Where Does External Labor Fit in a Nursing Workforce Strategy?

October 18, 2022
Sarah Gray, RN

We talk to nursing leaders everyday all over the United States and consistently hear perspectives about external labor on a spectrum from “We don’t want travel nurses” to “Travel nurses are key for us.” However, nearly every health system throughout the country has engaged external or contingent labor in some fashion over the last 3 years, especially across their nursing workforce, regardless of where they fall on this spectrum. 

While the supply of qualified healthcare professionals has not kept pace with the demand even well before the pandemic, the shifting values and priorities of nurses coupled with the difficulties of sustaining a career in a clinical environment and its subsequent lifestyle implications have challenged health systems even further with no sign of slowing down. According to Mckinsey Research, the United States may have a gap of between 200,000 to 450,000 nurses available for direct patient care, equating to a 10 to 20 percent gap in supply by 2025.

This in turn has accelerated the need for health systems to tweak, or fundamentally rethink, their approach to staffing. Some are changing their tune when it comes to engaging external labor while others are still laser-focused on investing in internal staff in the hopes that recruitment and retention will be the solution to ongoing staffing challenges.

Common Themes and Statistics Concerning External Labor

Some common themes we hear are:

  1. We spend too much on travelers
  2. We want to decrease our traveler utilization, or eliminate it altogether
  3. External labor impacts our culture

On the flip side, we also hear, often from the same people:

  1. Travelers are necessary
  2. We know realistically we’ll always need them
  3. We know the type of employment and lifestyle are attractive to nurses and aligns with what they want

And here are some things we do know:

  • According to a Trusted 2021 survey, nearly three-quarters of nurses (71%) say their experience as a nurse would improve if they had more control over their schedule.
  • COVID-19 proved that the “old way” of staffing was unsustainable, as clinicians all over the country left healthcare systems in favor of better pay and more flexible options offered by travel nursing agencies. With over two years of experience now tapping into flexible opportunities, many clinicians have no desire to go back to “the old way.” Those that can travel, are, and those that aren’t able to travel due to personal or family obligations, are choosing to leave the bedside.

The Answer: Build An Internal Agency

So what’s the right answer? Is it unique to each health system or is there a ‘right’ way to think about how, when, and where you should engage external labor? We think it’s about looking beyond the black and white and redefining “traveler” and “flexible” by building a labor pool that recognizes and offers what nurses want and need and marrying that with what is important to your health system, whether it’s culture, cost efficiency, operational efficiency, or all three.

It’s about thinking about ‘agency’ and flexibility more dynamically. The solution? Build an internal agency, or ‘travel program’.  With an internal travel program, hospitals can give nurses the schedule flexibility they’re craving, enable them to gain variety and exposure from working across multiple departments, hospitals and even geographies, all while receiving more competitive wages. This leads to a more engaged workforce, higher retention rates and the ability for hospitals to finally reduce their reliance on costly contract, or third-party external labor expenses.

Programs of this nature are comprised of a team of flexible clinicians or allied health professionals employed by the health system that work long-term contracts (4-26 weeks) or day of staffing assignments spanning multiple specialties, facilities and states. Most programs offer full-time or part time employment, vacation hours, insurance and other benefits, eliminating the need for them to resort to external agencies to have these needs met. 

Get Started on Developing an Internal Travel Program

Building a self-managed, flexible internal staffing program is achievable, but it does take planning and effort. For a roadmap for hospitals looking to move toward the development of an internal travel program and more information on how to get started, contact us at