Nursing Policy Leaders Advocate for Reform of Training Repayment Agreements

SAN FRANCISCO (November 7, 2023) – Training Repayment Agreement Provisions (TRAPs) are used across various industries to offer employees specialized training at no cost, with the stipulation that the training expenses must be reimbursed if the employee departs within a specified period. In healthcare environments, these programs are frequently employed for mandatory nurse training initiatives.

In an analysis featured in Health Affairs Forefront, nursing policy experts Tony Yang, Richard Ricciardi, and Eileen Fry-Bowers advocate for a thorough reform of TRAPs. They highlight concerns that these programs impose a substantial financial strain on employees who choose to leave their positions within the initial years of employment. The authors note that nearly 45 percent of nurses within the first five years of their careers feel constrained by these programs, with some facing repayments as high as $15,000. The authors contend that the financial pressures from these repayment programs adversely affect job satisfaction and employee well- being, subsequently influencing the quality of patient care.

“While training repayment agreements first emerged to promote a worker’s attainment of new technical career enhancing skills and to fill gaps in employer’s workforce needs, they over time have become more broadly used in healthcare settings and can have weighty negative consequences, such as restricting a nurse from accepting new career enhancing professional opportunities,” Ricciardi, professor and associate dean for Clinical Practice and Community Engagement at the George Washington University School of Nursing, says.

The authors assert that these repayment programs disproportionately burden nurses who are lower paid, a demographic that has historically included minority populations. According to the authors, these obligations compel nurses to tolerate suboptimal working conditions and accept inadequate salaries, leaving them with limited room to negotiate or seek better opportunities elsewhere.

Several states, including California and Connecticut, are implementing measures to safeguard healthcare employees. However, legally, courts have traditionally upheld TRAPs as contractual, but some lawsuits contest them as unjust contracts or coercive debts. Outcomes remain uncertain. Policy concerns include impacts on nurse advocacy, retention, burnout, equity, and patient care quality. But employers argue these repayment programs offset training costs in a competitive labor market.

“These employer arguments ignore the possibility that nurses bound by TRAPs feel constrained from voicing concerns about unsafe staffing or unfair working conditions, and overlook potential alternative solutions, such as enhancing employee benefits or improving working conditions to recruit and retain staff,” says Fry-Bowers, dean of the University of San Francisco School of Nursing and Health Professions. “Moreover, training provided under TRAPs varies widely, is frequently duplicative of education received in nursing school, or focused on mandated job
orientation.”

The analysis, “From Training to Trapping: The Paradox of Training Repayment Agreements in Nursing,” was published in Health Affairs Forefront. If you would like to speak with the authors, please contact USF Media Relations Specialist Kellie Samson at ksamson@usfca.edu.

About the USF School of Nursing and Health Professions

The School of Nursing and Health Professions advances the mission of the university by leading in innovative solutions to health inequities and transforming healthcare using evidence-informed approaches. For more information, visit usfca.edu/nursing. 

About the University of San Francisco

The University of San Francisco is a private, Jesuit Catholic university that reflects the diversity, optimism, and opportunities of the city that surrounds it. USF offers more than 230 undergraduate, graduate, professional, and certificate programs in the arts and sciences, business, law, education, and nursing and health professions. At USF, each course is an intimate learning community in which top professors encourage students to turn learning into positive action, so the students graduate equipped to do well in the world — and inspired to change it for the better. For more information, visit usfca.edu.