Lived Travel Nurse and Permanent Staff Nurse Pandemic Work Experiences as Influencers of Motivation, Happiness, Stress, and Career Decisions: A Qualitative Study.

Researchers explored travel nurses' and permanent staff nurses' COVID-19 pandemic work experiences, seeking to understand, "How do these experiences influence nurses' motivation, happiness, stress, and career decisions?" The COVID-19 pandemic took a heavy physical and psychological toll on health care providers. Demand outweighed resources as nurses accepted the monumental task of caring for communities affected by the catastrophe. We aimed to gain insight into nurses' lived pandemic experiences in the United States, while exploring the impact of these experiences on their motives to remain in current positions or alter their career paths. In this descriptive, phenomenological study, interview data collected from 30 nurses were analyzed using qualitative content analysis. Physical and emotional trauma experienced during the early and peak months of the pandemic led nurses to evaluate their current work arrangements and to ponder alternatives. Our results suggest that pandemic work environments contributed to a change in nursing workforce distribution and exacerbated widening nurse shortage gaps. A call to action bids leaders to institute retention measures based on factors influencing nurses' career trajectory decisions in the current environment. Our findings led to recommendations for leadership approaches to promote nurses' emotional healing and mental wellness.

THE WORLD HEALTH ORGANIZATION deemed COVID-19 a pandemic in March 2020. Shock, fear, and uncertainty took a heavy toll on the well-being of nurses during the initial crisis phase and beyond. Even 18 months later, health care systems worldwide still struggled to manage sporadic volume surges of patients infected by emerging variants. A stream of recently published studies acknowledges the worldwide, pandemic-induced physical, emotional, spiritual, and mental trauma endured by nurses as humans, exacerbated by repeating surges of devastation that continue to plague them.1–5

In this study, researchers took a qualitative approach to analyze perceptions articulated by US travel nurses (temporary contract nurses) and permanent staff nurses who practiced before, during, and following the height of the pandemic. Researchers aimed to describe and relate these nurses' experiences to (i) motivation to remain active in nursing; (ii) factors influencing happiness and stress in their current roles; and (iii) factors that influence professional choice in seeking new employment opportunities, including travel nursing and different permanent staff positions.

BACKGROUND

Studies published shortly after the SARS (severe acute respiratory syndrome) and MERS (Middle East respiratory syndrome) coronavirus outbreaks in 2003 and 2012, respectively, generated knowledge about their impact on health care professionals' mental and emotional well-being.6–8 Lessons learned from these prior deadly coronavirus outbreaks included the imperative for instituting prompt and continuous psychiatric interventions to support frontline health care professionals.6 This was an ominous signal to proactively establish protective measures as a state of readiness in the event of a future pandemic. Nearly 30% of 1327 US health care workers polled by The Washington Post–Kaiser Family Foundation in early 2021 considered leaving the health care sector because of the COVID-19 pandemic.9 Similar findings exposed by researchers in Quebec, Canada, exposed the link between perceived effects of the pandemic on practice environments and the proportion of nurses reporting a high intent to leave their practice areas (nearly 30%) or to leave the profession altogether (22%).10 Results of a cross-sectional study of Alabama nurses further corroborate, whereby more than 52% considered quitting their jobs due to the pandemic.11 Nurses represent an already compromised cohort of essential direct care providers. A small percentage of turnover at any level results in substantial disruption of staffing capacity. Brockopp and colleagues12 underscored the stabilizing impact of nursing leadership visibility, which in their study of critical care nurses was perceived during the COVID-19 pandemic as a beacon of hope and a healing stream of tangible recognition. Sadly, findings of a recent AONL longitudinal study exposed that the mental and emotional wellbeing of nurse leaders, whose role includes supporting direct care nurses, is also under siege from the pandemic.13

Researchers from a leading US health care workforce solutions firm worked with an international marketing research company to explore and compare the lived COVID-19 pandemic work experiences of travel nurses and permanent staff nurses. The researchers aimed to gain an understanding about how these experiences influence nurses' motivation, happiness, stress levels, and career decisions.

METHODOLOGY AND DESIGN

This qualitative, descriptive, phenomenological study was approved by the marketing research company's institutional review board. To avoid influencing participants' responses and put forth assurance of confidentiality, the research company (a qualified independent, nonemployer party) invited prospective participants, screened invitee respondents for eligibility, and then enrolled and interviewed the study participants. The research company served as a firewall through nondisclosure of participant identities to the workforce solutions firm and by securely retaining the study data.

A technologically randomized list of travel nurse invitees was generated from the workforce solutions firm's database, and that of permanent staff nurse invitees from the research company's database. The research company distributed an e-mail invitation to 488 prospective participants, yielding a 26% response rate. Eligible candidates were RNs practicing for the past 2 or more years in an acute hospital inpatient or emergency department. Invitation respondents were screened for eligibility in order of receipt. Those who qualified were selected, confirmed, and enrolled across 3 categorical cohorts: (i) 10 veteran travel nurses (nurses who took travel assignments both prior to and during the pandemic); (ii) 10 new travel nurses (nurses who first worked as a travel nurse during the pandemic); and (iii) 10 permanent nurses (nurses holding a staff position at a hospital and have never taken a travel assignment.) Interviews were scheduled once a balance of 10 participants was enrolled in each category.

We anticipated that 30 interviews would be sufficient to achieve thematic saturation (where no additional breadth and depth of insights emerges), and, if not, we were prepared to enroll additional respondents. The research company carried out the interviews as an entity distant and separate from the research participants and their realities. During May and June 2021, one researcher from the market research company engaged each participant in a 30-minute, semistructured, individual telephone interview. The researcher used a standardized interview guide consisting of open-ended and probing questions. Each interview was recorded, and the researcher took notes. Thematic saturation was achieved prior to the completion of all 30 interviews. Nonetheless, all 30 scheduled interviews were fulfilled, which further verified the evidence and yielded a collection of rich data. Participant demographics are shown in Table 1.

Table 1.

Participant Demographics

Practice setting
Emergency department	9
Inpatient hospital unit	20
Other: PACU	1
Gender
Male	3
Female	27
Age group
18-25 y	1
26-45 y	19
46-55 y	7
55-65 y	3
Nursing education—highest
Diploma or hospital program	1
Associate degree	3
Bachelor's degree	23
Postgraduate degree (DNP, PhD)	3
Average years of RN experience
Permanent staff	23.1
New travel nurse	7.8
Veteran travel nurse	15.6

Abbreviations: DNP, Doctor of Nursing Practice; PACU, postanesthesia care unit.

ANALYSIS

Audio recordings and interview notes were systematically examined using qualitative content analysis. Key concepts were identified and categorized at a descriptive level, preserving the verbatim expressions of nurses' lived experiences. Iterations of content analysis facilitated the emergence of meaningful essences, manifesting as themes.

RESULTS

Five themes became distinctly evident: (1) Pandemic effects drive major shifts in nurses' career path choices; (2) Animosity is growing between permanent staff nurses and travel nurses; (3) Happiness levels and stress levels influence career decisions; (4) Emotional impact of the pandemic is extensive; and (5) Nurses are seeking support from hospital management. The substance underpinning each theme is presented as follows.

Pandemic effects drive major shifts in nurses' career path choices

Permanent staff participants appreciated attributes of permanent job status such as perceived compensation package stability, balance and compatibility with personal and family life circumstances, and team camaraderie.

...my teammates ... they are my sisters.

These nurses generally signaled an intent to remain in a permanent staff work arrangement.

New travelers were those who switched from permanent staff positions to take their first travel assignment during the pandemic. The most frequently cited reason for these nurses' decisions to embark on this new path was the higher hourly pay differential. But monetary compensation was not the sole driver. Pandemic circumstances created a call to purpose-driven action, and these nurses sensed a duty to respond.

Nursing is my calling, and this was made even more clear to me during the pandemic.

The new travel nurses reported that gaining experience at different hospitals strengthened their competence and expanded their skills, while boosting confidence. Taking on difficult but manageable experiences is one of the building blocks of resilience.14 By venturing into travel nursing during a pandemic, the new travel nurses engaged in a robust professional growth experience.

The pandemic made me learn a new level of what I could handle.

This cohort also reported a sense of freedom to focus solely on their patients due to the absence of commitments beyond direct care duties typically expected of permanent staff.

Veteran travel nurses reported that pandemic-induced physical and emotional trauma wore them down and motivated them to contemplate leaving beside nursing to (i) explore alternative career paths within or outside of the nursing profession, (ii) continue their education, or (iii) take a break or early retirement.

I mentally can't do it anymore with COVID.... I'm bringing home way too much baggage.

Across all 3 subgroups, some nurses indicated they want to leave bedside nursing or the profession entirely. Reasons for this included feeling unsafe when personal protective equipment was scarce, inadequate staffing creating unavoidable compromises to patient care, logistical impossibility to deliver proper or timely treatment, and proning patients themselves, resulting in physical ailments such as back, wrist, and elbow injuries. Table 2 summarizes key findings related to career path intentions.

Table 2.

Future Plans

Permanent Staff	New Travel Nurses	Veteran Travel Nurses
Most intend to continue as a permanent staff nurse for the following reasons:	Most intend to continue as travel nurses for the following reasons:	Most intend to leave bedside nursing or current role for the following reasons:
1. Team is like family	1. Financial compensation	1. Leaving ICU/ED to work a different specialty
2. Financial compensation (salary and benefits) is secure	2. Pandemic inspired purpose	2. Considering retirement
3. Current life circumstances do not accommodate travel	3. Travel experience made them stronger nurses	3. Return to graduate school
	4. Working at different hospitals/locations	4. To take a break or leave of absence for a year
	5. More freedom to focus solely on patient care

Abbreviations: ED, emergency department; ICU, intensive care unit.

Animosity is growing between permanent staff nurses and travel nurses

Permanent staff nurses know that travelers are paid more. This perception of pay inequity between the 2 groups provokes animosity, jeopardizing morale and teamwork. While some permanent staff were grateful and welcoming, others were resentful and unimpressed with the travel nurses' presence. A benefit that appeals to travel nurses also contributes to animosity from permanent nurses. Travel nurses' enjoyment of freedom to focus more intently on patient care in the absence of additional responsibilities was perceived by some permanent staff as disinterest in how the unit is running and not being invested or ready to go the extra mile. Travel nurses reported feeling pressured to work overtime as a demonstration of their commitment to the team to overcome this perception. Half of the travel nurses reported being treated like outsiders; for example, being excluded from Nurses Week festivities. One travel nurse observed, “A lot of [permanent] nurses are burned out ... so they are not very nice.” Some travel nurses perceived they were bullied by staff nurses and given the heaviest assignments.

We are just a Band-Aid, they don't consider us part of the team.

Happiness levels and stress levels influence career decisions

Participants were asked to rate their job happiness and stress levels on a scale of 1 to 10 corresponding to 2 time periods: (1) prior to the pandemic and (2) at the time of the interview. Nearly every nurse reported greater happiness prior to the pandemic than at the time of the interviews, suggesting that the effects of the pandemic impacted job satisfaction. Veteran travelers and permanent nurses were very happy prior to the pandemic, while new travelers were not so happy at that time. Veteran travel nurses' prepandemic happiness scores dropped proportionately greater compared with the other groups by the time of the interviews.

All nurses gauged stress as 10+ at the height of the pandemic, which many described as teetering at the breaking point.

You feel like you just can't do it anymore, it's too much.

In the months leading to the interviews, the initial acute phase of the pandemic eased slightly, and stress ratings tapered somewhat, but still exceeded prepandemic levels. New travelers ranked highest in prepandemic stress levels, which, combined with their low happiness scores, perhaps tipped the scale in favor of shifting to travel nursing.

Veteran travel nurses reported the highest levels of happiness and lowest levels of stress prepandemic. Conversely, by the time of the interviews, their happiness levels dropped and their stress levels increased proportionately more than those of the other groups. More veteran travel nurses expressed intent to leave bedside nursing or the profession than the 2 other groups. Figures 1 and 2 depict changes in nurses' happiness and stress levels, respectively.

Figure 1.

Self-rated nurse happiness levels.

Figure 2.

Self-rated nurse stress levels.

Emotional impact of the pandemic is extensive

The extensive physical and emotional trauma that nurses experienced while working through the pandemic is perhaps the most profound factor currently influencing their career decisions. Most participants described being traumatized by the combination of the pandemic crisis, the acuity of the patients, and the number of deaths they helplessly witnessed (a video is available at https://vimeo.com/586883328/7fba6f4ad9, which presents a compelling collection of nurses' experiences, portrayed in their own words).

I didn't know what real burnout was like until the pandemic.

Many nurses reported their primary motivation to remain in nursing is the desire to help people.

I get a rush when I'm in a bad situation and I can fix it ... it's uplifting and encouraging.

However, patient acuities and volumes, inadequate staffing, and visitor restrictions hindered them from making that impact. These nurses felt defeated when they could not make a difference despite working extended hours. Chronic inadequacy of staffing resources combined with burgeoning patient volumes and relentless physical demands was oppressive.

The “why” changed. I'm no longer working to help people; only doing it for the money.

At the height of the pandemic, nurses were working 48 to 72 hours a week. They routinely worked 12+-hour shifts with no breaks. Without enough technicians, RNs had to prone patients on their own, leading to back, wrist, and elbow injuries.

I'm so exhausted it's bordering on dangerous.

Visitor restrictions caused considerable emotional stress and trauma. Patients were alone, and nurses wanted to do more to care for them but could not. Nurse to patient ratios were grossly inflated, while patient acuities spiked in tandem. Nurses felt it was impossible to do their jobs.

The pandemic was helpless nursing. We couldn't help the COVID patients.

I have seen more death in the past year than I did the 10 years before that in total.

Holding the phone for family members to say goodbye has taken its toll.

The nurses felt emotionally damaged and said they are suffering from anxiety as well as posttraumatic stress disorder (PTSD). They did not perceive hospital administration to offer mental/emotional support.

It's up to me as a nurse to take care of my own mental health.

Nurses are seeking support from hospital management

One of the reasons cited for low happiness and peaking stress before and during the pandemic was hospital culture and the perception of an unpleasant work environment. Perceived lack of support from hospital leadership and the effects of “hospital politics” motivated some nurses to switch to travel nursing. With short-term assignments, travel nurses enjoy avoiding corporate aspects of hospital employment dubbed “hospital politics.” Greater visibility of management figures and leaders who are perceived to advocate for nurses' well-being could increase nurses' perceived sense of happiness.

Hospital administration giving us pizza does not address emotional distress and PTSD.

Hospitals don't care about the emotional aspects, only the bottom line.

A profound yet unanticipated essence that emerged in our findings was a uniform sentiment vocalized by every participant during the interview process:

No one asked me, “Are you ok?”

DISCUSSION

Findings from this study provided fresh insight into nurses' perceptions, as well as factors influencing their career path decisions in a pandemic-ravaged practice environment. Our results suggest that pandemic work environments contributed to a change in nursing workforce distribution and exacerbated widening nurse shortage gaps. This knowledge beckons health care leaders to mind the gap forged by these circumstances. Like Brockopp and colleagues,12 our researchers observed how the research interview process itself doubled as a comforting, therapeutic outlet, where nurses willingly engaged with the interviewer in that safe moment to release pent up thoughts and feelings. Here, the power of the one-on-one interpersonal exchange is exemplified. Nurses incorporate this mode of therapeutic communication with patients every day but now—“It's time for us to care for each other.” We listened as the voice of nurses expressed a sense of disruption that urged them to contemplate altering their career trajectories. By iteratively honing their clinical and professional skills over the course of travel assignments traversing a series of states and hospitals, veteran travel nurses constitute a cohort of highly experienced, clinically astute, adaptable, and resilient health professionals. Their expressed intent to leave the profession triggers a dire warning that an exodus of nursing experience and knowledge may be imminent. Now is the time to offer veteran travel nurses and seasoned permanent staff nurses appealing new roles to facilitate the transfer of this wealth of knowledge to early- and mid-career nurses.

The pandemic jolted the profession to its core, and like the rest of the world's stage there is no turning back. “Geriatric Millennials” (aged 36-45 years), who now account for the largest proportion of the US workforce (including nurses), are leading the charge in what is being called “the great resignation.”15 Traditional recruitment and retention interventions such as financial “carrots,” float pools, etc, are not sufficient in this new environment. Nurses are thinking differently, intentionally, and more confidently about their career path options.

Nurse leaders are cognizant of the relationship between meaningful acknowledgment and nurses' intent to stay.13 In a recent study of Korean working nurses, researchers found that press media channels of recognition (news posts, articles, documentaries) and national sources of encouragement yielded the highest scores representing intent to stay.16 During the acute phase of the pandemic, waves of acknowledgment behavior were showcased in the United States and other countries (public applause from buildings and streets, banners, billboards, social media posts, full-page newspaper accolades, etc) but have since tapered off. Participants in our study perceived that recognition of their essential roles, the risks they take, sacrifices they make, and the direct impact of their work was temporary and fleeting.

One day you're a hero, the next you're a martyr. At first, we were very appreciated, now we are forgotten.

Finally, findings of this study revealed a simple but profound common denominator. Every participant perceived that during the height of the pandemic, no one asked them individually, “Are you ok?”

RECOMMENDATIONS

The findings of this study inspire a call to intervene with leadership behaviors aimed to assuage the negative effects of the prolonged public health crisis impacting nurses' physical, mental, and emotional well-being and by extension influencing their career decisions. Based on the findings of this study, the authors suggest 6 actionable approaches to facilitate healing and advance mental well-being across the nursing workforce.

On-demand mental health and well-being resources

Right now, nurses need support and resources to bolster their coping skills. One inclination may be to refer nurses to an employee assistance program, but with the surge in demand, it can take months to get an appointment with a provider. Digital on-demand coaching, therapy, and support programs are conveniently accessible from portable devices with no appointment wait-times. There are multiple resources, some for purchase and some that are budget neutral, all of which would require a cost-benefit analysis. Researchers in Quebec, Canada, observed that nurses who were well prepared to maintain better control during the pandemic were less likely to leave their jobs.10 Compartmentalization, resilience, mental toughness, and agility mindset skills training for staff nurses and nurse leaders are worthy investments to bolster stability and preparedness for the long term.

Prioritize time off

In this study, nurses reported working extended hours ranging from 48 to 72 hours per week. When not working, nurses may still be on the call list to help supplement staffing during coverage gaps. This does not allow time for rest and recovery. Honoring scheduled time off includes removing nurses from the call list, thereby facilitating freedom to fully disconnect and recharge during that period if they choose to. Leaders can analyze workforce reports, including PTO (paid time off) accruals, payroll, staffing/scheduling data to identify which employees need to take a break, and then encourage and accommodate them to do so.

Well-being rounding

Purposeful rounding principles are characterized by deep, active listening, empathetic acknowledgment, and expressing authentic interest at an individual level. This best practice is therapeutically implemented by nursing staff and leaders to build trusting relationships with patients and improve quality outcomes.17,18 These principles can also be adopted by facility leaders in the form of purposeful positive working rounds to promote nurses' well-being.19

Seek to understand each employee's current happiness and stress levels

New travel nurses self-rated the lowest happiness levels and highest stress levels prior to the pandemic and acted on the opportunity to embark on travel nursing during the pandemic. Here, we realize the importance of monitoring nurses' happiness and stress levels as one barometer of intent to leave—whether to work as a permanent nurse at another hospital, switch to travel nursing, or leave the profession altogether. Surveys and rounding can be used to collect data for a quantitative pulse check, facilitating timely stay interventions. Periodic one-on-one or group discussions can be effective to identify root causes of unhappiness and stress and to develop a restorative plan. Nurse leaders typically juggle a continuous flow of competing priorities, limiting their capacity to devote this important time and attention to their teams. Hence, some health systems choose to capitalize on the role of the nurse retentionist to focus exclusively on these matters.20

Connect the work to the why

Nurses in all groups affirmed that they entered the profession to make a difference in people's lives.

Helping people is why I became a nurse, to comfort them, make them less scared and put a smile on their face.

Many nurses became disenchanted and demotivated during the pandemic. Despite toiling relentlessly, they felt they were unable to make a positive impact. Sharing timely, positive patient feedback reassures nurses that they are indeed making a difference in people's lives. Digital apps exist to promote real-time patient engagement and to channel timely positive feedback from patients directly to nurses and their managers. Paper surveys and particularly handwritten recognition cards are also effective. A steady flow of recognition and just-in-time positive feedback can help nurses reconnect to why they became nurses.

The simple but powerful question, “Are you ok?” can foster a dialogue that shows the empathetic and caring side of leaders while providing nurses with an opportunity to share their experiences and talk about how they are feeling. Leaders who open this dialogue, listen actively, and respond compassionately can be better positioned to foster healing and well-being of their teams and to rekindle the motivation and engagement that energize nurses to reconnect to why they love what they do.

CONCLUSION

Findings from this qualitative study contribute to a growing body of knowledge toward understanding how the pandemic impacted nurses and what that means in terms of astutely managing nurse staffing resources in the “new normal” practice environment. Our key findings resonate with other similar studies1–5 and emphasize the need to ensure nurses (i) perceive that their individual and collective well-being is authentically cared about, and (ii) receive a steady flow of support, encouragement, and timely acknowledgment from multiple levels of leadership, across various channels. Absence of timely and sustained attention to these needs poses a serious threat to the integrity of an already compromised nursing workforce. The current health care environment warrants a deeper dive to discover meaningful and practical advancements that can facilitate respect, healing, and restoration toward a proud, capable, committed, and motivated nursing workforce. Patients and communities are counting on us to mind the gap.