Like many other hospitals around the country, Pomona Valley Hospital Medical Center in Southern California has contracted with travel nurses for years. The need for travelers surged when the pandemic inundated ICUs with an influx of new COVID-19 cases. Coincidentally, Lolla Mitchell, director of nursing operations and clinical practice at Pomona Valley, finalized a contract with a new nurse staffing agency just as the first cases were being reported in the United States. Her relationship with the agency and the timing of the surge allowed her to bring in an adequate number of travel nurses to respond to the emergency. Mitchell and her colleague, M. Carina Menjivar, quality nurse manager at Pomona Valley, spoke with AACN Clinical Practice Specialist Sarah Delgado about their experiences integrating travel nurses in their hospital. They say having travelers in the mix has been an effective strategy, and it’s important to set them up for success.
- Effective orientation process
- Buddy pairing system
- Materials shared with travelers prior to arrival
- Balance of own staff to travelers
- Communication between charge nurses and staffing office
- Culture of teamwork and inclusion
- Openness to travelers contributing unique ideas and expertise
- Support from finance and executive teams
Sarah Delgado: Can you tell us about the process you developed for orienting travel nurses?
Carina Menjivar: We established some criteria initially with our staffing agencies. We implemented requirements such as two years of experience with advanced cardiac life support (ACLS) and NIH stroke certification. Because we're a STEMI, trauma and Comprehensive Stroke Center, we preferred them to meet specific items in our screening process. Then when they were hired, one of the things that I believe we did well was to place all of our travelers within the float pool. Having them all within the float pool allowed for them to be divided into two levels of competency. We had critical care/telemetry nurses which floated between those two areas, and then we had telemetry/med surg nurses. This gave our staffing office the flexibility to be able to float those nurses to meet staffing demands while, as much as possible, attempting to keep them with some consistency.
The communication with our units was also very important. For example, if there was a nurse that our neuro ICU really liked because they were competent, then we could try to keep that consistency with the ability to schedule them into that unit, to fill their gaps as much as possible.
We did not keep them in orientation for three weeks. Before our critical point, it was maybe three days. The first day they came in and did all of the administrative requirements such as computer training, obtaining their badge, presigned competency acknowledgements, and making sure that they had access to the Omnicells, computer systems, and timecards with the ability to clock in and out.
We took care of all the logistics within the first half of the first day of orientation. We made it a point to do that on the first initial day before they got on the floor so that we wouldn't waste time during unit orientation trying to access systems. We spread out their orientation so that one unit wouldn't have six nurses orienting on one day. We tried not to put more than two orientees on a unit, so it wouldn't overwhelm them.
If we had a critical care tele nurse, then we gave her one day on critical care and then one day on tele. This helped them identify the differences in our systems with the understanding that they would float throughout all four of our critical care units and all four of our tele units.
We already had a pretty robust float pool and a pairing buddy system. In other words, when somebody floats into a unit, they're supposed to be paired up with a buddy who would not only welcome them but be a resource to them. This way, if they have any questions, if there's something that they don't know, then they have a welcoming buddy connection within the unit already and the charge nurse is not overwhelmed. For the most part, they all knew that they were supposed to do that. And that practice existed. And so it was easy to reinforce if we had some concerns with the orientation piece.
Lolla Mitchell: Otherwise, when you have just one traveler on your floor, the charge nurse can usually handle it. But when you start to have more people that are either floating from another unit, and/or they're traveling, that's a huge burden on top of all the other responsibilities your charge nurse has on the unit. So I think the charge nurses figured out they needed to assign buddies pretty quickly so that they weren't getting every single question from the travel nurses.
We created packets that the agencies could send to the travelers prior to their arrival. They could just upload and read while they were on the plane, or wherever, so that they came with general knowledge of our protocols and the important processes they were expected to manage on the nursing units.
This allowed them to be more prepared on their first day of orientation on the floor, to ask questions about the protocols and know where they could find the backup information and resources.
Menjivar: The benefit of working with these master booking agencies is they have learning management systems, right? So as we got smarter, as we needed to decrease our orientation time here, we sent these documents to upload into their learning management system, so that they would work with the agency to complete those before they even hit us. They made sure that they looked at our specific hospital policies such as hypoglycemic management, electrolyte imbalance or stroke management, anything that was specific to us.
Delgado: I'd love to hear more about how you respond when you are working with a travel nurse who may be new to the role and may not have developed those skills. We have heard from other nurses on units sort of finding that's the case -- that there may be less seasoned folks among the travel pool.
Mitchell: During the first year of COVID, most of the travelers were seasoned travelers and/or seasoned nurses. Maybe it was their first assignment, but they usually had 10 or 15 years of experience. They knew how to speak up. This last winter, however, I took nurses with just over a year to a year and a half of experience. We were not really set up for that new graduate or just past that first year of experience for a travel nurse, so we were not sure what to expect from this less experienced group of nurses. But my experience found that they were highly confident nurses and were not afraid of asking questions. They're usually not your timid nurses who decided to try travel nursing.
To be honest, I think our nurses, maybe in a different time when we weren't in crisis, would've said, "Get me somebody with more experience. I don't have time for them." But I think the staff was also in a place where they were very grateful to have adequate help. They knew that it was hard to get travel nurses to meet the demand. They knew what they had experienced with the early surges of COVID, how bad it was, and that we had been successful in getting them help. They understood they had to do their part in supporting the travelers.
Menjivar: One of the commitments that we talked about was to maintain at a minimum 50% of each unit's own staff at any given time, not just fill one unit with all travelers or all float pool staff. Having centralized staffing, the communication between the charge nurses and our staffing office, or even Lolla or myself, was very important.
Mitchell: One of the things we purposely did was to assign our nurse managers to each surge unit to manage and operationalize a staffing plan that was a mixture of their nurses and the travelers. So, if it was an ICU surge unit, one of our ICU managers was going to manage that unit. In addition, their charge nurses were going to be the charge nurses on the surge unit. That way we would keep 50% of our regular staff on all units, even the surge units. We did not assign travelers to only COVID units.
Delgado: Do you think there were actions you and Carina took to create an environment where permanent staff and travel staff collaborated more? Any specific tips for making that a smoother relationship?
Mitchell: I think after talking to [the staff] up front about what our challenges were to get them help, they were very appreciative of how much work we did to stay on top of it. One of the other keys that made it successful was our finance department and our executive team. We had very few shifts that were understaffed. And in those cases it was a shift at a time. It wasn't shift, after shift, after shift. Nurses can stay pretty resilient if that happens, and they know you've done everything you can. We incentivized our own staff to come in. We did what we could, but I think a lot of it is just being open and communicating. "What are you doing? And what do you need from them in order to keep the travelers here?" And we've hired some of our travelers.
We have a very high rating from the travelers, which is what you want. You want them to tell other people, “Pomona was a great place to work. Staff was helpful. I got to take my breaks. When they had Nurses Week, they included me. They didn't shun me." All those things are important to them. We also sent out a newsletter every day from the hospital on what we were doing related to the COVID-19 response, including staffing.
Sometimes I'll hear staff saying something (about travelers) like, "Well, they're making all this money, they can do the hard work." I've done registry in my career, and I've heard those same things many years ago. So, it's not a new phenomenon that we get jealous of people making more money, but it's not the right way to treat people. You have to remind them that you have those same choices to be a travel nurse. At the end of the day, we're all here to take care of our patients and that's not our culture.
I remind the charge nurses, "Remember, as part of your role under your license, you are making these assignments and delegating the care. So you have to know you made safe assignments.”
Menjivar: The other thing I would add is that we have to consider that we already had a well-established culture of teamwork within our organization. So, our nurses work well as a team. We had an existing float pool. The advice I would give is to really invest in how you optimize the use of a float pool within your organization. We have processes in place, so it's understood that when someone new comes into the unit you don't shun them off. You don't give them the worst assignment. You don't pretend that they're not part of your unit. You embrace them and you figure out how to include them. So, if you're having goodies or celebrations in your unit, then they're part of that.
We were always reinforcing that with our managers and our charge nurses to ensure they were being welcoming and inclusive. Make sure to remember that it is a two-way street in embracing anyone that's floating in your unit, so that people want to come back to you and help. Otherwise, you’ll get people not wanting to come and help on your unit, and you're working short and harder.
Mitchell: One of the lessons we learned very early with the first wave of the pandemic was to utilize some travelers who had already experienced the initial wave of the COVID crisis in Washington state. They had already figured out ways of proning and caring for these patients, including how to manage the PPE challenges. So, we used the travelers to educate our staff on how to do the proning and set up clean and dirty areas for PPE outside of the rooms. By involving them in our training, they were able to contribute back to our organization and staff.
I think the pandemic was a unique time, in that you start to see travelers coming from all over the country who had different experiences and ideas on how to solve the unique issues that the pandemic created. The lived, experienced knowledge the travelers brought allowed our staff to be more open to new ideas from outside our organization.
Delgado: I see what you're talking about having the travelers contribute their expertise. That's a form of meaningful recognition. It sounds to me like you both maintained a good relationship with managers and charge nurses.
Mitchell: I think that is a really important concept; it has to go both ways. For instance, if we had trouble with a traveler, we tried to keep them on the same unit. So they have the same leadership around them to really see, is it them or is it us? Or, can we get them to the competency they need? Maybe we'll change units because it is a conflict of personality types and they'll do well in another unit. But let's not have them float all over where we don't know that there's a problem going on, because they're one day here, and one day there.
It was important to trust that your own charge nurses were the best to run your surge unit. We never put any traveler in charge on a unit. We always used our own staff. We got them to work extra shifts to be in charge and cover that unit. They knew it was important and they did it. The managers took a lot of responsibility, and I think they felt ownership of the surge units.
There were some challenges for sure, but I think as an organization, we all pulled together.
Delgado: So you were able to anticipate the need ahead of manager requests?
Mitchell: Yes, for the most part. The finance department basically gave me the OK to negotiate and escalate rates if I needed to. So they put a lot of trust in me.
It's not a perfect science. And I think most people underestimate what they need, because “oh I have all these nurses on the schedule.” Well they're going to call out sick. Some of them were calling out sick just because they're stressed out.
Menjivar: I think overall, if you put it on the managers and you ask the managers, they're just looking at their own schedule and the holes. So they will tell you, "No, I don't need anyone, I'm OK."
So, it was really looking ahead and anticipating. They're just looking at the holes right now. We're looking at call offs, someone else's holes that you're going to have to float staff to cover the unit. So it wasn't a unit decision. It has to be a house-wide look at how the staff's going to be deployed.
Delgado: If you think about a nurse leader facing a deployment of travel nurses, any other words of advice?
Mitchell: Don't shortchange yourself, because it does take time to get them here. You have to have a response for that immediate problem, which your staff can do for a short time. I think we're seeing now that two years later they're tired. So I'm not sure that they can even tolerate short times anymore like they would in the beginning. So I say you’ve got to plan.
For some of our nurses it's been chaotic 24 hours a day for months. It wasn't just at work during the pandemic. It was their kids at home. All the changes in their life have been a lot. I think the challenge moving forward is how do we help our staff? What will the new normal look like? Because, I don't think we're going back to exactly what we had before the pandemic.