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Agency-nursing work: perceptions and experiences of agency nurses
International Journal of Nursing Studies 40 (2003) 269–279
Agency-nursing work: perceptions and experiences of agency nurses Elizabeth Maniasa,*, Robyn Aitkena, Anita Peersonb, Judith Parkera, Kitty Wonga a
School of Postgraduate Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Level 1, 723 Swanston Street, Carlton Vic. 3053, Australia b Education Centre, The Prince Charles Hospital, Rode Road, Chermside Ql 4032, Australia Received 21 March 2002; received in revised form 2 September 2002; accepted 26 September 2002
Abstract This paper explores agency-nursing work from the perspective of agency nurses to gain in-depth understanding of their clinical practice, their relationships with the employing agency, hospitals and permanent nurses, and their professional status. For this study, individual interviews were conducted with ten agency nurses who were registered with one of three nursing agencies in Melbourne, Australia. Five major themes emerged from interview data: orientation, allocation of agency nurses, reasons for doing agency-nursing work, experiences with hospital staff, and professionalism. The findings reveal that the primary reason for nurses engaging in agency-nursing work is for the flexibility it offers. While agency nurses described a commitment to professionalism, the findings emphasise the need to establish effective communication networks between agency nurses, nursing agencies and hospital institutions. Such communication between stakeholders is important to facilitate discussion of issues such as appropriate notification of shift availability, appropriate assignment of work and recognition of the agency nurse as a valuable member of the health care team. In particular, the findings highlight the importance of comprehensive orientation and education for agency nurses to shift the focus of their daily work from task completion to more comprehensive patient care. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Agency-nursing work; Agency nurses; Nursing agencies; Work experiences; Work perceptions
1. Introduction The perennial shortage of nurses combined with an increased demand for their services have contributed to a greater reliance on agency nurses. Despite continued use and considerable cost of temporary nursing services, little is known about agency nurses’ perceptions and experiences of their clinical practice, of their relationships with the employing agency, hospitals and permanent nurses, and of their professional status. This study was conducted as part of a larger project that examined agency-nursing work from the perspectives of agency nurses, agency nurse providers, hospital nursing
*Corresponding author. Tel.: +613-8344-0778. E-mail address: [email protected] (E. Manias).
managers and senior clinical nurses, in Melbourne, Australia. This paper reports on the first component of the project; which specifically sought information from agency nurses about their experiences and perceptions of working on a casual contracted basis in acute care hospitals.
2. Literature review For this study, agency nurses are defined as those who ‘‘have their working life organised by a private contractor, known generally as an agency, to carry out work within any number of hospitals within any one working week’’ (Bates, 1998, p. 140). Agency-nursing work refers to the nursing services provided by agency
0020-7489/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 7 4 8 9 ( 0 2 ) 0 0 0 8 5 - 8
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nurses employed on a casual contracted basis. Notwithstanding the growth of casual employment in femaledominated work environments (Burgess and MacDonald, 1990), the majority of literature on agency nurses involves personal accounts of nurses’ experiences with agency work (Chellel, 1987; Grau and Willens, 1989; Gunn, 1983; Mack, 1988; Phillips, 1983; Ward and Moore, 2000) and commentaries that compare permanent and agency work (Brooks-Shaverin, 1995; Dunsmore and Houston, 1990; Elson, 1995; Jones et al., 1990; Leigh, 1996; LeRoy, 1986; Roy and Runge, 1983; Watson, 1998). Most research studies on agency nurses have addressed reasons for choosing this type of work (Braddy et al., 1991), recruitment, retention and compensation of agency and hospital nurses (Hughes and Marcantonio, 1991), and evaluations of orientation programs designed for agency nurses (Bliss and Alsdorf, 1992; Leidy, 1992). Following an extensive survey of agency nurses ðn ¼ 3360Þ and hospital nurses ðn ¼ 3535Þ; Hughes and Marcantonio (1993) reported interesting comparisons of work schedules and clinical practice between these two groups. In response to work schedules, agency nurses were less likely to work day shifts and more likely to work afternoon and night shifts. They were also more likely to work more weekend shifts and fewer hours each week. With respect to clinical practice, agency nurses reported performing more physical and psychosocial examinations on their patients. They also reportedly evaluated clinical outcomes, and devised nursing diagnoses and therapeutic plans for more patients than their hospital counterparts. Furthermore, agency nurses indicated they had good opportunities to use their clinical skills in the ward setting compared to hospital nurses. Unfortunately, as Hughes and Marcantonio (1993) did not seek the perceptions and experiences of agency nurses, it is difficult to determine the various complexities underlying their clinical work. This lack of comprehensive exploration of agency-nursing work typifies the research conducted in this area. On the other hand, two studies have sought to provide an in-depth analysis of agency-nursing work from the agency nurses’ perspective. In an Australian study, Bates (1998) conducted individual interviews with 12 agency nurses to explore their contractual work arrangements in hospital settings. While Bates questioned their experiences, the focus was not on issues facing agency nurses at the local level of clinical nursing practice. Instead, Bates’s analysis emphasised the role of managerial strategies and labour market structures in shaping temporary employment processes. While these wider social and political forces are intrinsic in how work is organised and defined within hospitals, a dependence on these aspects in Bates’s analysis meant that the nurses’ views about their agency-nursing work were either obscure or overlooked.
In another Australian study, Schubert (1995) interviewed four agency nurses about professional relationships with their current agency and the processes of agency-nursing work. In contrast to Bates’s (1998) work, Schubert’s exploratory study provided some understanding of nurses’ experiences of agency-nursing work. Nurses identified control over work scheduling as a major reason for undertaking agency-nursing work. However, they also indicated a lack of professional autonomy and isolation in their practice. Issues such as access to continuing education and the maintenance of clinical skills were identified as problems associated with their practice. While Schubert’s study provided valuable insight on agency-nursing work from the agency nurses’ perspective, it had some limitations. The research was carried out using a small number of participants who were currently registered with the same agency. All participants were female and aged in their thirties. With such similarities in socio-demographic profiles, the participants’ experiences may not necessarily reflect those of other agency nurses. In summary, previous studies on the perceptions and experiences of agency nurses have not considered adequately the context in which agency-nursing work occurs. Aside from the studies conducted by Bates (1998) and Schubert (1995), there has been little attempt to determine the nature of agency-nursing work by detailing the context from the particular viewpoint of the agency nurse. Therefore, this exploratory study was conducted to examine agency-nursing work in acute metropolitan hospitals from the perspective of agency nurses. The aim of the study was to gain an in-depth understanding of agency nurses’ clinical practice, their relationships with the employing agency, hospitals and permanent nurses, and their professional status. This paper describes: *
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Agency nurses’ perceptions and experiences of working through a nursing agency; and Agency nurses’ perceptions and experiences of working in acute care hospital settings.
3. Method This qualitative research design used the interview technique in order to explore perceptions and experiences about agency-nursing work. A semi-structured interview schedule included questions that were designed to record the participants’ descriptions and explanations about their world (Gillis and Jackson, 2002). This information was sought from agency nurses who were registered with a nursing agency in Melbourne, Australia. Ethics approval was sought from the university ethics committee to conduct individual interviews with a representative sample of agency nurses who participated
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Following verbatim transcription of interviews, data were subjected to the ‘framework’ method of analysis (Ritchie and Spencer, 1994). This method of analysis provided a systematic, comprehensive and structured approach that also enabled data to be reworked and reconsidered because the analytical process was documented clearly and was therefore accessible. Such an approach facilitated the identification of themes in order to delineate participants’ perceptions and experiences of agency-nursing work. The framework comprised the following five stages: familiarisation, identification of a thematic framework, indexing, charting, and finally, mapping and interpretation. Familiarisation involved gaining a thorough overview of the interview transcripts. For developing the thematic framework, data were analysed to determine key issues. Indexing involved labelling the data into manageable units. For the charting stage, the transcript data were examined and a summary of the agency nurses’ perceptions and experiences was entered onto a chart. The mapping and interpreting stage involved comparing and contrasting participants’ comments, and searching for connections and explanations. To ensure rigour, two investigators conducted data analysis independently to determine the emerging themes, the results of which were compared and scrutinised.
in the larger project. Following ethics approval, the investigators provided information about the interviews in a mail-out to 100 active agency nurses. These nurses were registered with one of three major nursing agencies in metropolitan Melbourne. Together, these three agencies supply more than 50% of the agency nurse requirements for the acute care hospitals of metropolitan Melbourne. An active agency nurse was classified as one who had worked at least one agency shift in the previous three months. Agency nurses were invited to indicate their willingness to complete an individual interview by providing contact details to the investigators. Following receipt of this information, agency nurses were selected by means of a stratified sampling technique based on age, gender, number of years of experience as a registered nurse, and number of years of experience as an agency nurse. The final sample included ten agency nurses. The size of this sample was determined by the data analysis and ceased when no new themes arose from the interview questions and when all demographic characteristics were represented. Four nurses were registered with the first nursing agency, three nurses were registered with the second agency and the remaining three with the third agency. Participation was voluntary and confidentiality was assured. Interviews, which were approximately 60–90 min long, were tape-recorded to enable the interviewer to focus on responses and to guide the interview. In asking questions, the interviewer probed for depth and variety of responses and did not constrain the participants’ ability to put forward their own views. The interviewer provided clear instructions to ensure that variation in responses did not result from participants’ varied understandings of what was asked of them (Gillis and Jackson, 2002). For example, it was ensured that questions did not have more than one meaning. The semi-structured interview included questions relating to: employment conditions, the nature of interactions with agency company representatives, hospital staff and patients, recognition of professional knowledge and skills by agency nurses and other health care professionals, and perceived career opportunities and limitations.
4. Findings Demographic details for the ten agency nurses who participated in interviews are shown in Table 1. The participating nurses ranged in age from 25 to 46 years, with an average age of 33 years. While their length of nursing experience as a registered nurse varied from 4 to 25 years, their length of experience as an agency nurse ranged from 1 to 14 years. Five major themes were derived from interviews: orientation, allocation of agency nurses, reasons for doing agency-nursing work, experiences with hospital staff, and professionalism (Table 2). These themes are presented below, incorporating examples from the data.
Table 1 Demographic profile of agency nurses ðn ¼ 10Þ Gender Female Male
Age 9 1
20–29 years 30–39 years 40–49 years
Years of nursing experience as a registered nurse 5 2 3
4–6 7–9 10–12 13–15 > 15
years years years years years
Total years of experience as an agency nurse 1 4 1 1 3
1–3 4–6 7–9 10–12 13–15
years years years years years
4 2 1 2 1
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Table 2 Themes from interviews with agency nurses Orientation
Allocation of agency nurses
Reasons for doing agency work
Experiences with hospital staff
Professionalism
By the agency
Notification about a working shift
Flexibility
Career development
By the hospital
Cancellation of a shift
Personal development
Level of welcoming, friendship and belonging Support
Being sent to a particular ward area
Stress of permanent work Lack of respect in permanent work
Abuse by hospital staff Communication of information
Politics of the clinical setting
4.1. Orientation Orientation was an important consideration for agency nurses. Participants referred to the orientation provided by their agency and by a particular hospital. Nursing agencies prepared nurses for their role by communicating information at interview and by written handouts. Most participants indicated that the agencies provided information about a professional code of conduct, fees, uniforms, and agency regulations for working and cancelling shifts. Details about pay and superannuation were also generally given. Surprisingly few participants knew whether they were covered for professional indemnity, or about the process to follow if an incident involving serious misconduct occurred during their course of duty. The following comments were typical of the type of orientation nurses received from their agency: There was a police check. There was nothing asked about my level of competency. She [the agency nurse provider] also looked at my CV [curriculum vitae] and spoke with me about it. She decided then and there that I could start work y There was a brief statement about the code of conduct but there was no orientation about the hospitals. It was mostly about fees and uniforms. Only one participant commented that the agency provided comprehensive information about hospitals, including geographical location, car parks, patient system of care, and procedures to follow for emergency situations. Similarly only one participant indicated that a comprehensive assessment and analysis was carried out of her competencies at the time of her agency interview. The participants also commented about their orientation experiences from hospitals, which tended to be quite
Educational provision by the agency Educational provision by the hospital Individual responsibility to address educational needs Enhancement of clinical skills
varied. Agency nurses received some form of orientation on their first visit to a particular hospital. Thereafter, hospital employees assumed that agency nurses were familiar with an environment if they returned to work there, for example: Usually you get an orientation the first time you go there [to the hospital]. Some places give you a fabulous orientation so you know where all the fire exits are, and what the emergency procedures are, the people you are responsible to and the codes y Every hospital has a different code y and they don’t tell you every time. I was at a hospital that I work at a lot quite recently and they devised an orientation checklist for staff y but during my shifts I was lucky to fill out half of it and I have worked at that hospital on and off for six years. Furthermore, all agency nurses agreed that the hospital employees should make available a written orientation package for their ward setting. This package could be then taken away for future reference, for example: In the written package there should be the mission statement of the hospital. I think they should have objectives of what they want the nurse to achieve for the day. They should have something written about the legalities of documentation and a section about nurse registration y They should also have their fire drills and their code for resuscitation. If there are any problems or if there is a lack of support, agency nurses should have the contact names of hospital people they can contact. 4.2. Allocation of agency nurses Another theme to emerge was the allocation of agency nurses in particular hospitals and practice settings,
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which involved the notification and cancellation of a working shift, and the allocation to a specific ward area. Generally, participants considered that they received adequate notification about a forthcoming shift. They all mentioned that they were often notified a few hours beforehand about the possibility of a working shift. However, four participants commented they sometimes received short notice between notification of an agency shift and working in the clinical area. One participant who had experienced problems with shift allocation related the following poignant narrative: I had to be prepared to wait for the phone to ring, be it 6 a.m. for a morning shift or 11 a.m. for an afternoon shift. That took me weeks to just get the feel of it, and not to have a big anxiety attack that I wasn’t going to get any work. But you get used to that, you go with it and you need to be flexible. What was needed was psychological preparation. However, whilst participants’ comments suggested the need to be psychologically prepared in the notification process, some expressed difficulties in coping, for example: I only do night duty. Over 12 years I have dealt with that problem [of insufficient time for notification] by only doing night duty. I got to the stage where I became paranoid on the early morning calls. I don’t like that. I can deal with a phone call at 10.30 at night—I can deal with that better than at 6 o’clock in the morning. Participants’ comments highlighted that permanent staff in hospitals sometimes blamed agency nurses if they arrived late for their shifts. At times, permanent nursing staff did not accept the lateness of agency nurses was due to insufficient notification by the agency, as stated by the following participant: This girl [nurse] was in charge but she was only a junior. It was a medical ward. It started badly because I was called in late. Nursing administration hadn’t called in to say that the associate charge nurse was off sick. So I wasn’t phoned until after 9 p.m. This girl couldn’t deal with the fact that suddenly I was arriving late. It was not my fault. I got there as soon as I could after the phone call. The cancellation of a shift, which was initiated by hospitals and communicated through agencies to the nurses, caused much anxiety for participants. Agency nurses not only missed out on payment following a shift cancellation, but they also had spent time reorganising other commitments to make space for the proposed shift, for example: What is very annoying is that I do get a shift booked and the family gets all rigged up to function without
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me for the day and then they [the agency] ring me up half-an-hour before the shift and cancel. Participants also seemed wary of certain hospitals having a reputation for cancelling shifts. Agency nurses developed an understanding about which hospitals tended to cancel shifts, and have refused to work there as a result. When asked about the appropriateness of allocated ward areas, participants believed they asserted themselves if these settings were unsuitable. However, most of the time, participants indicated they felt satisfied about their ward allocation. The allocation of a ward area tended to be a two-stage process: the agency provider made initial contact to the nurses about the ward setting and then the hospitals confirmed this allocation upon their arrival. At either point, the initial ward allocated may have been changed by the agency or the hospital. Despite their expressions of assertiveness, such changes caused enormous anxiety for participants if they felt compelled to work in inappropriate settings. The following interview excerpt demonstrates a participant’s experience of being reallocated to intensive care following her arrival at the hospital: I said to the allocation officer that I wasn’t happy to go to intensive care because I am not ICU trained and I can’t look after that kind of patient. I was told, ‘Now will be a good time to learn.’ I said, ‘No, it wouldn’t,’ and said that if they didn’t allocate more appropriately, then I would have to go home. In the end, I still went to ICU but they reallocated the patients. They [nurses] basically ignored me for the shift and didn’t treat me very nicely. There were also occasions when agency providers themselves had organised inappropriate ward allocations, for example: I have been sent to places where I am really not competent. The worst time was once when I was given a shift in the emergency department of y hospital. I said, ‘I’m not competent to work there.’ They [the agency nurse provider] said, ‘It’s okay, you only have to do obs. [observations]. You won’t have to assess patients.’ They sent me there and I got four cubicles and I had to assess patients. I should have left, I really should have. They [the nurses] got so frustrated and angry with me. I had no idea what I was doing y I told the person in charge and then rang my agency, and they said, ‘Oh, we can’t do anything about it.’ They really washed their hands.
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4.3. Reasons for doing agency work Participants spoke animatedly about their reasons for undertaking agency-nursing work. The most common reason was the flexibility. Other reasons included personal development, the stress associated with permanent work, lack of respect of nurses in permanent roles and the politics of the clinical setting. Flexibility was the most common reason provided by participants for carrying out agency-nursing work. They needed flexible work hours, which were not accommodated by rigid hospital routines. Several participants reported their current work schedule enabled them to address social and personal commitments, which included time spent with partners, children and friends, volunteer work, church attendance, weekend retreats and informal outings, for instance: Work is important, sure, but I am not allowing work to encroach on my other activities. I do voluntary work inside my parish. I also participate in a couple of retreat programs and I go away to the country on weekends. With agency now I fit work around my own life. Some participants had health problems that tended to be aggravated by the inflexibility of permanent work schedules, as mentioned by the following nurse: Since starting agency work I haven’t worked night duty for 18 months, and I haven’t been sick for 18 months. That makes a big difference. I used to get sick once every four to six weeks with the cold or the flu because I was on night duty. Other participants had additional study or job commitments that demanded flexible work routines, for example: The one really big advantage of working agency is the flexibility. I’m a midwife, and I do home births and I’ve got my own clients. That way I’ve got the freedom to schedule my appointments and also to cancel some shifts if I’ve got a birth. Another reason provided by nurses for undertaking agency-nursing work involved increased opportunities for personal development. While nurses were able to pursue other areas of interests, they cultivated a more positive attitude to patient care, for example: I can do the work when I want for myself. I am sure that benefits me as a person. It enables the patient to benefit because I have got a better attitude to care. Participants associated permanent work with stress. On the other hand, agency-nursing work provided greater levels of autonomy and independence, for example:
I want to work for myself. I’m sick of tailing after people. That’s what I had to do all my life as a permanent nurse. I’ve never actually been one of those people who got promotion easily, so what’s the point of staying? Some nurses also felt that proponents of the health care system did not respect permanent hospital employees. According to participants, this lack of respect was evidenced by inadequate levels of pay and inappropriate working conditions. As mentioned by one participant: That side of nursing [permanent] is not highly valued. It is not something that I could do y I couldn’t do it because you just don’t get the respect. You don’t get the professional feedback, you are treated poorly y It is too demoralising. Finally, participants referred to hospital politics as being a major deterrent to undertaking permanent work, for example: Agency nursing trains my mind to assess things properly y because you don’t have all the political blockages. I found that I was so much in the politics of the system [when I was a permanent staff member] that I ended up nursing the staff more than the patients that were there y The obstructions between me and my patient have been a lot less during agency. 4.4. Experiences with hospital staff Another theme to emerge from participants’ comments concerned their experiences with hospital ward staff. There were four key aspects to these comments: agency nurses’ views about the level of welcoming, friendship and belonging, support provided by permanent nursing staff, abuse directed at agency nurses, and communication of information. With respect to experiences of welcoming, friendship and belonging, participants expressed fairly similar views. When agency nurses were allocated to new environments, they had to struggle against a feeling of wariness from permanent nurses. Associated with this wariness was the participants’ belief that they did not experience a sense of belonging to the health care team of the ward setting. Permanent nurses were also upset when their complement of nursing staff for a particular shift comprised agency nurses. As mentioned by the following participant: As much as you try to feel part of the team it is like a ‘us and them’ type thing. You feel sometimes a bit left out, a bit cold. In some places I work they are quite business-like, they don’t make you feel particularly welcome y In fact, they’re quite upset by the fact they have got agency nurses.
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For some participants, this lack of belonging extended to perceptions of isolation and difference. These perceptions were difficult to resolve because agency nurses were unable to develop adequate camaraderie during their infrequent encounters, for example: The working relationship is separate and isolated. I usually always feel different. Part of your working time within such an area is social contact with other nurses, camaraderie, that feeling of give and take with humour and information exchange. You don’t get any of that when you are doing agency. However, there was also a general view that agency nurses were able to establish a sense of belonging and friendship if they worked in one specific environment over a defined period. Participants also felt that permanent nurses treated them with respect if they had worked most of their shifts in the one unit. In relation to nursing support, participants believed they received adequate help during their working shift. At times, however, agency nurses did not feel well supported in the clinical area. Interestingly, this situation occurred in settings where they had regularly worked in an environment, and permanent staff perceived that agency nurses were relatively familiar with policies and protocols. Participants also felt that they were inadequately supported in extremely busy situations because permanent nurses had exorbitant workloads despite agency allocation, for example: Sometimes the [permanent] nurses haven’t got the time or the resources to have someone around to ask questions. They are just too busy y Sometimes the person-in-charge has got their own workload and that is where you get problems with support because there is no one around. Occasionally permanent nurses ignored participants’ requests for help, especially if they involved procedures that disrupted particular ward routines, for example:
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participant, experiences of abuse were physical in nature, for example: The worst experience I had [as an agency nurse] was only a few weeks ago where another nurse actually physically shoved me out of the way to attend to a client that I was about to attend to. I’m not sure why. I had to inform the person-in-charge of the unit, and she told the nurse supervisor on that shift, and I believe the woman was spoken to but I didn’t get any feedback on it. For two participants, experiences of abuse tended to be verbal in nature. For one participant, she had the following to say: I was there to help the nurse in charge but she was very unprepared for the job. I happened to ask her for help with a patient during the night. It was an unfortunate circumstance as this patient had extreme diarrhoea and had to be changed many times. This girl [nurse] happened to say, ‘Well, he can lie in it.’ I took exception to that, so I had my say to her about that standard of care. She took exception to me. In the end she abused me, shouted at me. I said, ‘Look that’s fine, you will never see me again.’ I spoke to the agency and said, ‘I don’t want to go back to that ward again.’ In these situations of abuse, the agency nurses contacted their employing agency to complain. However, aside from refusing to send the agency nurses back to these ward settings, there was no further follow-up with the hospitals. Notably, some participants also made comments that highlighted communication of information in the clinical setting. Communication concerned mainly dialogue between the permanent hospital nurses and agency nurses about professional issues and patient care information. Since agency nurses were not present in the setting for a prolonged period, they all experienced a sense of urgency about voicing any concerns with permanent staff, for example: In the couple of places where I’ve had really bad experiences, I have told the person-in-charge y If by the end of the shift they haven’t done anything to help me or resolve the issue, I would usually say to them that I was very disappointed in this and for this reason, and that I won’t return to the unit.’
On this aged care rehab. [rehabilitation] setting I felt that I was disrupting the nurses’ routines. Three staff had gone to dinner so that left me with two other nurses. The two other nurses were going around together putting patients to bed. They were not answering any buzzers—I was answering the buzzers y I would say, ‘Can I have some help, this patient needs to go to the toilet.’ And they would say, ‘Oh no, I am putting these patients to bed.’ It was just inappropriate.
Participants also perceived that communicating about patient care information tended to focus on tasks requiring completion rather than on the holistic needs of patients, for example:
Three participants commented on experiences of abuse by permanent nurses, which had a profound effect on their confidence and demeanour. For one
When I ask for information about a patient’s past history so I can care for them better, I usually don’t get the right information. I usually just get the
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comment, ‘You just have to do this thing,’ rather than answer my question so I can make my own decision on what I am going to do. I feel that they don’t really to let me know the patient’s holistic picture because they want me to do a series of tasks. 4.5. Professionalism Agency nurses spoke about professionalism, which could be broadly divided into five major aspects. These aspects involved the following: career development with agency-nursing work, educational provisions by agencies, educational provisions by hospitals, individual responsibility in addressing educational needs, and enhancement of clinical skills. Participants were divided in their opinions about whether agency-nursing work assisted their career development as a nurse. Some nurses felt that agency-nursing work did not facilitate career progression because they focused on completing tasks rather than improving their knowledge and skills. Nursing agencies were also regarded as corporate entities, which were more concerned about cost efficiencies and addressing personnel shortfalls rather than focusing on the professional needs of their nurses. The following participant highlighted her difficulty in career progression because of her stressful work experiences: The experiences of most agency nurses working are ‘come in and go out’. It’s a stressful full-on day and if they haven’t worked there before they’re just extremely anxious most of the day and can’t wait to get out the door. So I can’t see it as an enriching professional experience at all. There is very little time in the day to devote to extra-curricular things like education or updating skills. It’s just not done y I see this job as a short time-filler. Other participants believed their careers were affected in a positive way by agency work. Their wealth of experience in a variety of settings allowed them to consolidate their skills to the point where they could provide high quality patient care. Issues were also raised about the educational provision by the nursing agency. Some participants commented about the benefits associated with the education programs provided by their respective agency. Some nursing agencies conducted regular in-service sessions that were readily utilised by nurses. However, there also appeared to be some ambivalence about their value because of associated cost, lack of accessibility and lack of relevance, for example: I also don’t have the opportunity to attend courses when I am doing agency. I have to make my own time to attend the courses. Often you have to pay for the courses yourself y whereas if you are working in
a hospital, you have the opportunity of attending ongoing in-service education for free. Another participant commented about the possible relevance of educational sessions delivered by agencies: I am a midwife, and my agency doesn’t do that many midwifery in-services. If you are permanently working in a hospital you would have more access to the midwifery in-services. For other participants who were associated with a smaller agency, no education was offered at all, for example: The unit that I have been working on provides a continuous update for staff about new equipment y But my agency has never offered me any education y If I have any clinical questions I just ask at the hospital. All participants agreed unanimously that they would have benefited from participating in hospital in-service sessions. However, they reported that there was a general feeling of negativity from permanent nurses if agency nurses attempted to attend these sessions. Agency nurses were expected to remain at the bedside because these sessions were only devised for permanent staff, for example: There would be some hospitals I work at frequently where an extra person [an agency nurse] y at an inservice wouldn’t bother them. But most places would look at that as taking up a space that someone else could use. They’re [permanent nurses] not necessarily going to get benefits of knowledge if they went instead of you. This is wrong. Aside from education provided by agencies and hospitals, participants commented on the importance of being individually responsible for maintaining current knowledge. As already addressed previously, educational sessions conducted by agencies were not always relevant and participants often experienced difficulties in making time available to attend these sessions. Participants addressed their knowledge needs in a number of ways, including subscribing to professional journals, attending nursing conferences, accessing the Internet, and completing courses conducted by private providers. This reliance upon self-education and individual responsibility appeared to be related to nurses’ perceptions about their knowledge deficits, for example: I think it’s your own responsibility to make sure you are on top of things, and if you are not then to find out or access people who can get you up-to-date. Only you would know what your deficits are. When asked about their professional development, participants believed their clinical skills were enhanced
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since commencing agency-nursing work. The major reason for skill enhancement related to the various clinical settings in which tasks were practised. However, some participants conceived their skills were not improved because they felt stressed and sometimes lacked experience in the practice areas to which they were allocated. For one participant, her enhancement of clinical skills was compared to the nurse practitioner role: My clinical skills were very much enhanced by the variety of work. You become more of a nurse practitioner because you are standing alone. If you take the job seriously you have to know your limits very carefully, and you have to know your assessment and procedures very well y You are going from one patient to another, and going to different hospitals. It really makes you grow y It has opened my eyes a lot. For another participant, she developed an appreciation of how particular tasks could be completed in a number of different ways and became more flexible in how she carried out clinical procedures: It [agency-nursing work] has given me an incredible ability to enhance my performance and skills. That has been really positive. It has given me a good understanding of how some hospitals are so adamant that things are done one way and their way is best. In another hospital they do something totally different and they’re just as adamant that their way is best. So it has given me an understanding that there isn’t just one way of doing things—there are as many different ways as there are hospitals.
5. Discussion This research provides valuable insight into the demands of agency-nursing work from the perspective of agency nurses. Nurses were concerned about shift allocation, which involved notification about a working shift and ramifications for being late. They also emphasised the importance of work flexibility, developing positive experiences with permanent staff, communicating about patient care activities, and maintaining clinical skills. Agency nurses were concerned about hospital and ward allocation, which included the notification of a working shift and the assignment to a particular ward area. While participants believed that they had adequate notification about a forthcoming shift, nearly half the participants had experienced receiving short notice about the availability of a particular shift. The perceived flexibility of agency work could be threatened if these nurses continued to experience difficulties with balan-
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cing other commitments if inadequate time was available to plan for working shifts. Furthermore, participants perceived that hospital nurses sometimes blamed them if they arrived late for a shift. Often lateness was beyond the control of the agency nurses because it occurred if there was insufficient notification about a forthcoming shift by the nursing agency or hospital. Lateness may cause considerable anxiety for agency nurses as well as permanent staff. For agency nurses, the amount of time available for orientating about patient care needs and the nuances of the environment may be limited. For permanent nurses, they are required to address the additional workload until the agency nurses’ arrival. This situation of lateness also affects permanent nurses’ perceptions of professional commitment by agency nurses, and as found by Burda (1992) it may lead to decreased hospital staff morale. The assignment to a particular ward area was another concern relating to allocation. Participants felt able to self-regulate and refuse to work in particular work settings if these placements were viewed as unsuitable to their skill level. Despite their perceived assertiveness, participants were extremely anxious if they felt compelled to work in inappropriate settings. While agency nurses’ refusal to work in a particular setting may be viewed as a form of control over work placements, it could reduce their choices of future work opportunities and employment prospects (Schubert, 1995). Furthermore, in order to obtain the goodwill of the agency, temporary workers could feel obliged to accept assignments that do not necessarily suit them (Merolle, 1988). The flexibility of agency employment was the most common reason voiced by participants for doing agency-nursing work. They needed flexible work hours, which were not addressed by the rigidity of permanent hospital routines. Similarly, Braddy et al. (1991) reported that flexible scheduling was the most frequently listed reason among nurses for undertaking agency work. The reluctance of hospitals to structure flexible work patterns in female dominated professions, especially in those professions where shiftwork is the accepted pattern of employment, hinders greatly women’s participation in the workforce and capacity to balance other commitments. Interestingly, while low pay and inadequate promotional opportunities have been found to influence nurses’ dissatisfaction with hospital employment (Bates, 1998; Braddy et al., 1991; Huey and Hartley, 1988), participants did not comment about financial remuneration as a reason for undertaking agency-nursing work. This lack of influence of financial incentives was also supported by the work of Braddy et al., which indicated the promise of a better salary would influence only 39% of the nurses surveyed to leave their agency work and return to permanent hospital employment.
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Another significant issue was agency nurses’ experiences with hospital staff. Although some participants enjoyed supportive relationships that served to enrich their practice, others described a lack of supportive consultation especially in settings where they worked regularly and in relatively busy situations. Again, it appeared as though the temporary nature of employment influenced how permanent hospital nurses perceived the agency nurse and the degree of support they gave or withheld (Bates, 1998). The withholding of support may serve to minimise the agency nurses’ work autonomy in patient decision-making. In view of the complex and changing nature of clinical work, agency nurses depend on support from the health care professionals with whom they are working. If this support is not provided, agency nurses may experience professional isolation and deliver poor patient care (Schubert, 1995). Gunn (1983) encountered a similar situation when agency nurses found themselves isolated from the decision making process within the area they were working. Communication about the completion of patient tasks was another important aspect of agency nurses’ experiences with permanent staff. Participants perceived that their communication was orientated towards the need to complete tasks within tight time frames rather than to develop a comprehensive, holistic understanding of patient care needs. While the findings indicated that the level of communication from permanent nurses may be limited, Bates (1998) reported in her study that agency nurses had few opportunities to access the necessary information from medical records because of constant interruptions, a lack of familiarity with the ward environment, and the immediacy of patient needs. Task completion could be difficult when information, either oral or written, is not always readily accessible. As a result, agency nurses may feel compelled to develop a rapid problem solving or ‘quick fix’ response to completing tasks and addressing patient problems (Street, 1992). However, this form of response tends to focus on the immediate concerns of the patient, such as resuscitation emergencies and vital sign assessment, while other, less valued concerns, such as family support and spiritual needs, go unnoticed. Furthermore, the lack of appropriate communication about patient care may necessitate the need for decisions to be passed on to permanent staff, thereby decreasing agency nurses’ autonomy (Bates, 1998). With respect to professionalism, participants commented on their responsibility in maintaining and updating clinical skills through continuing education. While permanent nurses had access to educational opportunities in the workplace, agency nurses were expected to maintain their own professional development. In Schubert’s study (1995), agency nurses commented on the cost of continuing education, and
felt they were missing opportunities to update their knowledge and skills that were readily available to hospital employees. The temporary nature of employment may motivate hospital employers to extract the maximum labour power for the duration of the work assignment (Bernstein, 1986). Subsequently, employers could be reluctant to include agency nurses in educational sessions normally meant for permanent nurses. The limitations of this study concern the small number of individual interviews conducted with agency nurses who worked in Melbourne, Australia. Due to the voluntary means of participation, it may be assumed that the findings reveal the perceptions and experiences of agency nurses who had a strong interest in their work. Nevertheless, the comprehensive findings, which represent the views of ten individuals with varying levels of experience in agency-nursing work, are likely to resonate with other agency nurses in similar positions.
6. Conclusion and implications The findings of this study make a unique contribution to knowledge about agency nurses’ perceptions and experiences of their work in acute care hospital settings. While these participants had undertaken agency nursing to maintain flexibility and control in their practice, their relationships with nursing agencies and hospitals meant that they were left with little opportunity to obtain adequate hospital orientation, negotiate allocation of shifts, communicate in a supportive manner with permanent staff and experience professional advancement. The findings reinforce the need to create strong collaborative networks between agency nurses, nursing agencies and hospital institutions, in which all stakeholders could discuss issues of concern and negotiate an agreed position. In particular, as agency nurses now comprise a significant portion of nurses who work in hospital settings, they need to be orientated adequately, and to have some sense of belonging and autonomy in the workplace. Further research could involve an exploration of the experiences of agency nurses who are employed in different health care institutions, including long-term care, aged care, community health and psychiatric settings. While this research focused on participants employed in the metropolitan area, it would also be of interest to consider if agency nurses’ views differ between metropolitan, regional and rural areas. Another neglected area concerns the views of permanent nurses who work with agency nurses. It is vital that comprehensive understandings of different perspectives of agency-nursing work are sought to enhance professional nurses’ satisfaction with their practice and to facilitate quality patient care.
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Acknowledgements The authors wish to acknowledge the Nurses’ Board of Victoria that provided financial assistance to support the study upon which this paper is based.
References Bates, B., 1998. Contractual work: new production processes in nursing. In: Keleher, H., McInerney, F. (Eds.), Nursing Matters: Critical Sociological Perspectives. Churchill Livingstone, Marrickville, pp. 139–155. Bernstein, D., 1986. The subcontracting of cleaning work: a case study in the casualisation of labour. Sociological Review 34 (2), 376–422. Bliss, J.B., Alsdorf, P., 1992. Generic orientation for agency nurses. The Journal of Continuing Education in Nursing 23 (2), 60–62. Braddy, P.K., Washburn, T.A., Carroll, L.L., 1991. Factors influencing nurses to work for agencies. Western Journal of Nursing Research 13 (3), 353–362. Brooks-Shaverin, R., 1995. Quality at the bank. Nursing Standard 9 (44), 47. Burda, D., 1992. Use of nurse temps affects staff morale— survey. Modern Healthcare 22 (October 26), 52. Burgess, J., MacDonald, D., 1990. The labour flexibility imperative. Journal of Australian Political Economy 27 (1), 15–33. Chellel, A., 1987. The bank nurse’s bonus. Nursing Times 83 (10), 40. Dunsmore, C., Houston, R., 1990. Travelling nurses: a valuable resource. Nursing Management 21 (10), 70–81. Elson, L., 1995. Agency advantages. Nursing Standard 10 (9), 46. Gillis, A., Jackson, W., 2002. Research for Nurses: Methods and Interpretation. F.A. Davis, Philadelphia. Grau, P., Willens, J., 1989. Staff nurses vs agency nurses: seeing it from both sides. Nursing 19 (12), 48–49. Gunn, M., 1983. Agency nursing: advantages and disadvantages. Nursing Mirror 156 (13), 52.
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Huey, F., Hartley, S., 1988. What keeps nurses in nursing: 3500 nurses tell their stories. American Journal of Nursing 88 (2), 181–188. Hughes, K.K., Marcantonio, R.J., 1991. Recruitment, retention, and compensation of agency and hospital nurses. Journal of Nursing Administration 21 (10), 46–52. Hughes, K.K., Marcantonio, R.J., 1993. The clinical practice of supplemental nursing personnel. Nursing Administration Quarterly 17 (3), 83–87. Jones, K., Yancer, D., McGinley, S., Galbraith, P., 1990. An agency-staffed nursing unit project. Nursing Management 21 (10), 36–37. Leidy, K., 1992. Effective screening and orientation of independent contract nurses. The Journal of Continuing Education in Nursing 23 (2), 64–68. Leigh, J., 1996. Response: you’re more your own boss nurses’ experiences of agency work. Contemporary Nurse 5 (2), 45. LeRoy, L., 1986. Continuity in change: power and gender in nursing. Journal of Professional Nursing 2 (1), 28–38. Mack, A., 1988. The very best job a nurse ever had. RN 51 (1), 35–37. Merolle, D., 1988. The nuts and bolts of agency nursing. RN 51 (1), 37–39. Phillips, P., 1983. Moonlight—and roses? Nursing Times 79 (30), 14. Ritchie, J., Spencer, L., 1994. Qualitative data analysis for applied policy research. In: Bryman, A., Burgess, R.G. (Eds.), Analyzing Qualitative Data. Routledge, London, pp. 173–194. Roy, M., Runge, E., 1983. Flexi-hour nurses. Nursing Management 14 (9), 54–56. Schubert, S., 1995. ‘You’re more your own boss’: nurses’ experiences of agency work. Contemporary Nurse 4 (4), 166–173. Street, A.F., 1992. Inside Nursing: A Critical Ethnography of Clinical Nursing Practice. State University of New York Press, Albany. Ward, S., Moore, A., 2000. Agency staff: do the locumotive. Health Service Journal 110 (5724), 26–30. Watson, S., 1998. Agency nurses get paid leave thanks to Europe. Nursing Standard 12 (41), 7.
Agency-nursing work: perceptions and experiences of agency nurses Elizabeth Maniasa,*, Robyn Aitkena, Anita Peersonb, Judith Parkera, Kitty Wonga a
School of Postgraduate Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Level 1, 723 Swanston Street, Carlton Vic. 3053, Australia b Education Centre, The Prince Charles Hospital, Rode Road, Chermside Ql 4032, Australia Received 21 March 2002; received in revised form 2 September 2002; accepted 26 September 2002
Abstract This paper explores agency-nursing work from the perspective of agency nurses to gain in-depth understanding of their clinical practice, their relationships with the employing agency, hospitals and permanent nurses, and their professional status. For this study, individual interviews were conducted with ten agency nurses who were registered with one of three nursing agencies in Melbourne, Australia. Five major themes emerged from interview data: orientation, allocation of agency nurses, reasons for doing agency-nursing work, experiences with hospital staff, and professionalism. The findings reveal that the primary reason for nurses engaging in agency-nursing work is for the flexibility it offers. While agency nurses described a commitment to professionalism, the findings emphasise the need to establish effective communication networks between agency nurses, nursing agencies and hospital institutions. Such communication between stakeholders is important to facilitate discussion of issues such as appropriate notification of shift availability, appropriate assignment of work and recognition of the agency nurse as a valuable member of the health care team. In particular, the findings highlight the importance of comprehensive orientation and education for agency nurses to shift the focus of their daily work from task completion to more comprehensive patient care. r 2003 Elsevier Science Ltd. All rights reserved. Keywords: Agency-nursing work; Agency nurses; Nursing agencies; Work experiences; Work perceptions
1. Introduction The perennial shortage of nurses combined with an increased demand for their services have contributed to a greater reliance on agency nurses. Despite continued use and considerable cost of temporary nursing services, little is known about agency nurses’ perceptions and experiences of their clinical practice, of their relationships with the employing agency, hospitals and permanent nurses, and of their professional status. This study was conducted as part of a larger project that examined agency-nursing work from the perspectives of agency nurses, agency nurse providers, hospital nursing
*Corresponding author. Tel.: +613-8344-0778. E-mail address: [email protected] (E. Manias).
managers and senior clinical nurses, in Melbourne, Australia. This paper reports on the first component of the project; which specifically sought information from agency nurses about their experiences and perceptions of working on a casual contracted basis in acute care hospitals.
2. Literature review For this study, agency nurses are defined as those who ‘‘have their working life organised by a private contractor, known generally as an agency, to carry out work within any number of hospitals within any one working week’’ (Bates, 1998, p. 140). Agency-nursing work refers to the nursing services provided by agency
0020-7489/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 7 4 8 9 ( 0 2 ) 0 0 0 8 5 - 8
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nurses employed on a casual contracted basis. Notwithstanding the growth of casual employment in femaledominated work environments (Burgess and MacDonald, 1990), the majority of literature on agency nurses involves personal accounts of nurses’ experiences with agency work (Chellel, 1987; Grau and Willens, 1989; Gunn, 1983; Mack, 1988; Phillips, 1983; Ward and Moore, 2000) and commentaries that compare permanent and agency work (Brooks-Shaverin, 1995; Dunsmore and Houston, 1990; Elson, 1995; Jones et al., 1990; Leigh, 1996; LeRoy, 1986; Roy and Runge, 1983; Watson, 1998). Most research studies on agency nurses have addressed reasons for choosing this type of work (Braddy et al., 1991), recruitment, retention and compensation of agency and hospital nurses (Hughes and Marcantonio, 1991), and evaluations of orientation programs designed for agency nurses (Bliss and Alsdorf, 1992; Leidy, 1992). Following an extensive survey of agency nurses ðn ¼ 3360Þ and hospital nurses ðn ¼ 3535Þ; Hughes and Marcantonio (1993) reported interesting comparisons of work schedules and clinical practice between these two groups. In response to work schedules, agency nurses were less likely to work day shifts and more likely to work afternoon and night shifts. They were also more likely to work more weekend shifts and fewer hours each week. With respect to clinical practice, agency nurses reported performing more physical and psychosocial examinations on their patients. They also reportedly evaluated clinical outcomes, and devised nursing diagnoses and therapeutic plans for more patients than their hospital counterparts. Furthermore, agency nurses indicated they had good opportunities to use their clinical skills in the ward setting compared to hospital nurses. Unfortunately, as Hughes and Marcantonio (1993) did not seek the perceptions and experiences of agency nurses, it is difficult to determine the various complexities underlying their clinical work. This lack of comprehensive exploration of agency-nursing work typifies the research conducted in this area. On the other hand, two studies have sought to provide an in-depth analysis of agency-nursing work from the agency nurses’ perspective. In an Australian study, Bates (1998) conducted individual interviews with 12 agency nurses to explore their contractual work arrangements in hospital settings. While Bates questioned their experiences, the focus was not on issues facing agency nurses at the local level of clinical nursing practice. Instead, Bates’s analysis emphasised the role of managerial strategies and labour market structures in shaping temporary employment processes. While these wider social and political forces are intrinsic in how work is organised and defined within hospitals, a dependence on these aspects in Bates’s analysis meant that the nurses’ views about their agency-nursing work were either obscure or overlooked.
In another Australian study, Schubert (1995) interviewed four agency nurses about professional relationships with their current agency and the processes of agency-nursing work. In contrast to Bates’s (1998) work, Schubert’s exploratory study provided some understanding of nurses’ experiences of agency-nursing work. Nurses identified control over work scheduling as a major reason for undertaking agency-nursing work. However, they also indicated a lack of professional autonomy and isolation in their practice. Issues such as access to continuing education and the maintenance of clinical skills were identified as problems associated with their practice. While Schubert’s study provided valuable insight on agency-nursing work from the agency nurses’ perspective, it had some limitations. The research was carried out using a small number of participants who were currently registered with the same agency. All participants were female and aged in their thirties. With such similarities in socio-demographic profiles, the participants’ experiences may not necessarily reflect those of other agency nurses. In summary, previous studies on the perceptions and experiences of agency nurses have not considered adequately the context in which agency-nursing work occurs. Aside from the studies conducted by Bates (1998) and Schubert (1995), there has been little attempt to determine the nature of agency-nursing work by detailing the context from the particular viewpoint of the agency nurse. Therefore, this exploratory study was conducted to examine agency-nursing work in acute metropolitan hospitals from the perspective of agency nurses. The aim of the study was to gain an in-depth understanding of agency nurses’ clinical practice, their relationships with the employing agency, hospitals and permanent nurses, and their professional status. This paper describes: *
*
Agency nurses’ perceptions and experiences of working through a nursing agency; and Agency nurses’ perceptions and experiences of working in acute care hospital settings.
3. Method This qualitative research design used the interview technique in order to explore perceptions and experiences about agency-nursing work. A semi-structured interview schedule included questions that were designed to record the participants’ descriptions and explanations about their world (Gillis and Jackson, 2002). This information was sought from agency nurses who were registered with a nursing agency in Melbourne, Australia. Ethics approval was sought from the university ethics committee to conduct individual interviews with a representative sample of agency nurses who participated
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Following verbatim transcription of interviews, data were subjected to the ‘framework’ method of analysis (Ritchie and Spencer, 1994). This method of analysis provided a systematic, comprehensive and structured approach that also enabled data to be reworked and reconsidered because the analytical process was documented clearly and was therefore accessible. Such an approach facilitated the identification of themes in order to delineate participants’ perceptions and experiences of agency-nursing work. The framework comprised the following five stages: familiarisation, identification of a thematic framework, indexing, charting, and finally, mapping and interpretation. Familiarisation involved gaining a thorough overview of the interview transcripts. For developing the thematic framework, data were analysed to determine key issues. Indexing involved labelling the data into manageable units. For the charting stage, the transcript data were examined and a summary of the agency nurses’ perceptions and experiences was entered onto a chart. The mapping and interpreting stage involved comparing and contrasting participants’ comments, and searching for connections and explanations. To ensure rigour, two investigators conducted data analysis independently to determine the emerging themes, the results of which were compared and scrutinised.
in the larger project. Following ethics approval, the investigators provided information about the interviews in a mail-out to 100 active agency nurses. These nurses were registered with one of three major nursing agencies in metropolitan Melbourne. Together, these three agencies supply more than 50% of the agency nurse requirements for the acute care hospitals of metropolitan Melbourne. An active agency nurse was classified as one who had worked at least one agency shift in the previous three months. Agency nurses were invited to indicate their willingness to complete an individual interview by providing contact details to the investigators. Following receipt of this information, agency nurses were selected by means of a stratified sampling technique based on age, gender, number of years of experience as a registered nurse, and number of years of experience as an agency nurse. The final sample included ten agency nurses. The size of this sample was determined by the data analysis and ceased when no new themes arose from the interview questions and when all demographic characteristics were represented. Four nurses were registered with the first nursing agency, three nurses were registered with the second agency and the remaining three with the third agency. Participation was voluntary and confidentiality was assured. Interviews, which were approximately 60–90 min long, were tape-recorded to enable the interviewer to focus on responses and to guide the interview. In asking questions, the interviewer probed for depth and variety of responses and did not constrain the participants’ ability to put forward their own views. The interviewer provided clear instructions to ensure that variation in responses did not result from participants’ varied understandings of what was asked of them (Gillis and Jackson, 2002). For example, it was ensured that questions did not have more than one meaning. The semi-structured interview included questions relating to: employment conditions, the nature of interactions with agency company representatives, hospital staff and patients, recognition of professional knowledge and skills by agency nurses and other health care professionals, and perceived career opportunities and limitations.
4. Findings Demographic details for the ten agency nurses who participated in interviews are shown in Table 1. The participating nurses ranged in age from 25 to 46 years, with an average age of 33 years. While their length of nursing experience as a registered nurse varied from 4 to 25 years, their length of experience as an agency nurse ranged from 1 to 14 years. Five major themes were derived from interviews: orientation, allocation of agency nurses, reasons for doing agency-nursing work, experiences with hospital staff, and professionalism (Table 2). These themes are presented below, incorporating examples from the data.
Table 1 Demographic profile of agency nurses ðn ¼ 10Þ Gender Female Male
Age 9 1
20–29 years 30–39 years 40–49 years
Years of nursing experience as a registered nurse 5 2 3
4–6 7–9 10–12 13–15 > 15
years years years years years
Total years of experience as an agency nurse 1 4 1 1 3
1–3 4–6 7–9 10–12 13–15
years years years years years
4 2 1 2 1
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Table 2 Themes from interviews with agency nurses Orientation
Allocation of agency nurses
Reasons for doing agency work
Experiences with hospital staff
Professionalism
By the agency
Notification about a working shift
Flexibility
Career development
By the hospital
Cancellation of a shift
Personal development
Level of welcoming, friendship and belonging Support
Being sent to a particular ward area
Stress of permanent work Lack of respect in permanent work
Abuse by hospital staff Communication of information
Politics of the clinical setting
4.1. Orientation Orientation was an important consideration for agency nurses. Participants referred to the orientation provided by their agency and by a particular hospital. Nursing agencies prepared nurses for their role by communicating information at interview and by written handouts. Most participants indicated that the agencies provided information about a professional code of conduct, fees, uniforms, and agency regulations for working and cancelling shifts. Details about pay and superannuation were also generally given. Surprisingly few participants knew whether they were covered for professional indemnity, or about the process to follow if an incident involving serious misconduct occurred during their course of duty. The following comments were typical of the type of orientation nurses received from their agency: There was a police check. There was nothing asked about my level of competency. She [the agency nurse provider] also looked at my CV [curriculum vitae] and spoke with me about it. She decided then and there that I could start work y There was a brief statement about the code of conduct but there was no orientation about the hospitals. It was mostly about fees and uniforms. Only one participant commented that the agency provided comprehensive information about hospitals, including geographical location, car parks, patient system of care, and procedures to follow for emergency situations. Similarly only one participant indicated that a comprehensive assessment and analysis was carried out of her competencies at the time of her agency interview. The participants also commented about their orientation experiences from hospitals, which tended to be quite
Educational provision by the agency Educational provision by the hospital Individual responsibility to address educational needs Enhancement of clinical skills
varied. Agency nurses received some form of orientation on their first visit to a particular hospital. Thereafter, hospital employees assumed that agency nurses were familiar with an environment if they returned to work there, for example: Usually you get an orientation the first time you go there [to the hospital]. Some places give you a fabulous orientation so you know where all the fire exits are, and what the emergency procedures are, the people you are responsible to and the codes y Every hospital has a different code y and they don’t tell you every time. I was at a hospital that I work at a lot quite recently and they devised an orientation checklist for staff y but during my shifts I was lucky to fill out half of it and I have worked at that hospital on and off for six years. Furthermore, all agency nurses agreed that the hospital employees should make available a written orientation package for their ward setting. This package could be then taken away for future reference, for example: In the written package there should be the mission statement of the hospital. I think they should have objectives of what they want the nurse to achieve for the day. They should have something written about the legalities of documentation and a section about nurse registration y They should also have their fire drills and their code for resuscitation. If there are any problems or if there is a lack of support, agency nurses should have the contact names of hospital people they can contact. 4.2. Allocation of agency nurses Another theme to emerge was the allocation of agency nurses in particular hospitals and practice settings,
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which involved the notification and cancellation of a working shift, and the allocation to a specific ward area. Generally, participants considered that they received adequate notification about a forthcoming shift. They all mentioned that they were often notified a few hours beforehand about the possibility of a working shift. However, four participants commented they sometimes received short notice between notification of an agency shift and working in the clinical area. One participant who had experienced problems with shift allocation related the following poignant narrative: I had to be prepared to wait for the phone to ring, be it 6 a.m. for a morning shift or 11 a.m. for an afternoon shift. That took me weeks to just get the feel of it, and not to have a big anxiety attack that I wasn’t going to get any work. But you get used to that, you go with it and you need to be flexible. What was needed was psychological preparation. However, whilst participants’ comments suggested the need to be psychologically prepared in the notification process, some expressed difficulties in coping, for example: I only do night duty. Over 12 years I have dealt with that problem [of insufficient time for notification] by only doing night duty. I got to the stage where I became paranoid on the early morning calls. I don’t like that. I can deal with a phone call at 10.30 at night—I can deal with that better than at 6 o’clock in the morning. Participants’ comments highlighted that permanent staff in hospitals sometimes blamed agency nurses if they arrived late for their shifts. At times, permanent nursing staff did not accept the lateness of agency nurses was due to insufficient notification by the agency, as stated by the following participant: This girl [nurse] was in charge but she was only a junior. It was a medical ward. It started badly because I was called in late. Nursing administration hadn’t called in to say that the associate charge nurse was off sick. So I wasn’t phoned until after 9 p.m. This girl couldn’t deal with the fact that suddenly I was arriving late. It was not my fault. I got there as soon as I could after the phone call. The cancellation of a shift, which was initiated by hospitals and communicated through agencies to the nurses, caused much anxiety for participants. Agency nurses not only missed out on payment following a shift cancellation, but they also had spent time reorganising other commitments to make space for the proposed shift, for example: What is very annoying is that I do get a shift booked and the family gets all rigged up to function without
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me for the day and then they [the agency] ring me up half-an-hour before the shift and cancel. Participants also seemed wary of certain hospitals having a reputation for cancelling shifts. Agency nurses developed an understanding about which hospitals tended to cancel shifts, and have refused to work there as a result. When asked about the appropriateness of allocated ward areas, participants believed they asserted themselves if these settings were unsuitable. However, most of the time, participants indicated they felt satisfied about their ward allocation. The allocation of a ward area tended to be a two-stage process: the agency provider made initial contact to the nurses about the ward setting and then the hospitals confirmed this allocation upon their arrival. At either point, the initial ward allocated may have been changed by the agency or the hospital. Despite their expressions of assertiveness, such changes caused enormous anxiety for participants if they felt compelled to work in inappropriate settings. The following interview excerpt demonstrates a participant’s experience of being reallocated to intensive care following her arrival at the hospital: I said to the allocation officer that I wasn’t happy to go to intensive care because I am not ICU trained and I can’t look after that kind of patient. I was told, ‘Now will be a good time to learn.’ I said, ‘No, it wouldn’t,’ and said that if they didn’t allocate more appropriately, then I would have to go home. In the end, I still went to ICU but they reallocated the patients. They [nurses] basically ignored me for the shift and didn’t treat me very nicely. There were also occasions when agency providers themselves had organised inappropriate ward allocations, for example: I have been sent to places where I am really not competent. The worst time was once when I was given a shift in the emergency department of y hospital. I said, ‘I’m not competent to work there.’ They [the agency nurse provider] said, ‘It’s okay, you only have to do obs. [observations]. You won’t have to assess patients.’ They sent me there and I got four cubicles and I had to assess patients. I should have left, I really should have. They [the nurses] got so frustrated and angry with me. I had no idea what I was doing y I told the person in charge and then rang my agency, and they said, ‘Oh, we can’t do anything about it.’ They really washed their hands.
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4.3. Reasons for doing agency work Participants spoke animatedly about their reasons for undertaking agency-nursing work. The most common reason was the flexibility. Other reasons included personal development, the stress associated with permanent work, lack of respect of nurses in permanent roles and the politics of the clinical setting. Flexibility was the most common reason provided by participants for carrying out agency-nursing work. They needed flexible work hours, which were not accommodated by rigid hospital routines. Several participants reported their current work schedule enabled them to address social and personal commitments, which included time spent with partners, children and friends, volunteer work, church attendance, weekend retreats and informal outings, for instance: Work is important, sure, but I am not allowing work to encroach on my other activities. I do voluntary work inside my parish. I also participate in a couple of retreat programs and I go away to the country on weekends. With agency now I fit work around my own life. Some participants had health problems that tended to be aggravated by the inflexibility of permanent work schedules, as mentioned by the following nurse: Since starting agency work I haven’t worked night duty for 18 months, and I haven’t been sick for 18 months. That makes a big difference. I used to get sick once every four to six weeks with the cold or the flu because I was on night duty. Other participants had additional study or job commitments that demanded flexible work routines, for example: The one really big advantage of working agency is the flexibility. I’m a midwife, and I do home births and I’ve got my own clients. That way I’ve got the freedom to schedule my appointments and also to cancel some shifts if I’ve got a birth. Another reason provided by nurses for undertaking agency-nursing work involved increased opportunities for personal development. While nurses were able to pursue other areas of interests, they cultivated a more positive attitude to patient care, for example: I can do the work when I want for myself. I am sure that benefits me as a person. It enables the patient to benefit because I have got a better attitude to care. Participants associated permanent work with stress. On the other hand, agency-nursing work provided greater levels of autonomy and independence, for example:
I want to work for myself. I’m sick of tailing after people. That’s what I had to do all my life as a permanent nurse. I’ve never actually been one of those people who got promotion easily, so what’s the point of staying? Some nurses also felt that proponents of the health care system did not respect permanent hospital employees. According to participants, this lack of respect was evidenced by inadequate levels of pay and inappropriate working conditions. As mentioned by one participant: That side of nursing [permanent] is not highly valued. It is not something that I could do y I couldn’t do it because you just don’t get the respect. You don’t get the professional feedback, you are treated poorly y It is too demoralising. Finally, participants referred to hospital politics as being a major deterrent to undertaking permanent work, for example: Agency nursing trains my mind to assess things properly y because you don’t have all the political blockages. I found that I was so much in the politics of the system [when I was a permanent staff member] that I ended up nursing the staff more than the patients that were there y The obstructions between me and my patient have been a lot less during agency. 4.4. Experiences with hospital staff Another theme to emerge from participants’ comments concerned their experiences with hospital ward staff. There were four key aspects to these comments: agency nurses’ views about the level of welcoming, friendship and belonging, support provided by permanent nursing staff, abuse directed at agency nurses, and communication of information. With respect to experiences of welcoming, friendship and belonging, participants expressed fairly similar views. When agency nurses were allocated to new environments, they had to struggle against a feeling of wariness from permanent nurses. Associated with this wariness was the participants’ belief that they did not experience a sense of belonging to the health care team of the ward setting. Permanent nurses were also upset when their complement of nursing staff for a particular shift comprised agency nurses. As mentioned by the following participant: As much as you try to feel part of the team it is like a ‘us and them’ type thing. You feel sometimes a bit left out, a bit cold. In some places I work they are quite business-like, they don’t make you feel particularly welcome y In fact, they’re quite upset by the fact they have got agency nurses.
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For some participants, this lack of belonging extended to perceptions of isolation and difference. These perceptions were difficult to resolve because agency nurses were unable to develop adequate camaraderie during their infrequent encounters, for example: The working relationship is separate and isolated. I usually always feel different. Part of your working time within such an area is social contact with other nurses, camaraderie, that feeling of give and take with humour and information exchange. You don’t get any of that when you are doing agency. However, there was also a general view that agency nurses were able to establish a sense of belonging and friendship if they worked in one specific environment over a defined period. Participants also felt that permanent nurses treated them with respect if they had worked most of their shifts in the one unit. In relation to nursing support, participants believed they received adequate help during their working shift. At times, however, agency nurses did not feel well supported in the clinical area. Interestingly, this situation occurred in settings where they had regularly worked in an environment, and permanent staff perceived that agency nurses were relatively familiar with policies and protocols. Participants also felt that they were inadequately supported in extremely busy situations because permanent nurses had exorbitant workloads despite agency allocation, for example: Sometimes the [permanent] nurses haven’t got the time or the resources to have someone around to ask questions. They are just too busy y Sometimes the person-in-charge has got their own workload and that is where you get problems with support because there is no one around. Occasionally permanent nurses ignored participants’ requests for help, especially if they involved procedures that disrupted particular ward routines, for example:
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participant, experiences of abuse were physical in nature, for example: The worst experience I had [as an agency nurse] was only a few weeks ago where another nurse actually physically shoved me out of the way to attend to a client that I was about to attend to. I’m not sure why. I had to inform the person-in-charge of the unit, and she told the nurse supervisor on that shift, and I believe the woman was spoken to but I didn’t get any feedback on it. For two participants, experiences of abuse tended to be verbal in nature. For one participant, she had the following to say: I was there to help the nurse in charge but she was very unprepared for the job. I happened to ask her for help with a patient during the night. It was an unfortunate circumstance as this patient had extreme diarrhoea and had to be changed many times. This girl [nurse] happened to say, ‘Well, he can lie in it.’ I took exception to that, so I had my say to her about that standard of care. She took exception to me. In the end she abused me, shouted at me. I said, ‘Look that’s fine, you will never see me again.’ I spoke to the agency and said, ‘I don’t want to go back to that ward again.’ In these situations of abuse, the agency nurses contacted their employing agency to complain. However, aside from refusing to send the agency nurses back to these ward settings, there was no further follow-up with the hospitals. Notably, some participants also made comments that highlighted communication of information in the clinical setting. Communication concerned mainly dialogue between the permanent hospital nurses and agency nurses about professional issues and patient care information. Since agency nurses were not present in the setting for a prolonged period, they all experienced a sense of urgency about voicing any concerns with permanent staff, for example: In the couple of places where I’ve had really bad experiences, I have told the person-in-charge y If by the end of the shift they haven’t done anything to help me or resolve the issue, I would usually say to them that I was very disappointed in this and for this reason, and that I won’t return to the unit.’
On this aged care rehab. [rehabilitation] setting I felt that I was disrupting the nurses’ routines. Three staff had gone to dinner so that left me with two other nurses. The two other nurses were going around together putting patients to bed. They were not answering any buzzers—I was answering the buzzers y I would say, ‘Can I have some help, this patient needs to go to the toilet.’ And they would say, ‘Oh no, I am putting these patients to bed.’ It was just inappropriate.
Participants also perceived that communicating about patient care information tended to focus on tasks requiring completion rather than on the holistic needs of patients, for example:
Three participants commented on experiences of abuse by permanent nurses, which had a profound effect on their confidence and demeanour. For one
When I ask for information about a patient’s past history so I can care for them better, I usually don’t get the right information. I usually just get the
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comment, ‘You just have to do this thing,’ rather than answer my question so I can make my own decision on what I am going to do. I feel that they don’t really to let me know the patient’s holistic picture because they want me to do a series of tasks. 4.5. Professionalism Agency nurses spoke about professionalism, which could be broadly divided into five major aspects. These aspects involved the following: career development with agency-nursing work, educational provisions by agencies, educational provisions by hospitals, individual responsibility in addressing educational needs, and enhancement of clinical skills. Participants were divided in their opinions about whether agency-nursing work assisted their career development as a nurse. Some nurses felt that agency-nursing work did not facilitate career progression because they focused on completing tasks rather than improving their knowledge and skills. Nursing agencies were also regarded as corporate entities, which were more concerned about cost efficiencies and addressing personnel shortfalls rather than focusing on the professional needs of their nurses. The following participant highlighted her difficulty in career progression because of her stressful work experiences: The experiences of most agency nurses working are ‘come in and go out’. It’s a stressful full-on day and if they haven’t worked there before they’re just extremely anxious most of the day and can’t wait to get out the door. So I can’t see it as an enriching professional experience at all. There is very little time in the day to devote to extra-curricular things like education or updating skills. It’s just not done y I see this job as a short time-filler. Other participants believed their careers were affected in a positive way by agency work. Their wealth of experience in a variety of settings allowed them to consolidate their skills to the point where they could provide high quality patient care. Issues were also raised about the educational provision by the nursing agency. Some participants commented about the benefits associated with the education programs provided by their respective agency. Some nursing agencies conducted regular in-service sessions that were readily utilised by nurses. However, there also appeared to be some ambivalence about their value because of associated cost, lack of accessibility and lack of relevance, for example: I also don’t have the opportunity to attend courses when I am doing agency. I have to make my own time to attend the courses. Often you have to pay for the courses yourself y whereas if you are working in
a hospital, you have the opportunity of attending ongoing in-service education for free. Another participant commented about the possible relevance of educational sessions delivered by agencies: I am a midwife, and my agency doesn’t do that many midwifery in-services. If you are permanently working in a hospital you would have more access to the midwifery in-services. For other participants who were associated with a smaller agency, no education was offered at all, for example: The unit that I have been working on provides a continuous update for staff about new equipment y But my agency has never offered me any education y If I have any clinical questions I just ask at the hospital. All participants agreed unanimously that they would have benefited from participating in hospital in-service sessions. However, they reported that there was a general feeling of negativity from permanent nurses if agency nurses attempted to attend these sessions. Agency nurses were expected to remain at the bedside because these sessions were only devised for permanent staff, for example: There would be some hospitals I work at frequently where an extra person [an agency nurse] y at an inservice wouldn’t bother them. But most places would look at that as taking up a space that someone else could use. They’re [permanent nurses] not necessarily going to get benefits of knowledge if they went instead of you. This is wrong. Aside from education provided by agencies and hospitals, participants commented on the importance of being individually responsible for maintaining current knowledge. As already addressed previously, educational sessions conducted by agencies were not always relevant and participants often experienced difficulties in making time available to attend these sessions. Participants addressed their knowledge needs in a number of ways, including subscribing to professional journals, attending nursing conferences, accessing the Internet, and completing courses conducted by private providers. This reliance upon self-education and individual responsibility appeared to be related to nurses’ perceptions about their knowledge deficits, for example: I think it’s your own responsibility to make sure you are on top of things, and if you are not then to find out or access people who can get you up-to-date. Only you would know what your deficits are. When asked about their professional development, participants believed their clinical skills were enhanced
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since commencing agency-nursing work. The major reason for skill enhancement related to the various clinical settings in which tasks were practised. However, some participants conceived their skills were not improved because they felt stressed and sometimes lacked experience in the practice areas to which they were allocated. For one participant, her enhancement of clinical skills was compared to the nurse practitioner role: My clinical skills were very much enhanced by the variety of work. You become more of a nurse practitioner because you are standing alone. If you take the job seriously you have to know your limits very carefully, and you have to know your assessment and procedures very well y You are going from one patient to another, and going to different hospitals. It really makes you grow y It has opened my eyes a lot. For another participant, she developed an appreciation of how particular tasks could be completed in a number of different ways and became more flexible in how she carried out clinical procedures: It [agency-nursing work] has given me an incredible ability to enhance my performance and skills. That has been really positive. It has given me a good understanding of how some hospitals are so adamant that things are done one way and their way is best. In another hospital they do something totally different and they’re just as adamant that their way is best. So it has given me an understanding that there isn’t just one way of doing things—there are as many different ways as there are hospitals.
5. Discussion This research provides valuable insight into the demands of agency-nursing work from the perspective of agency nurses. Nurses were concerned about shift allocation, which involved notification about a working shift and ramifications for being late. They also emphasised the importance of work flexibility, developing positive experiences with permanent staff, communicating about patient care activities, and maintaining clinical skills. Agency nurses were concerned about hospital and ward allocation, which included the notification of a working shift and the assignment to a particular ward area. While participants believed that they had adequate notification about a forthcoming shift, nearly half the participants had experienced receiving short notice about the availability of a particular shift. The perceived flexibility of agency work could be threatened if these nurses continued to experience difficulties with balan-
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cing other commitments if inadequate time was available to plan for working shifts. Furthermore, participants perceived that hospital nurses sometimes blamed them if they arrived late for a shift. Often lateness was beyond the control of the agency nurses because it occurred if there was insufficient notification about a forthcoming shift by the nursing agency or hospital. Lateness may cause considerable anxiety for agency nurses as well as permanent staff. For agency nurses, the amount of time available for orientating about patient care needs and the nuances of the environment may be limited. For permanent nurses, they are required to address the additional workload until the agency nurses’ arrival. This situation of lateness also affects permanent nurses’ perceptions of professional commitment by agency nurses, and as found by Burda (1992) it may lead to decreased hospital staff morale. The assignment to a particular ward area was another concern relating to allocation. Participants felt able to self-regulate and refuse to work in particular work settings if these placements were viewed as unsuitable to their skill level. Despite their perceived assertiveness, participants were extremely anxious if they felt compelled to work in inappropriate settings. While agency nurses’ refusal to work in a particular setting may be viewed as a form of control over work placements, it could reduce their choices of future work opportunities and employment prospects (Schubert, 1995). Furthermore, in order to obtain the goodwill of the agency, temporary workers could feel obliged to accept assignments that do not necessarily suit them (Merolle, 1988). The flexibility of agency employment was the most common reason voiced by participants for doing agency-nursing work. They needed flexible work hours, which were not addressed by the rigidity of permanent hospital routines. Similarly, Braddy et al. (1991) reported that flexible scheduling was the most frequently listed reason among nurses for undertaking agency work. The reluctance of hospitals to structure flexible work patterns in female dominated professions, especially in those professions where shiftwork is the accepted pattern of employment, hinders greatly women’s participation in the workforce and capacity to balance other commitments. Interestingly, while low pay and inadequate promotional opportunities have been found to influence nurses’ dissatisfaction with hospital employment (Bates, 1998; Braddy et al., 1991; Huey and Hartley, 1988), participants did not comment about financial remuneration as a reason for undertaking agency-nursing work. This lack of influence of financial incentives was also supported by the work of Braddy et al., which indicated the promise of a better salary would influence only 39% of the nurses surveyed to leave their agency work and return to permanent hospital employment.
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Another significant issue was agency nurses’ experiences with hospital staff. Although some participants enjoyed supportive relationships that served to enrich their practice, others described a lack of supportive consultation especially in settings where they worked regularly and in relatively busy situations. Again, it appeared as though the temporary nature of employment influenced how permanent hospital nurses perceived the agency nurse and the degree of support they gave or withheld (Bates, 1998). The withholding of support may serve to minimise the agency nurses’ work autonomy in patient decision-making. In view of the complex and changing nature of clinical work, agency nurses depend on support from the health care professionals with whom they are working. If this support is not provided, agency nurses may experience professional isolation and deliver poor patient care (Schubert, 1995). Gunn (1983) encountered a similar situation when agency nurses found themselves isolated from the decision making process within the area they were working. Communication about the completion of patient tasks was another important aspect of agency nurses’ experiences with permanent staff. Participants perceived that their communication was orientated towards the need to complete tasks within tight time frames rather than to develop a comprehensive, holistic understanding of patient care needs. While the findings indicated that the level of communication from permanent nurses may be limited, Bates (1998) reported in her study that agency nurses had few opportunities to access the necessary information from medical records because of constant interruptions, a lack of familiarity with the ward environment, and the immediacy of patient needs. Task completion could be difficult when information, either oral or written, is not always readily accessible. As a result, agency nurses may feel compelled to develop a rapid problem solving or ‘quick fix’ response to completing tasks and addressing patient problems (Street, 1992). However, this form of response tends to focus on the immediate concerns of the patient, such as resuscitation emergencies and vital sign assessment, while other, less valued concerns, such as family support and spiritual needs, go unnoticed. Furthermore, the lack of appropriate communication about patient care may necessitate the need for decisions to be passed on to permanent staff, thereby decreasing agency nurses’ autonomy (Bates, 1998). With respect to professionalism, participants commented on their responsibility in maintaining and updating clinical skills through continuing education. While permanent nurses had access to educational opportunities in the workplace, agency nurses were expected to maintain their own professional development. In Schubert’s study (1995), agency nurses commented on the cost of continuing education, and
felt they were missing opportunities to update their knowledge and skills that were readily available to hospital employees. The temporary nature of employment may motivate hospital employers to extract the maximum labour power for the duration of the work assignment (Bernstein, 1986). Subsequently, employers could be reluctant to include agency nurses in educational sessions normally meant for permanent nurses. The limitations of this study concern the small number of individual interviews conducted with agency nurses who worked in Melbourne, Australia. Due to the voluntary means of participation, it may be assumed that the findings reveal the perceptions and experiences of agency nurses who had a strong interest in their work. Nevertheless, the comprehensive findings, which represent the views of ten individuals with varying levels of experience in agency-nursing work, are likely to resonate with other agency nurses in similar positions.
6. Conclusion and implications The findings of this study make a unique contribution to knowledge about agency nurses’ perceptions and experiences of their work in acute care hospital settings. While these participants had undertaken agency nursing to maintain flexibility and control in their practice, their relationships with nursing agencies and hospitals meant that they were left with little opportunity to obtain adequate hospital orientation, negotiate allocation of shifts, communicate in a supportive manner with permanent staff and experience professional advancement. The findings reinforce the need to create strong collaborative networks between agency nurses, nursing agencies and hospital institutions, in which all stakeholders could discuss issues of concern and negotiate an agreed position. In particular, as agency nurses now comprise a significant portion of nurses who work in hospital settings, they need to be orientated adequately, and to have some sense of belonging and autonomy in the workplace. Further research could involve an exploration of the experiences of agency nurses who are employed in different health care institutions, including long-term care, aged care, community health and psychiatric settings. While this research focused on participants employed in the metropolitan area, it would also be of interest to consider if agency nurses’ views differ between metropolitan, regional and rural areas. Another neglected area concerns the views of permanent nurses who work with agency nurses. It is vital that comprehensive understandings of different perspectives of agency-nursing work are sought to enhance professional nurses’ satisfaction with their practice and to facilitate quality patient care.
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Acknowledgements The authors wish to acknowledge the Nurses’ Board of Victoria that provided financial assistance to support the study upon which this paper is based.
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