No single coverage model closes a staffing gap on its own. Facilities combine internal float pools, per diem coverage, contract labor, scheduling changes, and long-term pipeline work, and the healthcare staffing models that fit depend on the setting, census volatility, and budget structure.
Nine models account for how most facilities cover shifts today. The healthcare staffing crisis looks different in a 300-bed hospital and in a 90-bed skilled nursing facility, so each one is laid out by mechanics and tradeoffs rather than ranked against the others.
Where healthcare staffing stands now
The aggregate picture has changed enough since the early 2020s that plans built on 2022 assumptions are worth rebuilding.
Registered nurse (RN) employment has recovered to its pre-2020 level, with roughly 3.3 million RNs employed nationally. The U.S. Bureau of Labor Statistics (BLS) projects about 6% growth in RN employment over the current 10-year projection period, with the vast majority of annual openings coming from replacement needs rather than newly created positions.
Distribution is where the pressure sits. Acute care recruitment has broadly stabilized, while long-term care has not, and that gap shows up in how long roles stay open rather than in national headcount.
Within nursing homes, staffing levels vary widely between facilities, and coverage tends to thin on nights and weekends. Rural facilities, and the licensed practical nurse (LPN) and nursing assistant roles they lean on hardest, face the more difficult version of the same problem.
How to compare staffing coverage models
The 9 nurse staffing models in use today differ less in what they cover than in how quickly they deploy, how much they cost per shift, and what infrastructure they require.
Staffing models facilities use to cover shifts
Each of the nursing shortage strategies below is described in the same way, covering how it works, where it fits, and what it does not solve.
What is a nurse float pool?
A nurse float pool is a group of internal employees cross-trained to move between units within a facility or across a small campus. Nurses are typically paid a differential above base rate, which still lands well below any external option, making this a cost-effective way to staff a shift.
Float pools are well-suited to facilities with several units of comparable acuity and predictable daily variation. They require competency validation for every unit a nurse floats to, as well as scheduling infrastructure that can match skill sets to openings in real time.
Facilities that skip the competency piece tend to end up with a pool that can only float between 2 units, which defeats the purpose.
What a float pool does not do is add headcount. It redistributes existing staff to whichever unit is thinnest, thereby protecting nurse-to-patient ratios on the unit most in need while leaving total capacity unchanged. If every unit is short at once, the pool has nowhere to draw from.
How do internal staffing agencies work?
An internal staffing agency is an entity owned and operated by a health system that deploys clinicians across its facilities. Pay typically falls between staff rates and external agency rates, capturing the margin an outside vendor would otherwise take.
This model fits multi-hospital systems with enough combined volume to keep an internal bench occupied year-round. It requires real capital, dedicated recruiting and scheduling staff, and the administrative machinery to run payroll, credentialing, and compliance for a workforce that moves between sites under different state licensure conditions.
Scale is the binding constraint. A standalone hospital or nursing home generally cannot generate enough internal demand to justify the overhead, so this remains largely a system-level play rather than a facility-level one.
What is per diem staffing?
Per diem nurse staffing covers shifts one at a time through a marketplace or platform, with qualified clinicians. There is no minimum commitment or long-term obligation, and facilities pay only for shifts worked.
Activation is fast, usually in days once credentialing is set up, which makes per diem the practical answer to a callout, a census spike, or a leave that starts next week. Coverage depends entirely on local clinician supply, so fill rates in rural markets differ substantially from metro markets.
Per diem covers shifts rather than filling roles, so it does not by itself resolve a vacancy. A clinician picking up an occasional shift arrives without the unit-specific familiarity a staff nurse brings, so there is some onboarding for the charge nurse each time, though facilities that see the same clinicians return build that familiarity over time.
When does travel and contract labor make sense?
Travel nurse contracts run multiple weeks or months through an agency, with the clinician committed to a set schedule for the contract term. This suits sustained vacancies, predictable seasonal census swings, and new unit openings where you need reliable clinicians on a known schedule.
Cost per hour is the highest of any model, and lead time runs several weeks between requisition and start date.
Contracts also carry cancellation exposure in both directions, which matters when census drops mid-term. Read the cancellation and guaranteed-hours clauses closely, because the terms vary more between agencies than the headline rate does.
How does flexible scheduling reduce coverage gaps?
Flexible scheduling for nurses covers self-scheduling, shorter shift lengths, split shifts, and structured shift-swapping. The direct cost is close to zero, and it addresses a real mismatch: some departures stem from schedule rigidity rather than pay or workload.
Flexible scheduling fits any setting, though it demands scheduling technology capable of handling the complexity and managers willing to give up some control over the grid.
Facilities that schedule via spreadsheets will find that the administrative burden climbs quickly, and self-scheduling, in particular, needs guardrails to ensure weekends and nights are not left uncovered.
Flexible scheduling redistributes the hours you already have. Where headcount is genuinely short, it makes existing staff more likely to stay without creating additional capacity, which is useful but not sufficient.
What is virtual nursing?
Virtual nursing places experienced RNs remotely to handle admissions, discharges, documentation, patient education, and second-nurse verification via in-room audio and video so that bedside staff can spend more of the shift on hands-on care.
The model is largely confined to acute care and is capital- and IT-intensive. Rooms need hardware, the workflow needs redesign, and someone has to own the integration with the electronic health record (EHR).
Virtual nursing also depends on having experienced nurses available to staff the remote role, which is not a given in a market where experience is scarce.
What virtual nursing does not do is put another pair of hands at the bedside. It shifts documentation and verification work off the floor nurse rather than adding coverage, so a unit that is short-staffed at the bedside stays short-staffed.
Results so far largely come from individual health systems reporting on their own programs, so treat vendor figures as claims rather than findings, and ask what they were measured against.
How does international recruitment work?
International nurse recruitment brings foreign-educated nurses into permanent positions, a process that requires NCLEX passage, credential evaluation through a recognized service, English proficiency testing, and an immigrant visa.
Along with pipeline work, this is one of only 2 models here that add permanent headcount. It fits facilities that can absorb a long lead time and want to solve next year rather than next week.
Timelines are the constraint, governed by visa availability rather than anything a facility controls. When the queue for employment-based visas backs up, projected start dates move back with it, and a facility has little ability to speed that up.
What are pipeline and academic partnerships?
Pipeline work covers clinical placement agreements, tuition assistance, apprenticeships, and nurse residency programs built jointly with nursing schools. It builds long-term local supply and can improve first-year retention among new graduates.
The payoff runs multiple years, and the ceiling is set by faculty capacity rather than student interest. Facilities can influence that ceiling directly by providing clinical sites and paid preceptor time, which schools most often say they need.
There is a structural imbalance worth naming. Most clinical placements route to hospitals, even though long-term care faces a more severe vacancy problem.
When do incentive and bonus shifts work?
Premium pay induces existing staff to pick up open shifts. It works immediately, requires no new infrastructure, and is often the only lever available at 6 p.m. on a Friday.
Costs escalate faster than most budgets anticipate, and repeated use creates equity friction between nurses who pick up extra shifts and those whose circumstances do not allow it. Sustained reliance on bonus shifts signals that the gap is structural rather than episodic.
What staffing models do not fix
Every model above manages capacity. None of them touches the cause. If a facility is losing nurses faster than it can replace them, coverage models buy time at increasing cost without changing the trajectory, and the cost curve steepens as the vacancy count grows.
Sound workforce planning in healthcare separates coverage from retention. Facilities that treat the first as a substitute for the second tend to discover the difference in the agency invoice.
How do you choose the right staffing mix?
Four steps narrow the field faster than evaluating all 9 models at once.
- Identify whether you have a vacancy problem, a volatility problem, or a scheduling problem.
- Check what your setting can realistically support, since capital-intensive and scale-dependent models rule themselves out for most standalone facilities.
- Layer by speed, using fast-deploy options to cover immediate gaps while slower structural options build underneath them.
- Track cost per covered shift for every model you run, so the comparison rests on your numbers rather than on assumptions.
Most facilities end up running 3 or 4 models at once. That is the expected outcome, not a sign of poor planning. What matters is that each model is doing the job it is suited to, rather than covering for a gap another model should be closing.
For the shift-by-shift end of that mix, Nursa is a per diem marketplace with fast coverage and block scheduling. Create a facility account to see the clinician supply in your market.
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