October–December  2010 333

Use of temporary nurses and nurse and

patient safety outcomes in acute care
hospital units
Sung-Heui Bae
Barbara Mark
Bruce Fried

Background: To deal with nursing shortages and inadequate hospital nurse staffing, many solutions have been
tried, including utilizing temporary nurses. Relatively little attention has been given to use of temporary nurses
and its association with both nurse and patients outcomes.
Purpose: The purpose of this study is to investigate the association between use of temporary nurses and nurse
(needlesticks and back injuries) and patient (patient falls and medication errors) safety outcomes at the nursing
unit level.
Methodology/Approach: Data came from a large organizational study which investigated the relationship
between registered nurse (RN) staffing adequacy, work environments, organizational, and patient outcomes. The
sample for this study was 4,954 RNs on 277 nursing units in 142 hospitals.
Findings: Nurses working on nursing units with high levels (more than 15%) of external temporary RN hours were
more likely to report back injuries than nurses working on nursing units that did not use external temporary RNs.
Nurses working on these nursing units also reported greater levels of patient falls compared with those who did not
use temporary RNs. This study found that nurses working on nursing units with moderate levels (5–15%) of external
temporary RN hours reported fewer medication errors than those without using any external temporary RNs.
Practice Implications: Hospitals need to monitor the levels of temporary nurse use and maintain a level of
approximately 15% to ensure both nurse and patient safety outcomes. The temporary nurse use to manage nursing
shortfall may provide both benefit and harm to nurse and patient safety depending on the level of the use.

A
sufficient supply of registered nurses (RNs) is
critical for hospitals to provide high-quality pa-
tient care, and hospitals have adopted numerous
Key words: back injuries, medication errors, needlesticks,
patient falls, temporary nurses
Sung-Heui Bae, PhD, MPH, RN, is Research Assistant Professor,
School of Nursing, University at Buffalo, The State University of New
York. E-mail: sbae7@buffalo.edu.
Barbara Mark, PhD, RN, FAAN, is Sarah Frances Russell Dis-
tinguished Professor, School of Nursing, University of North Carolina
at Chapel Hill.
Bruce Fried, PhD, is Associate Professor, Health Policy and
Management, Gillings School of Global Public Health, University of
North Carolina at Chapel Hill.
DOI: 10.1097/HMR.0b013e3181dac01c
Health Care Manage Rev, 2010, 35(3), 333-344
Copyright A 2010 Wolters Kluwer Health | Lippincott Williams & Wilkins
strategies to respond to shortages. These strategies
include instituting mandatory overtime (Hassmiller &
Cozine, 2006), tolerating and adapting to chronically
high vacancy rates (Rondeau, Williams, & Wagar, 2008),
delivering fewer RN hours of care (Blegen, Vaughn, &
Vojir, 2008), and using temporary nurses, also referred to
as agency, traveling, or floating nurses (Hassmiller &
Cozine, 2006; May, Bazzoli, & Gerland, 2006). Tem-
porary nursing staff includes nurses employed both
internally by the hospital (per diem and floating nurses)
and externally (agency nurses) (Aiken, Xue, Clarke, &
Sloane, 2007). In 2001, 56% of hospitals used temporary
nurses, including agency, per diem, or traveling nurses
(American Hospital Association, 2001), and Aiken et al.
(2007) reported that in 2000, nearly 6% of hospital staff
nurses were temporary hires. Despite their prevalence,
many hospitals have tried to reduce dependence on

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
334 Health Care Management Review
temporary nurses because of cost and safety concerns
(May et al., 2006).
Although several authors have suggested that tempo-
rary nurse staffing negatively influences safety and conti-
nuity of care, prior research has provided little empirical
support for the association between use of temporary
nurses and hospital outcomes (Castle, Engberg, & Men,
2008). Furthermore, a more recent study found that tem-
porary nurses were not related to nurse or patient safety
and quality problems (Aiken et al., 2007). Therefore, in
this research, we examined the relationship between use
of temporary nurses and nurse and patient safety out-
comes at the nursing unit level.
Previous Research
From previous research in this area, we found opinion
articles and descriptive studies of temporary nurse use
but few empirical studies examining the association
between use of temporary nurses and patient outcomes.
Most of these empirical studies have shown a negative
association between use of temporary nurses and patient
outcomes. For example, the spread of nosocomial in-
fection among patients was found to be associated with
greater use of temporary nurses (Alonso-Echanove et al.,
2003); needlestick injuries were more prevalent in tem-
porary nurses (Aiken, Sloane, & Klocinski, 1997), and
medication errors increased with the use of temporary
nurses (Rosemen & Booker, 1995).
In contrast, using the 2000 National Sample Survey
of Registered Nurses, Aiken et al. (2007) found that
temporary nurses were not less qualified than permanent
nurses but were more likely than permanent nurses to
have baccalaureate degrees. Using data from a survey
conducted in Pennsylvania, they also found that after
controlling for adequacy of staffing and resources, the
use of temporary nurses was not associated with nurses’
and patient safety and quality problems. In some cases,
having more temporary nurses was related to better pa-
tient outcomes (fewer medication errors). From these
findings, Aiken et al. suggested that quality problems in
hospitals using more temporary nurses might have re-
sulted from inadequate staffing and resources rather than
from hiring temporary nurses. Another current study found
a nonlinear relationship between use of agency nurse aide
and quality outcomes (Castle et al., 2008). Although low
levels of agency nurse aid use had little impact on quality
of care, high levels of use of agency nurse aid were asso-
ciated with poor quality of care.
Therefore, continuing effort to understand the asso-
ciation between use of temporary nurses and nurse and
patient safety outcomes is necessary to improve care
provided in hospitals. Furthermore, this association
needs to be examined at the nursing unit level instead
of at the hospital level because nursing staff work in
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
October–December  2010
teams, and nursing units provide a proximal work con-
text of the nursing care provided by temporary nurses
(Kozlowski, Steve, & Bell, 2003). To investigate the
association between use of temporary nurses and nurse
and patient safety outcomes at the nursing unit level,
we included both nurse safety outcomes (needlesticks
and back injuries) and patient safety outcomes (patient
falls and medication errors) in this study. To control
for alternative explanations for nurse and patient safety
outcomes, the analytic model included measures of rele-
vant aspects of the hospital and nursing unit work en-
vironment characteristics and selected nurse and patient
characteristics.
Conceptual Approach
We were unable to find a conceptual model specific to
understanding the relationship between temporary nurse
use and outcomes in hospitals. However, Castle (2009)
recently developed a conceptual model that illustrates
potential reasons that might underlie such a relationship
in nursing homes. His model suggests that although use
of agency staff might help to increase staffing levels, it
might also lead to poor patient quality of care because of
influence on other staff, facility operation, and patients.
Because temporary nurses and permanent nurses have to
work together, use of temporary nurses may lead to de-
creased teamwork, increased workload, and increased
supervision. The use of temporary nurses can be expen-
sive, can increase administrative burden, and can disrupt
routines. Regarding influence on patients, temporary
nursing staff may interfere with continuity of care be-
cause of unfamiliarity with care practice and patients
and unstable relationship with patients. Castle et al.
(2008) also suggested the possibility of a nonlinear
association between agency staffing levels and quality;
low levels of temporary nurse use may be a proactive way
of maintaining patient quality of care and may not in-
terfere much with care delivery processes, whereas high
levels of temporary nurse use may adversely influence
outcomes.
We hypothesized a positive association between high
levels of temporary nurse use and adverse nurse and
patient outcomes. Figure 1 presents the model proposed
in this study on the basis of Castle’s (2009) model. We
tested the direct relationships between use of temporary
nurses and patient safety outcomes (illustrated in the
solid boxes and solid arrows in Figure 1). The underlying
mechanisms of these direct relationships (dashed boxes
and dashed arrows in Figure 1), including the impact on
other staff (decreased teamwork, increased workload,
and increased supervision), facility operations (i.e., in-
creased expense, increased administrative burden, dis-
rupted routines), and patients (i.e., reduced continuity
of care), were not tested in this study.
Temporary Nurses
Figure 1
Conceptual model
Nurse Safety Outcomes
Needlesticks and nurse back injuries are a relatively com-
mon injury with potentially serious outcomes (Aiken
et al., 1997; American Nurses Association, 2008; Vieira,
Kumar, Coury, & Narayan, 2005). Currently, safety equip-
ment and lifting devices are available to lower risk of
percutaneous needlesticks and low back injuries, and
some researchers have found that injuries have been re-
duced with the adoption of these devices (Clarke, Rockett,
Sloane, & Aiken, 2002; Tan, Hawk, & Sterling, 2001;
Vieira et al., 2005). However, some handling of exposed
needles is likely to be a permanent feature of nursing
practice. In addition, it is unlikely that technologies
or procedural guidelines can entirely eliminate needle-
sticks resulting from unpredictable movements of dis-
oriented patients (Clarke et al., 2002). Temporary nurses
frequently need increased supervision (Deitzer, Wessell,
Myles, & Trimble, 1992) and may disrupt routines
(Merolle, 1988). Thus, temporary nurses can be distract-
ing to other staff who may be carrying out sensitive
nursing functions in which they are handling sharps or
trying to lift patients. Thus, permanent nurses as well as
temporary nurses may be at risk for these injuries.
Furthermore, permanent staff working on units that
depend heavily on temporary nurses may also experience
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
335
frequent patient reassignment (Castle et al., 2008), and
temporary staff may not be able to perform all of the re-
quired tasks and may not be familiar with equipment and
patients (Manias, Aitken, Peerson, Parker, & Wong,
2003). Therefore, the presence of temporary staff may
increase the workload for permanent staff (Amenta,
1977) and the frequent reassignment of staff can increase
physical job demands, which in turn lead to increased
nurse back injuries. In addition, temporary nurses may not
be familiar with the culture of help seeking in their new
workplace. Therefore, they may work alone and take un-
necessary risks in trying to lift patients. This practice can
also increase risks of back injuries of temporary nurses.
Hypothesis 1a: Greater use of temporary nurses will
be associated with high levels of nurse needlesticks.
Hypothesis 1b: High levels of temporary nurse use
will be associated with high levels of nurse back
injuries.
Patient Safety Outcomes
Temporary nurses might provide more labor that allows
for more complete falls risk assessments. However,
336 Health Care Management Review
beyond such standardized risk assessments, ‘‘knowing
the patient,’’ which is defined as knowledge specific to
the patient’s fall risk and need for help, is considered
as a core aspect of fall prevention (Rush et al., 2009).
This strategy for fall prevention includes effort not
only by individual nurses but also by the entire nurs-
ing unit, which is an aggregate of individuals on the
unit (Rush et al., 2009). Recent research has shown
higher nurse staffing levels to be associated with lower
fall rates (Dunton, Gajewski, Taunton, & Moore, 2004;
Potter, Barr, McSweeney, & Sledge, 2003; Sovie &
Jawad, 2001). However, temporary nurses may not be
familiar with practices and patients (Deitzer et al., 1992)
and may be less engaged in team work (Bloom, Alexander,
& Nuchols, 1997). As a result, nursing units with a high
proportion of temporary nurses may be less effective in
preventing falls than nursing units with more permanent
nurses.
Similarly, temporary nurses’ lack of familiarity with
the specific types of medications used on a nursing unit
and lack of knowledge about unit-specific medication
administration policies may pose a risk for medication
errors. Roseman and Booker (1995) found that medica-
tion errors increased when the number of patient days
worked by temporary nurses increased but decreased as
overtime worked by permanent nursing staff members
increased. On the contrary, Aiken et al. (2007) found
that the proportion of temporary nurses was negatively
associated with nurse-reported frequency of medication
errors in which patients received the wrong medication
or dose. This relationship was significant after control-
ling nurse characteristics and staffing-resource adequacy.
Because medication errors result from multiple factors in
complex health care systems (Reed, Blegen, & Goode,
1998), researchers have emphasized the importance of
technology, policies, and practices related to correct ad-
ministration of medications as well as interaction among
health care providers involved in medication admin-
istration (Carlton & Blegen, 2006; Kohn, Corrigan, &
Donaldson, 2000). However, when nursing units rely on
temporary nurses, permanent staff and mangers may ex-
perience frequent nursing staff changes, which may lead
to inadequate and insufficient interaction among staff
nurses. Furthermore, temporary nurses’ lack of knowl-
edge about policies and procedures and lack of sufficient
information about a patient’s condition may also lead
to insufficient interaction among staff members. In
such nursing units, medication errors may be more likely
to occur.
Hypothesis 2a: High levels of temporary nurse use
will be associated with high levels of patient falls.
Hypothesis 2b: High levels of temporary nurse use
will be related to high levels of medication errors.
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
October–December  2010
Hospital, Nursing Unit, Nurse, and Patient
Characteristics
The importance of the work environment in nurse and
patient safety outcomes has been emphasized in lit-
erature pertaining to health care safety. In a previous
study of temporary nurses (e.g., Aiken et al., 2007), work
environment characteristics played an important role in
explaining the association between use of temporary
nurses and outcomes. Therefore, in this study, hospital
and nursing unit characteristics were included to adjust
for factors that have been shown to affect nurse and
patient safety outcomes (Clarke, 2007).
Hospital characteristics include hospital size, tech-
nological sophistication, teaching status, and Magnet
certification. Larger hospitals may have better support
systems for patient care (Daft, 1992) and thus fewer
adverse events. Nurses in teaching hospitals are likely
to experience higher patient acuity and greater work
complexity (Iezzoni et al., 1990), both of which may
contribute to a higher likelihood of adverse events for
both patients and nurses. Advanced technological ser-
vices have been linked to better quality of care (Kuhn,
Hartz, Gottlieb, & Rimm, 1991). In addition, previ-
ous studies have found that nurses in Magnet-certified
hospitals reported fewer adverse events (Aiken et al.,
1997).
At the nursing unit level, work complexity, unit size,
and availability of support services are considered as
work environment conditions that may help explain
nurse and patient safety outcomes (Mark et al., 2007).
In a nursing unit with greater work complexity and more
beds, nurses may more frequently encounter time-
sensitive situations. This might influence adherence of
nurse staff to safe practices, which in turn may affect
work-related nurse and patient safety outcomes. The
availability of support services may help to reduce nurse
workload, which may contribute to the reduction of
nurse injuries and patient safety (Mark et al., 2007).
Certain nurse characteristics may also play a role in
nurse injuries. For example, older nurses may be at higher
risk for back injuries (Sherehiy, Karwowski, & Marek,
2004). Nurse tenure and education levels and the pro-
portion of total nursing care hours provided by both
permanent and temporary RNs have been found to be
associated with patient outcomes (Clarke, 2007; Berney,
Needleman, & Kovner, 2005; Kane, Shamliyan, Mueller,
Duval, & Wilt, 2007).
In terms of patient characteristics, studies indicate that
medication errors and falls are more common among
elderly patients (Thomas & Brennan, 2000). In addition,
those with lower perceived health status are likely to be
more acutely ill (Mommersteeg, Denollet, Spertus, &
Pedersen, 2009) and therefore more at risk for falls and
medication errors.
Temporary Nurses
Methods
Sample
The current study is a secondary analysis of data from the
Outcomes Research in Nursing Administration Project II
(ORNA II), a nonexperimental, longitudinal causal mod-
eling study (Mark et al., 2007) that used the nursing unit
as the unit of analysis. The ORNA II study was under-
taken to investigate the relationship between RN staffing
adequacy, work environments, and organizational and pa-
tient outcomes. The hospital sample was selected through
a SAS computer-generated random selection procedure
using the American Hospital Association Survey of Hos-
pitals. Using the inclusion criteria of hospitals (nonfed-
eral, nonpsychiatric, not-for-profit, JCAHO-accredited
acute care hospitals with more than 99 beds), 1,401 hos-
pitals were entered into the selection pool. Inclusion crite-
ria for the two nursing units in each hospital were ‘‘general’’
medical-surgical units and medical-surgical specialty units.
The final ORNA II sample consisted of 286 medical, sur-
gical, and general medical-surgical nursing units from 143
hospitals throughout the United States. All RNs working
on each nursing unit who had worked on the unit more
than 3 months were invited to participate in the study, and
staff nurses responded to survey questionnaires measuring
work complexity and availability of support services in the
first of three rounds of data collection. Ten patients who
were 18 years or older, able to speak English, and hospi-
talized on the unit for at least 48 hours were randomly
selected from each participating unit to complete a patient
survey that contained information on their age and health
status. A total of 2,720 patients responded (response rate
of 91%). ORNA II data collection began in 2003 and
ended in 2004. Because of missing values for the selected
study variables, the final dataset for the current study con-
sisted of 277 nursing units from 142 hospitals. The staff
nurse response rates were 75% (4,911) at the first round,
58% (3,689) at the second round, and 54% (3,272) at
the third round.
Data Collection
Data from each nursing unit were obtained during three
rounds of data collection conducted over six consecutive
months. Nurse managers in each nursing unit reported
the care hours provided by temporary nurses, the in-
cidence of staff nurses’ needlesticks and back injuries,
and the number of patient falls and medication errors
during the 6-month study period. Staff nurses completed
a survey to measure work complexity and availability
of support services in their work unit at the first month
of the data collection period (first round). Hospital,
nursing unit, and nurse characteristics were collected at
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
337
the first round. In the last month of data collection,
patients provided information about their age and how
they perceived their health.
Measures
Independent Variables. To measure use of temporary
nurses, we used three variables (care hours provided by
internal temporary nurses [float and per diem], care hours
provided by external temporary nurses [agency RNs], and
total temporary care hours provided by internal and ex-
ternal temporary nurses). In previous studies, researchers
examined only external temporary nurses such as agency
staff (Castle, 2009) or percentages of supplemental/float
nurses (Aiken et al., 2007). This study used an advanced
approach to measure use of temporary nursing staff by
examining the relationship separately between internal
temporary nurses/outcomes, external temporary nurses/
outcomes, and total temporary nurses/outcomes. This pro-
vided us with a unique opportunity to examine whether
there might be any differences in the relationships be-
tween temporary staff and outcomes on the basis of the
specific type of temporary nurses. The care hours pro-
vided by temporary nurses were calculated by the total
hours of care delivered by temporary RNs divided by the
total nursing care hours delivered by RNs, yielding a
percentage. The distribution of temporary RN hours was
right skewed; therefore, they were grouped into four
categories, and the cutoff points from the study of Aiken
et al. (2007) were used: zero (reference group), low (i.e.,
greater than 0% to less than 5%), moderate (5–15%),
and high (greater than 15%).
Dependent Variables. Nurse safety outcomes were mea-
sured as the number of incidents (needlesticks and back
injuries) reported during the 6 months of data collection.
Needlesticks were defined as any break of the skin with a
needle or sharp instrument that was used on a patient;
back injuries were defined as any musculoskeletal disorder
of the back caused or made worse by the physical de-
mands of the work of caring for patients (Mark et al.,
2007). Because the number of those incidents per RN
within a nursing unit during the 6-month study period
was so small, the analysis used the number of needlesticks
or back injuries reported per 10 RNs on a unit.
Patient falls, defined as an unplanned descent to the
floor, were measured as the rate of patient falls per 1,000
patient days. Patient falls included any kind of patient
falls. Medication errors were defined as the wrong dose,
the wrong patient, the wrong time, the wrong drug, the
wrong route, or an error of omission; these were also
measured as the number of incidents per 1,000 patient
days. To reduce the problem of underreporting of medi-
cation errors, this study used a measure of medication
errors that resulted in increased nursing observation,
338 Health Care Management Review October–December  2010

technical monitoring, laboratory and radiographic test-
ing, medical intervention or treatment, or transfer of the
patient to another unit (Hofmann & Mark, 2006).
Control Variables. Control variable definitions are dis-
played in Table 1. Because of limited space, we present
here selected control variables requiring additional expla-
nation. Work complexity was measured using a 7-item
Likert-type scale from the Perceived Environmental Un-
certainty Scale (Salyer, 1996). Cronbach’s alpha for the
scale in the current study was .85. These items asked
about the extent to which (a) nurses perceive a need for
more information about their patients, (b) physicians
change orders frequently, and (c) frequency of admis-
sions, transfers, and discharges makes it difficult to get the
work done. Higher scores indicate a higher level of work
complexity. The availability of support services was mea-
sured by a check list of 21 items, completed by staff nurses

Table 1

Definitions and descriptive statistics for study variables

Variables Definitions Mean or % SD ICC(1) rwg

Explanatory variables
External temporary nurse Percentage of nursing care hours delivered 4.29 7.72
care hours by external temporary (agency) RNs
Internal temporary nurse Percentage of nursing care hours delivered 6.85 8.03
care hours by internal temporary (float/per diem) RNs
Total temporary nurse Percentage of nursing care hours delivered 11.15 12.20
care hours by all temporary RNs
Dependent variables
Nurse needlesticks Total number of nurse needlesticks per 0.29 0.43
10 RNs on the unit
Nurse back injuries Total number of nurse back injuries per 0.67 0.99
10 RNs on the unit
Patient falls Total number of patient falls per 1,000 4.05 2.10
patient days
Medication errors Total number of medication errors per 0.79 1.40
1,000 patient days
Control variables
Hospital characteristics
Hospital size Total number of maintained beds 346.56 187.04
Technological Saidin index (weighted sum of the number 4.62 1.81
sophistication of technologies and services available in
the hospital)
Teaching status Ratio of medical and dental residents to 0.13 0.25
the number of hospital maintained beds
Magnet certification If the hospital was currently certified by 13.36
the American Nurses Credentialing Center
for Excellence in Nursing (yes, n = 37)
Nursing unit characteristics
Work complexity Work complexity (Salyer, 1996) 3.84 0.50 .15 .72
Unit size Total number of nursing unit beds 33.58 11.26
Availability of support Proportion of 21 support services 32.33 2.52 .15 .96
services (Mark et al., 2007)
Nurse characteristics
Nurse age Average age of RNs on the unit 40.25 10.73
Education level Proportion of nurses with a bachelor’s 0.37 0.20
degree or higher
Unit tenure Average months of nurses’ tenure on the unit 74.50 33.17
RN hours Percentage of nursing care hours delivered 61.76 13.62
by unit RNs (including only permanent RNs)
Patient characteristics
Patient age Average age 56.88 7.57
Health status Patients’ perceived health status (five categories) 3.45 0.45
Note. N = 277(nursing units). SD = standard deviation; ICC = intraclass correlation; rwg = interrater agreement.

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Temporary Nurses 339

who indicated the availability (not available, inconsistently
available, and consistently available) of selected support
services (Mark et al., 2007). Examples of support services
included computerized order entry, automated medica-
tion administration system, and intravenous team service.
Data Analysis
Because the nursing unit was the unit of analysis in this
study, selected study variables (work complexity and
availability of support services) measured at the indi-
vidual level were aggregated to the nursing unit level.
To justify the aggregation of lower level data to higher
level units of analysis, we used measures of intraclass
correlation coefficient (ICC[1]) and interrater agreement
(rwg). ICC(1) assessed how within-group variance con-
trasted with between-group variance, and rwg was used in
the event that observed group variances differed from
some theoretically expected random variance. The com-
mon threshold for such justification is an rwg value equal
to or greater than .70, and a larger ICC(1) is accepted as
a greater similarity within group.
The current analysis with a sample size of 277 units
had sufficient power to test the proposed model (Cohen,
1988). When the dependent variable is the count of
some outcome and its distribution is skewed right, count
models are used (Hutchinson & Hotman, 2005). In this
study, a Poisson regression model with an adjustment for
overdispersion was used for this reason.
Findings
The means, standard deviations, and, where appropriate,
ICC(1) and rwg for the study variables are presented in
Table 1. Results of a Poisson regression with control vari-
ables are presented in Tables 2 and 3.

Table 2

Associations of nurse injuries with temporary nurse care hours in units

Needlesticks Back injuries

External temporary
nurse care hours
0–5% 1.285 (0.348) 1.303 (0.240)
5–15% 0.802 (0.293) 0.997 (0.234)
>15% 1.126 (0.445) 1.730 (0.400)*
Internal temporary
nurse care hours
0–5% 1.464 (0.494) 1.011 (0.225)
5–15% 1.162 (0.404) 1.296 (0.274)
>15% 1.402 (0.529) 1.548 (0.348)*
Total temporary
nurse care hours
0–5% 1.746 (0.665) 1.061 (0.271)
5–15% 1.093 (0.420) 1.039 (0.252)
>15% 1.362 (0.510) 1.533 (0.343)
Control variables
Hospital size 0.999 (0.001) 0.999 (0.001) 0.999 (0.001) 0.999 (0.001) 0.999 (0.001) 0.999 (0.001)
Technological 1.248 (0.117)* 1.254 (0.122)* 1.258 (0.123) 1.021 (0.060) 1.017 (0.061) 1.029 (0.061)
sophistication
Teaching status 1.294 (0.620) 1.125 (0.551) 1.219 (0.600) 0.826 (0.283) 0.858 (0.297) 0.756 (0.264)
Magnet certification 0.986 (0.355) 0.981 (0.354) 0.954 (0.346) 0.600 (0.172) 0.555 (0.159)* 0.567 (0.172)
Work complexity 1.093 (0.281) 1.145 (0.294) 1.143 (0.291) 0.981 (0.163) 0.973 (0.164) 1.002 (0.169)
Unit size 1.001 (0.010) 1.007 (0.010) 1.007 (0.010) 1.010 (0.007) 1.009 (0.007) 1.009 (0.007)
Availability of 0.956 (0.046) 1.145 (0.294) 0.964 (0.047) 1.029 (0.033) 1.043 (0.033) 1.041 (0.033)
support services
Nurse age 1.008 (0.032) 1.014 (0.032) 1.016 (0.032) 1.045 (0.022)* 1.052 (0.021)* 1.052 (0.021)*
Education level 0.961 (0.567) 1.045 (0.665) 0.948 (0.597) 2.426 (0.951)* 2.911 (1.193)* 2.722 (1.081)*
Unit tenure 0.993 (0.004) 0.994 (0.004) 0.994 (0.004) 0.995 (0.003) 0.994 (0.003)* 0.995 (0.003)*
RN hours 0.994 (0.010) 0.994 (0.010) 0.993 (0.010) 1.008 (0.006) 1.010 (0.006) 1.009 (0.006)
Patient age 0.996 (0.016) 0.993 (0.016) 0.997 (0.016) 0.986 (0.011) 0.985 (0.011) 0.983 (0.011)
Health status 0.836 (0.216) 0.872 (0.227) 0.911 (0.235) 0.912 (0.155) 0.904 (0.154) 0.928 (0.157)
Note. N = 277. Reference groups are 0% temporary nurse care hours. Incident rates are presented, and standard errors are in parentheses.
*Significant at .05.

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340 Health Care Management Review October–December  2010

Table 3

Associations of patient safety with temporary nurse care hours in units

Patient falls Medication errors

External temporary
nurse care hours
0–5% 1.015 (0.077) 0.951 (0.159)
5–15% 1.023 (0.090) 0.564 (0.133)*
>15% 1.050 (0.118) 0.863 (0.239)
Internal temporary 0.899 (0.187)
nurse care hours
0–5% 1.085 (0.092) 1.224 (0.227)
5–15% 0.952 (0.082) 1.280 (0.266)
>15% 1.143 (0.106)
Total temporary 0.726 (0.166)
nurse care hours
0–5% 1.174 (0.113) 1.043 (0.201)
5–15% 0.999 (0.093) 0.938 (0.182)
>15% 1.188 (0.106)*
Control variables
Hospital size 1.000 (0.000) 1.000 (0.000) 1.000 (0.000) 0.999 (0.001) 0.999 (0.001) 0.999 (0.001)
Technological 0.985 (0.023) 0.990 (0.024) 0.990 (0.024) 1.094 (0.062) 1.098 (0.062) 1.092 (0.063)
sophistication
Teaching status 0.684 (0.110)* 0.671 (0.107)* 0.671 (0.108)* 0.684 (0.287) 0.589 (0.245) 0.584 (0.247)
Magnet certification 0.992 (0.094) 0.998 (0.093) 1.003 (0.095) 1.368 (0.265) 1.391 (0.270) 1.410 (0.274)
Work complexity 1.032 (0.068) 1.040 (0.069) 1.053 (0.070) 0.759 (0.110) 0.724 (0.106)* 0.725 (0.106)*
Unit size 1.000 (0.003) 1.000 (0.003) 0.999 (0.003) 1.007 (0.006) 1.006 (0.006) 1.007 (0.006)
Availability of 1.032 (0.068) 1.040 (0.069) 1.002 (0.013) 0.759 (0.110) 0.952 (0.030) 0.949 (0.030)
support services
Nurse age 1.002 (0.008) 1.003 (0.008) 1.002 (0.008) 1.002 (0.019) 1.000 (0.019) 1.003 (0.019)
Education level 1.291 (0.212) 1.307 (0.217) 1.289 (0.212) 0.125 (0.052)* 0.128 (0.054)* 0.132 (0.055)*
Unit tenure 1.000 (0.001) 1.000 (0.001) 1.000 (0.001) 1.005 (0.002)* 1.005 (0.002)* 1.005 (0.002)*
RN hours 1.002 (0.002) 1.003 (0.002) 1.002 (0.313) 1.012 (0.005)* 1.014 (0.005)* 1.013 (0.005)*
Patient age 1.007 (0.004) 1.007 (0.004) 1.007 (0.004) 1.005 (0.010) 1.002 (0.010) 1.001 (0.010)
Health status 0.794 (0.054)* 0.804 (0.054)* 0.811 (0.055)* 0.827 (0.130) 0.836 (0.129) 0.826 (0.128)
Note. N = 277. Reference groups are 0% temporary nurse care hours. Incident rates are presented, and standard errors are in parentheses.
*Significant at .05.

Across the 277 nursing units, 57 (20.58%) nursing
units did not use any temporary RNs, and 57 (20.58%),
78 (28.16%), and 85 (30.69%) nursing units used low
(greater than 0% to less than 5%), moderate (5–15%),
and high (greater than 15%) levels of temporary RNs,
respectively. One hundred thirty-nine (50.18%) nursing
units did not use external temporary nurses, and 69
(24.91%), 44 (15.88%), and 25 (9.03%) nursing units
fell in the low, moderate, and high levels of external
temporary nurses, respectively. Seventy-five (27.08%)
nursing units did not use internal temporary nurses, and
76 (27.44%), 78 (28.16%), and 48 (17.33%) nursing
units used low, moderate, and high levels of internal
temporary RNs, respectively. During the study period,
on average, nursing units reported 0.29 needlesticks and
0.67 back injuries per 10 nurses. On average, there were
4.05 patient falls and 0.79 medication errors per 1,000
patient days.
The association of nurse safety outcomes with tem-
porary nurse care hours when hospital and nursing unit
work conditions and nurse and patient characteristics
were controlled is presented in Table 2. Incident rates
of more than one indicate a higher likelihood of nurse
safety outcomes. As evidenced by Table 2, the greater use
of external or internal temporary nurses had no signifi-
cant association with the reporting of nurse needlesticks.
In terms of back injuries, we found that nurses working
on units with 15% or more of total nursing hours provided
by external temporary RNs were 1.730 times more likely to
have back injuries than nurses on units without using any
temporary RNs. In other words, as nurses working on
nursing units with no agency RNs reported 0.56 back
injuries per 10 nurses on average, those working on nursing
units with 15% or more agency RN hours reported 0.97
(1.730  0.56) back injuries per 10 nurses during a
6-month study period. That was equal to a 73% increase in

Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Temporary Nurses
nurse back injuries, which was statistically significant ( p <
.05). Similarly, nurses working on nursing units with 15%
or more internal temporary nurses were likely to have
1.548 times ( p = .05) as many back injuries as those on
nursing units that did not use temporary RNs. However,
the relationship between total temporary nurse care hours
and back injuries was not statistically significant (incident
rate = 1.533, p = .056). In addition, we found that older
nurses reported more back injuries (4% increase, p < .05).
One interesting finding was that nursing units with a high
proportion of RNs with bachelor’s degrees or higher re-
ported more incidents of back injury than nurses employed
on units with a lower proportion of nurses with bachelor’s
degrees (142.6% increase, p < .05).
Table 3 presents the association of patient safety out-
comes (patient falls and medication errors) with temporary
nurse care hours after controlling for hospital and nursing
unit work characteristics and nurse and patient character-
istics. Nurses in nursing units providing 15% or more direct
care hours by temporary RNs reported an 18.8% increase in
patient falls compared with those nursing units that did not
use temporary RNs; the difference was statistically sig-
nificant. As expected, the incidence of patient falls was
negatively related to average patient health status on the
unit. Patients on nursing units in hospitals that had greater
involvement in teaching were less likely to have patient
falls than patients in hospitals that were less involved in
teaching (32.9% decrease, p < .05).
Nurses working on nursing units with 5% to 15% ex-
ternal temporary nurse care hours reported fewer medi-
cation errors than those nursing units that did not use
external temporary RNs (incident rate = 0.564, p < .05).
This suggested that when nursing units with no agency
RN hours reported 0.91 medication errors during the
study period on average, those with 5% to 15% reported
0.51 (0.564  0.91) medication errors, which was a 43.6%
decrease in medication errors.
Another important finding was a negative relationship
between nurse education level and medication errors.
Nursing units with high proportions of bachelors or higher
degree-prepared nurses reported fewer medication errors
than units with lower proportions of nurses possessing a
bachelor’s degree or higher (87.5% decrease, p < .05). Al-
though unit tenure (0.5% increase) and RN hours (1.4%
increase) had statistically significant associations with
medication errors, the magnitude of their impact was small.
To sum up, the results suggested that greater use of tem-
porary RNs was associated with high levels of nurse back
injuries and patient falls. Moderate levels of temporary
nurses were also related to lower levels of medication errors.
Discussion
The use of temporary nurses has been used frequently as
a short-term strategy for managing nurse shortages (May
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
341
et al., 2006). In this study, the use of temporary nurses
in hospitals was prevalent. We found that 75% of nurs-
ing units used either external or internal temporary
nurses. These findings showed an increase in use of tem-
porary nurses in hospitals compared with previous studies
(American Hospital Association, 2001). Also, we found
that some nursing units depended heavily on temporary
nurses to provide nursing care. At the most, nursing units
used external temporary nurses to deliver 32.7% of nurs-
ing care hours. In the case of internal temporary nurses,
nursing units used them to make up 41.46% of nursing
care hours. When considering the number of nursing care
hours provided by both external and internal temporary
nurses, nursing units used temporary nurses to deliver pa-
tient care up to 62.37% of nurse care hours.
The most important findings of this study were the
positive associations between use of temporary RN hours
and nurse back injuries and patient falls. Nurses working
on nursing units with 15% or more external temporary
RN hours or internal temporary RN hours were more
likely to report back injuries than nurses working on nurs-
ing units that did not use temporary RNs, after controll-
ing for hospital and nursing unit characteristics and nurse
and patient characteristics. When we used all temporary
RN hours, this result was not significant ( p = .056). The
increase in back injuries might result from frequent
reassignment of staff (Castle et al., 2008), physical job
demands of permanent nurses, and temporary nurses’ un-
necessary risk taking to lift patients. As stated earlier,
nurses working on units with 15% or more external tem-
porary RN hours reported a 73% increase in nurse back
injuries than those working on units with no external
temporary RNs. The incidence was 0.67 back injuries per
10 nurses during a 6-month study period, on average. In
other words, a nurse working on a unit can expect one
back injury about every 8 years (during a year 0.134 [0.67
 2 / 10] back injuries per a nurse = every 8 years 1 back
injury per a nurse). Although the incidence of back in-
juries is very small, the increase associated with heavy use
of temporary nurses is of concern.
Compared with nurses on units that did not use tem-
porary RNs, nurses on nursing units providing 15% or
more direct care hours by temporary RNs were 18.8%
more likely to report patient falls. These findings were
consistent with previous studies that found a negative
relationship between use of temporary nurses and pa-
tient safety (infections and medication errors; Aiken
et al., 1997; Alonso-Echanove et al., 2003). This implies
that although at certain levels of use temporary nurses
may provide necessary labor to prevent the risk of pa-
tient falls, the high levels of dependency on temporary
nurses seemed to increase patient fall incidents. As Rush
et al. (2009) pointed out, it is important for individual
nurses and the entire nursing team to know the patient
to help prevent patient falls. To do that, a stable work
342 Health Care Management Review
relationship and teamwork is a core element. Nursing
units heavily depending on the temporary nurses cannot
maintain that stable work relationship.
We found an interesting relationship between use of
external temporary nurses and medication errors. Nurs-
ing units with 5% to 15% external temporary RN hours
reported fewer medication errors than those nursing units
that did not use temporary RNs. Aiken et al. (2007) also
found a similar result after accounting for the difference
in the adequacy of staffing and resources. Nurses in hos-
pitals with high levels of nonpermanent staff were less
likely to report high levels of dispensing the wrong medi-
cation. Our findings showed that the reduction in medi-
cation errors occurred only at moderate levels (5–15%) of
external temporary RN use. This may imply that in nurs-
ing shortfalls, using temporary nurses may be a proactive
way to maintain patient quality of care.
Among control variables, we found nurses working
on nursing units with a high proportion of RNs with
bachelor’s degrees or higher reported more incidents of
back injury than nurses employed on units with fewer
bachelors prepared nurses. One possible explanation
might be that the educational programs of nurses with
BS degrees emphasize the importance of reporting these
events. In contrast, education level was associated with
fewer reported medication errors. Because our definition
of medication errors focused on those that resulted in
increased nursing observation, technical monitoring, labo-
ratory and radiographic testing, medical intervention or
treatment, or transfer of the patient to another unit, this
result is not likely due to underreporting. The relation-
ship between education level and fewer medication errors
thus may be explained by better preparation in the edu-
cational program regarding the importance of adhering to
safe medication practices.
Limitations and Suggestions for
Further Research
The first limitation was that the study did not account
for the characteristics of the temporary nurses that were
used. In this study, the use of temporary nurses was evalu-
ated by using only patient care hours provided by tem-
porary nurses. However, to more accurately assess the
association between use of temporary nurses and nurse
and patient safety outcomes, the temporary nurse charac-
teristics should also be assessed. These characteristics,
such as education level, tenure at the workplace, ex-
perience working on certain types of nursing units, can
affect the ability of temporary nurses to deliver patient
care and to make adjustments to unit policy and practice
related to patient care. For future research, these char-
acteristics of temporary nurses should be considered.
This study attempted to control hospital (size, tech-
nological sophistication, teaching status, and Magnet
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
October–December  2010
certification), nursing unit (work complexity, size, and
availability of support service), nurse (age, education,
unit tenure, and staffing), and patient (age, health sta-
tus) characteristics to eliminate alternative explanations
for nurse and patient safety outcomes. However, it may
not have been possible to completely exclude alterna-
tive explanations for safety outcomes such as resource
adequacy and orientation for temporary nurses and the
unit and hospital’s ability to recruit and retain perma-
nent nurses (Aiken, 2007; Aiken et al., 2007). For future
studies, such variables need to be accounted for in the
model to obtain the true relationship between temporary
nurses and nurse and patient safety outcomes.
This study found different impacts on falls and
medication errors of different kinds of temporary staff.
In terms of patient falls, only total temporary nurse use
more than 15% of RN hours contributed to more falls.
Thus, the type of temporary staff, be it internal or ex-
ternal, may not be the critical factor related to patient
falls; rather, it may be the total hours of care provided by
temporary staff. In contrast, total temporary hours had
no relationship to medication errors. What did make a
difference was the type of temporary staff. In this case,
only the use of external temporary nurses for between
5% and 15% of hours was significantly related to fewer
medication errors; there was no relationship between
internal temporary nurse use and medication errors. One
possible explanation might be that temporary nurses
from outside the hospital may recognize and respect
their lack of familiarity with the medication adminis-
tration systems, are therefore more careful, and make
fewer reported errors. Another possible explanation might
be that external temporary nurses may have a long-term
contract on a unit and may be familiar with medication
processes. To make a conclusion regarding impacts on
falls and medication errors, future studies need to include
the temporary nurse characteristics, such as working
experience, contract period, and education. In addition,
studies that examine specifically the hypothesized mecha-
nisms underlying these relationships in terms of increase
workload, decreased teamwork, and continuity of care
(Castle et al., 2008) would help to elucidate how these
changes depend on the magnitude and type of temporary
nurse utilization.
Permanent nurse’ overtime practice can be used to
control nurse shortfall instead of hiring temporary nurses.
However, we did not have information what percentage
of RN hours were provided by permanent nurse overtime
hours. Because of this limited information, we were
unable to investigate whether nurse mangers used nurse
overtime hours as a substitute for temporary nurse care
hours. Thus, future studies need to collect information
regarding overtime hours worked by permanent nurses to
examine the relationship between use of temporary RNs
and patient outcomes.
Temporary Nurses
Practice Implications
These study findings have several implications for prac-
tice. The current nursing shortage contributes to inade-
quate hospital nurse staffing. Hospitals use temporary
nurses, either external (agency RNs) or internal (float/
per diem RNs), to manage nurse staffing shortfalls as a
short-term strategy, which seems to be a prevalent prac-
tice (American Hospital Association, 2001; May et al.,
2006). Using the data collected from medical-surgical
nursing units, this study found that the use of temporary
RNs for greater than 15% of total RN hours was posi-
tively related to both the number of back injuries nurses
reported and the patient falls. Health care institutions,
especially hospitals, need to monitor the levels of tem-
porary nurse usage and maintain this level below 15% of
RN hours to ensure both nurse and patient safety. At
the same time, nurse managers need to consider how use
of temporary nurses influences the care process, such as a
disrupted continuity of care and an increase in the ad-
ministrative workload of permanent nurses who attempt
to supervise and orient temporary nurses. To reduce such
adverse influences, nurse managers need to assess more
carefully the capability of temporary nurses and the fit-
ness of these nurses to carry out nursing tasks. Also, an
orientation program for temporary nurses conducted be-
fore temporary nurses come into nursing units may be an
effective way to reduce the burden of permanent staff
(Aiken, 2007).
Another practice implication is related to the posi-
tive association between moderate levels of employment
of temporary nurses and fewer medication errors. This
study found that when nursing units use temporary nurses
at a level between 5% and 15% of RN hours, these nurs-
ing units reported fewer medication errors when com-
pared with those that did not employ temporary nurses,
suggesting that a moderate level of temporary nurse use
may be appropriate. At the same time, additional evi-
dence regarding the association between use of temporary
nurses and outcomes is needed before this becomes a
standard practice.
Conclusions
Temporary nurses are commonly used in hospitals to
fulfill nurse shortfalls (Aiken et al., 2007; American
Hospital Association, 2001). It is believed that use of
temporary nurses is associated with poor quality (e.g.,
Deitzer et al., 1992). The results of this study showed
that high levels of use of temporary RN staff (i.e., 15%
or more temporary RN hours) were associated with high
levels of back injuries and patient falls. We also found
that moderate utilization (i.e., 5–15% temporary nurse
care hours) were related to fewer medication errors. Al-
though we controlled possible variables related to safety
Copyright @ 2010 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
343
outcomes, omitted variables may still explain our find-
ings. Future studies should investigate not only the
possibility of inadequate resources, poor orientation for
temporary nurses, and deficiencies in recruiting and re-
taining nurses, these studies should also attempt to
measure the underlying causal processes we outlined in
our conceptual framework. In this way, we can develop
more definitive conclusions about the association be-
tween use of temporary nurses and nurse and patient
safety outcomes.
Acknowledgments
This work was supported by grant no. 5R01NR003149
from the National Institute of Nursing Research and had
an exemption of the University at Buffalo institutional
review board approval because of using a de-identified
secondary data.
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