Travel Nurse Drops Anchor

Kimberly Wipfler Photo

Travel nurse Coltan Jacobson at YNHH: Plans change; staying in town.

Coltan Jacobson drove 22 hours from Minnesota to New Haven to take care of Covid-19 patients at Yale New Haven Hospital. Soon after he arrived, he got Covid. 

It was a shock to the system,” he recalled.

He hung in, recovered — and has now decided to stay helping New Haven tackle the pandemic, longer than he had planned.

Jacobson has been driving throughout the country since 2019. He is a travel nurse, traveling from state to state to help hospitals fill staffing shortfalls. Travel nurses have been in high demand since Covid broke out.

Jacobson started his assignment at YNHH in July in the gastroenterology unit. His first contract ended this past September. He has signed back up with the hospital since and intends to stay in New Haven until April.

Travel agencies facilitate agreements between hospital administrations and travel nurses to establish a fair wage for the nurse and ensure the hospital has adequate staffing. Hospitals pay the agency, and the agency pays the nurse. 

During the pandemic, hospitals around the country — including YNHH — have relied more and more heavily on travel nurses to temporarily fill staffing gaps exacerbated by burnout and retirements. That great need for nurses has meant that hospitals like YNHH are now paying more than they ever have before to bring in highly sought-after travel nurses, like Jacobson.

It’s supply and demand,” Yale New Haven Health Chief Nursing Executive Beth Beckman told the Independent in a phone interview about this Covid-era healthcare phenomenon. There is a decreased supply of nurses, and an increased demand for nurses. Salaries and prices for getting nurses have gone up, and they have gone up astronomically.” (See more below for Beckman’s perspective on the rising importance of travel nurses during the pandemic.)

Jacobson’s royal blue YNHH scrubs just barely cover the tattoos on his upper arms, which are mostly line drawings of hands. There’s a peace sign; he called it an homage to his queer identity. His pushed back hair falls just below his ears, one of which has a small hoop piercing. 

His warm smile and attentive green-eyed gaze represent the kind of demeanor necessary in nursing. He is tall, in his late 20s, and immediately disarming. Jacobson speaks in a soothing tone — knowledgeable, but never cocky. He is the kind of person you would want to see when admitted to the hospital.

After several years working at the Mayo Clinic in Rochester, Minnesota, Jacobson wanted something new. I was sick of Minnesota winters.” He wanted to see new things” and meet new people.” So Jacobson and two of his nursing friends signed onto their first assignment as travel nurses in San Antonio. Having people to go with added to the fun of it,” he said.

In Texas, Jacobson had one training shift. I started at 7 p.m. They gave me eight hours until 3 a.m., sent me home, and the next day I was by myself.”

At the end of his contract in San Antonio, he signed with a hospital in Phoenix, where he was hired to work on a cardiac medical floor. Initially, his contract was for about $1,600 per week.

Right after he started in Phoenix, the pandemic hit the U.S. The floor he had been working on quickly switched over to completely Covid patients.

At one point we had the most Covid patients in the nation, which is inadvertently the world at that point,” because the U.S. was leading the globe in reported Covid numbers by an exorbitant amount,” he said.

Halfway through, we saw this huge influx of travel nurses,” who were earning five or six thousand a week.” The new travelers may have worked an extra shift or two, but still there was this huge influx of money.”

Jacobson and his colleagues were unsure where the huge chunk” of money came from and why it appeared suddenly. And those big checks never stopped.” Now, the money” has been the biggest factor in staff nurses leaving their job to travel and pick up shifts elsewhere.” 

At YNHH, Jacobson makes at least $1,000 more each week than he did in Arizona at the peak of Covid. I don’t know if that’s just because Covid was so fresh that they weren’t sure what those pay packages would look like or what they even look like now.” He said travel nurses converse with each other online to compare rates, but that it seems companies don’t want you to share the pay package.” 

If word gets out that your contact is exposed, that could be potentially bad news. I don’t think you’d be reprimanded for it, but they don’t want too much competition,” with nurses comparing wages.

He spent about nine months in Phoenix working in the trenches of Covid.” When his contract ended, he took some time off in San Diego, hoping for a calm beach getaway.”

Patient expectations can sometimes feel steep given the conditions of the pandemic, he said. If we could give a crash course” for patients on what to expect to be catered toward while you’re an inpatient, it’d really be a blessing for nurses. Especially with Covid patients, we have a full hazmat suit on.” When you exit the patient’s room you have to dispose of some articles” and clean others.” So if a nurse has four to five patients, you can’t be in that room constantly to bring them a glass of water or something.”

I wish there was a better understanding of the limits that nurses can do for caring for patients. We will always do what they need, but it definitely takes a toll on you during a 12 hour shift if you’re constantly gowning up and down, trying to satisfy” both the safety mechanisms” and patient needs.

After a much-needed respite, Jacobson took on an assignment in California on a GI unit, which also quickly turned into a Covid-only unit. But at that point, I was used to it, and I felt like the ratios were much better.”

California is the only state in the nation with strict laws that dictate a minimum nurse-to-patient ratio of 1:4. They’ll cap you off and bring in other nurses if they can,” he noted. Laws like this one ensure a better and safer practice,” for both nurses and patients, he said. Nurses in California are also guaranteed a 30-minute break around lunchtime which is strictly enforced,” and something Jacobson had yet to experience.

Not only did I feel like I could manage my patient assignment much safer,” and spend more time with each patient” to evaluate and look at changes in their vital signs,” but I also felt like I got a reprieve to take a break and have that time away.”

Having less patients, in my opinion, means better patient satisfaction and patient outcomes,” Jacobson said.

Since Jacobson left the hospital in California, administrations have had to overlook” the nurse-to-patient ratio law, and nurses are now getting five or six patients instead of four.”

Travel nurses can work in a state for up to 11 months before their gig becomes deemed as a local practice,” which can affect a nurse’s pay. When Jacobson reached the limit in California, he took off for three months to return home and spend time with his family.

That’s when Jacobson signed a contract with YNHH, through his agent Amanda Aapgar at Host Healthcare.

His orientation to the unit was two days, which is double the time that you usually get as a traveler.” He said YNHH provided a lot of stability and foundation” with educational materials before he began working on his unit.

When Jacobson started on the GI unit, he was the only traveler on his floor. Around September, he renegotiated for higher pay in response to the rising Covid numbers, as his floor began seeing more travel nurses. Now, if there are five nurses on, probably two of us are travelers,” he said. (He did not provide precise pay figures.)

The change accounts for staff nurses feeling burnt out and leaving the bedside” to work at jobs with lower stress levels, like at a clinic, in public health, or other nursing opportunities with less direct care,” Jacobson said.

A recent moment on the clock reminded Jacobson why he continues caring for sick patients.

One of his patients was experiencing a panic attack. I was able to sit with her, de-escalate, chat like this” — he lowered his voice to a calming tone — and make her feel more at ease.”

Because Jacobson had a manageable number of patients at that time, he said, he could spend more time tending to her needs.

And she looks at me, and she goes, How does it feel to find your purpose at such a young age?’

And I thought, Damn, I didn’t think this was my purpose. Thank you so much.’

I’m really grateful for responses like that. And that just shows that caring for patients can be really rewarding, and that’s not an easy thing to give up.”

Exhaustion Sets In

Thomas Breen Photo

Pandemic-stressed Yale New Haven nurses at a community support rally.

Like many other hospitals enduring ongoing staffing shortages, YNHH has signed an increasing number of temporary contracts with travel nurses such as Jacobson. This influx of travel nurses has yielded a mix of frustration and sympathy from staff nurses, who are locally-based and receive pay from the hospital directly.

Morgan McMinn, a recent nursing school graduate, described nurses as rundown” from taking on new shifts” or having their schedules mixed up” during her rotation in the children’s Emergency Department. 

Some nurses are tired of the pay and the treatment. They feel like they’re getting really overlooked, and they’ve been there for six years. It’s been frustrating for them, and so they want a new opportunity,” McMinn said.

RN Katie Caldwell, who currently works in the Labor & Delivery Unit at YNHH, said, With Covid, things have been on the rougher side because people have been leaving. I’ve seen a lot of nurses going to like outpatient clinics just because the hospitals are short-staffed.” 

Staffing shortages have meant that nurses have had to take on more patients than normal, which can lead to a detriment in the quality of patient care, according to a 2007 study in Health Affairs.

McMinn said some days the unit was way over capacity,” and nurses could only spend two minutes” with a patient before having to move on to the next. Nurses typically are assigned approximately five patients, but understaffing has required they take on 10 to 13” patients on some floors, she said. 

In the hospital, for each additional patient a nurse has to care for, the chances of one of those patients dying increases by 7 percent, found researchers in a 2006 study in Quality and Safety of Healthcare.

Caldwell said she worries about the patient care she has provided under these conditions, recalling a moment when she had two patients in labor and was unable to offer the best labor support.”

I wish I could do more for my patients, ” Caldwell said. I’m not able to provide the best care that I could.”

Travel nurses could pose risks for hospitals, Caldwell argued: With a short orientation” of just one or two shifts, there could be room for errors.”

McMinn said that she noticed travel nurses sometimes receive more challenging assignments than staff nurses. Sometimes they’d be given the more difficult patients, which is kind of unfair,” to the nurses, given the shorter duration of travel nurses’ tenure at the hospital and reduced training.

The desperation to fill roles has created a bidding war among hospitals to secure travel nurses, and hospitals have seen the cost of a travel nurse increase by 120 percent since the start of the pandemic. Travel nurses can earn at least double, if not more than triple,” what a staff nurse makes, which lures staff nurses away from their current positions, said a former YNHH nurse.

Staff nurses could make “$1,500 a week,” but travel nurses could see up to “$4,000 or $5,000 each week,” said McMinn.

Caldwell said YNHH has begun to incentivize nurses with contract pay, which can be an extra $75 an hour,” for nights and weekends. She said she is skeptical of what the inflated wage says about safety conditions for travel nurses. With that crazy amount of money, it makes me think that it’s very unsafe conditions for nursing to patient ratios,” emphasizing that your license can be on the line.”

Caldwell said that when she began in her current unit, there were only about 10 travel nurses, but today, travel nurses make up about half of the nursing staff.”

YNHH Nursing Exec: "First Choice Is Always To Get More Staff"

Yale New Haven Health Chief Nursing Executive Beth Beckman.

Hospital administration has struggled to retain staff through the duration of the pandemic. In October of 2021, Melissa Turner, senior vice president for human resources for Yale New Haven Health, told CT Insider that finding candidates for a large volume of open positions has been difficult. This year, particularly, all positions I would say have become more challenging and some difficult.”

Beth Beckman, chief nursing executive for Yale New Haven Health, also told CT Insider at the time that many nurses have migrated to traveler jobs, where they may find higher pay.

In a phone interview with the Independent Wednesday, Beckman reiterated just how challenging it has been for YNHH to fill staff nursing jobs during the pandemic — and how those staffing crunches necessitate a reliance on traveling nurses.

It’s been a true paradigm shift in the workforce for nursing,” she said.

Before Covid, YNHH would bring in travel nurses on situational” bases — for example, if a number of nurses happened to be out at the same time after giving birth. 

When the pandemic hit, however — bringing with it a new novel respiratory virus, shortages in personal protective equipment, surges in very sick patients, and major shifts in domestic responsibilities around everything from home-schooling kids to looking after elderly parents — many nurses resigned or retired. (“I don’t think the public has understood how difficult this journey has been” for nurses, she said. The general stress,” both personal and professional, has been immense for nurses during the pandemic — leading to emotional and psychological trauma” for many in the field.”)

So travel nurses became more and more critical for YNHH to keep its hospitals staffed and ensure patients were getting the quality of care they need.

Beckman noted that the increased earning power of travel nurses has also drawn staff nurses out of hospitals like YNHH and towards travel agencies in pursuit of an opportunity to make higher pay.

Beckman said that the YNHH — which includes seven hospital campuses in Connecticut and Rhode Island — currently has between 250 and 450 travel nurses on the payroll. That’s in comparison to the roughly 7,200 staff nurses YNHH employees full time.

Travel nurses can make upwards of $150 to $200 per hour at this stage of the pandemic, she said, which is significantly higher than the $60 to $70 range they made (on the high end) before Covid.

We probably have more asks for travel nurses than we are able to fill,” Beckman said. That is: the need for travel nurses still outstrips the supply.

Asked about those ever-increasing travel nurse costs, Beckman said, Our concern today, and it has been throughout the pandemic, is getting enough people with the right skills to take care of patients and be good team members. We have been less concerned about the finances around that. Our number one mission is to take good care of patients.”

Beckman said that travel nurses at YNHH sign on for a minimum 13-week assignment. 

Many re-up for multiple assignments, she said, meaning that in some cases, an individual travel nurse will stay on for over a year.

Asked about how long the orientation and training period is for travel nurses at YNHH, Beckman said it really depends on the nurse and on the unit they’ve been assigned to.

More experienced nurses receive three to five days worth of orientation on average, she said, while less experienced can receive several weeks or even one to two months.”

The orientation is as long as they need it to be,” she said.

Asked about why YNHH does not hire more full-time staff nurses instead of spending increasingly higher rates on temporary travel nurses, Beckman said that YNHH’s first choice is always to get more staff” rather than relying only on travel nurses.

We’re always looking to invest in the permanent solution,” she said. If we were able to get the applications and the hires that we need, we would not be resorting to the use of travelers.”

What about legislatively mandated nurse-patient ratios, like the one in place in California? Would that help here in Connecticut, and does the lack of such a law incentivize hospitals like YNHH to hire fewer full-time employees than it needs — and to rely on surges in temp staff in times of crisis?

Beckman said that the problem with California’s nurse-patient ratio mandate is that it doesn’t take into account how acuity and circumstances change almost on an hourly, if not a minute by minute level” in hospitals. Oftentimes the actual experience of caring for many different patients in a hospital requires nurses to be moving around frequently, leaving one patient and prioritizing another depending on the urgency of the situation.

Laws like California’s are too inflexible” to accommodate that type of real-world fluidity, she said. 

As for whether or not a lack of legislatively mandated ratios encourages hospitals not to hire as many staff as they need, Beckman replied, Definitively, absolutely not. There is no desire for anyone not to have the staff that they need to make sure that they take great care of patients. … There is nobody that’s holding back resources.”

So… given how unsustainable this current reliance on ever-more-expensive, ever-shorter-in-supply travel nurses is, what’s the answer? How does YNHH work its way out of this staffing crunch?

We have to innovate new ways of how we deliver care,” Beckman said. We have to innovate new ways of how we prepare new nurses [for the workplace] and expand the pipeline.”

One such way that YNHH is doing just that is through the relatively new position of clinical nurse transition coach.”

Beckman said that those are expert nurses who love to teach” and who are assigned to new hires on the night shift and on weekends. Each coach is assigned to 10 new nurses, and their job is to teach time management, critical thinking, and communication, among other skills important to develop for a new nurse.

Beckman said this program has been quite successful so far in retaining nurses. She said the national turnover for new nurses in 2021 was 24.1 percent within their first year. For new nurses at YNHH in this coach program, she said, that first-year turnover rate was just 7.5 percent.

If you can hold onto a nurse and get him or her through their first three years of practice, they’ll be fine,” Beckman said. Programs like this are designed to do just that.

"X Times Five"

Meanwhile, nobody has been able to answer how long the higher pay for travel nurses will endure.

Hospitals are stuck between a rock and a hard place,” noted Jacobson. At the start of the pandemic, employee retention efforts focused on better pay for staff. However, as the need for outside help increased, staff nurses would see that they got paid X amount” and then travelers would come in and earn X times five.”

Jacobson said that hospital administrations could increase staff wages, but if Covid dies out in six months, they probably can’t sustain that higher pay for staff that long,” and that the administration would not necessarily want to take money away.”

Jacobson said that the rise of nurses who leave their staff job to travel with the promise of better pay” inadvertently increases the staff crisis.” But that’s not why Jacobson began to travel. 

When he signed his first contract in 2019, travel nurses saw a fraction of the wages they receive now.

Once the remainder of his student loans are paid off, he said, he will consider leaving hospital work to pursue public health or teaching. The bedside is just getting to me. Management tries their best to absolve some of that stress, but at the same time,” with the staffing issues and potential for Covid numbers to increase again, that stress will remain.” 

Lately, Jacobson has been considering his dream job, to open a coffee shop with a wine bar, live music, and space for artists to come and share their work.” As he imagined the space, he smiled.

But for now, he knows where he belongs.

By September, Jacobson could have left New Haven and signed with a different hospital. He said he has signed several extensions” because he really does like the hospital,” his coworkers, and the ratios here.”

The most patients that I’ve ever had on this floor is five,” which he said is busy, don’t get me wrong,” but more manageable. 

He and his friends considered signing a contract in Myrtle Beach before signing with Yale, but their ratios could mean nurses got seven to eight patients each.

Connecticut doesn’t necessarily have that law like California does, where you can cap patients. But the reason why I’ve stayed so long is that they have been really good about not exceeding that limit too much on their own.”

It’s interesting to me that California can instill this sharp, wonderful ratio, and Connecticut, too, is doing such a good job of that. And then you go down a state or two, and Florida has really high ratios, both the Carolinas. How do nurses maintain that long term?”

There’s some legislation that needs to get passed in order to provide better and safer care.”

Thomas Breen contributed to this report.

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