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History of Travel Nursing

Travel nursing as a business dates from 1978, when the first agency sent seven nurses from Boston to New Orleans. The practice of sending nurses to places that could not otherwise be staffed is older than that by sixty years, and it started in government public health work rather than in hospitals.

The two strands are genuinely different. Early travelling nurses went where there were patients and no services. Modern travel nurses go where there are services and no staff. What connects them is that both exist because the supply of nurses has never been distributed the way the need is.

Traveling nurses before there was an industry

In 1917 Julia Lathrop, the first director of the federal Children's Bureau, argued for a national programme of infant and maternal health that would employ traveling nurses, noting that communities recognised the need for them but that "no nurses are to be had." Her advocacy fed into the Sheppard-Towner Maternity and Infancy Protection Act of 1921, which funded over three million home visits by traveling nurses.

The federal government was already employing them elsewhere. The Commissioner of Indian Affairs reported to the Secretary of the Interior in 1920 that the health service had roughly 100 stationed nurses and six traveling nurses, working against tuberculosis, typhus, influenza and measles, and noted that it had not been practicable to fill every nursing post with a trained nurse.

The most extreme version of the job was in Alaska. A 1936 Interior Department budget requested $4,600 to send two traveling nurses to spend a month at a time in remote villages that had only recently become reachable by bush plane. Thomas Parran, then Surgeon General, wrote in a 1954 report that these nurses travelled by dog-team and later by air, lived "under the most primitive conditions," and faced "dangers and hardships which their Stateside colleagues could scarcely comprehend."

Nothing about that work resembles a thirteen-week contract at a metropolitan hospital. The employer was a government agency, the purpose was to reach patients with no access to care at all, and the nurse was often the entire health service for a district.

1978: the first agency

By the late 1970s the shortage had turned acute. Hospitals raised pay and benefits and still could not fill posts. They used local nurse registries and per diem agencies to cover shifts, and recruited nurses from Canada and the Philippines, and it was not enough. Sending American nurses temporarily to other parts of the country was the remaining idea.

Bruce Male, then an executive at the international staffing firm Medox, proposed a travel nursing division. The company turned him down, so he started his own, Traveling Nurse Corps, in Boston in 1978. He described the beginning to the New York Times in 1991: "To start, I had $1,739 in my checkbook, a telephone, plus an American Express card to use for booking flights for the first nurses I sent out. I also had two kids, a mortgage and no income."

In late October 1978 the company sent seven nurses from Boston to Tulane University Medical Center in New Orleans. Nurses from the firm worked New Orleans during Mardi Gras the following year, contracts with Hospital Corporation of America followed, and by the end of 1979 there were reportedly more than 200 nurses on assignment. Traveling Nurse Corps later became TravCorps and merged with Cross Country in 1999.

The 1980s, and how the pay structure formed

Through the 1980s the industry went from one company to dozens. Two things about the modern arrangement were settled in this period.

The first is who employs the nurse. The earliest travellers were paid directly by hospitals, which also provided housing. Within a few years most travellers were employed and paid by the agency, which provided housing and other benefits and billed the hospital an hourly rate covering all of it. That structure is still what a travel nurse signs today, and it is the reason the pay package is split the way it is.

The second is that travel was one answer among several to the same shortage. Hospitals in this period also experimented with weekend programmes that paid two days as three, recruited internationally at scale, and expanded their own flexible rosters. Congress created the first visa category specifically for nurses, the H-1A, in the Immigration Nursing Relief Act of 1989. See internationally educated nurses and the history of per diem nursing.

Demand has always been cyclical

The industry's own history is the strongest argument against treating any particular rate as normal.

Demand fell in the early 1990s as health maintenance organisations and managed care squeezed hospital budgets. It fell again during the 2002 downturn, and again during the recession from 2007 to 2009, when nurses who had left the workforce returned to it and vacancies closed. By 2010 demand was higher than it had ever been, as the economy recovered, the population aged, and coverage expanded under the Affordable Care Act.

Every one of those swings was described at the time as a structural change. Each turned out to be a cycle.

Consolidation, and the layer between nurse and hospital

Two firms came to dominate. American Mobile Nurses was founded in 1985 by Steve and Gayle Francis, Gayle having been one of the first nurses placed by Traveling Nurse Corps; it grew into American Mobile Healthcare and then AMN Healthcare. Aya Healthcare was founded as Access Nurses by Alan Braynin in 2001. Both grew by acquisition.

Their more consequential move was into the middle of the market. As hospitals tired of managing contracts with a dozen agencies, they outsourced the whole process to a single vendor, which either supplied its own nurses or subcontracted to other agencies. These managed service provider and vendor management system arrangements put the largest firms in the position of gatekeeper between the hospital and every other agency. AMN acquired the vendor management platform Shiftwise in 2013; HealthTrust Workforce Solutions grew out of Parallon, founded by HCA in 2011; other platforms include FocusOne and Medefis.

For a nurse this is invisible until it affects the rate. The agency calling you may be a subvendor placing you through another agency's contract, and each layer is paid out of the same hourly bill rate. See agencies and recruiters.

Licensure stopped being the obstacle it was

Until 2000 a travel nurse needed a separate licence from every state worked in. The Nurse Licensure Compact, launched in 1999 and replaced by the enhanced version that went live in January 2018, allows one multistate licence to authorise practice across the participating states. Forty states now issue and honour it. California, the highest-paying state in the country, has never had a compact bill filed. See Nurse Licensure Compact and licensing a travel assignment.

The pandemic, and the largest swing in the industry's history

In spring 2020 the average travel nurse cost a hospital $80 an hour. By spring 2022 that figure was $154, with the top of the range at $225 an hour and weekly packages that touched $12,000.

The workforce moved with the money, and it is visible in federal employment data. The number of registered nurses employed by staffing agencies rather than by a facility went from 57,270 in 2019 to 130,890 in 2023, an increase of 129 percent, while the number employed by nursing homes fell 18 percent over the same four years. Before the pandemic, researchers at the national council of boards of nursing put travel nurses at roughly 2 percent of registered nurses; at the 2022 peak, estimates of the share of nursing staff working on travel contracts ran as high as one in ten.

Inside nursing homes the shift can be measured directly, because contract hours are reported to Medicare. Contract staff went from 3 to 4 percent of nurse hours before the pandemic to a peak in 2022, and 43 percent of nursing homes used contract nurses in 2021 against 19 percent in 2017.

The political reaction arrived quickly. In January 2022, 195 members of the House of Representatives, led by Peter Welch and Morgan Griffith, wrote to the White House coronavirus response coordinator asking that federal agencies investigate nurse staffing agency pricing, alleging that agencies were charging double or triple their pre-pandemic rates while retaining 40 percent or more of what they billed. No federal price legislation followed, but the states began legislating: registration schemes, contract filing and rate reporting. See nurse staffing agencies.

Then it deflated. Hospital-side rates went to $127 in 2023, $102 in 2024, $93.81 in spring 2025 and $91.23 on the 2026 figures: a fall of about 40 percent from the peak that still leaves rates above where they stood in 2019. Volume fell harder than price. The largest publicly traded health care staffing firm booked $5.24 billion in revenue in 2022 and $2.98 billion in 2024, and travel nurse hours billed across the industry fell 17 percent in 2023 alone. Contract staff in nursing homes fell back to 7.5 percent of nurse hours by early 2024, from 10.1 percent a year before.

The comparison that puts the whole episode in proportion is the staff nurse line. Over the same six years, the hospital's hourly cost for an employed registered nurse including benefits went $46, $46, $53, $52, $54, $56. The pandemic transformed the price of a travel nurse and barely touched the price of a staff nurse.

Who ends up doing this work

The first large profile of the travel workforce, drawn from the 2022 national nursing workforce survey and covering about 2,000 travel nurses against some 42,000 non-travellers, found a consistent picture: travel nurses were younger than their staff counterparts, more likely to be male, Black or Hispanic, better paid, and far more likely to hold a multistate licence, roughly two thirds of travel registered nurses against about a third of the rest.

The last of those is causal rather than incidental. The compact is what makes a series of short assignments in different states practical, and the nurses who take them are the ones who can cross a state line without a new application. Where those assignments actually are is set out in where the assignments are.

What the history is good for

Three things recur.

Travel staffing expands when hospitals cannot hire and contracts when they can, and no boom in the record has lasted.

The nurse is almost never the hospital's employee, and the money is almost always divided among more parties than the nurse can see.

And the shortage that created the industry in 1978 has never been solved, only repriced. See the nursing shortage.

Sources

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