By Ying Xue, Joyce Smith, Deborah A. Freund, and Linda H. Aiken Supplemental Nurses Are Just As Educated, Slightly Less Experienced, And More Diverse Compared To Permanent Nurses ABSTRACT In the past three decades, the shortage of nurses willing to work in hospitals has been a persistent challenge in the United States. Hiring supplemental registered nurses—nurses on short-term contracts obtained through an external staffing agency—has been common to fill gaps in nurse staffing. But there has been insufficient evidence about supplemental nurse workforce trends to inform workforce policy. To address this concern, we compared qualifications and characteristics of supplemental nurses with those of permanent nurses during 1984–2008. The two groups shared similar education levels in terms of possessing a baccalaureate or higher degree. Supplemental nurses were somewhat less experienced than permanent nurses, averaging fifteen years of experience in 2008 compared to eighteen years for permanent nurses. The supplemental nurse workforce was more diverse racially and ethnically and more likely to be male than the permanent nurse workforce. These data show that employing supplemental nurses could help meet the challenges of an aging nursing workforce, the projected future shortage of nurses, and an increasingly diverse US population. I n the past three decades, the shortage of nurses willing to work in hospitals has been a persistent challenge in many parts of the United States. The use of supplemental registered nurses re- tained through external staffing agencies has been a common response to gaps in nurse staff- ing in both hospitals and long-term care facili- ties. 1–3 Supplemental nurses are employed to maintain or improve nurse staffing levels, be- cause robust evidence has shown that better nurse staffing is associated with better patient outcomes. 4 Supplemental nursing positions have a short- term contract, from per diem to multiple months. These positions have some benefits that appeal to nurses, such as more flexibility and greater travel opportunities. However, use of supplemental registered nurses is often per- ceived as more costly compared to hiring perma- nent registered nurses, and concerns have been raised about how the use of supplemental nurses affects patient outcomes. 3 Results of the few empirical studies that have examined the relationship between use of sup- plemental nurses and patient outcomes are in- consistent. 5–10 In the studies 6–9 reporting an asso- ciation between supplemental nurse use and adverse patient outcomes, one possible explan- ation is that supplemental nurses might be sim- ply less qualified than permanent nurses. The importance of nursing qualifications was highlighted in a landmark Institute of Medicine report, The Future of Nursing: Leading Change, Advancing Health, 11 which concluded that nurses should achieve higher levels of education and training through an improved education system that promotes seamless academic progression. Although supplemental nurses have been used for decades, there has been a lack of evidence on doi: 10.1377/hlthaff.2011.1297 HEALTH AFFAIRS 31, NO. 11 (2012): 2510–2517 ©2012 Project HOPE— The People-to-People Health Foundation, Inc. Ying Xue (Ying_Xue@ URMC.Rochester.edu) is an associate professor in the School of Nursing at the University of Rochester, in New York Joyce Smith is a senior information analyst at the University of Rochester School of Nursing. Deborah A. Freund is president of Claremont Graduate University, in California. Linda H. Aiken is the Claire M. Fagin Leadership Professor of Nursing, a professor of sociology, and the director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania, in Philadelphia. 2510 Health Affairs November 2012 31:11 Nursing Downloaded from HealthAffairs.org on June 07, 2020. Copyright Project HOPE—The People-to-People Health Foundation, Inc. For personal use only. All rights reserved. Reuse permissions at HealthAffairs.org.