1). The total number of RNs also increased. Nurse-to-patient assignments of 6:1 occurred only in MSA units, increasing from a mean (SD) of 488 (206) in 2019 to 969 (347) in 2022, then declining to 540 (199) in 2023 (Table 1).

Agency Staffing

Agency use rose sharply between 2019 and 2023. The mean (SD) number of monthly shifts by agency nurses in the CCA increased from 4 (3.1) in 2019 to 186 (68.5) in 2022, before falling to 70 (81) in 2023; in the MSA, it went from 65.8 (36.5) in 2019 to 796.6 (245.6) in 2023; in the ED, it went from 1.5 (0.8) to 339.8 (100.6); and overall, from 70.9 (36.7) to 1206 (353.5) (Table 1). As a share of total shifts, agency nursing increased from 0.2% to 2.4% in the CCA (peaking at 7.0% in 2022), from 1.3% to 14.2% in the MSA, from 0.1% to 31.3% in the ED, and from 0.9% to 12.7% overall (Figure 1).

PSIs and HAIs Over Time

PSI events rose from a mean (SD) of 7.1 (2.4) per month in 2019 to 9.3 (5.2) per month in 2023 (Table 2). Among HAIs, VAP per month increased from a mean (SD) of 0.6 (1) to 3.9 (1.6), C difficile from 7.2 (1.4) to 9.3 (2.8), and MRSA from 1.4 (1.7) to 3.3 (2.1). CLABSIs and CAUTIs declined from 1.4 (0.7) and 2.4 (1.2) in 2019 to 0.7 (0.6) and 1.5 (0.9) in 2023, respectively. Overall infections per month increased from 15.8 (1.7) to 20.5 (3.3) (Table 2).

Correlation Between Staffing Indices and Outcomes

Hospital-wide, no significant associations were observed between staffing indices and hospital falls with hip fractures (PSI 08), postoperative respiratory failure (PSI 11), perioperative pulmonary embolism or deep venous thrombosis (PSI 12), CAUTI, MRSA, or C difficile. Higher agency staffing percentages correlated with pressure ulcers (PSI 03), postoperative acute kidney injury requiring dialysis (PSI 10), total PSIs, VAP, and total infections. Nursing ratios correlated with postoperative bleeding (PSI 09). Six-to-one assignments correlated with postoperative bleeding (PSI 09), postoperative acute kidney injury (PSI 10), and VAP. Census correlated with postoperative acute kidney injury (PSI 10), VAP, and total infections. CLABSIs correlated negatively with agency percentage, 6:1 assignment, and census (Table 3).

By unit, in the CCA, agency percentage correlated positively with VAP, C difficile, and total infections; census correlated positively with total infections but negatively with CLABSIs and CAUTIs. In the MSA, CLABSIs correlated negatively with agency percentage, census, and 6:1 assignment, whereas nursing ratio correlated positively with CLABSIs and total infections (Table 3).

Comparison Between Agency Categories

We then stratified by agency staffing percentage into 3 tiers: less than 5%, 5% to 10%, and greater than 10%. There were 25 months when agency staffing was less than 5%, 15 months when it was 5% to 10%, and 17 months when it was greater than 10%. The RN to patient ratio was the same for all 3 groups. On the other hand, the census, the number of 6:1 shifts, and CMI were higher in the group with more agency nurses compared with the others (eAppendix Table [eAppendix available at ajmc.com]). PSIs increased from 7.0 to 7.6 to 10.1 (P = .022) and infections increased from 17.2 to 18.4 to 20.4 (P = .039) in the less than 5%, 5% to 10%, and greater than 10% agency staffing tiers, respectively (Figure 2 and eAppendix Table).

Multivariate Analysis

We performed a linear regression analysis to assess the independent association between staffing indices and the outcomes: total PSIs and total infections. We entered the following variables: year of admission, CMI, total census, RN ratio, number assigned to a 6:1 ratio, and agency nursing tier (< 5%, 5%-10%, and > 10%). We used a forward selection model. For the outcome of total PSIs, the only variable that was significantly associated was nursing agency tier, with an unstandardized coefficient of 1.5 (95% CI, 0.4-2.6; P = .009). For the outcome of total infections, only CMI was significantly associated, with a coefficient of 29 (95% CI, 15.7-42.3; P < .001).

DISCUSSION

Our study offers contemporary insights into the impact of agency nursing on hospital-wide PSIs and HAIs over a 5-year period spanning 2019 through 2023. Our findings highlight a marked increase in agency nurse utilization across all units, particularly in MSAs and EDs, and an associated rise in specific adverse outcomes, notably pressure ulcers (PSI 03), postoperative acute kidney injury requiring dialysis (PSI 10), VAP, and total infection rates. Importantly, multivariate analysis identified agency nursing tiers as independently associated with total PSIs, underscoring the potential influence of supplemental staffing on patient safety.

The utility of contract or travel nurses is straightforward: They address immediate staffing needs. But their use may come at a cost. Prior literature presents conflicting results. Extensive studies involving more than 40,000 nurses across 665 hospitals have concluded that supplemental RNs help alleviate staffing problems and do not worsen outcomes.^4-9 The rationale is that travel nurses possess transferable training and skills that are applicable across various settings.

However, other studies indicate decreased efficiency²² and increased potential for medical errors,²³ likely due to unfamiliarity with hospital-specific protocols, weaker team integration, and transient employment. Travel nurses also tend to be younger and less experienced, factors associated with increased patient safety events.^10,24 Poor outcomes linked to non–unit-based nurses include a higher incidence of bloodstream infections,^13,16 mortality,^14,15 and PSIs¹⁴ as well as decreased patient satisfaction.¹⁵

Our findings align with those of Pittman et al, showing higher agency percentages associated with pressure ulcers,¹⁷ and they additionally demonstrate correlations with postoperative acute kidney injury requiring dialysis (PSI 10) and VAP.²⁵ These differences may reflect our intensive care unit–rich case mix, the use of percentage agency shifts vs hours per patient-day, and the inclusion of device-associated infections. These data suggest that the dose of agency staffing matters: Modest use may be safe, but heavy reliance is associated with select adverse outcomes.

Notably, our multivariate regression analysis demonstrated that agency nurse staffing tiers were independently associated with total PSIs and that CMI independently predicted total infections. This confirms that the proportion of agency nurses exerts an independent influence on patient safety outcomes, beyond census, RN ratio, and 6:1 assignments.

Specific outcomes, including hospital falls with hip fractures, postoperative respiratory failure, perioperative venous thromboembolism, CAUTI, MRSA, and C difficile, showed no correlation with agency use, suggesting these events may be less sensitive to staff composition. Conversely, nursing ratio and 6:1 assignments correlated with postoperative bleeding (PSI 09), postoperative acute kidney injury requiring dialysis (PSI 10), and VAP, consistent with time constraints limiting careful monitoring and protocol adherence.

The COVID-19 pandemic likely amplified some findings because elevated census, longer lengths of stay, and personal protective equipment requirements increased care complexity. Agency nursing percentages rose from less than 2% prepandemic to more than 10% in 2021, with some units exceeding 30%, providing a unique opportunity to observe potential effects on PSIs and HAIs.²⁶

Overall, although travel nurses fill a vital staffing need, hospital systems should hesitate to rely too heavily on them. When hospital systems increase the number of individuals unfamiliar with their protocols and other employees, certain safety events and infectious complications may also increase. This study aimed to highlight the need to understand the nature of the relationship between agency nurses and staffing indices with specific outcomes to establish preventive approaches.

Limitations

Our study is not without limitations. The ability to control confounding was challenging to implement in the study design. The impact of the COVID-19 pandemic (eg, changes in infection prevention practices) on our results was also difficult to disentangle from the observed associations. Prior studies have demonstrated an association between COVID-19 and increased rates of VAP, particularly cases caused by multidrug-resistant organisms. The data on the number of agency nurses are also unknown. If a travel nurse spends enough time on a single assignment, they will eventually provide care identical to that of an employed nurse. Additionally, we did not examine the number of pool nurses who travel within a single hospital but work in different units for the outcomes. Finally, breaking down the outcomes by unit category (CCA, MSA, ED) or even a specific unit may allow for a better understanding of the rationale behind them.

CONCLUSIONS

Between 2019 and 2023, the use of travel nurses at our institution increased, and a higher proportion of agency nurses was associated with a greater incidence of infections and complications. Reliance above 10% was particularly linked to higher overall adverse outcomes. These observational findings cannot establish causality, and confounding factors are likely to have contributed to the results. Larger studies are needed to confirm these results and to clarify the impact of agency nurse utilization on care quality. 

Acknowledgments

The authors want to thank Mr Olivier Rachoin for his invaluable work in extracting the data.

Author Affiliations: Department of Medicine (JB, AG, RN, JSR) and Department of Obstetrics and Gynecology (AB), Cooper University Health Care, Camden, NJ; Cooper Medical School of Rowan University (JB, AG, RN, AD, JSR), Camden, NJ.

Source of Funding: None.

Author Disclosures: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Authorship Information: Concept and design (AG, AB, AD, JSR); acquisition of data (AB, AD, JSR); analysis and interpretation of data (JB, RN, JSR); drafting of the manuscript (JB, AG, RN, AB, AD, JSR); critical revision of the manuscript for important intellectual content (JB, AG, RN, AB, JSR); statistical analysis (JSR); and administrative, technical, or logistic support (JB).

Address Correspondence to: Jean-Sebastien Rachoin, MD, Cooper Medical School of Rowan University, 401 Haddon Ave, Education and Research Bldg, 3rd Floor, Camden, NJ 08103. Email: rachoin-jean@cooperhealth.edu.

REFERENCES

1. Randolph LB. Tracking travel trends. Nurs Manage. 2003;34(suppl 5):9-11. doi:10.1097/00006247-200310005-00003

2. Bernstein L. As COVID persists, nurses are leaving staff jobs—and tripling their salaries as travelers. Washington Post. December 6, 2021. Accessed September 1, 2025. https://www.washingtonpost.com/health/covid-travel-nurses/2021/12/05/550b15fc-4c71-11ec-a1b9-9f12bd39487a_story.html

3. Tanzi A. U.S. travel nurses are being offered as much as $8,000 a week. Bloomberg. August 31, 2021. Accessed September 1, 2025. https://www.bloomberg.com/news/articles/2021-08-31/there-s-a-market-for- 8k-a-week-nurses-in-u-s-as-delta-spreads

4. Xue Y, Aiken LH, Freund DA, Noyes K. Quality outcomes of hospital supplemental nurse staffing. J Nurs Adm. 2012;42(12):580-585. doi:10.1097/NNA.0b013e318274b5bc

5. Breckenridge-Sproat S, Johantgen M, Patrician P. Influence of unit-level staffing on medication errors and falls in military hospitals. West J Nurs Res. 2012;34(4):455-474. doi:10.1177/0193945911407090

6. Bae SH, Brewer CS, Kelly M, Spencer A. Use of temporary nursing staff and nosocomial infections in intensive care units. J Clin Nurs. 2015;24(7-8):980-990. doi:10.1111/jocn.12718

7. Aydin C, Donaldson N, Stotts NA, Fridman M, Brown DS. Modeling hospital-acquired pressure ulcer prevalence on medical-surgical units: nurse workload, expertise, and clinical processes of care. Health Serv Res. 2015;50(2):351-373. doi:10.1111/1475-6773.12244

8. Alvarez MR, Kerr BJ Jr, Burtner J, Ledlow G, Fulton LV. Effects of outsourced nursing on quality outcomes in long-term acute-care hospitals. J Nurs Adm. 2011;41(3):138-143. doi:10.1097/NNA.0b013e31820c7258

9. Aiken LH, Shang J, Xue Y, Sloane DM. Hospital use of agency-employed supplemental nurses and patient mortality and failure to rescue. Health Serv Res. 2013;48(3):931-948. doi:10.1111/1475-6773.12018

10. Patrician PA, Loan L, McCarthy M, et al. The association of shift-level nurse staffing with adverse patient events. J Nurs Adm. 2011;41(2):64-70. doi:10.1097/NNA.0b013e31820594bf

11. Ferguson A, Bradywood A, Williams B, Blackmore CC. Association of use of contract nurses with hospitalized patient pressure injuries and falls. J Nurs Scholarsh. 2020;52(5):527-535. doi:10.1111/jnu.12572

12. Dunton N, Gajewski B, Taunton RL, Moore J. Nurse staffing and patient falls on acute care hospital units. Nurs Outlook. 2004;52(1):53-59. doi:10.1016/j.outlook.2003.11.006

13. Robert J, Fridkin SK, Blumberg HM, et al. The influence of the composition of the nursing staff on primary bloodstream infection rates in a surgical intensive care unit. Infect Control Hosp Epidemiol. 2000;21(1):12-17. doi:10.1086/501690

14. Kane RL, Shamliyan TA, Mueller C, Duval S, Wilt TJ. The association of registered nurse staffing levels and patient outcomes: systematic review and meta-analysis. Med Care. 2007;45(12):1195-1204. doi:10.1097/MLR.0b013e3181468ca3

15. Dall’Ora C, Maruotti A, Griffiths P. Temporary staffing and patient death in acute care hospitals: a retrospective longitudinal study. J Nurs Scholarsh. 2020;52(2):210-216. doi:10.1111/jnu.12537

16. Alonso-Echanove J, Edwards JR, Richards MJ, et al. Effect of nurse staffing and antimicrobial-impregnated central venous catheters on the risk for bloodstream infections in intensive care units. Infect Control Hosp Epidemiol. 2003;24(12):916-925. doi:10.1086/502160

17. Pittman P, Tiunn HL, Luo Q, Herron M, Tatum D, Martin J. Increased utilization of overtime and agency nurses and patient safety. JAMA Netw Open. 2025;8(4):e252875. doi:10.1001/jamanetworkopen.2025.2875

18. Aiken LH, Xue Y, Clarke SP, Sloane DM. Supplemental nurse staffing in hospitals and quality of care. J Nurs Adm. 2007;37(7-8):335-342. doi:10.1097/01.nna.0000285119.53066.ae

19. Vander Weerdt C, Peck JA, Porter T. Travel nurses and patient outcomes: a systematic review. Health Care Manage Rev. 2023;48(4):352-362. doi:10.1097/HMR.0000000000000383

20. Aiken LH, Sloane DM, Bruyneel L, et al; RN4CAST Consortium. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet. 2014;383(9931):1824-1830. doi:10.1016/S0140-6736(13)62631-8

21. Aiken LH, Clarke SP, Sloane DM, Lake ET, Cheney T. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38(5):223-229. doi:10.1097/01.NNA.0000312773.42352.d7

22. Bartel AP, Beaulieu ND, Phibbs CS, Stone PW. Human capital and productivity in a team environment: evidence from the healthcare sector. Am Econ J Appl Econ. 2014;6(2):231-259. doi:10.1257/app.6.2.231

23. Pham JC, Andrawis M, Shore AD, Fahey M, Morlock L, Pronovost PJ. Are temporary staff associated with more severe emergency department medication errors? J Healthc Qual. 2011;33(4):9-18. doi:10.1111/j.1945-1474.2010.00116.x

24. Stalpers D, de Brouwer BJ, Kaljouw MJ, Schuurmans MJ. Associations between characteristics of the nurse work environment and five nurse-sensitive patient outcomes in hospitals: a systematic review of literature. Int J Nurs Stud. 2015;52(4):817-835. doi:10.1016/j.ijnurstu.2015.01.005

25. Clarke SP, DePesa CD. Overtime and agency nurse staffing and impacts on patient safety. JAMA Netw Open. 2025;8(4):e252880. doi:10.1001/jamanetworkopen.2025.2880

26. Yang YT, Mason DJ. COVID-19’s impact on nursing shortages, the rise of travel nurses, and price gouging. Health Affairs Forefront. January 28, 2022. Accessed September 1, 2025. https://www.healthaffairs.org/content/forefront/covid-19-s-impact-nursing-shortages-rise-travel-nurses-and-price-gouging