When Kevin Saavedra landed at Seattle's Harborview Medical Center in February, it became the sixth hospital he's worked at in less than three years.
He drives from place to place, his two Rottweilers in tow, and has a growing list of states he'd be eager to return to.
Saavedra is a travel nurse, one of thousands in the United States contracted to work short-term stints in hospitals. Historically, the role has helped bolster staffs during occasional times of peak injury or illness — winter flu season, for example.
Now, hospitals need them to survive, but the shift has come at a big cost.
Hospitals continue to lean on travelers because the influx of patients has not slowed in months — some are in for COVID-19 treatments, but many are admitted for summer injuries or delayed care due to the pandemic.
Health care leaders say they are caught in a messy cycle: Hospitals need travel nurses to cover standard shifts, but travelers are expensive, and the longer hospitals retain high levels of contract nurses, the worse financial shape they'll be in.
Salaries for travelers, whose pay rates can be up to two or three times more than a permanent staffer's, are one of the major reasons hospital systems in the Pacific Northwest — home to a large community of travel nurses — are having budget problems, hospital leaders say. And it leads to morale issues with the permanent nurses.
Short-term solutions are unclear, leaving hospitals and their staffers to navigate complex discussions around the future of the health care workforce. That might mean slowly reducing the reliance on these travel nurses or providing new and different opportunities for nurses who call Seattle home.
It's quiet at the start of a recent night shift on one of Harborview's telemetry floors, where staffers focus on cardiac monitoring, and Saavedra has time to chat with one of his favorite patients, who's been recovering from back surgery for the past week.
Robin Rebecca Lerum, of Gig Harbor, is still in pain and unable to walk just yet, though she'll start physical therapy the following day, but piles on praise for the nursing staff the minute Saavedra walks in. Despite her injuries, she always thanks them, he said.
"It's like a bottomless well of patience here," said Lerum, 64. She pauses to wipe away a few tears. "The compassion and kindness is kind of overwhelming."
It's Saavedra's sixth shift in a row, though he was only initially scheduled to work three, and he's exhausted. But patients like Lerum make things easier — and are partly why, along with Seattle's cultural diversity and natural beauty, he's extended his Harborview contract three times.
Before starting in Seattle, Saavedra worked monthslong contracts in New Jersey, Missouri, Texas and North Carolina. He likes the pay, but is also drawn to the freedom the nomadic role offers, the opportunity to live in different parts of the country and the ability to often sidestep hospital politics.
"People are always like, 'Oh, it's all about the money,' " the 29-year-old Charleston, South Carolina native said. "And that is a very good incentive. But underlying, if you're being treated right, if you like your co-workers, if you're being taken care of — you'll actually want to stay."
"For me, it's about what you want out of life, and your happiness and mental health," he continued.
On Saavedra's floor at Harborview, travelers make up at least half the nurses on the night shift, charge nurse Taylor Radford said. She's noticed traveler numbers are starting to fall slightly, but the unit still depends on them. And that's hurt the bottom line.
This summer, the Washington State Hospital Association reported hospitals across the state suffered a net loss of about $929 million in the first three months of 2022. While operating revenue increased by 5%, operating expenses increased by 11%.
Association CEO Cassie Sauer said at the time that if the trend continued, hospitals would likely have to cut some services or close inpatient units — or, in a worst-case scenario, close or file for bankruptcy. Some large Seattle hospitals have already shown signs of strain.
In August, for example, a lack of bed space and an increasing number of high-cost patients staying for long periods forced Harborview to temporarily divert some patients to nearby hospitals.
The hospital began to again accept all types of patients the following week, but Mark Taylor, Harborview senior associate administrator, later said he wasn't confident they'd be able to avoid similar disruptions in the future.
In addition, Providence Regional Medical Center Everett has temporarily stopped accepting patients to its inpatient pediatrics unit. Yakima Valley Memorial Hospital is having trouble staffing all their beds.
Because of the continued staffing strains, travel nurses are still in fairly high demand in the Seattle area despite some nationwide reports that the "travel-nurse bubble" has popped. While rates are starting to settle back down after soaring to new heights earlier in the pandemic, local hospital leaders say they're already starting to see demand creep back up as fall — and respiratory illness season — approaches.
At Providence Swedish, for example, previous bill rates, set by staffing agencies, capped at $150 per hour have fallen to about $111 per hour.
"I don't think the [travel-nurse] bubble has burst," Kevin Brooks, chief operating officer of Providence Swedish, said in an interview. "I think it's normalizing in a post-pandemic world, at a rate much higher than we were pre-pandemic."
"Supply and demand 101"
During the pandemic, as nurse burnout peaked and turnover rates rose, so did the number of people interested in leaving full-time employment for these contract spots.
Silas Emrys, another traveler working at Harborview, discovered contract nursing during a time when he was tight on cash. He had been working at a hospital in Denver for about a year, and liking it for the most part — but he felt like he wasn't paid enough because of the high cost of living there. Then, a new business venture for his parents, who had moved home to the Philippines, went south.
"I had pretty much sent all my savings to help them out," said Emrys, 35. "I was close to bankruptcy. My credit cards were maxed out."
A few months later, he started his first travel assignment at Harborview.
He sometimes misses the stability of a permanent staff job, but says it's hard to find one that pays as well as travel jobs do.
"I want to be able to comfortably take care of them," he said of his parents. "They're older and ... I want them to live their life in pursuit of their own happiness. I can't have that in the back of my mind — them struggling — without trying to help."
Brooks acknowledged the benefits of travel nursing and said it's easy to see why nurses would be drawn to the job.
"It builds great flexibility in their lifestyle and they get to tour the country and see different places," Brooks said. "And for some of them, it's just a great economic opportunity. And no one faults them for this, by the way. I get it. It's supply and demand 101. But it certainly is a problem for us to solve in health care."
Between January and June this year, Providence Swedish spent about $167 million on traveler contracts — more than three times the amount the hospital system spent on travel nurses during the same time period in 2019 (before Swedish merged with Providence).
MultiCare, another large Washington hospital system with locations in the Puget Sound region and the Spokane area, is spending about $30 million more per month on overtime, premium pay and travelers compared with before the pandemic, according to hospital figures sent to The Seattle Times.
By mid-2022, MultiCare had spent $187 million on travelers — compared with $160 million in all of 2021, $71 million in 2020 and $68 million in 2019.
Virginia Mason Franciscan Health spent 500% more on travelers in the last 12 months compared with the prior year.
Hospitals say they're doing what they can to reduce traveler head counts and costs, but the travelers are still filling needed roles, Brooks said.
That reality is frustrating to many permanent staff nurses — some who had been at the same hospital for years without seeing anything close to a traveler's salary, and who were suddenly tasked with leading training after training for temporary co-workers.
"The nurses see what the travelers are making that are working right next to them," said Edna Cortez, a registered nurse at Seattle Children's who has considered traveling but says she loves her patients too much to leave. "I've been at Children's for 30 years and I've worked with travelers that have way less experience than me and make more money than I do as a staff nurse. That's really difficult."
It's not their fault, she said, adding that it's up to hospitals to better balance wages and keep in mind how the pay gap might affect the morale and mental health of permanent staffers.
"Nobody blames them. ... And we really appreciate the support and the help of our travelers," said Erin Doyle, who's worked as a Children's nurse for almost three years. "They are doing us a great service by helping us. But it is hard and frustrating when it gets to the point where almost half of our staff on certain floors and on certain units are travelers."
Some recent negotiations between hospitals and their permanent nursing staffs have led to ratified contracts that include significant raises and incentives, including at Children's and Providence Swedish. While workers say the pay increases are just the first step toward increasing long-term retention rates, Cortez called the new contracts huge wins.
Still, health care labor unions have argued that hospitals had long known about the coming nurse shortage and they could have done more to bolster their workforce.
Brooks, of Providence Swedish, has pushed back against that thought, saying that at his hospital system, administrators hired "to patient demand," meaning that although there's always a need for more nurses, the hospital was "volume-adjusting [its] workforce appropriately" heading into the pandemic.
"We do desire to pay our own caregivers more and reduce agency [staffers], and we're trying to walk that line," he said.
A changing industry
Hospital and health care experts have acknowledged for months that the industry is evolving, and that goes well beyond the reliance on contract nurses. They've witnessed a recent rise in telenursing and gig nursing opportunities. Many new nurses are prioritizing part-time work, opting for a more stable work-life balance. Tech companies are digging into health care.
One new startup in particular has caught the eye of Providence Swedish leaders.
CareRev, an online marketplace started by a former RN in San Francisco, aims to connect nurses with open shifts at different, local hospitals. Unlike travel contracts, which often require nurses to work the same assignment for a minimum of 12 weeks, CareRev pairs nurses up with one-off shifts. Nurses could work at a different hospital every week, blocking out whichever days or times they want.
Earlier this year, Providence Swedish picked up more than 1,000 nursing shifts through CareRev. While the gig system isn't the most ideal for hospitals, most of whom would prefer to employ their own staffers, Brooks said, health care leaders really have no choice but to get on board.
"The train has left the station," said Brooks. "Nurses are going to do this. It's too convenient for them not to. And so we can bury our head in the sand or we can accept the reality that the workforce is changing and we need to be able to accommodate gig workers."
While pay rates for gig nurses vary by hospital, they generally trend closer to traveler rates, as opposed to those of permanent staffers, said Natalie Kozimor, a Providence Swedish spokesperson.
At the same time, the priority remains on retaining permanent staffers, he said.
And while a wave of burnt out nurses made the jump to travel roles during the pandemic, some have made the opposite move.
Nicole Bohn, who joined UW Medical Center Northwest as a traveler at the end of April, said she sought out an assignment in Washington because she'd heard good things about nursing in the Northwest.
She started on an orthopedic floor, supporting patients with broken bones or recovering from surgery, and liked it so much that she decided to apply for a permanent position. Starting in October, Bohn will be a night-shift clinical nurse educator, providing support to new night nurses in the emergency department and acute care and intensive care units.
Hospitals would like to see more nurses making the shift like Bohn, but they are realistic. Relying on travelers and shouldering the extra cost won't go away quickly.
"This is probably a new normal for an unforeseen duration," Brooks said. "This is not a short-term crisis."