Expanded Use of Supplemental Nurses during the COVID-19 Pandemic (GAO-24-106447)
Summary
A GAO report to congressional addressees, GAO-24-106447, dated August 2024, on hospitals' use of supplemental nurses, meaning nurses temporarily contracted through external staffing agencies. GAO reports that use of supplemental nurses increased in the selected hospitals in its review during the COVID-19 pandemic. GAO requested data from 11 selected hospitals from 2019 to 2022, and six were able to provide complete data for those 4 years. The report describes how hospitals rely on nurses to meet patients' treatment and care needs and may contract supplemental staff when they lack enough employed staff.
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United States Government Accountability Office
Report to Congressional Addressees
HOSPITALS
August 2024
Expanded Use of
Supplemental Nurses
during the COVID-19
Pandemic
GAO-24-106447
August 2024
HOSPITALS
Expanded Use of Supplemental Nurses during the
COVID-19 Pandemic
Highlights of GAO-24-106447, a report to
congressional addressees
Why GAO Did This Study What GAO Found
Hospitals are reliant on nurses, among Use of supplemental nurses—nurses temporarily contracted by hospitals through
other clinicians and staff, to meet the external staffing agencies—increased in the selected hospitals in GAO’s review
treatment and care needs of their during the COVID-19 pandemic. Specifically, GAO requested data from 11
patients. When they do not have selected hospitals from 2019 to 2022. Of the six selected hospitals that were able
enough employed staff to provide care to provide complete data for these 4 years, five of the hospitals reported that the
for their patients, they may contract proportion of registered nurse (RN) hours worked by supplemental RNs more
with external staffing agencies for than doubled. Overall use ranged from 2 to 28 percent in 2022 (see table).
supplemental nurses.
Proportion of Supplemental Registered Nurse (RN) Use in Selected Hospitals, 2019 and 2022
The CARES Act includes a provision
for GAO to report on its ongoing Hospital A Hospital B Hospital C Hospital D Hospital E Hospital F
COVID-19 monitoring and oversight 2019 3% <1% <1% 4% 13% 8%
efforts. GAO was also asked to review 2022 6% 7% 16% 12% 2% 28%
hospitals’ use of supplemental nurses Source: GAO analysis of data on supplemental RN hours or full-time equivalent employees provided by selected hospitals. | GAO-24-
106447
during the COVID-19 pandemic. This
report describes (1) selected hospitals’ Data provided to GAO by the six selected hospitals also show the average hourly
use of supplemental nurses from 2019 cost of RNs increased from 2019 to 2022, with a greater rate of increase for
through 2022 and (2) selected supplemental RNs than for directly employed nurses. Specifically, the percentage
hospitals’ other strategies for increases for these six hospitals ranged from 14 to 45 percent for directly
responding to staffing challenges employed RNs and from 53 to 266 percent for supplemental RNs. GAO found
during the pandemic. similar trends in use and average hourly cost in California hospital data.
GAO interviewed a nongeneralizable Representatives GAO interviewed from 11 selected hospitals reported
sample of 11 acute care hospitals that implementing a range of new and pre-existing strategies, to respond to staffing
represent a variety of locations, health challenges in the COVID-19 pandemic (see figure). Nine of the 11 hospitals
system affiliations, ownership types,
avoided reductions in operating capacity during the pandemic, representatives
and numbers of licensed beds. Six of
told GAO. However, representatives from two of the hospitals reported
these hospitals were able to provide
GAO complete data for 2019 through operational changes, such as closing a unit or reducing the number of beds
2022 on their use of, spending on, and available for patients. Representatives from seven of the nine hospitals credited
average hourly cost of supplemental their hospitals’ ability to maintain capacity, as the pandemic continued, to the
nursing staff. GAO also interviewed increased use of supplemental nurses.
representatives from four health care
Examples of Selected Hospitals’ Strategies for Responding to Staffing Shortages
staffing agencies selected based on
market size and seven academic
researchers with relevant expertise.
GAO also analyzed 2019-2022 data
from California hospitals on the use
and cost of nursing staff. GAO selected
California as it had publicly available
data for directly employed and
supplemental nursing staff. GAO also
analyzed data from national sample
surveys of RNs by the Health
Resources and Services
Administration in 2018 and 2022.
View GAO-24-106447. For more information,
contact Leslie V. Gordon at (202) 512-7114 or
GordonLV@gao.gov.
United States Government Accountability Office
Contents
Letter 1
Background 4
Use and Hourly Cost of Supplemental Nurses in Selected
Hospitals Increased during the COVID-19 Pandemic 7
Selected Hospitals Reported Using a Range of Strategies to
Address Staffing Challenges 15
Agency Comments 18
Appendix I Information about Selected Hospitals 21
Appendix II Information about California Hospitals 26
Appendix III Information from National Sample Surveys of Licensed Registered
Nurses in 2018 and 2022 30
Appendix IV Strategies Used by Selected Hospitals to Address Staffing Needs and
Changes to the Strategies during the COVID-19 Pandemic 34
Appendix V GAO Contact and Staff Acknowledgments 43
Tables
Table 1: Supplemental Registered Nurse (RN) Use as a
Percentage of Total RN Use in Selected Hospitals, 2019
to 2022 8
Table 2: Spending on Supplemental Registered Nurse (RN) as a
Percentage of Total Hospital Spending on RNs in
Selected Hospitals, 2019 to 2022 9
Table 3: Hours Worked by Type of Nursing Staff in California
Hospitals That Reported Supplemental Nursing Staff Use,
Fiscal Years 2019 to 2022 10
Table 4: Percentage Change in Average Hourly Cost for
Registered Nurses (RN) in Selected Hospitals, from 2019
to 2022 12
Page i GAO-24-106447 Hospital Use of Supplemental Nurses
Table 5: Average Hourly Cost for Nursing Staff Reported by
California Hospitals That Used Supplemental Nursing
Staff, Fiscal Years 2019 to 2022 14
Table 6: Characteristics of Selected Hospitals 21
Table 7: Supplemental Registered Nurses (RN) Hours or Full-
Time Equivalent Employees (FTE) in Selected Hospitals,
2019 – 2022 23
Table 8: Spending on Supplemental Registered Nurses (RN) in
Selected Hospitals, 2019 – 2022 24
Table 9: Average Hourly Cost for Registered Nurses (RN) in
Selected Hospitals, 2019 – 2022 24
Table 10: Characteristics of California Short-term Acute Care
Hospitals That Reported Using Supplemental Nursing
Staff, Fiscal Year 2019 – 2022 27
Table 11: Hours Worked by Nursing Staff in California Hospitals
That Reported Supplemental Nursing Staff Use, Annually,
Fiscal Year 2019 – 2022 29
Table 12: Average Hourly Cost for Nursing Staff Reported by
California Hospitals That Reported Using Supplemental
Nursing Staff, Fiscal Year 2019 – 2022 29
Table 13: National Estimates of Licensed Registered Nurses (RN)
in Inpatient Hospital Settings, by Employment Type, 2017
and 2021 32
Figure
Figure 1: Selected Hospitals’ Reported Strategies for Responding
to Staffing Shortages 16
Page ii GAO-24-106447 Hospital Use of Supplemental Nurses
Abbreviation
RN registered nurse
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Page iii GAO-24-106447 Hospital Use of Supplemental Nurses
Letter
441 G St. N.W.
Washington, DC 20548
August 1, 2024
Congressional Addressees
Hospitals are reliant on nursing staff, along with other clinicians and
hospital staff, to meet the treatment and care needs of their patients.
When hospitals do not have enough employed staff to provide care for
their patients, they may contract with external staffing agencies for
temporary staff. This practice has been an important part of nurse staffing
for decades.
Surges in COVID-19 cases during periods of the pandemic, often
associated with the emergence of new variants, stressed hospitals with
high patient volumes. 1 It also depleted nursing staff and clinicians who
faced exposure to the virus as part of their jobs. The extended length of
the COVID-19 pandemic—over 3 years—placed further stress on
hospitals and their staff, leading to increased staff burnout, exhaustion,
and trauma.
Local and national news media reported that wages paid to contracted
temporary nursing staff, which we refer to as supplemental nurses,
jumped during the pandemic. Media reports indicated that wage
differences between nurses directly employed by hospitals and
supplemental nurses led to some nurses leaving direct hospital
employment in favor of contracts with staffing agencies. These reports
1The Secretary of Health and Human Services first declared the COVID-19 pandemic a
public health emergency under section 319 of the Public Health Service Act on January
30, 2020. In addition, on March 13, 2020, the President declared COVID-19 a national
emergency under the National Emergencies Act and a nationwide emergency under
section 501(b) of the Robert T. Stafford Disaster Relief and Emergency Assistance Act
(Stafford Act). The national emergency declaration terminated on April 10, 2023, and the
Stafford Act declarations terminated on May 11, 2023, though the nation is still recovering
from the public health and economic effects of the pandemic.
Page 1 GAO-24-106447 Hospital Use of Supplemental Nurses
also highlighted the potential financial implications to hospitals due to the
increased need for, and cost of, supplemental nurses. 2
The CARES Act includes a provision for us to report on our ongoing
monitoring and oversight efforts related to the COVID-19 pandemic. 3
Further, you asked us to examine how hospitals’ use of supplemental
nurses changed during the pandemic.
This report describes (1) selected hospitals’ use of supplemental nurses
from 2019 through 2022, and (2) selected hospitals’ other strategies for
responding to staffing challenges during the COVID-19 pandemic.
To address both objectives, we interviewed representatives and
requested data from a nongeneralizable selection of 11 acute care
hospitals. 4 We selected the 11 hospitals to represent a variety of
locations, health system affiliations, ownership types, and numbers of
licensed beds. We cannot generalize our findings from the 11 hospitals to
other hospitals. (See appendix I for more information on our 11 selected
hospitals and how we selected them.)
2Nurses are a labor cost to hospitals. Unlike physicians and advanced practice registered
nurses, the care that nurses provide is not directly billed to insurance.
For examples of media reports, see Lenny Bernstein, “As COVID Persists, Nurses Are
Leaving Staff Jobs – and Tripling their Salaries as Travelers,” The Washington Post, Dec.
6, 2021; Leticia Miranda, “Rural Hospitals Losing Hundreds of Staff to High-Paid Traveling
Nurse Jobs,” NBC Business News, Sept. 15, 2021; Abby Vesoulis and Abigail Abrams,
“Contract Nurse Agencies Are Making Big Money in the Age of COVID-19. Are They
‘Exploiting’ the Pandemic?” TIME, Feb. 23, 2022; and Jessie Hellmann and Alex Kacik,
“Beyond the Byline: Providers Accuse Staffing Agencies of Price Gouging,” Modern
Healthcare, Mar. 17, 2022.
3Pub. L. No. 116-136, § 19010(b), 134 Stat. 281, 579 (2020). The American Rescue Plan
Act of 2021 also includes a provision for us to conduct oversight of the COVID-19
response. Pub. L. No. 117-2, § 4002, 135 Stat. 4, 78. All of GAO’s reports related to the
COVID-19 pandemic are available on GAO’s website at https://www.gao.gov/coronavirus.
Since 2020, we have reported on challenges hospitals experienced during the COVID-19
pandemic, including federal efforts to respond to them. See the following reports related to
hospital staffing challenges: (1) GAO, Public Health Preparedness: COVID-19 Medical
Surge Experiences and Related HHS Efforts, GAO-22-105461 (Washington, D.C.: Aug.
17, 2022); (2) GAO, Behavioral Health and COVID-19: Higher-Risk Populations and
Related Federal Relief Funding, GAO-22-104437 (Washington, D.C., Dec. 10, 2021); and
(3) GAO, COVID-19: Opportunities to improve Federal Response and Recovery Efforts,
GAO-20-625 (Washington, D.C.: Jun. 25, 2020).
4There are no comprehensive federal hospital nurse staffing data that distinguish between
directly employed and supplemental nursing staff.
Page 2 GAO-24-106447 Hospital Use of Supplemental Nurses
From the 11 selected hospitals, we requested data for 2019 through 2022
for both directly employed and supplemental nursing staff—including
registered nurses (RN), licensed vocational nurses, and certified nurse
assistants. 5 Six of the 11 hospitals were able to provide data for all 4
years requested. To address our first objective, we analyzed and reported
the following data from these six selected hospitals:
• inpatient nurse use (reported in either inpatient nursing hours or
inpatient nursing full-time equivalents),
• total hospital spending, and
• hourly cost paid by the hospital.
We limited our analysis to RNs because four of the six selected hospitals
did not report use of other supplemental nursing staff, such as licensed
vocational nurses and certified nursing assistants.
To provide additional context, we also identified and examined publicly
available data from California hospitals for 2019 through 2022 on the
annual use of and hourly cost for both directly employed and
supplemental nursing staff. 6 We examined California hospital data
because the data distinguished between directly employed and
supplemental nursing staff, which may include RNs, licensed vocational
nurses, and aides and orderlies. We limited our analysis of California
hospitals to short-term general acute care hospitals that reported a full
year of data, among other exclusions. (See appendix II for more
information on our analysis of data on California hospitals.) Our analysis
of California hospital data is not generalizable to other states.
We assessed the reliability of the data provided by our selected hospitals
by interviewing hospital representatives and reviewing the data to identify
any anomalies. We also assessed the reliability of the California data by
reviewing relevant data documentation, interviewing knowledgeable
officials, and performing tests of the data to identify any outliers or
5In this report, we use the term licensed vocational nurses, which includes both licensed
vocational nurses and licensed practical nurses. According to the U.S. Bureau of Labor
Statistics, these types of nurses have nearly identical responsibilities, but their titles vary
across states.
6Certain hospitals licensed by the California Department of Public Health must submit
annual financial disclosure reports. See Cal. Health and Safety Code § 128735 (2024).
These reports are compiled based on the end date of the fiscal year reported.
Page 3 GAO-24-106447 Hospital Use of Supplemental Nurses
anomalies. We determined that the data were sufficiently reliable for the
purposes of our reporting objectives.
To inform both objectives, we also reviewed documents and interviewed
three national stakeholder associations representing hospitals, staffing
agencies, and nurses; four health care staffing agencies selected based
on largest market size in 2021; and seven academic researchers with
expertise on hospital nurse staffing and use of supplemental nurses. For
example, in these interviews, we discussed the nurse staffing challenges
during the pandemic and the pandemic’s impact on hospital use of and
spending on supplemental nurses. We also interviewed officials from
relevant Department of Health and Human Services’ agencies, including
the Centers for Medicare & Medicaid Services, the Health Resources and
Services Administration, and the Office of the Assistant Secretary for
Planning and Evaluation.
We conducted this performance audit from December 2022 to August
2024 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.
More than 1.8 million nurses worked in hospitals at the end of 2021.
Background Nurses are critical to hospitals and have a direct effect on patient care.
They provide most patient assessments, evaluations, and physical care,
often attend to patients’ social and mental needs, and prepare patients
and their families to leave the hospital. Further, as patient care has
become more complex, nurses may need to make critical decisions
associated with care for sicker, frailer patients and help patients manage
chronic illnesses. When hospitals have temporary nurse vacancies, they
may contract for supplemental nurses through external staffing agencies
using a variety of different arrangements. Prior to the COVID-19
pandemic, use of supplemental nurses was a common hospital practice.
Hospitals have varying options in how they structure contracts with
external staffing agencies.
Supplemental Nurse Health care staffing agencies hire nurses to fill temporary assignments
Arrangements wherever nurses are needed. Supplemental nurses often work in
hospitals, but may also work in other settings, such as nursing homes.
The educational and licensing requirements and daily responsibilities of a
supplemental nurse are typically the same as a directly employed nurse.
Page 4 GAO-24-106447 Hospital Use of Supplemental Nurses
A nurse may hold jobs through a staffing agency as a primary job,
secondary job, or both.
Staffing agencies offer a range of temporary assignment types for
supplemental nurses. Common arrangements include:
• per diem (payment per day) arrangements, in which nurses work
locally and typically operate on a shift-by-shift basis,
• travel arrangements, in which nurses fill temporary vacancies for a
contracted period of time. 7 The contract length for travel
arrangements is often 13 weeks, but it can vary depending on the
hospital’s needs.
Health care staffing agencies typically screen each nurse candidate for
the necessary training, licensure, and clinical competencies needed for
the client’s facility. Once a nurse’s contract begins, staffing agencies
typically provide their nurses with complete compensation packages
during their temporary assignments, which may include competitive
wages, professional liability insurance, retirement savings plans, and,
when travel is required, reimbursements for housing, meals, and travel
expenses, among other things.
Staffing Agency Contracts In their arrangements with staffing agencies, hospitals can (1) manage
with Hospitals one or more staffing agency contracts directly or (2) contract with a single
staffing agency to manage their supplemental nursing needs, known as a
managed service provider agreement. In such an arrangement, the
managed service provider typically uses a combination of nurses through
its own staffing agency and from other staffing agencies to fulfill the
hospital’s needs and manages that process for the hospital.
For hospitals part of larger health systems, the staffing agency contract
structure, and decisions about the need for supplemental nurses, can
vary. Specifically, some staffing agency contracts may be between the
agency and the health system, with decisions on the need for
supplemental nurses occurring either at the hospital- or health system-
level. Other contracts may be between the agency and the individual
7Health care staffing agencies may offer other types of contractual arrangements for
supplemental nurses and hospitals, such as rapid response arrangements (quick
responses to regional emergencies, such as natural disasters, in which a large number of
nurses are needed for a shorter period of time).
Page 5 GAO-24-106447 Hospital Use of Supplemental Nurses
hospital, with decisions on the need for supplemental nurses occurring at
the hospital level.
A hospital’s contract with a staffing agency may vary in the amount of
support the agency provides the hospital with supplemental nurse
recruitment and hiring. For example, staffing agencies may conduct
interviews with nurse candidates and send the most qualified to the
hospital for selection or staffing agencies may provide all potential nurse
candidates to the hospital to interview and select.
Hospitals pay staffing agencies an hourly amount for each supplemental
nurse placed in the facility. The hourly amount includes more than just the
hourly pay rate to the supplemental nurse. The total hourly cost of the
supplemental nurse to the hospital, is made up of both the (1) nurse costs
(including, but not limited to, hourly pay rate, payroll taxes, and benefits)
and (2) operating expenses (the staffing agency’s overhead costs) and
staffing agency earnings. 8 In comparison, the hourly cost to the hospital
for a directly employed nurse includes the nurse’s hourly wages, benefits
(health insurance, retirement, paid time off), and payroll taxes. 9
Hospitals generally decide what they are willing to pay staffing agencies
for each supplemental nurse. Staffing agencies may provide hospitals
with market rate information to help in that determination. Further, once
placed in the hospital, day-to-day oversight of the supplemental nurse is
generally provided by the hospital’s on-site supervisor. Other
responsibilities are managed by the staffing agency, including payroll,
insurance and other benefits, and worker’s compensation, among other
things.
8A supplemental nurse’s hourly pay rate was the largest component of the bill rate (about
52 percent) in 2022, followed by housing and meal reimbursement (about 21 percent),
according to an industry report based on a survey of staffing agencies. See Staffing
Industry Analysts and National Association of Travel Healthcare Organizations’ Travel
Nurse Benchmarking Survey, Historical Trends Report: Survey Years 2018 through 2023
(Mountain View, CA: Staffing Industry Analysts, 2023).
9Hourly cost to the hospital for directly employed nurses does not include indirect costs,
such as recruiting costs and sign-on bonuses, among other costs.
Page 6 GAO-24-106447 Hospital Use of Supplemental Nurses
The use and cost of supplemental nurses increased in selected hospitals,
Use and Hourly Cost as well as in California hospitals, from 2019 to 2022. Supplemental RN
of Supplemental staffing as a percentage of total RN staffing in 2022 varied across the six
selected hospitals that provided data for all 4 years. The peak in use of,
Nurses in Selected and average hourly cost for, supplemental nurses across the four years of
Hospitals Increased data we analyzed occurred in the latter years of the pandemic (2021 or
2022) in both our selected hospitals and California hospitals. The average
during the COVID-19 hourly cost for nurses increased for all nursing types in our selected
Pandemic hospitals and for California hospitals, and the increase in average hourly
costs for supplemental nurses exceeded the increase in average hourly
costs for directly employed nurses.
Selected Hospitals’ Use of The use of and spending on supplemental nurses—specifically RNs—in
Supplemental Nurses the inpatient setting in most of our six selected hospitals increased during
the COVID-19 pandemic, especially in the pandemic’s later stages (2021
Increased during the
and 2022). We saw similar trends in California hospitals. National RN and
Pandemic, with the employer survey data also show increases in RNs employed by staffing
Percentage of agencies during the pandemic.
Supplemental Nurses to
Total Nurses Ranging from Selected hospitals increased supplemental nurse use. Specifically,
five out of six selected hospitals that reported all 4 years of data (2019 to
2 to 28 in 2022 2022), reported increases in the use of supplemental RNs from 2019 to
2022. Data from the sixth hospital showed variation across the 4 years,
with an overall decrease in its use of supplemental nurses.
For example, one hospital reported 304 total hours for supplemental RNs
in 2019, which increased to 16,270 total hours in 2022. For directly
employed RNs, this hospital reported 230,935 total hours in 2019, which
decreased to 220,096 total hours in 2022. (See app. I.)
Supplemental RN staffing as a percentage of total RN staffing ranged
from less than 1 to 13 percent in 2019 and ranged from about 2 to 28
percent of total RN staffing in 2022, in our six hospitals. 10 (See table 1.)
10The proportion of supplemental RN staffing for one of these hospitals was about 28
percent in 2022, following no use of supplemental RN staff in 2020. Representatives noted
that the hospital relied more on supplemental staffing in 2021 and 2022 as it converted
into a regional medical center and recruited directly hired staff.
Page 7 GAO-24-106447 Hospital Use of Supplemental Nurses
Table 1: Supplemental Registered Nurse (RN) Use as a Percentage of Total RN Use in Selected Hospitals, 2019 to 2022
Hospitals’ supplemental RN staffing (reported as either hours worked by or
full-time equivalent employees) as a percentage of total RN staffing Change
Selected hospital 2019 2020 2021 2022 2019 to 2022
Hospital A 3 4 5 6 ▲
Hospital B <1a 5 10 7 ▲
Hospital C <1b 0c 3 16 ▲
Hospital D 4 7 12 12 ▲
Hospital Ed 13 3 20 2 ▼
Hospital Fe 8 0 20 28 ▲
▲ indicates an increase.
▼ indicates a decrease.
Source: GAO analysis of data provided by six of GAO’s selected hospitals. | GAO-24-106447
Note: Of the six hospitals that provided data for all 4 years, two hospitals reported data by hospital
fiscal year (defined as July 1 through June 30) and four hospitals reported by calendar year.
a
This value was 0.1.
b
This value was 0.5.
c
This hospital used no supplemental RN staffing in 2020.
d
Representatives told us they needed supplemental nurses due to major changes to their patient
census in 2021 during the pandemic. The hospital reduced use of supplemental nursing staff in 2022
because they were able to hire directly employed nurses.
e
This hospital used no supplemental RN staffing in 2020, when the hospital had significantly reduced
hiring of directly employed staff in anticipation of a change in ownership. Representatives noted that
the hospital relied more on supplemental staffing in 2021 and 2022 as it converted into a regional
medical center and recruited directly hired staff.
In the five hospitals that reported increases in their use of supplemental
RNs, reported hospital spending on supplemental RNs increased from
2019 to 2022, and these increases in spending on supplemental RNs
outpaced the increases in their use. For example, one hospital’s spending
on supplemental RNs approximately quadrupled, increasing from
$2,310,411 in 2019 to $9,262,158 in 2022, while its use of supplemental
RNs doubled during the same period. For directly employed RNs, this
hospital reported spending $73,434,510 in 2019 and $85,136,777 in 2022
(an increase of nearly $12 million), while its use of directly employed RNs
stayed nearly the same. (See app. I.)
Five of the six hospitals that reported an increased use of supplemental
nurses also reported increased spending on supplemental RNs as a
proportion of their total spending. Hospital spending on supplemental RNs
as a percentage of total hospital spending on RNs grew to 50 percent or
more for two of the hospitals by 2022, with spending on supplemental
Page 8 GAO-24-106447 Hospital Use of Supplemental Nurses
nurses remaining under 20 percent of total spending on RNs for the other
four hospitals. (See table 2.)
Table 2: Spending on Supplemental Registered Nurses (RN) as a Percentage of Total Hospital Spending on RNs in Selected
Hospitals, 2019 to 2022
Hospitals’ reported spending on supplemental RNs (as a percentage of total
RN spending) Change
Selected hospital 2019 2020 2021 2022 2019 to 2022
Hospital A 3 4 5 10 ▲
Hospital B <1a 8 20 12 ▲
Hospital C 2 0b 16 67 ▲
Hospital D 5 11 22 18 ▲
Hospital E 20 5 32 4 ▼
Hospital F 12 0b 44 50 ▲
▲ indicates an increase.
▼ indicates a decrease.
Source: GAO analysis of data provided by six of GAO’s selected hospitals. | GAO-24-106447
Note: Two of the six hospitals reported data by hospital fiscal year (defined as July 1 through June
30) and four of the hospitals reported by calendar year.
a
This value was 0.2.
b
Hospitals C and F used no supplemental RN staffing in 2020.
All six selected hospitals reported that their use of and spending on
supplemental RNs peaked during later stages of the COVID-19
pandemic—2021 or 2022—rather than in the first year. The use of
supplemental RNs as a percentage of total RN use and spending on
supplemental RNs as a percentage of total hospital spending also
increased. For example, data reported by two hospitals showed the
highest proportion of use and spending in 2021, and the other three
hospitals showed the highest proportion of use and spending in 2022.
The remaining hospital showed its highest proportion of use in 2021,
which remained the same in 2022. Representatives from one of the
hospitals attributed this to staff beginning to fall ill in 2021 and pandemic-
related turnover in nurses increasing in 2022. The hospital’s issues with
turnover did not begin until the end of 2021, leading into 2022, and
coincided with a 15 percent increase in patient volume. (See app. I for
additional information on RN use and spending over time in selected
hospitals.)
California hospitals also show increase in use of supplemental
nurse staffing. Similar to our selected hospitals, we found California
hospitals also reported increases in their use of supplemental nursing
Page 9 GAO-24-106447 Hospital Use of Supplemental Nurses
staff during the COVID-19 pandemic. (For the California hospitals, these
increases in supplemental nursing staff use may have included increased
use of RNs, licensed vocational nurses, and aides and orderlies, unlike
for our selected hospitals where we report on supplemental RN use
specifically.) Most California hospitals (about 92 percent each year)
reported using supplemental nursing staff; the average total hours worked
by supplemental nursing staff in these hospitals increased from about
29,000 hours in fiscal year 2019 to about 42,000 hours in fiscal year 2022
(a 45 percent increase). See appendix II for more information.
Overall use of supplemental nursing staff in California hospitals as a
percentage of total nurse staff remained under 10 percent in 2022.
Specifically, for California hospitals reporting the use of supplemental
nurses, the average proportion of annual hours worked by supplemental
nursing staff increased from fiscal year 2019 to fiscal year 2022. The
average proportion of annual hours worked by directly employed RNs
increased, while the proportion of annual hours worked by other directly
employed nursing staff decreased. (See table 3.)
Table 3: Hours Worked by Type of Nursing Staff in California Hospitals That Reported Supplemental Nursing Staff Use, Fiscal
Years 2019 to 2022
Average Percentage of Annual Hours Worked by Each Type of
Nursing Staff of Total Nurse Staffing Hours in California Hospitals
Fiscal year Fiscal year Fiscal year Fiscal year
2019 2020 2021 2022 Change
Type of nursing staff (n=243) (n=238) (n=238) (n=236) 2019 to 2022
Directly Registered nurses 71 72 72 72 ▲
employed Licensed vocational nurses 6 5 5 4 ▼
nursing staff
Aides and orderlies 20 20 20 19 ▼
Supplemental nursing staffa 5 5 5 7 ▲
▲ indicates an increase.
▼ indicates a decrease.
Source: GAO analysis of California Department of Health Care Access and Information, Hospital Annual Financial and Utilization data. | GAO-24-106447
Notes: We limited our analysis to short-term general and short-term children’s acute care hospitals
that reported a full year of data. Totals are from all hospital inpatient units in these hospitals, which
may include non-acute care units.
We excluded 31 Kaiser hospitals from our analysis that did not report average hourly cost for all 4
years in our review.
Totals in columns do not add to 100 percent due to rounding.
a
In this report, we refer to the state’s category of registry nursing personnel (which may include
registered nurses, licensed vocational nurses, and aides and orderlies) as supplemental nursing staff.
National survey data also showed increases in RNs employed by
staffing agencies. National survey data estimates indicated similar
Page 10 GAO-24-106447 Hospital Use of Supplemental Nurses
trends. Specifically, data from a sample survey of RNs conducted by the
Health Resources and Services Administration within the Department of
Health and Human Services showed that the number of hospital RNs
employed by staffing agencies increased during the pandemic.
Approximately 2 percent of the estimated 1.17 million RNs whose primary
job was in an inpatient hospital setting were employed by a staffing
agency in 2017, compared with approximately 10 percent of the
estimated 1.27 million RNs working in an inpatient hospital setting in
2021. (See app. III for more information.) Additionally, data from a sample
survey of employers conducted by the U.S. Bureau of Labor Statistics
showed that the estimated percentage of employees working as RNs for
external staffing agencies in any sector of the economy (including, but not
limited to, the health care sector) increased during the pandemic, with
about 2 percent of RNs working for external staffing agencies in 2019 and
about 3 percent in 2022. 11
Nurse Hourly Costs Data we collected from six selected hospitals show average hourly cost
Increased for Selected for both directly employed RNs and supplemental RNs increased from
2019 to 2022, with a greater rate of increase for supplemental RNs. 12
Hospitals during the
Specifically, of the six selected hospitals that reported all 4 years of data,
Pandemic, with Greater all hospitals reported increases in average hourly cost for RNs from 2019
Rates of Increase for to 2022. The percentage increase ranged from about 14 to 45 percent for
Supplemental Nurses directly employed RNs and from about 53 to 266 percent for
supplemental RNs. (See table 4.)
11The U.S. Bureau of Labor Statistics’ Occupational Employment and Wage Statistics
program produces employment and wage estimates for approximately 830 occupations
based on a survey of business establishments (employers). Data are published annually
with a May reference date and each year’s estimates were produced by a model-based
estimation method using three years of data. See U.S. Bureau of Labor Statistics’ “All May
2022 Data,” Occupation Employment and Wage Statistics Tables, accessed June 7, 2024,
and “All May 2019 Data,” Occupation Employment and Wage Statistics Tables, accessed
Jan. 9, 2024, https://www.bls.gov/oes/tables.htm.
12The hourly cost to the hospital for a directly employed nurse includes the nurse’s hourly
wages, benefits, and payroll taxes. The hourly cost to the hospital for a supplemental
nurse is the rate paid to the staffing agency. This rate includes both the nurse costs
(including hourly pay rate, payroll taxes, and benefits) and operating expenses (the
staffing agency’s overhead costs) and earnings.
Page 11 GAO-24-106447 Hospital Use of Supplemental Nurses
Table 4: Percentage Change in Average Hourly Cost for Registered Nurses (RN) in Selected Hospitals, from 2019 to 2022
Directly employed RNs average Supplemental RNs average hourly
hourly cost (in dollars) cost (in dollars)
Hospital 2019 2022 Change (percent) 2019 2022 Change (percent)
Hospital A $76.49 $94.94 24% $76.61 $143.82 88%
Hospital B $46.24 $62.12 34% $76.02 $116.31 53%
Hospital C $30.00 $40.25 34% $41.00 $150.00 266%
Hospital D $35.59 $40.55 14% $57.35 $93.14 62%
Hospital E $43.18 $50.17 16% $71.80 $123.18 72%
Hospital F $36.26 $52.58 45% $58.28 $131.76 126%
Source: GAO analysis of data provided by six of GAO’s selected hospitals. | GAO-24-106447
Notes: Two of the six hospitals reported data by hospital fiscal year (defined as July 1 through June
30) and four of the hospitals reported by calendar year.
The hourly cost to the hospital for a directly employed nurse includes the nurse’s hourly wages,
benefits, and payroll taxes. The hourly cost to the hospital for a supplemental nurse is the rate paid to
the staffing agency. This rate includes both the nurse costs (including hourly pay rate, payroll taxes,
and benefits) and operating expenses (the staffing agency’s overhead costs) and earnings.
According to representatives from three of the six hospitals, hourly costs
for supplemental RNs were trending down and stabilizing as of the time
we conducted the interviews, which was after the federal government
ended the COVID-19 public health emergency declaration in May 2023. 13
For example, representatives at one of the hospitals noted declining costs
for supplemental nurses as of September 2023, but stated that they did
not anticipate that supplemental nurse payment rates would ever return to
pre-pandemic levels. Representatives at another one of the hospitals
echoed this, describing higher payment rates for supplemental nurses as
the “new normal.”
According to representatives from most of the selected hospitals and
staffing agencies we interviewed, hospitals or their health systems decide
what total hourly amount they are able or willing to pay staffing agencies
for each supplemental nurse. The supplemental nurse’s hourly payment
rate and benefits make up a large portion of the total cost, but other
components, such as staffing agency overhead and earnings, also
contribute. For example, representatives from one hospital noted that
their managed service provider furnishes market reports on supplemental
13Representatives from two additional selected hospitals and two selected staffing
agencies also described decreasing payment rates to supplemental RNs at the time we
conducted interviews in mid-2023. Specifically, we conducted interviews with hospital and
staffing agency representatives from June through October 2023.
Page 12 GAO-24-106447 Hospital Use of Supplemental Nurses
nurse payment rates and supplemental nurse payments the hospital is
making, which the hospital executives use to discuss ways to reduce
costs.
Representatives from two hospitals said the cost of supplemental nurses
increased because they were competing with hospitals across the nation.
For example, representatives at one hospital said the high sign-on
bonuses and rates paid to supplemental nurses did not increase the
number of available nurses in the workforce. Rather, representatives
explained, the increased compensation created incentives for nurses to
leave the hospital’s direct employment and work as supplemental nurses
elsewhere. The representatives said this movement of nurses around the
country made the hospital’s workforce less stable and managing it took
hospital staff time and energy away from caring for patients.
Representatives from one staffing agency also noted the shift to
nationwide competition for nurses. These representatives said as the
entire country began experiencing COVID-19 surges (rather than in
isolated geographic regions), competition for supplemental nurses
became national. They explained this shift allowed nurses the opportunity
to pursue the highest payment rate and often prompted hospitals to offer
payment rates above the highest existing rate.
Example of a Staffing Agency’s Gross Hospital representatives we spoke with raised concerns about the profits
Profit and Margins retained by external staffing agencies, while staffing agencies we spoke
AMN Healthcare is a publicly traded health with told us that their profit margins declined during the pandemic.
care staffing agency and, as such, it releases
annual financial reports. From 2019 through
Specifically, representatives we interviewed from three hospitals said that
2022, AMN reported increases in its gross the increases in the hospitals’ hourly payments to staffing agencies were
profits, but a decrease in its gross margin. not passed on to supplemental nurses as increases in their hourly wages.
Specifically, AMN’s gross profits increased
from $743.5 million in 2019 to $1,716.7 million
in 2022 and its gross margins decreased from Also, the American Hospital Association reported that the margin retained
about 34 percent in 2019 to about 33 percent
in 2022. by staffing agencies increased during the pandemic from an average of
AMN also reported gross margin for its nurse about 15 percent in 2019 to an average of about 62 percent in January
and allied health professionals (such as 2022. 14 In contrast, an analysis by Staffing Industry Analysts and The
physical therapists and lab technicians)
segment specifically, with gross margins National Association of Travel Healthcare Organizations reported that
decreasing from about 28 percent in 2019 to staffing agencies’ gross margin percentage decreased from about 26
about 26 in 2022.
Source: GAO review of AMN Healthcare financial reports. |
GAO-24-106447
14See The American Hospital Association, Massive Growth in Expenses and Rising
Inflation Fuel Continued Financial Challenges for America’s Hospitals and Health Systems
(Washington, D.C.: The American Hospital Association, 2022).
Page 13 GAO-24-106447 Hospital Use of Supplemental Nurses
percent in 2018 to 23 percent in 2022. 15 Staffing agency representatives
attributed the large increase in prices to the spike in demand for a finite
number of nurses. In addition, representatives from one agency noted
that the staffing agency market was not concentrated enough for
individual agencies to affect prices and that states with rate caps in place
waived them during the pandemic because those hospitals could not
attract supplemental nurses.
Similar to what we found in the data provided by our six selected
hospitals, California hospitals also reported increases in the average
hourly cost paid for all nursing staff during the pandemic, with the rate of
increase in the cost for supplemental nursing staff exceeding the rate of
increase in cost for directly employed nurses. Of the California hospitals
that used supplemental nursing staff,
• the total average hourly cost for directly employed RNs increased by
about 10 percent, increasing from $58.70 in fiscal year 2019 to $64.70
in fiscal year 2022.
• the total average hourly cost for supplemental nursing staff increased
by about 62 percent, increasing from $81.40 in fiscal year 2019 to
$131.50 in fiscal year 2022. (See table 5.)
Table 5: Average Hourly Cost for Nursing Staff Reported by California Hospitals That Used Supplemental Nursing Staff, Fiscal
Years 2019 to 2022
Average hourly cost (in dollars)
Type of nursing staff Fiscal year 2019 Fiscal year 2022 Change (percent)
Directly employed Registered nurses $58.70 $64.70 10%
nursing staff Licensed vocational nurses $32.00 $34.60 8%
Aides and orderlies $21.80 $24.40 12%
Supplemental nursing staffa $81.40 $131.50 62%
Source: GAO analysis of California Department of Health Care Access and Information, Hospital Annual Financial and Utilization data. | GAO-24-106447
Notes: We limited our analysis to short-term general and short-term children’s hospitals that reported
a full year of data. Totals are from all hospital units in these hospitals, which may include non-acute
care units.
We excluded 31 Kaiser hospitals from our analysis that did not report staffing data for all 4 years in
our review.
15Gross margin is the hourly rate the staffing agencies charge for a supplemental nurse,
minus the total cost of sales, which includes licensing and medical benefits for the
supplemental nurse. See Staffing Industry Analysts and National Association of Travel
Healthcare Organizations’ Travel Nurse Benchmarking Survey, Historical Trends Report:
Survey Years 2018 through 2023 (Mountain View, CA: Staffing Industry Analysts, 2023).
Page 14 GAO-24-106447 Hospital Use of Supplemental Nurses
a
In this report, we refer to the state’s category of registry nursing personnel (which may include
registered nurses, licensed vocational nurses, and aides and orderlies) as supplemental nursing staff.
The 11 selected hospitals we interviewed for this review reported
Selected Hospitals implementing a range of strategies to respond to staffing challenges in
Reported Using a the COVID-19 pandemic. Specifically, representatives from the 11
selected hospitals described using nine types of new and pre-pandemic
Range of Strategies staffing strategies to address the increased and more complex nurse
to Address Staffing staffing needs of the pandemic. We categorized these nine strategies into
four broader categories—hospital use of its directly employed nurses,
Challenges hospital use of health system nurses, other hospital staffing strategies,
and hospital use of staffing agencies. See figure 1 below for a description
of each staffing strategy and appendix IV for more detailed information on
how selected hospitals used each strategy, including changes during the
pandemic.
Page 15 GAO-24-106447 Hospital Use of Supplemental Nurses
Figure 1: Selected Hospitals’ Reported Strategies for Responding to Staffing Shortages
Representatives from five hospitals described that they prioritized starting
with their own directly employed nurses before moving to supplemental
nurses when filling immediate staffing needs. For example,
representatives from one hospital described first trying to fill staffing
needs with their own nurses through financial incentives for extra shifts or
the use of nurses from the hospital’s own float pool (a group of nurses
Page 16 GAO-24-106447 Hospital Use of Supplemental Nurses
who float across separate units within a single hospital), then bringing in
nurses from other hospitals in the health system, when applicable, before
contracting with supplemental nurses through external staffing agencies.
While facing staffing challenges during the pandemic, representatives
from nine of the 11 selected hospitals reported they were able to avoid
reductions in available beds or unit closures, aside from operating room
closures early in the pandemic. 16 Representatives at seven of these nine
hospitals credited their hospital’s ability to maintain capacity to the
increased use of supplemental nurses. For example, representatives from
one hospital stated that without the help of supplemental nurses, the
hospital’s operating capacity and ability to care for patients would have
been diminished.
In contrast, representatives from two selected hospitals stated that the
hospitals struggled to meet staffing needs using the strategies discussed
above, and as a result, had to make operational changes.
• One of the two hospitals closed its acute rehabilitation unit during the
pandemic, which hospital representatives attributed to the high cost of
both supplemental nurses and directly employed nurses. 17
• Representatives from the other hospital stated that shortages in
nurses reduced the number of beds the hospital could make available
to patients, particularly at the beginning of the pandemic. According to
hospital representatives, the hospital’s owners at that time decided
not to replace any nurses that left, which led the hospital to decrease
16Nine selected hospitals reported temporarily closing operating rooms or significantly
limiting operating room capacity early in the pandemic. Hospital representatives indicated
that these changes were often in response to certain state orders or recommended by
some state hospital associations.
While none of our selected hospitals described furloughing or laying off nurses during the
COVID-19 pandemic, representatives of a stakeholder organization and a few researchers
we spoke with noted that many hospitals furloughed staff at the beginning of the pandemic
when elective surgeries were put on hold. According to survey data, almost a quarter of
the RN workforce experienced some form of employer-driven employment disruption
during the pandemic, including forced leave, furloughs (with or without pay), and layoffs.
See Department of Health and Human Services’ Health Resources and Services
Administration, National Center for Health Workforce Analysis, Experience of Nurses
Working During the COVID Pandemic – Data from the 2022 National Sample Survey of
RNs (March 2024).
17Hospital representatives noted that the acute rehabilitation unit was still closed at the
time of our interview in August 2023. Representatives explained that as the hospital hired
new nurses, it continued to assess whether to reopen the unit.
Page 17 GAO-24-106447 Hospital Use of Supplemental Nurses
its capacity and transfer patients to hospitals outside of the immediate
area. Representatives explained that the hospital changed owners in
late 2020, and there was a shift in philosophy and hiring practices.
The new owners increased their staffing levels through use of
supplemental nurses while they converted the hospital into a regional
medical center.
During the pandemic, some of the hospitals in our review also made other
operational changes in response to the increase in patient volume and
the change in patient needs. Specifically, representatives from five
hospitals reported they opened new units or converted existing units to
care for COVID-19 patients. Representatives from four hospitals also
reported stopping new admissions when they reached capacity or being
unable to transfer patients to other facilities in the region. For example,
representatives from one hospital reported that they opened a second
intensive care unit when they were not able to transfer patients who
needed a higher level of care, such as a heart bypass machine.
We provided a draft of this report to the Department of Health and Human
Agency Comments Services for review and comment. The Department provided technical
comments, which we incorporated as appropriate.
We are sending copies of this report to the appropriate congressional
committees, the Secretary of Health and Human Services, and other
interested parties. In addition, the report is available at no charge on the
GAO website at http://www.gao.gov.
If you or your staff have any questions about this report, please contact
me at (202) 512-7114 or at GordonLV@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff who made key contributions to this
report are listed in Appendix V.
Leslie V. Gordon
Director, Health Care
Page 18 GAO-24-106447 Hospital Use of Supplemental Nurses
List of Addressees
The Honorable Patty Murray
Chair
The Honorable Susan Collins
Vice Chair
Committee on Appropriations
United States Senate
The Honorable Ron Wyden
Chairman
The Honorable Mike Crapo
Ranking Member
Committee on Finance
United States Senate
The Honorable Bernie Sanders
Chair
The Honorable Bill Cassidy, M.D.
Ranking Member
Committee on Health, Education, Labor and Pensions
United States Senate
The Honorable Gary C. Peters
Chairman
The Honorable Rand Paul, M.D.
Ranking Member
Committee on Homeland Security and Governmental Affairs
United States Senate
The Honorable Tom Cole
Chairman
The Honorable Rosa L. DeLauro
Ranking Member
Committee on Appropriations
House of Representatives
The Honorable Cathy McMorris Rodgers
Chair
The Honorable Frank Pallone, Jr.
Ranking Member
Committee on Energy and Commerce
House of Representatives
Page 19 GAO-24-106447 Hospital Use of Supplemental Nurses
The Honorable Mark E. Green, M.D.
Chairman
The Honorable Bennie G. Thompson
Ranking Member
Committee on Homeland Security
House of Representatives
The Honorable James Comer
Chairman
The Honorable Jamie Raskin
Ranking Member
Committee on Oversight and Accountability
House of Representatives
The Honorable Jason Smith
Chairman
The Honorable Richard Neal
Ranking Member
Committee on Ways and Means
House of Representatives
The Honorable Tracey Mann
House of Representatives
Page 20 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix I: Information about Selected
Appendix I: Information about Selected
Hospitals
Hospitals
In order to describe hospitals’ use of supplemental nurses from 2019
through 2022, we interviewed representatives from a nongeneralizable
selection of 11 acute care hospitals. To select these hospitals, we used
data from the Centers for Medicare & Medicaid Services to take a random
sample of 121 of the 4,860 hospitals located in the 50 states and the
District of Columbia as of December 2022. The hospitals in our sample
included short-term acute care hospitals, critical access hospitals, and
children’s hospitals. 1
We removed hospitals with hiring and staffing models that likely differed
significantly from general acute care hospitals. These included hospitals
owned and operated by the Department of Veterans Affairs, the Indian
Health Service, and the Department of Defense, as well as specialty
hospitals, emergency department-only hospitals, and outpatient-only
facilities. Removing these hospitals resulted in a final sample of 108
hospitals.
We then reached out to the 93 hospitals for which we could find contact
information to request an interview. Representatives from 11 hospitals
accepted our invitation for interviews from July through October 2023. We
cannot generalize our findings from the 11 hospitals to other hospitals.
The 11 hospitals we interviewed represent a variety of locations, health
system affiliations, ownership types, and numbers of licensed beds. (See
table 6.)
Table 6: Characteristics of Selected Hospitals
Characteristic Number of selected hospitals (n = 11)
Hospital type • Short-term general acute care hospital: 10
• Critical access hospital: 1
• Children’s hospital: 0
Census region • Northeast: 3
• South: 4
• Midwest: 4
• West: 0
1All other types of hospitals and other provider types were excluded. To select the random
samples, we used the publicly available Centers for Medicare & Medicaid Services’
December 2022 Provider of Services file, accessed on March 23, 2023, from
https://data.cms.gov/provider-characteristics/hospitals-and-other-facilities/provider-of-
services-file-hospital-non-hospital-facilities.
Page 21 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix I: Information about Selected
Hospitals
Characteristic Number of selected hospitals (n = 11)
Location type • Urban: 5
• Rural: 6
Health system affiliation • Yes: 8
• No: 3
Ownership type • For-profit: 1
• Nonprofit: 8
• State government: 2
• Other: 0
Number of licensed inpatient beds • 100 beds or less: 4
reported by the hospital during our • 101-250 beds: 5
data collection (July to November
• More than 250 beds: 2
2023)
Source: GAO summary of interviews with and data submitted by 11 selected hospitals. | GAO-24-106447
Note: Our random sample of 121 hospitals, from which we interviewed the 11 hospitals, included
short-term acute care hospitals, critical access hospitals, and children’s hospitals. None of the 11
hospitals that agreed to an interview were children’s hospitals.
Data requested from selected hospitals. We requested data from the
11 selected hospitals on use of, spending on, and hourly cost for directly
employed and supplemental nurses. We requested data from 2019
through 2022. Of the nine hospitals providing data, six provided data for
all 4 years, and three were able to provide data for 1 or 2 years. 2 We
reported data for the six hospitals that were able to provide data for all 4
years requested. These six hospitals reported minimal use of
supplemental licensed vocational nurses or supplemental certified nurse
aides, so we limited our analysis to registered nurses (RN). To analyze
each hospital’s
• use of supplemental nurses, we used data hospitals provided on
inpatient nursing hours or inpatient nursing full-time equivalents for all
directly employed nursing staff and all supplemental nursing staff. 3
This included information on the totals for all nurses (registered
nurses, licensed vocational nurses, and certified nurse aides), as well
as totals specifically for RNs.
2Three hospitals were able to provide data for 1 or 2 years. These hospitals were each
acquired by a different health system during our period of review and were unable to
provide data for years under the prior ownership, according to representatives from these
hospitals. The other two hospitals did not provide us with the requested data.
3Our data request directed hospitals to indicate whether they were reporting inpatient
nursing hours or inpatient nursing full-time equivalents. Of the six hospitals that provided
all 4 years of data, four reported inpatient nursing hours and two reported inpatient nursing
full-time equivalents.
Page 22 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix I: Information about Selected
Hospitals
• spending on inpatient nurse staffing, we used data hospitals provided
on total spending for all directly employed nurse staff and directly
employed RNs, as well as all supplemental nurse staff and
supplemental RNs, specifically. 4
• average hourly cost for inpatient nurse staff, we used data hospitals
provided on all directly employed nurses and supplemental nurses
(RN, licensed vocational nurses, and certified nurse aides), as well as
specifically for RNs. 5
Hospitals indicated whether they were reporting by fiscal year or calendar
year. Of the six hospitals that provided all 4 years of data, two reported by
fiscal year and four reported by calendar year. Both hospitals’ fiscal years
were July 1 through June 30. 6
Additional information on use of and spending on RNs in selected
hospitals. The use of, and spending on, supplemental RNs peaked later
in the COVID-19 pandemic, with three of the selected hospitals showing a
peak in 2021, and the other three hospitals showing a peak in 2022. (See
tables 7 and 8.)
Table 7: Supplemental Registered Nurse (RN) Hours or Full-Time Equivalent Employees (FTE) in Selected Hospitals, 2019 –
2022
Directly employed RNs Supplemental RNs
2019 2020 2021 2022 2019 2020 2021 2022
Reported in FTEs
Hospital A 476 469 462 478 15 18 22 31
Hospital D 451 407 360 349 20 32 49 48
Reported in hours
Hospital B 230,935 226,063 206,839 220,096 304 12,711 21,904 16,270
Hospital C 149,696 147,512 145,958 138,229 782 0a 4,436 25,710
4Our data request directed hospitals to include, in spending on inpatient nurse staffing, the
wages and salaries and benefits for directly employed nurses, and staffing agency costs
for supplemental nursing staff. We directed hospitals not to include spending on hiring and
retention efforts for directly employed nurses.
5Our data request directed hospitals to include, in their average hourly cost of inpatient
nursing, the wages and salaries and benefits for directly employed nurses, and staffing
agency costs for supplemental nursing staff. We directed hospitals not to include spending
on hiring and retention efforts for directly employed nurses.
6The three hospitals that provided data for 1 or 2 years, reported by fiscal year (July 1
through June 30). The remaining two hospitals did not provide data.
Page 23 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix I: Information about Selected
Hospitals
Directly employed RNs Supplemental RNs
2019 2020 2021 2022 2019 2020 2021 2022
Hospital E 17,028 18,997 17,807 20,665 2,492 606 4,569 386
Hospital F 68,120 64,418 79,574 72,547 5,983 0a 19,119 28,647
Source: GAO analysis of data provided by six of GAO’s selected hospitals. | GAO-24-106447
Note: Two of the six hospitals reported data by hospital fiscal year (defined as July 1 through June
30) and four of the hospitals reported by calendar year.
a
Hospitals C and F did not use any supplemental RNs in 2020.
Table 8: Spending on Supplemental Registered Nurses (RN) in Selected Hospitals, 2019 – 2022
Dollars
Directly employed RNs Supplemental RNs
2019 2020 2021 2022 2019 2020 2021 2022
Hospital A 73,434,510 75,048,541 77,856,409 85,136,777 2,310,411 2,900,708 4,451,109 9,262,158
Hospital B 10,677,874 10,974,998 10,482,416 13,672,610 23,073 963,911 2,635,296 1,892,373
Hospital C 7,022,300 7,232,504 6,177,073 2,715,910 115,008 0a 1,184,965 5,542,664
Hospital D 43,600,000 42,700,000 39,900,000 41,700,000 2,400,000 5,300,000 11,100,000 9,300,000
Hospital E 735,311 985,197 1,000,577 1,036,659 178,911 53,256 463,122 47,548
Hospital F 2,470,292 2,556,276 3,407,177 3,814,395 348,708 0a 2,618,042 3,774,470
Source: GAO analysis of data provided by six of GAO’s selected hospitals. | GAO-24-106447
Note: Two of the six hospitals reported data by hospital fiscal year (defined as July 1 through June
30) and four of the hospitals reported by calendar year.
a
Hospitals C and F did not use any supplemental RNs in 2020.
Additionally, average hourly costs for directly employed RNs and
supplemental RNs generally increased from 2019 to 2022, with the
average hourly cost for supplemental RNs seeing a greater increase.
(See table 9.)
Table 9: Average Hourly Cost for Registered Nurses (RN) in Selected Hospitals, 2019 – 2022
Dollars
Directly employed RNs Supplemental RNs
2019 2020 2021 2022 2019 2020 2021 2022
Hospital A 76.49 79.95 85.57 94.94 76.61 77.99 99.23 143.82
Hospital B 46.24 48.55 50.68 62.12 76.02 75.84 120.31 116.31
Hospital C 30.00 31.50 35.00 40.25 41.00 0a 70.00 150.00
Hospital D 35.59 37.82 37.77 40.55 57.35 79.51 108.50 93.14
Hospital E 43.18 51.86 56.19 50.17 71.80 87.82 101.37 123.18
Page 24 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix I: Information about Selected
Hospitals
Directly employed RNs Supplemental RNs
2019 2020 2021 2022 2019 2020 2021 2022
Hospital F 36.26 39.68 42.82 52.58 58.28 0a 136.93 131.76
Source: GAO analysis of data provided by six of GAO’s selected hospitals. | GAO-24-106447
Notes: Two of the six hospitals reported data by hospital fiscal year (defined as July 1 through June
30) and four of the hospitals reported by calendar year.
The hourly cost to the hospital for a directly employed nurse includes the nurse’s hourly wages,
benefits, and payroll taxes. The hourly cost to the hospital for a supplemental nurse is the rate paid to
the staffing agency. This rate includes both the nurse costs (including hourly pay rate, payroll taxes,
and benefits) and operating expenses (the staffing agency’s overhead costs) and earnings.
a
Hospitals C and F did not use any supplemental RNs in 2020.
Page 25 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix II: Information about California
Appendix II: Information about California
Hospitals
Hospitals
In order to describe hospitals’ use of supplemental nurses from 2019
through 2022, we identified and examined available data from California
hospitals that distinguished between directly employed and supplemental
nursing staff. Specifically, we examined 2019 through 2022 data from
hospital annual financial disclosure reports compiled based on the end of
the fiscal year reported and publicly available from California’s
Department of Health Care Access and Information (California officials). 1
We limited our analysis to acute care hospitals, including short-term
general or short-term children’s hospitals that reported a full year of data,
and excluded any hospitals that did not provide emergency services. 2
We also excluded hospitals that did not report using supplemental nursing
staff in a given year, and 31 Kaiser hospitals that reported data on the
average hourly cost for the latter two years of our time period (fiscal years
2021 and 2022), but not in the first two years (fiscal years 2019 and
2020). 3 Following these exclusions, the number of California acute care
hospitals that reported data for fiscal years 2019 through 2022 were 243,
238, 238, and 236, respectively. Our analysis of California hospital data is
not generalizable to other states. In particular, California hospitals may
1Certain hospitals licensed by the California Department of Public Health must submit
these reports. See Cal. Health and Safety Code § 128735 (2024). California officials told
us that the data are self-reported and self-certified using an electronic system. While
California officials conduct a desk audit on these reports—during which they check for
reasonableness and comparability—before the data are made publicly available, it is
possible that hospitals might not complete certain parts of the report.
These data were downloaded from https://data.chhs.ca.gov/dataset/hospital-annual-
financial-disclosure-report-complete-data-set in April and October 2023. These data
represent point-in-time snapshots of California hospital staffing.
Hospitals’ fiscal years may vary. These reports were grouped by fiscal years ending from
June 30, 2018, through June 29, 2019, as fiscal year 2019; June 30, 2019, through June
29, 2020, as fiscal year 2020; June 30, 2020, through June 29, 2021, as fiscal year 2021;
and June 30, 2021, through June 29, 2022, as fiscal year 2022.
2We excluded hospitals that were identified in the data set as short- and long-term
psychiatric care, short- and long-term specialty care, long-term general care, and long-
term children’s care. We also excluded hospitals for fiscal years where they did not report
any registered nurse hours, or where they reported less than a year of data, which may be
due to situations including changes in ownership or licensure.
3Most California hospitals (about 92 to 93 percent each fiscal year) reported using
supplemental nurses.
Some California hospitals, including Kaiser hospitals, are not required to submit full annual
reports, either by law or when a reporting modification has been granted, primarily when
the data to be reported are not comparable to data filed by other hospitals. California
officials told us that, until 2021, Kaiser hospitals had a long-time exemption from reporting
some revenue data.
Page 26 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix II: Information about California
Hospitals
differ from hospitals in other states due to California’s mandatory
minimum nurse-to-patient staffing ratios that began in 2004. 4
To understand the population of California hospitals in our analysis, we
examined descriptive information on available facility characteristics. A
majority of the hospitals were owned by a non-profit or church-based
organization and almost half of the hospitals had more than 250 licensed
beds. (See table 10.)
Table 10: Characteristics of California Short-term Acute Care Hospitals That Reported Using Supplemental Nursing Staff,
Fiscal Year 2019 – 2022
Number (percentage)
Fiscal year 2019 Fiscal year 2020 Fiscal year 2021 Fiscal year 2022
(n = 243) (n = 238) (n = 238) (n = 236)
Type of ownership
Church/Nonprofit 148 (61) 146 (61) 146 (61) 147 (62)
Investor 58 (24) 57 (24) 57 (24) 57 (24)
County or local government 37 (15) 35 (15) 35 (15) 32 (14)
Licensed inpatient beds
100 beds or less 40 (17) 37 (16) 37 (16) 37 (16)
101 to 250 beds 98 (40) 98 (41) 92 (39) 92 (39)
More than 250 beds 105 (43) 103 (43) 109 (46) 107 (45)
Source: GAO analysis of California Department of Health Care Access and Information, Hospital Annual Financial and Utilization data. | GAO-24-106447
Notes: We limited our analysis to short-term general and short-term children’s acute care hospitals
that reported a full year of data. Totals are from all hospital inpatient units in these hospitals, which
may include non-acute care units.
We excluded 31 Kaiser hospitals from our analysis that did not report staffing data for all 4 years in
our review.
Variables of analysis. To analyze changes in
• the use of supplemental nurses across the 4 years from the California
hospital data, we used data on nursing staff hours reported. For
directly employed nursing staff hours, we used the variable
“productive hours” for registered nurses (RN), licensed vocational
nurses, and aides and orderlies, which are each reported separately.
4According to one researcher we interviewed who studies health care workforce trends in
California, the heavily unionized environment differentiates California from other states
and may reduce nurses’ incentives to become supplemental nurses. Specifically, the
researcher noted that there is a general perception of higher wages for directly employed
hospital nurses and better hospital working conditions, such as nurse-to-patient ratios in
California than in other regions of the country.
Page 27 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix II: Information about California
Hospitals
For supplemental nursing staff hours, we used the variable “contract
hours,” which combines any reported hours for supplemental RNs,
licensed vocational nurses, and aides and orderlies into a single
variable. 5
• nurse hourly costs, we used the variable “average hourly rate.” As
with the prior variables, rates for directly employed RNs, licensed
vocational nurses, and aides and orderlies are each reported
separately. Rates for supplemental nurses combine any reported
hourly rates for supplemental RNs, licensed vocational nurses, and
aides and orderlies into a single variable.
We were not able to examine changes in California hospital spending on
supplemental nurses because the state does not collect these data.
In our report, we present the mean value (or average), which may mask
variation among hospitals. Some hospitals in our sample may report
higher values and some may report lower values—of hours worked, and
average hourly costs. As a result, the increase or decrease in use and
hourly cost of nurses from 2019 through 2022 for some hospitals may be
greater than or lower than the average values we present.
Additional information on California hospitals’ use of supplemental
nurses. Among California hospitals reporting the use of supplemental
nursing staff—which may have included RNs, licensed vocational nurses,
and aides and orderlies—average annual hours decreased from 2019 to
2020 and increased from 2020 to 2022. 6 (See table 11.) Additionally, the
average hourly cost for all types of nursing staff increased from 2019 to
2022, with the average hourly cost for supplemental nursing staff seeing a
greater increase than for directly employed nursing staff. (See table 12.)
5In this report, we refer to the state’s category of registry nursing personnel (which may
include RNs, licensed vocational nurses, and aides and orderlies) as supplemental
nursing staff.
6The types of supplemental nurses are not broken out for hospitals.
Page 28 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix II: Information about California
Hospitals
Table 11: Hours Worked by Nursing Staff in California Hospitals That Reported Supplemental Nursing Staff Use, Annually,
Fiscal Years 2019 – 2022
Annual average hours worked
Type of nursing staff Fiscal year 2019 Fiscal year 2020 Fiscal year 2021 Fiscal year 2022
Directly employed nursing staff 655,688 671,221 732,453 707,887
Registered nurses 504,676 517,982 569,856 554,411
Licensed vocational nurses 28,097 25,039 25,866 21,588
Aides and orderlies 136,511 141,369 149,409 140,817
Supplemental nursing staffa 28,866 27,719 31,823 41,966
Source: GAO analysis of California Department of Health Care Access and Information, Hospital Annual Financial and Utilization data. | GAO-24-106447
Notes: We limited our analysis to short-term general and short-term children’s acute care hospitals
that reported a full year of data. Totals are from all hospital inpatient units in these hospitals, which
may include non-acute care units. About 92 to 93 percent of these hospitals reported hours for
supplemental nursing staff.
We excluded 31 Kaiser hospitals from our analysis that did not report staffing data for all 4 years in
our review.
a
In this report, we refer to the state’s category of registry nursing personnel (which may include
registered nurses, licensed vocational nurses, and aides and orderlies) as supplemental nursing staff.
Table 12: Average Hourly Cost for Nursing Staff Reported by California Hospitals That Reported Using Supplemental Nursing
Staff, Fiscal Years 2019 – 2022
Dollars
Fiscal year Fiscal year Fiscal year Fiscal year
Type of nursing staff 2019 2020 2021 2022
Directly employed Registered nurses 58.70 60.70 59.10 64.70
nursing staff Licensed vocational nurses 32.00 32.80 32.50 34.60
Aides and orderlies 21.80 22.60 22.10 24.40
Supplemental nursing staffa 81.40 84.10 91.90 131.50
Source: GAO analysis of California Department of Health Care Access and Information, Hospital Annual Financial and Utilization data. | GAO-24-106447
Notes: We limited our analysis to short-term general and short-term children’s acute care hospitals
that reported a full year of data. Totals are from all hospital inpatient units in these hospitals, which
may include non-acute care units.
We excluded 31 Kaiser hospitals from our analysis that did not report staffing data for all 4 years in
our review.
The hourly cost to the hospital for a directly employed nurse includes the nurse’s hourly wages,
benefits, and payroll taxes. The hourly cost to the hospital for a supplemental nurse is the rate paid to
the staffing agency. This rate includes both the nurse costs (including hourly pay rate, payroll taxes,
and benefits) and operating expenses (the staffing agency’s overhead costs) and earnings.
a
In this report, we refer to the state’s category of registry nursing personnel (which may include
registered nurses, licensed vocational nurses, and aides and orderlies) as supplemental nursing staff.
Page 29 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix III: Information from National
Appendix III: Information from National Sample
Surveys of Licensed Registered Nurses in
Sample Surveys of Licensed Registered
2018 and 2022
Nurses in 2018 and 2022
To describe the number of nurses working as supplemental nurses in
hospitals prior to and during the COVID-19 pandemic, we analyzed
publicly available data from two sample surveys of registered nurses (RN)
collected by the Department of Health and Human Services’ Health
Resources and Services Administration in 2018 and 2022, the two most
recent surveys at the time of our analysis. 1
The data from the 2018 survey included a weighted study sample of an
estimated 2.99 million licensed nurses (RNs and advanced practice RNs
working in primary positions requiring RN licenses), of which about 1.17
million (about 39 percent) reported working in the hospital inpatient
setting as of December 31, 2017. The data from the 2022 survey included
a weighted study sample of an estimated 3.12 million licensed nurses, of
which about 1.27 million (about 41 percent) reported working in the
hospital inpatient setting as of December 31, 2021. 2
We then analyzed data for the primary nursing position for RNs employed
in a hospital inpatient setting, including those employed by a staffing
agency. 3 We also analyzed how many RNs were employed by a staffing
agency in their secondary nursing position, if applicable. 4 Comparisons
between years are statistically significant at the 95 percent confidence
interval unless otherwise noted. 5
1See U.S. Department of Health and Human Services’ Health Resources and Services
Administration’s 2018 National Sample Survey of Registered Nurses, accessed on June 6,
2023, and 2022 National Sample Survey of Registered Nurses, accessed on March 22,
2024, https://data.hrsa.gov/topics/health-workforce/nursing-workforce-survey-data. The
two independent surveys provide point-in-time estimates. The National Sample Survey of
RNs is not a longitudinal survey and does not track panels of the same nurses over time.
2To be consistent with the standard applied by the Department of Health and Human
Services’ Health Resources and Services Administration to ensure the statistical reliability
of the estimates the agency presents of its survey data, all estimates we report have
percent relative standard errors of less than 30 percent unless otherwise noted.
3The survey instructions categorized acute inpatient units, the emergency department,
and other non-acute hospital units, including hospital-sponsored outpatient clinics, urgent
care, and ancillary units, in its hospital employment setting type, but excluded other
inpatient settings, such as mental health hospitals and nursing homes not located within a
hospital. Our report focuses on inpatient units within the hospital setting type.
4Data on RNs working as supplemental nurses in secondary nursing jobs are not available
by setting and may include RNs working in hospitals, other inpatient settings, ambulatory
settings, or other settings.
5Statistical significance at the 95 percent level means that there is a 5 percent probability
or less of the differences between estimated values being due to chance alone.
Page 30 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix III: Information from National Sample
Surveys of Licensed Registered Nurses in
2018 and 2022
We assessed the reliability of these data by reviewing relevant agency
data documentation, interviewing knowledgeable agency officials, and
performing tests of the data to identify any outliers or anomalies. We
determined that the data were sufficiently reliable for the purposes of our
reporting objectives.
The percentage of hospital RNs working for staffing agencies increased
more than four times during the COVID-19 pandemic, according to
national survey data estimates. Specifically, approximately 2 percent of
the estimated 1.17 million RNs whose primary position were in inpatient
hospital settings were employed by staffing agencies in 2017 compared
to approximately 10 percent of the estimated 1.27 million RNs working in
inpatient hospital settings in 2021. 6 (See table 13.) These data likely
underestimate the total number of RNs working as supplemental nurses
in inpatient hospital settings as, according to the survey results, many
RNs also held secondary positions as supplemental nurses. However, the
estimates of RNs’ secondary positions as supplemental nurses were not
available by setting, so it was not possible to determine the total number
of RNs working as supplemental nurses in inpatient hospital settings in
those years. 7
6While most supplemental hospital RNs worked in inpatient settings (about 82 percent in
2021), supplemental RNs also worked in the emergency department (about 12 percent in
2021) and other hospital settings, such as hospital-sponsored ambulatory or outpatient
care and hospital-sponsored ancillary units (about 6 percent in 2021).
7RNs may be simultaneously employed in another, secondary, nursing position for pay.
The number of supplemental RN positions filled at hospitals would include RNs working in
primary positions as well as RNs working in secondary positions through staffing
agencies. In 2017, about 1 percent of the estimated 2.99 million RNs working in a primary
nursing job, regardless of setting, also worked one or more secondary jobs as a
supplemental nurse employed by a staffing agency. In 2021, about 1 percent of the
estimated 3.12 million RNs working in a primary job, regardless of setting, also worked
one or more secondary jobs as a supplemental nurse employed by a staffing agency.
Page 31 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix III: Information from National Sample
Surveys of Licensed Registered Nurses in
2018 and 2022
Table 13: National Estimates of Licensed Registered Nurses (RN) in Inpatient Hospital Settings, by Employment Type, 2017
and 2021
December 31, 2017 December 31, 2021
Estimated Estimated Estimated Estimated
Employment situation number percentage number percentage
Employed by the hospital at which the RN worked 1,131,959 97 1,135,175 89
Employed by a staffing agency 28,190 2 129,570 10
Self-employed 6,715 1 — —
Total 1,166,865 100 1,272,584 100
“— “ indicates that data were suppressed to ensure statistical reliability because the percent relative standard error was greater than 30 percent.
Source: GAO analysis of the Department of Health and Human Services’ Health Resources and Services Administration, 2018 National Sample Survey of RNs and 2022 National Sample Survey of RNs.
| GAO-24-106447
Notes: This analysis was based on weighted study samples of RNs and advanced practice RNs
working in a primary position requiring an RN license.
All reported estimates have percent relative standard errors of less than 30 percent, except as noted.
We calculated the 95 percent confidence interval for each estimated percentage and examined
whether there was overlap between confidence intervals. The confidence intervals did not overlap
between 2017 and 2021 for RNs employed by the hospital at which they worked or for RNs employed
by a staffing agency, which suggests a statistically significant difference between estimates.
Researchers we interviewed, as well as representatives from a nursing
stakeholder organization, discussed how the COVID-19 pandemic
intensified the hospital work environment for nurses. For example,
interviewees discussed concerns about nurse burnout, with stakeholder
representatives and one researcher noting that nurses experienced
higher levels of and more frequent feelings of burnout during the
pandemic. 8 In addition, interviewees said that nurses experienced
increases in workplace violence related to patients’ and families’ anger
regarding pandemic restrictions. At the same time, researchers and
stakeholder representatives noted that nurses’ trust in the hospitals
employing them was eroding. These interviewees said that some
hospitals were putting nurses into vulnerable situations, including the
following:
• sometimes being the only type of clinician going into COVID-19-
positive patients’ rooms,
8According to survey data, most RNs (about 89 percent of RNs who had been employed
in the same position for at least a year and had experienced burnout) indicated that their
feelings of burnout had increased during the pandemic. In addition, the report indicated
that feelings of burnout became more frequent during the pandemic. See U.S. Department
of Health and Human Services’ Health Resources and Services Administration, National
Center for Health Workforce Analysis, Experience of Nurses Working During the COVID
Pandemic – Data from the 2022 National Sample Survey of RNs (March 2024).
Page 32 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix III: Information from National Sample
Surveys of Licensed Registered Nurses in
2018 and 2022
• working multiple shifts in a row without sufficient rest,
• stretching nurse-to-patient ratios to potentially unsafe levels.
Researchers and stakeholder representatives we interviewed noted that
these types of work environment issues likely pushed some nurses to
leave the hospital setting or to leave the profession altogether. 9 It also
may have made travelling as a supplemental nurse appealing to more
nurses due to both the higher pay and the contractual relationship with
the hospital.
9According to survey data, about 9 percent of RNs employed left their employer for
another nursing job. In addition, about 5 percent of the RN workforce left the workforce
altogether during the pandemic, most commonly due to working conditions, such as high-
risk conditions, overwork or burnout, and inadequate staffing levels. See Health
Resources and Services Administration, Experience of Nurses Working During the COVID
Pandemic.
Page 33 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix IV: Strategies Used by Selected
Appendix IV: Strategies Used by Selected
Hospitals to Address Staffing Needs and
Hospitals to Address Staffing Needs and
Changes to the Strategies during the COVID-19
Pandemic
Changes to the Strategies during the COVID-
19 Pandemic
Representatives at the 11 selected hospitals we interviewed described
using nine types of new and pre-pandemic staffing strategies to address
the increased and more complex nurse staffing needs of the COVID-19
pandemic. We categorized these nine strategies into four broader
categories—use of directly employed nurses, use of health system
nurses, other staffing strategies, and use of supplemental nurses.
Use of Directly Employed Selected hospitals described three staffing strategies that used their own
Nurses directly employed nurses to meet staffing needs—shift-based financial
incentives, temporary nurse reassignment, and single hospital float pools.
Shift-based financial incentives. To meet staffing needs, hospitals may
provide shift-based financial incentives to its nurses within a unit.
Representatives from 10 of the 11 selected hospitals discussed using this
strategy. For example, one hospital paid nurses who worked an extra shift
in their unit a $300 bonus for the pay period and another hospital paid
nurses an extra $35 per hour when working one extra shift a week.
Further, representatives from one hospital described extending financial
incentives to nurses in supervisory roles, such as nurse directors, by
offering bonuses to cover shifts providing patient care.
Representatives from one of these ten hospitals specifically noted that the
hospital implemented this strategy in response to the COVID-19
pandemic—creating a program that paid premium rates to nurses who
worked additional shifts. However, representatives from three other
hospitals described how this strategy was less effective during the
pandemic. For example, representatives from one hospital explained that
prior to the pandemic, if they offered an incentivized overtime shift, it
would draw volunteers. These same representatives recounted that
during the pandemic they could not rely on the financial incentives to
draw volunteers for overtime shifts. These representatives noted that
nurse staff seemed to prioritize their time over the extra money, which
was beneficial for the hospital’s workforce but made meeting their staffing
needs more challenging. In addition, representatives at two hospitals
opined that their nurses became less likely to respond to financial
incentives for additional shifts during the pandemic, due to exhaustion
and burnout.
Page 34 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix IV: Strategies Used by Selected
Hospitals to Address Staffing Needs and
Changes to the Strategies during the COVID-19
Pandemic
Temporary nurse reassignment. Hospitals may temporarily reassign
nurses that typically work in a specific unit to a different unit or reassign
non-clinical nurses to work at the patient bedside, as appropriate.
Representatives from nine of the 11 selected hospitals reported using this
strategy when needed. Three of these nine hospitals described having
this policy in place prior to the pandemic. Specifically, representatives
from one of the hospitals stated that it was their hospital’s expectation
that nurses work in any unit that needed assistance, as appropriate, and
the hospital offered its nurses cross-training for other units and
specialties. Representatives from another hospital noted that, due to the
hospital’s small size, they expected nurses to move between like units or
units where they have been cross-trained.
Six of these nine hospitals began temporarily reassigning nurses and two
of the three hospitals that already had this strategy in place expanded
their use of it to meet staffing needs during the COVID-19 pandemic.
Representatives from these hospitals described two ways in which they
used this strategy:
• During non-essential operating room closures early in the pandemic
(in response to certain state orders or recommended by some state
hospital associations), some hospitals temporarily reassigned their
operating room nurses to other units. For example, representatives
from one hospital noted that when reassigning operating room nurses
to the intensive care unit, those nurses were not functioning as
intensive care unit nurses, but they were able to use their
competencies to assist the nurse team.
• Some hospitals temporarily reassigned non-clinical nurses or nurse
leaders to the patient bedside when needed. For example,
representatives from one hospital said certain times during the
pandemic required creative staffing and an “all hands on deck”
approach that included moving nurse coordinators and nurse
administrators to the patient bedside. Representatives from another
hospital described providing non-clinical nurses with a “crash course”
orientation early in the pandemic so that they could assist intensive
care unit nurses at the patient bedside.
Page 35 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix IV: Strategies Used by Selected
Hospitals to Address Staffing Needs and
Changes to the Strategies during the COVID-19
Pandemic
Single hospital float pool. A single hospital float pool operates at the
individual hospital level by employing a group of nurses to “float,” or
move, between multiple units within a specialty or who are cross-trained
and oriented to float to multiple different specialty units. Representatives
from eight of the 11 selected hospitals discussed using this strategy.
Nearly all of the eight hospitals had their single hospital float pools in
place prior to the start of the pandemic, and representatives from a few of
the eight hospitals indicated that single hospital float pool nurses were
paid more than nurses not in the float pool.
In response to COVID-19 pandemic staffing challenges, one of the eight
hospitals created a single hospital float pool, and another hospital
expanded its existing program:
• Representatives from the hospital that created a single hospital float
pool did so later in the pandemic by cross-training some of their
nurses to work in three separate units—the medical-surgical unit, the
intensive care unit, and the emergency department—and then paying
those float nurses an additional $15 per hour.
• Representatives from another hospital described expanding their
hospital’s float pool by adding a new part-time option to make it more
attractive to the hospital’s nurses.
Use of Health System Selected hospitals described two staffing strategies that use nurses from
Nurses other hospitals within its health system to meet staffing needs—multi-
hospital float pools and internal staffing agencies.
Multi-hospital float pool. A multi-hospital float pool operates across
hospitals within a defined geographical region, and within the same health
system, by employing a group of nurses to float to whichever hospital
they are needed for a given shift. These nurses are typically cross-trained
and oriented to float to multiple different specialty units as well.
Representatives from six of the eight selected hospitals that were part of
a health system discussed using this strategy. For example,
representatives at one hospital noted that nurses in the multi-hospital float
pool received an additional $7 to $9 to their hourly base pay.
Representatives at another hospital noted while the nurses they bring in
from the multi-hospital float pool may not be familiar with their specific
hospital, the nurses still worked under their health system. The
representatives added that this alignment of nurse expectations across
the health system made using this strategy to meet staffing needs more
Page 36 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix IV: Strategies Used by Selected
Hospitals to Address Staffing Needs and
Changes to the Strategies during the COVID-19
Pandemic
desirable than contracting with supplemental nurses from external staffing
agencies.
At the time of our interviews, two of the six hospitals were working with
their health systems to develop multi-hospital float pools. While
representatives at both hospitals discussed informally using float nurses
from other nearby health system hospitals during the COVID-19
pandemic, they were in the process of formalizing the programs. For
instance, representatives from one of the hospitals noted that nurses in
this program would float between three hospitals and earn a $20 per hour
premium to their hourly payment rate.
Internal staffing agency. An internal staffing agency operates within a
health system and employs nurses to travel between system hospitals for
assigned periods of time, such as 4 weeks, before moving to the next
assignment at another hospital. These nurses are typically cross-trained
and oriented to float to multiple different specialty units as well.
Representatives from two of the eight selected hospitals that were part of
a health system discussed using this strategy to meet their staffing
needs. 1 They both compared their internal staffing agencies to the
services provided by external staffing agencies and noted that
participating nurses received premium pay similar to supplemental nurses
from external agencies. However, they also both explained that the
hospital and the health system were able to save money by eliminating
the external staffing agency and its fees.
The health system of one of the two hospitals using internal staffing
agencies created its program during the COVID-19 pandemic in response
to staffing and cost demands. Specifically, hospital representatives stated
that their internal travel program launched in January 2022, which
coincided with a surge in COVID-19 cases, and, by the end of 2022, the
hospital was using more internal agency staffing than external agency
staffing. The representatives noted that nurses working for their internal
staffing agency receive benefits and pay rates comparable with
supplemental nurses, and the representatives reported saving 20 percent
1Representatives from one of the three selected hospitals that was not part of a health
system described creating an internal supplemental staffing program in 2023 as an
alternative to using supplemental nurses from external staffing agencies. Since the
hospital was not part of a health system, representatives noted that the internal
supplemental staff were usually from other organizations in the local area.
Page 37 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix IV: Strategies Used by Selected
Hospitals to Address Staffing Needs and
Changes to the Strategies during the COVID-19
Pandemic
or more by running the program internally rather than using external
staffing agencies.
Other Staffing Strategies Selected hospitals described three other types of staffing strategies that
they used to meet staffing needs—nurse retention efforts, nurse
recruitment efforts, and changes to nursing care delivery models.
Nurse retention efforts. To encourage nurse retention, hospitals may
implement various types of programs, incentives, benefits, or pay
increases to directly employed nurses. 2 Representatives from 10 of the
11 hospitals discussed using this strategy to meet their staffing needs.
Representatives at four selected hospitals noted that their nurse payment
rates and benefits packages have been competitive, even prior to the
pandemic. For example, representatives from two hospitals noted that
they periodically conduct market reviews of nurse payment rates and
make payment adjustments, as appropriate, and representatives from the
two other hospitals noted that higher education benefits were key to
encouraging retention.
In response to COVID-19 pandemic staffing challenges, most of the 10
hospitals made changes or added to their retention efforts.
• A few hospitals provided retention bonuses to their directly employed
nurses. For instance, representatives at one hospital explained that
they chose to financially reward their staff who stayed with the
hospital rather than direct that money toward recruitment.
Representatives from another hospital noted that they used COVID-
19-related state funds to provide qualifying staff with pandemic
bonuses. Further, representatives from several hospitals noted
increasing pay rates for directly employed nurses during the
pandemic.
• A few hospitals developed new employee benefits or programs
intended to increase retention. For example, one hospital rolled out an
employee wellness program during the pandemic, which included
dedicating certain spaces for employee breaks, and a new virtual
mental health platform benefit available to both employees and their
families. Representatives from another hospital reported that they
accelerated their plans to open an on-site childcare center for
employees during the pandemic. Further, a third hospital focused on
2In response to a question on whether COVID-19 vaccine mandates during the pandemic
affected selected hospitals’ ability to retain or hire nurses, representatives from all 11
selected hospitals said that the mandates had little or no effect.
Page 38 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix IV: Strategies Used by Selected
Hospitals to Address Staffing Needs and
Changes to the Strategies during the COVID-19
Pandemic
reducing first-year nurse turnover by developing a nurse residency
program—a year-long program for newly-graduated nurses hired by
the hospital. Representatives noted that the program focuses on
providing participants with both peer and mentor support.
Nurse recruitment efforts. Hospitals may offer competitive
compensation packages, financial incentives, or programs at the time of
hiring to recruit new nurses or develop partnerships with local colleges
and universities to create a “nurse pipeline” where newly graduated
nurses are more likely to join the hospital’s workforce. Representatives
from all 11 selected hospitals discussed using this strategy to meet their
staffing needs. Competitive compensation packages may dually serve to
retain nurses, as previously described, and to recruit new nurses.
Representatives from four selected hospitals stated that their nurse
payment rates and benefits were competitive, even prior to the pandemic.
In addition, representatives at most hospitals described established
partnerships with local colleges and universities and several noted
offering sign-on and referral bonuses to nurses prior to or during the
pandemic to recruit nurses.
In response to staffing challenges during the COVID-19 pandemic, most
hospitals adjusted or enhanced existing recruitment efforts or started new
recruitment programs. For example:
• Representatives from one hospital with an established educational
partnership described expanding the types of nurses they recruited.
Prior to the pandemic, representatives said that the hospital only
recruited nurses from four-year degree programs, but that during the
pandemic they began recruiting nurses from two-year degree
programs and then encouraged those nurses to use the hospital’s
educational benefits to continue their higher education.
Representatives from another hospital said that they began offering
free nursing school tuition to ancillary staff (personal care assistants,
radiology technicians, etc.) during the pandemic. They noted that the
program helps recruit ancillary staff, but in the long term, it will also
provide new nurses who are already familiar with the hospital.
• Representatives from three hospitals noted that each hospital
increased both its sign-on bonuses and referral bonuses during the
pandemic. Representatives from a fourth hospital said that the
hospital began offering sign-on bonuses to new hires during the
pandemic. They noted that the bonuses had conditions in place to
ensure that new hires worked a certain number of years in exchange
for the bonus.
Page 39 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix IV: Strategies Used by Selected
Hospitals to Address Staffing Needs and
Changes to the Strategies during the COVID-19
Pandemic
• Representatives from three hospitals described efforts to recruit
supplemental nurses. Two of the three hospitals were focused on
bringing back nurses who had left the hospital for supplemental
employment. For instance, representatives from one of the hospitals
described a health system-wide “welcome back home” campaign and
noted that the effort recruited nurses who had more experience. The
third hospital’s efforts were broader—offering direct employment into
the hospital’s internal staffing agency to any supplemental nurses that
had worked at the hospital (rather than only to nurses who had
previously had direct employment at the hospital). Representatives
said that 60 percent of these supplemental nurses offered a direct
employment position within the hospital’s internal staffing agency
made the conversion, with some later converting to the hospital’s
standard permanent staff. Representatives credited their hospital’s
work environment for the program’s success.
Nursing care delivery models. Nursing care delivery can vary by how
independent or collaborative nurses are in the provision of direct care to a
group of patients. The two predominant modes of nursing care delivery in
most acute care settings are total patient care (one RN is mainly
responsible for the complete care of a group of patients throughout a
shift) and team nursing (a designated team of both RNs and other nursing
staff with various skill levels and scopes of practice give care to a group
of patients). To meet nurse staffing challenges, a hospital may decide to
shift its approach to care delivery. Representatives from five of the 11
hospitals discussed using this strategy to meet their staffing needs. One
of the five hospitals already used this strategy prior to the COVID-19
pandemic. Representatives stated that the hospital used licensed
vocational nurses in addition to RNs in a team nursing model. 3
Four of the five hospitals began using this strategy during the pandemic
to meet their staffing needs and most continued to use the strategy at the
time of our interviews. Specifically, representatives from three hospitals
discussed shifting to a team nursing model by hiring licensed vocational
nurses to work with RNs. For instance, representatives from one hospital
explained that each nursing team consists of one RN, one licensed
vocational nurse, and one patient care technician. That team provides
care to 8 to 10 patients with the RN responsible for patient assessment
3Licensed vocational nurses have a 1-year degree, are licensed by the state, and typically
provide routine bedside care, such as taking vital signs. RNs have at least a 2-year
degree, are also licensed by the state, and are generally responsible for managing patient
nursing care and performing complex procedures, such as starting intravenous feeding or
fluids.
Page 40 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix IV: Strategies Used by Selected
Hospitals to Address Staffing Needs and
Changes to the Strategies during the COVID-19
Pandemic
and the licensed vocational nurse responsible for performing tasks such
as wound care, medication administration, and patient education. The
representatives compared this to their prior model where the RN provided
total patient care with the assistance of one patient care technician.
Under that model, the RN and technician would be assigned six patients,
at most, with a target goal of four to five patients.
Use of Supplemental Selected hospitals described contracting with external staffing agencies to
Nurses bring in supplemental nurses to fill temporary daily (per diem) or longer-
term (for instance, 13-week assignments) staffing needs.
External staffing agencies. Representatives from all 11 selected
hospitals discussed using this strategy to meet their staffing needs.
Representatives from 10 of the 11 hospitals described contracting with
external staffing agencies to bring in supplemental nurses at least
occasionally prior to the COVID-19 pandemic, often to fill planned long-
term absences such as parental leaves. Early in the pandemic, along with
various combinations of other staffing strategies, six of these 10 hospitals
continued to use supplemental nurses at rates similar to before the
pandemic while two of these 10 hospitals decreased their use of
supplemental nurses in 2020 and the remaining two hospitals increased
their use of supplemental nurses in 2020. Further, the hospital that did not
use supplemental nurses prior to the pandemic began to do so in 2021.
As the pandemic continued, hospital representatives of all 11 hospitals
described increasing their reliance on supplemental nurses even as
hourly costs for these nurses also increased. For example:
• Representatives at one hospital stated that as the pay rates for
supplemental nurses increased across the country, some of their
nurses left the hospital to work for external staffing agencies. They
explained that at the same time that nurses were leaving the hospital,
it also became more difficult for the hospital to recruit directly
employed nurses to replace them. So as the pandemic continued, the
hospital hired more supplemental nurses to maintain operating
capacity.
• Representatives at another hospital described using other staffing
strategies during the first year of the pandemic, such as temporarily
reassigning their operating room nurses to assist in the intensive care
unit while non-essential surgeries were suspended. When the
hospital’s operating rooms reopened in the summer of 2020, those
nurses returned to their units. According to this hospital’s
representatives, as the pandemic continued into its second and third
Page 41 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix IV: Strategies Used by Selected
Hospitals to Address Staffing Needs and
Changes to the Strategies during the COVID-19
Pandemic
years the hospital’s staffing challenges compounded, leading to the
hospital bringing on more supplemental nurses to meet the
community’s needs.
Page 42 GAO-24-106447 Hospital Use of Supplemental Nurses
Appendix V: GAO Contact and Staff
Appendix V: GAO Contact and Staff
Acknowledgments
Acknowledgments
Leslie V. Gordon, (202) 512-7114 or GordonLV@gao.gov
GAO Contact
In addition to the contact named above, Corissa Kiyan-Fukumoto
Staff (Assistant Director), Kathryn Richter (Analyst in Charge), Nicole
Acknowledgments Annunziata, Joy Grossman, Isabella Guyott, Giao N. Nguyen, and Dan
Ries made key contributions to this report. Also contributing to the report
were Todd Anderson, Jennie Apter, Ethiene Salgado-Rodriguez, and
Jennifer Rudisill.
Page 43 GAO-24-106447 Hospital Use of Supplemental Nurses
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