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Us and them: Experiences of agency nurses in intensive care units
Intensive & Critical Care Nursing xxx (xxxx) xxx
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Research article
Us and them: Experiences of agency nurses in intensive care units Linda Ronnie ⇑ University of Cape Town, South Africa
a r t i c l e
i n f o
Article history: Received 2 February 2019 Revised 16 September 2019 Accepted 5 October 2019 Available online xxxx Keywords: Agency nurses Intensive care units ICU managers Nurse managers South Africa
a b s t r a c t Objective: This qualitative case study describes the work experiences of agency nurses from their perspective. It explores their interactions with intensive care unit managers to whom they report in their designated intensive care units and their relationships with fellow permanent nurses. Methods: A qualitative study was undertaken in three intensive care units at a public hospital in South Africa. Face-to-face interviews were used to collect data from eleven agency nurses. Thematic analysis of the data was undertaken. Findings: The challenges of agency nursing work were haphazard clinical allocation, a lack of self-efficacy and competence, and feelings of exclusion. Positive aspects of the agency nurse experience included feedback and support from permanent nurses and intensive care unit managers and occurrences of belonging and acceptance. Conclusion: The findings of this study point to the importance of agency nurse relationships with managers and fellow permanent nurses. To ensure patient care is not compromised, managers and nurse managers have a responsibility to ensure a welcoming, inclusive and nurturing environment for all staff tasked with intensive care unit responsibilities. Ó 2019 Elsevier Ltd. All rights reserved.
Implications for Clinical Practice Agency nurses are challenged by haphazard clinical allocation, perceived unfair task allocation, a lack of requisite ICU skills and feelings of exclusion from the ICU team. Positive aspects of the agency nurse experience include feedback on tasks, support through on-the-job training, and occurrences of belonging and acceptance. ICU managers and nurse managers are encouraged to maintain a healthy working environment for agency staff through collaborative and inclusive practices that ensure the maintenance of patient care levels.
Introduction As in other parts of the world, South African hospitals have been moved to supplement their nursing staff with temporary practitioners who are employed by placement agencies and are therefore known as ‘‘agency nurses” (Seo and Spetz, 2013). Although the agency nursing rate in South Africa varies by region, sector and type of nurse, the overall figures are significant: 58.4% for private sector nurses and 28.4% for public sector nurses (Rispel et al., 2014). However, in spite of the complexity introduced to opera⇑ Address: Leslie Commerce Building, Engineering Way, Rondebosch 7700, South Africa E-mail address: [email protected]
tions and management by the use of temporary staff (Berg Jansson and Engström, 2016), there remains a dearth of recent literature on the working dynamics of agency nurses. In particular, little is known about the views of agency nurses in South Africa (Matlakala and Botha, 2015). This study describes the work experiences of agency nurses from their perspective. It explores their interactions with intensive care unit (ICU) managers to whom they report in their designated ICUs and their relationships with fellow permanent nurses. As an increasing number of hospitals make use of agency nurses to deliver essential healthcare services, it becomes imperative to understand their experiences and working relationships as communication and teamwork are considered to be critical for ensuring patient care (Reader et al., 2009; Savjani et al., 2018).
https://doi.org/10.1016/j.iccn.2019.102764 0964-3397/Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: L. Ronnie, Us and them: Experiences of agency nurses in intensive care units, Intensive & Critical Care Nursing, https://doi.org/ 10.1016/j.iccn.2019.102764
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Certain aspects of agency nurse work are regarded as universal. Research indicates that flexibility in working hours is the main driver for agency nurses (Manias et al., 2003). Although there are advantages to this flexibility, Hass et al. (2006) found that agency nurses commonly experienced a lack of confidence and selfassurance in more pressurised environments such as intensive care. ICUs are among the most stressful and demanding environments for nurses (Jakimowicz et al., 2018). Nurses working in ICUs require specialised training to cope with life-threatening health symptoms, knowledge of technology and with the decisionmaking linked to critically ill patients. Other than a Master’s programme option, registered nurses in South Africa who wish to be registered as critical care nurses complete a year of practical education and training in an accredited ICU (Makombo, 2018). A key concern for ICU managers, particularly as they work with agency nurses with whom they are not familiar, is the distinction between under-experienced nurses and unqualified nurses. In this setting, an agency nurse may feel like a novice nurse, overwhelmed and unprepared for the tasks at hand (Odland et al., 2014). In their study of agency nurses working at public hospitals in South Africa, Rispel and Moorman (2015) found that nurse management perceived agency nurses to be unreliable and unable to deliver the same quality of care as their permanent counterparts. Similarly, in her examination of South African ICUs, Matlakala (2012) noted that, in addition to an apparent lack of professionalism, agency nurses were cited as not having the requisite technical skills to be in the ICU. Exploring interpersonal dynamics within the ICU from an agency nurse perspective may shed light on these perceived challenges although, it should be noted, this study does not focus on the responsibility of the staffing agency in this regard. Methods The study used an exploratory case study research design and a qualitative approach. The unit of analysis was the agency nurse. Case study research design focusses on interactions within a single setting and permits the recognition of cases as integrated systems with an opportunity to explore complex social problems within an organisation (Stake, 1995). Setting The tertiary public hospital in South Africa within which the study was conducted has five intensive care wards. Each ICU has a maximum of 20 patients and attends to a variety of trauma (motor vehicle, gunshots, stabbing), cardiothoracic, critical injuries including those of a neurological nature, and a combination of medical and surgical patients with high anaesthetic risk. These ICUs are considered Level 1 units as they have round-the-clock medical specialists, residents and medical officers, sophisticated equipment and a nurse-patient ratio of 1:1 or 1:2 (De Beer et al., 2011). Each ICU is managed by an operational or unit manager involved with dayto-day organisation and structure of shifts and are the first line of reporting for monitoring and control measures and performance. The hospital within which the study was conducted has several unit managers per ICU with a minimum of one per shift. ICU managers report to nurse managers who are individuals with executive authority regarding nursing matters. For example, nurse managers approve agency use and determine allocation, decide which staff go for training, and resolve disciplinary issues. Participants A purposive sampling strategy, as recommended by Merriam (1989) for a case study approach, was followed. Eighteen agency
nurses, employed by a nursing agency but permanently deployed to the hospital’s ICUs, were approached with a request for their participation in the study. This process was enabled through ICU management who allowed the researcher to explain the study to nurses during their lunch breaks. An email was also sent to all identified staff who met the criterion. At the time of the study, agency nurses were only employed in three of the five ICUs – cardio-thoracic, neuro-surgical, and respiratory. Eleven nurses participated in the study: two Enrolled Nursing Assistants (ENAs), seven Enrolled Nurses (ENs), and two Registered Nurses (RNs). Although all of the sample had some ICU experience, none of the agency nurses held an ICU qualification. Table 1 shows the three nurse categories with descriptions and length of education and training. Table 2 presents an overview of the participants. Ethical considerations The relevant university’s Human Research Ethics Committee granted approval for the study (HREC REF: 682/2016) as did the hospital Chief Executive Officer. The anonymity of respondents and the health institution and the confidentiality of data were maintained. Informed consent was obtained from each participant at the start of their recorded interview when they were also informed of the voluntary nature of the study. To ensure participant confidentiality, pseudonyms are used throughout. Data collection Eleven agency nurses were interviewed during their breaks in a private room away from the ICU ward they had been allocated to on the day. Interviews took place between 13th and 25th July 2017. The interviews were recorded and later transcribed. The face-to-face interviews, which lasted between 13 and 29 minutes, comprised of two sections: i) demographic information related to their age, job category, overall nursing and ICU nursing experience; and ii) semi-structured questions regarding their role and relationships in their ICU assignments. To give them the opportunity to relate their story, each interviewee was asked ‘‘What have been your experiences of working in the ICU?”. The main thrust of the questions was to explore their working relationships within the ICU. To obtain more detailed information, follow-up prompts such as ‘Provide an example of that’ or ‘As a nurse, how did that make you feel?’ were used.
Table 1 Nurse categories. Category
Description
Education and training
Registered nurse (RN)
A person who is qualified and competent to independently practise comprehensive nursing in the manner and to the level prescribed and who is capable of assuming responsibility and accountability for such practice. A person educated to practise basic nursing in the manner and to the level prescribed who must be supervised by a RN. A person educated to provide elementary nursing care in the manner and to the level prescribed who must be supervised by a RN.
Completion of a fouryear programme or via a two-year bridging programme from EN to RN.
Enrolled nurse (EN)
Enrolled nurse assistant (ENA)
Completion of a twoyear programme.
Completion of a oneyear programme.
Source: South African Nursing Council (2019).
Please cite this article as: L. Ronnie, Us and them: Experiences of agency nurses in intensive care units, Intensive & Critical Care Nursing, https://doi.org/ 10.1016/j.iccn.2019.102764
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L. Ronnie / Intensive & Critical Care Nursing xxx (xxxx) xxx Table 2 Participant sample. Name
Job category
Age
Nursing experience (years)
ICU experience (years)
Beauty Betty Dorothy Noni Cecilia Redi Lily Elsie Hayley Mariam Thato
ENA ENA EN EN EN EN EN EN EN RN RN
35–39 25–29 25–29 20–25 50–54 25–29 20–25 30–34 25–29 45–49 55–59
>4 and >1 and >2 and >1 and >30 >6 and >1 and >5 and >1 and >25 >30
>4 >1 >1 >0 >2 >3 >0 >2 >0 >1 >1
Data analysis Drawing on Stake’s (1995) case study research design, the data were collected and analysed simultaneously and relied on inductive thematic analysis. Each interview transcript was reviewed using a thematic analysis technique drawn from Ryan and Bernard (2003) that ensured some flexibility in data coding. This process was particularly important in allowing a more comprehensive picture to emerge. All transcripts were manually coded as there was a manageable volume of data. Given that the data were in qualitative form, each ‘unit of meaning’ was identified through key storylines in each transcript. Although time-consuming, to ensure reliability of the analytic process and thus the emerging themes, a fellow qualitative researcher was requested to review a sample of the transcripts and code them independently. We discussed any differences, revised categories and recoded extracts where appropriate. Using these methods, extracts from the data were clustered under four significant thematic categories. To ensure authenticity of data interpretation, two focus groups were held with the sample where findings of the study were shared. This member checking process provided a useful method to ensure trustworthy construal of the data (Bazeley, 2013).
<5 <2 <3 <2 <7 <2 <6 <2
and and and and and and and and and and and
<5 <2 <2 <1 <3 <4 <1 <3 <1 <2 <2
and that their role in assisting critically ill patients had developed into a meaningful part of their jobs. However, a lack of familiarity with the full range of duties undertaken by an ICU nurse, typically performed in conjunction with others, gave rise to feelings of inequality. Perceptions of unfair task allocation were rife: ‘I came to work and was sent to a different ICU [to the previous day]. The manager told me to do the observations for all the patients. I was so upset. Permanent staff work together but I was left alone’ (Mariam, RN). ‘When I come to the unit, I get two patients compared to the permanent nurses who just get one. I’m [for]ever tired’ (Thato, RN). In this regard, lack of explanation and poor communication from the ICU manager lay at the heart of the agency nurses’ unhappiness. It appeared that agency nurses in this study, regardless of category, had been allocated seemingly mundane individual activities. However, the range of activities undertaken by ICU nurses include very specialised responsibilities and ultimate accountability for patient care; without highly specialised training, including the assessment of critical health symptoms and knowledge of appropriate technology, even an agency RN is unable to perform the required tasks.
Findings
Self-efficacy and competence
The findings are clustered under four key themes: clinical allocation; self-efficacy and competence; feedback and support; and being the outsider.
The system of constant rotation across the ICUs led to nurses feeling hindered in their learning and stymied in the development of their competence:
Clinical allocation Agency staff perceived that the practice of allocating them to their duties occurred in a first come-first served manner. Consequently, being assigned to an ICU was much of a lottery for agency nurses:
‘What are you going to learn in one day? It’s like any other job, you won’t know things at first; but if you work in one place for a week, then at least some knowledge will be retained’ (Redi, EN). ‘There are suspicions in the team about your competence; that you are unable to do the task. As an agency nurse, you might not be allowed to touch the drug box, for example’ (Lily, EN).
‘I don’t work at the same ICU every day. For the past year, I’ve worked in all the ICUs at the hospital’ (Mariam, RN). ‘Sometimes you’re here [in this ICU] and then you come back 3 weeks later to another unit’ (Thato, RN).
Agency nurses often arrived at their assigned ICUs with minimal to no prior training or orientation and believed they could perform better if they had been exposed to some level of preparation. The general sentiment among the nurse participants was that:
Despite the challenges of being allocated to an ICU in this haphazard fashion, agency nurses felt privileged to work in the stressful environment as the following excerpts illustrate:
‘[We are made to feel that] we know absolutely nothing and it’s unfair towards others who must take us’ (Cecilia, EN).
‘Nursing in the ICU is not easy, its traumatising. But if you have someone to motivate you, you fall in love with the job’ (Hayley, EN). ‘Being asked to come back to the ICU was very, very motivating for me. This is where I want to work permanently’ (Beauty, ENA). Participants believed that, despite the relatively short and sporadic periods spent in the ICUs, they were drawn to intensive care
The lack of specialist knowledge required in the ICU was a source of frustration to the agency nurses themselves: ‘A lot of agency staff are from other parts of the country that have no ICU that provides training. Give us some time to learn’ (Betty, ENA). However, the nature of the ICU is that there was often no time for formal training as the ICU nurse was expected to do all the
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required clinical tasks. Even agency nurses with significant years of experience felt at sea within their allocated ICUs:
Fortunately, several agency nurses also had positive experiences with their ICU managers:
‘I have past paediatric ICU knowledge, so I have some experience, but I don’t have in-depth knowledge of adult ICUs. I’m just starting to build up that knowledge’ (Mariam, RN). ‘They leave me just because I’m an experienced nurse. But I don’t know everything in ICU’ (Cecilia, EN).
‘I had a needle prick incident and the manager organised everything and even checked up on me weeks’ later’ (Beauty, ENA). ‘He’s very patient: he’s a top guy. He walked me through the procedure step-by-step. I was very happy. I asked him: ‘‘Can I please, please come back here tomorrow?”’ (Hayley, EN). ‘Most managers are fantastic because they ask you ‘‘Have you been here before? Can you do certain things? If not, you can just ask”’ (Redi, EN).
Agency nurses, with a keen sense of their own limitations, had also indicated explicitly to the ICU manager when they felt out of their depth professionally: ‘They allocated me to a very sick patient and I said to the manager ‘‘this is outside my scope of practice. I don’t know how to use the machines that they need”. Then they took me off that patient’ (Elsie, EN). However, the strategy of simply removing an agency nurse from a patient because she had no prior knowledge of the procedural process to be followed had an unintended negative consequence: ‘I asked what I must do as I haven’t ever taken someone off dialysis. The manager said ‘‘fine, just leave it”. So, now I still don’t know what to do or where to start’ (Thato, RN). Despite the experience levels of some of the older participants, the skills gap between agency and permanent ICU nurses in this study was acknowledged and apparent to all. As this deficit was difficult to address – and made more so given the relentless work demands – agency staff experienced an ongoing erosion of their self-belief in their ability to perform the required tasks. Feedback and support As agency nurses report directly to the ICU managers after being allocated to the specific ICU, the interactions between these two parties set the tone for what would follow. When asked what role ICU managers should play, agency nurses replied that visibility, availability and on-the-job training were key elements: ‘The role of the manager is make sure that everyone is happy when they’re working. When staff ask questions, they must be able to explain to them rather than saying ‘‘you’re asking too much”’ (Noni, EN). ‘They need to be working alongside the nurses. This can help a lot, to be hands-on. If there’s new equipment, you need to know how it works. As an agency nurse, I go to the manager to find out as she’s the first port of call’ (Mariam, RN). ‘The manager should take me around and explain the status of the patients. She should show me things I’m supposed to know’ (Elsie, EN). ‘It is their role to motivate staff. When you get those comments: ‘‘study further”, ‘‘you did well today”, it boosts your self-esteem’ (Redi, EN). Actual on-the-job experiences between agency nurses and ICU managers painted a somewhat mixed picture. There were reported instances of extremely demotivating interactions, such as public reprimands and lack of professional support: ‘[When she is] shouting at you – ‘look here, what have you done?’ – you feel like you want to leave what you’re doing. They let you down by not encouraging you’ (Betty, ENA). ‘One time I was working night shift and instead of guiding me with the critically ill patient whose vital signs were very low during the day, I got shouted at and went home very dejected. The next day I didn’t come to work’ (Hayley, EN).
As difficult as it might be for agency staff who do not have a sense of permanent placement or the requisite skills to work in ICU, it appeared to be an environment where they had the prospect of acquiring the knowledge of new processes and procedures. However, the opportunity to learn and remain motivated was influenced by the workplace culture – as shown in the examples of feedback and support – that was created by ICU managers. Being the outsider Just as ICU managers often set the tone for the level of collaboration with agency nurses in their ICUs, so the work relationships between agency and permanent nurses typically followed suit. It was in these day-to-day interchanges that agency nurses felt the lack of inclusion most keenly. These experiences centred on three aspects: trust, belonging and acceptance: ‘At the beginning, the permanents monitor you all the time because they don’t really trust you. I understand you’re new but how committed can you be if you feel you’re not trusted?’ (Thato, RN). ‘I get treated different because I’m an agency. You feel you don’t belong in the team’ (Dorothy, EN). ‘The permanents shouldn’t look down upon us, like we don’t know anything. Talk to us as human beings. Talk to us, tell us what to do. We do have feelings’ (Lily, EN). ‘The senior nurses, they were junior nurses before, so they know what it’s like to be in my shoes. Maybe they would treat me differently if I was permanent. I wouldn’t do that to anyone else if I was permanent’ (Noni, EN). As is clear from the excerpts, the feeling of being an outsider had an impact on the self-esteem of the agency nurse. These instances are likely to undermine the confidence of the affected staff and may potentially affect the level of patient care. Where interactions between agency and permanent nurses were more effective, agency nurses felt a sense of fitting in: ‘We are working as a team, and you can ask questions if you want to. Teamwork is very important’ (Dorothy, EN). ‘Positive ones make you feel like you belong. I pray almost every day to get someone who is helpful’ (Noni, EN). Issues of inclusivity and teamwork surfaced in the accounts of agency nurses in terms of their relationships with permanent ICU nurses. There appeared to be a perception among the sample that, due to their very status as temporary workers, agency nurses were discounted from being accepted as part of the team. Discussion Findings from the study showed that the inherent challenges of the agency nurses’ experiences of the ICU were haphazard clinical allocation, perceived unfair task allocation, a lack of requisite skills, the absence of formal ICU experience and feelings of exclusion from the ICU team. Positive aspects of the agency nurse experience
Please cite this article as: L. Ronnie, Us and them: Experiences of agency nurses in intensive care units, Intensive & Critical Care Nursing, https://doi.org/ 10.1016/j.iccn.2019.102764
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included feedback and support from permanent staff including ICU managers and instances of belonging and acceptance. These findings are important for ICU managers and nurse managers as they provide insights for the improvement of agency nurses’ training and development, workplace relationships, and engagement. A common finding, confirmed in this study, has been the need for ongoing training and professional development of ICU agency nurses (Hass et al., 2006; Matlakala et al., 2015). Indeed, Rispel and Moorman (2015) found that while ICU managers would complain about the sub-optimal performance of their temporary staff, they spent little to no time on induction processes to orientate or prepare agency nurses, which Manias et al. (2003) discovered to be vital to patient care. Although mixed findings regarding relationships between agency nurses and ICU managers were reported in this study, the recommendation to implement orientation programmes appears pertinent and would be welcomed by agency nurses. During these sessions, agency nurses should be reminded about potentially unsafe practices when functioning beyond the scope of their own practice. This discussion would be particularly pertinent for the more junior nurses who, under normal circumstances, would be precluded from working in an ICU. These suggestions, however, do not absolve nurse placement agencies of their responsibility for the training and ongoing development of their nursing staff. Members of the Allied Healthcare Association of South Africa (AHASA), the association body for nurse placement agencies, must ensure that their staff are fully trained and registered with the SANC. Furthermore, as Manias et al. (2003) argued, there is a need to build collaborative relationships between hospitals, staffing agencies, and agency nurses to address and resolve issues of concern such as these. This study highlighted that even experienced nurses require ongoing education and training to keep up to date with medical knowledge, specialised technology and processes. One of the underlying reasons for the predominantly poor interactions between agency and permanent nurses may be the responsibility laid on nurses with ICU qualifications and experience to supervise nurses without the relevant ICU experience, such as the agency nurses in this study. This creates a further burden for ICU personnel tasked with critical care responsibilities (Matlakala and Botha, 2015). Another factor linked to training and development was the process of clinical allocation which, in this research context, meant that agency nurses experienced ostensibly random assignment to units resulting in a lack of continuity that affected skills development and relationships. Where it is commonplace for agency nurses to work in many different units and hospitals for short spaces of time, they have reported concerns of ‘‘de-skilling”. Hass et al. (2006) identified that agency nurses believe they lose technical competence because they are assigned the simplest tasks that require minimum input. Although participants in this study did not allude to the loss of their skills, they experienced frustration at being assigned menial tasks without the necessary explanatory communication. This discomfort was mostly keenly felt by the three agency nurses with more than 25 years of experience. This practice of preventing non ICU-trained nurses from performing more complex tasks, although entirely consistent with patient care responsibilities in the ICU, has consequences for morale and the professional development of individual nurses and has the potential to negatively impact on the provision of quality healthcare and compromise continuity of care over the medium to long term (Morse et al., 2005). The frequent use of temporary workers adds an element of complexity to the working environment as agency nurses have little time to acclimatise to the culture of the organisation of a particular ICU unit. In addition, the use of ad hoc agency workers can create instability within the nursing team as the relationship
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dynamics constantly change (Chênevert et al., 2016). Savjani et al. (2018) pointed to the environment and culture as the ultimate determinants of quality care in ICUs. Difficult though they may be to quantify, adverse workplace culture and processes may negatively affect nurses, as they are seen to do in this study, in addition to the unique stressors of being temporary staff members. In her critique of ICU leadership where poor participation from leaders featured as the central issue, Rouse (2009) discussed the importance of mentorship and role modelling mechanisms by senior nurses and managers in order to in improve employee morale. Strategies for managing agency staff in similar ways are needed. As confirmed by the findings of this study, agency nurses often report feelings of isolation, of not being part of the team (Hass et al., 2006). Lapalme and Doucet (2018) suggested that nurse managers who want to create more collaboration within their blended workforce, containing temporary and permanent staff, must create a shared identity among the group. This can be effected by leader inclusiveness, distributive justice and nurses’ perception of similarity. Furthermore, they reported that the establishment of a common identity led to increased knowledge sharing among the group. This suggestion is crucial in an environment, such as this research setting, where agency nurses lack the requisite skills and experience to function optimally in the ICU.
Limitations Due to the study’s qualitative design, participants were limited in number. The precarious nature of agency nurses’ employment may have meant they were reluctant to participate in the study. As noted, the role of the agency itself is not a focus of the study. The findings regarding the responsibilities of agency nurses is primarily discussed with regard to ICU managers and nurse managers in the research setting.
Conclusion Hospitals often turn to agency nurses as a means of cost-saving and improved efficiency, trying to align the supply to demand on a daily or weekly basis. The findings of this study, which focussed on the work experiences of agency nurses, point to the importance of their relationships with ICU managers and fellow permanent nurses. ICU managers and nurse managers are therefore encouraged to navigate the nursing shortage in ways that enable quality care for patients, maintain a healthy working environment for staff and are cost effective for hospitals. It is insufficient to employ agency nurses to merely fill employment gaps without addressing the needs of this group. To ensure that patient care is not compromised, ICU managers and nurse managers have a responsibility to ensure a welcoming, inclusive, and nurturing environment for all staff tasked with ICU responsibilities.
Declaration of Competing Interest The author declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper
Acknowledgments The author would like to thank Grace Cairns for her assistance during the access and data management phases.
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Funding There were no funding or sources of support for this study. Ethical approval The University of Cape Town Faculty of Health Sciences’ Human Research Ethics Committee granted ethical approval for the study. Ethical approval number: HREC 682/2016. References Allied Healthcare Association of South Africa (AHASA). 2019. About us. http://ahasa. org/about/ (accessed 2019-04-07). Bazeley, P., 2013. Qualitative Data Analysis: Practical Strategies. Sage Publications, London. Berg Jansson, A.B., Engström, A., 2016. Working together: critical care nurses experiences of temporary staffing within Swedish health care. Intensive Crit. Care Nurs. 41, 3–10. Chênevert, D., Jourdain, G., Vandenberghe, C., 2016. The role of high-involvement work practices and professional self-image in nursing recruits’ turnover: a three-year prospective study. Int. J. Nurs. Stud. 53, 73–84. https://doi.org/ 10.1016/j.ijnurstu.2015.09.005. De Beer, J., Brysiewicz, P., Bhengu, B.R., 2011. Intensive care nursing in South Africa. S. Afr. J. Crit Care 27, 6–10. Hass, H., Coyer, F.M., Theobald, K.A., 2006. The experiences of agency nurses working in a London teaching hospital. Intensive Crit. Care Nurs. 22, 144–153. Jakimowicz, S., Perry, L., Lewis, J., 2018. Compassion satisfaction and fatigue: a cross-sectional survey of Australian intensive care nurses. Aust. Crit. Care 31, 396–405. Lapalme, M., Doucet, O., 2018. The social integration of healthcare agency workers in long-term care facilities: a cross-sectional study. Int. J. Nurs. Stud. 82, 106–112. Makombo, T., 2018. Health, in: South Africa Survey. South Africa Institute of Race Relations, Pretoria, pp. 617–736.
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Please cite this article as: L. Ronnie, Us and them: Experiences of agency nurses in intensive care units, Intensive & Critical Care Nursing, https://doi.org/ 10.1016/j.iccn.2019.102764
Contents lists available at ScienceDirect
Intensive & Critical Care Nursing journal homepage: www.elsevier.com/iccn
Research article
Us and them: Experiences of agency nurses in intensive care units Linda Ronnie ⇑ University of Cape Town, South Africa
a r t i c l e
i n f o
Article history: Received 2 February 2019 Revised 16 September 2019 Accepted 5 October 2019 Available online xxxx Keywords: Agency nurses Intensive care units ICU managers Nurse managers South Africa
a b s t r a c t Objective: This qualitative case study describes the work experiences of agency nurses from their perspective. It explores their interactions with intensive care unit managers to whom they report in their designated intensive care units and their relationships with fellow permanent nurses. Methods: A qualitative study was undertaken in three intensive care units at a public hospital in South Africa. Face-to-face interviews were used to collect data from eleven agency nurses. Thematic analysis of the data was undertaken. Findings: The challenges of agency nursing work were haphazard clinical allocation, a lack of self-efficacy and competence, and feelings of exclusion. Positive aspects of the agency nurse experience included feedback and support from permanent nurses and intensive care unit managers and occurrences of belonging and acceptance. Conclusion: The findings of this study point to the importance of agency nurse relationships with managers and fellow permanent nurses. To ensure patient care is not compromised, managers and nurse managers have a responsibility to ensure a welcoming, inclusive and nurturing environment for all staff tasked with intensive care unit responsibilities. Ó 2019 Elsevier Ltd. All rights reserved.
Implications for Clinical Practice Agency nurses are challenged by haphazard clinical allocation, perceived unfair task allocation, a lack of requisite ICU skills and feelings of exclusion from the ICU team. Positive aspects of the agency nurse experience include feedback on tasks, support through on-the-job training, and occurrences of belonging and acceptance. ICU managers and nurse managers are encouraged to maintain a healthy working environment for agency staff through collaborative and inclusive practices that ensure the maintenance of patient care levels.
Introduction As in other parts of the world, South African hospitals have been moved to supplement their nursing staff with temporary practitioners who are employed by placement agencies and are therefore known as ‘‘agency nurses” (Seo and Spetz, 2013). Although the agency nursing rate in South Africa varies by region, sector and type of nurse, the overall figures are significant: 58.4% for private sector nurses and 28.4% for public sector nurses (Rispel et al., 2014). However, in spite of the complexity introduced to opera⇑ Address: Leslie Commerce Building, Engineering Way, Rondebosch 7700, South Africa E-mail address: [email protected]
tions and management by the use of temporary staff (Berg Jansson and Engström, 2016), there remains a dearth of recent literature on the working dynamics of agency nurses. In particular, little is known about the views of agency nurses in South Africa (Matlakala and Botha, 2015). This study describes the work experiences of agency nurses from their perspective. It explores their interactions with intensive care unit (ICU) managers to whom they report in their designated ICUs and their relationships with fellow permanent nurses. As an increasing number of hospitals make use of agency nurses to deliver essential healthcare services, it becomes imperative to understand their experiences and working relationships as communication and teamwork are considered to be critical for ensuring patient care (Reader et al., 2009; Savjani et al., 2018).
https://doi.org/10.1016/j.iccn.2019.102764 0964-3397/Ó 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: L. Ronnie, Us and them: Experiences of agency nurses in intensive care units, Intensive & Critical Care Nursing, https://doi.org/ 10.1016/j.iccn.2019.102764
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Certain aspects of agency nurse work are regarded as universal. Research indicates that flexibility in working hours is the main driver for agency nurses (Manias et al., 2003). Although there are advantages to this flexibility, Hass et al. (2006) found that agency nurses commonly experienced a lack of confidence and selfassurance in more pressurised environments such as intensive care. ICUs are among the most stressful and demanding environments for nurses (Jakimowicz et al., 2018). Nurses working in ICUs require specialised training to cope with life-threatening health symptoms, knowledge of technology and with the decisionmaking linked to critically ill patients. Other than a Master’s programme option, registered nurses in South Africa who wish to be registered as critical care nurses complete a year of practical education and training in an accredited ICU (Makombo, 2018). A key concern for ICU managers, particularly as they work with agency nurses with whom they are not familiar, is the distinction between under-experienced nurses and unqualified nurses. In this setting, an agency nurse may feel like a novice nurse, overwhelmed and unprepared for the tasks at hand (Odland et al., 2014). In their study of agency nurses working at public hospitals in South Africa, Rispel and Moorman (2015) found that nurse management perceived agency nurses to be unreliable and unable to deliver the same quality of care as their permanent counterparts. Similarly, in her examination of South African ICUs, Matlakala (2012) noted that, in addition to an apparent lack of professionalism, agency nurses were cited as not having the requisite technical skills to be in the ICU. Exploring interpersonal dynamics within the ICU from an agency nurse perspective may shed light on these perceived challenges although, it should be noted, this study does not focus on the responsibility of the staffing agency in this regard. Methods The study used an exploratory case study research design and a qualitative approach. The unit of analysis was the agency nurse. Case study research design focusses on interactions within a single setting and permits the recognition of cases as integrated systems with an opportunity to explore complex social problems within an organisation (Stake, 1995). Setting The tertiary public hospital in South Africa within which the study was conducted has five intensive care wards. Each ICU has a maximum of 20 patients and attends to a variety of trauma (motor vehicle, gunshots, stabbing), cardiothoracic, critical injuries including those of a neurological nature, and a combination of medical and surgical patients with high anaesthetic risk. These ICUs are considered Level 1 units as they have round-the-clock medical specialists, residents and medical officers, sophisticated equipment and a nurse-patient ratio of 1:1 or 1:2 (De Beer et al., 2011). Each ICU is managed by an operational or unit manager involved with dayto-day organisation and structure of shifts and are the first line of reporting for monitoring and control measures and performance. The hospital within which the study was conducted has several unit managers per ICU with a minimum of one per shift. ICU managers report to nurse managers who are individuals with executive authority regarding nursing matters. For example, nurse managers approve agency use and determine allocation, decide which staff go for training, and resolve disciplinary issues. Participants A purposive sampling strategy, as recommended by Merriam (1989) for a case study approach, was followed. Eighteen agency
nurses, employed by a nursing agency but permanently deployed to the hospital’s ICUs, were approached with a request for their participation in the study. This process was enabled through ICU management who allowed the researcher to explain the study to nurses during their lunch breaks. An email was also sent to all identified staff who met the criterion. At the time of the study, agency nurses were only employed in three of the five ICUs – cardio-thoracic, neuro-surgical, and respiratory. Eleven nurses participated in the study: two Enrolled Nursing Assistants (ENAs), seven Enrolled Nurses (ENs), and two Registered Nurses (RNs). Although all of the sample had some ICU experience, none of the agency nurses held an ICU qualification. Table 1 shows the three nurse categories with descriptions and length of education and training. Table 2 presents an overview of the participants. Ethical considerations The relevant university’s Human Research Ethics Committee granted approval for the study (HREC REF: 682/2016) as did the hospital Chief Executive Officer. The anonymity of respondents and the health institution and the confidentiality of data were maintained. Informed consent was obtained from each participant at the start of their recorded interview when they were also informed of the voluntary nature of the study. To ensure participant confidentiality, pseudonyms are used throughout. Data collection Eleven agency nurses were interviewed during their breaks in a private room away from the ICU ward they had been allocated to on the day. Interviews took place between 13th and 25th July 2017. The interviews were recorded and later transcribed. The face-to-face interviews, which lasted between 13 and 29 minutes, comprised of two sections: i) demographic information related to their age, job category, overall nursing and ICU nursing experience; and ii) semi-structured questions regarding their role and relationships in their ICU assignments. To give them the opportunity to relate their story, each interviewee was asked ‘‘What have been your experiences of working in the ICU?”. The main thrust of the questions was to explore their working relationships within the ICU. To obtain more detailed information, follow-up prompts such as ‘Provide an example of that’ or ‘As a nurse, how did that make you feel?’ were used.
Table 1 Nurse categories. Category
Description
Education and training
Registered nurse (RN)
A person who is qualified and competent to independently practise comprehensive nursing in the manner and to the level prescribed and who is capable of assuming responsibility and accountability for such practice. A person educated to practise basic nursing in the manner and to the level prescribed who must be supervised by a RN. A person educated to provide elementary nursing care in the manner and to the level prescribed who must be supervised by a RN.
Completion of a fouryear programme or via a two-year bridging programme from EN to RN.
Enrolled nurse (EN)
Enrolled nurse assistant (ENA)
Completion of a twoyear programme.
Completion of a oneyear programme.
Source: South African Nursing Council (2019).
Please cite this article as: L. Ronnie, Us and them: Experiences of agency nurses in intensive care units, Intensive & Critical Care Nursing, https://doi.org/ 10.1016/j.iccn.2019.102764
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L. Ronnie / Intensive & Critical Care Nursing xxx (xxxx) xxx Table 2 Participant sample. Name
Job category
Age
Nursing experience (years)
ICU experience (years)
Beauty Betty Dorothy Noni Cecilia Redi Lily Elsie Hayley Mariam Thato
ENA ENA EN EN EN EN EN EN EN RN RN
35–39 25–29 25–29 20–25 50–54 25–29 20–25 30–34 25–29 45–49 55–59
>4 and >1 and >2 and >1 and >30 >6 and >1 and >5 and >1 and >25 >30
>4 >1 >1 >0 >2 >3 >0 >2 >0 >1 >1
Data analysis Drawing on Stake’s (1995) case study research design, the data were collected and analysed simultaneously and relied on inductive thematic analysis. Each interview transcript was reviewed using a thematic analysis technique drawn from Ryan and Bernard (2003) that ensured some flexibility in data coding. This process was particularly important in allowing a more comprehensive picture to emerge. All transcripts were manually coded as there was a manageable volume of data. Given that the data were in qualitative form, each ‘unit of meaning’ was identified through key storylines in each transcript. Although time-consuming, to ensure reliability of the analytic process and thus the emerging themes, a fellow qualitative researcher was requested to review a sample of the transcripts and code them independently. We discussed any differences, revised categories and recoded extracts where appropriate. Using these methods, extracts from the data were clustered under four significant thematic categories. To ensure authenticity of data interpretation, two focus groups were held with the sample where findings of the study were shared. This member checking process provided a useful method to ensure trustworthy construal of the data (Bazeley, 2013).
<5 <2 <3 <2 <7 <2 <6 <2
and and and and and and and and and and and
<5 <2 <2 <1 <3 <4 <1 <3 <1 <2 <2
and that their role in assisting critically ill patients had developed into a meaningful part of their jobs. However, a lack of familiarity with the full range of duties undertaken by an ICU nurse, typically performed in conjunction with others, gave rise to feelings of inequality. Perceptions of unfair task allocation were rife: ‘I came to work and was sent to a different ICU [to the previous day]. The manager told me to do the observations for all the patients. I was so upset. Permanent staff work together but I was left alone’ (Mariam, RN). ‘When I come to the unit, I get two patients compared to the permanent nurses who just get one. I’m [for]ever tired’ (Thato, RN). In this regard, lack of explanation and poor communication from the ICU manager lay at the heart of the agency nurses’ unhappiness. It appeared that agency nurses in this study, regardless of category, had been allocated seemingly mundane individual activities. However, the range of activities undertaken by ICU nurses include very specialised responsibilities and ultimate accountability for patient care; without highly specialised training, including the assessment of critical health symptoms and knowledge of appropriate technology, even an agency RN is unable to perform the required tasks.
Findings
Self-efficacy and competence
The findings are clustered under four key themes: clinical allocation; self-efficacy and competence; feedback and support; and being the outsider.
The system of constant rotation across the ICUs led to nurses feeling hindered in their learning and stymied in the development of their competence:
Clinical allocation Agency staff perceived that the practice of allocating them to their duties occurred in a first come-first served manner. Consequently, being assigned to an ICU was much of a lottery for agency nurses:
‘What are you going to learn in one day? It’s like any other job, you won’t know things at first; but if you work in one place for a week, then at least some knowledge will be retained’ (Redi, EN). ‘There are suspicions in the team about your competence; that you are unable to do the task. As an agency nurse, you might not be allowed to touch the drug box, for example’ (Lily, EN).
‘I don’t work at the same ICU every day. For the past year, I’ve worked in all the ICUs at the hospital’ (Mariam, RN). ‘Sometimes you’re here [in this ICU] and then you come back 3 weeks later to another unit’ (Thato, RN).
Agency nurses often arrived at their assigned ICUs with minimal to no prior training or orientation and believed they could perform better if they had been exposed to some level of preparation. The general sentiment among the nurse participants was that:
Despite the challenges of being allocated to an ICU in this haphazard fashion, agency nurses felt privileged to work in the stressful environment as the following excerpts illustrate:
‘[We are made to feel that] we know absolutely nothing and it’s unfair towards others who must take us’ (Cecilia, EN).
‘Nursing in the ICU is not easy, its traumatising. But if you have someone to motivate you, you fall in love with the job’ (Hayley, EN). ‘Being asked to come back to the ICU was very, very motivating for me. This is where I want to work permanently’ (Beauty, ENA). Participants believed that, despite the relatively short and sporadic periods spent in the ICUs, they were drawn to intensive care
The lack of specialist knowledge required in the ICU was a source of frustration to the agency nurses themselves: ‘A lot of agency staff are from other parts of the country that have no ICU that provides training. Give us some time to learn’ (Betty, ENA). However, the nature of the ICU is that there was often no time for formal training as the ICU nurse was expected to do all the
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required clinical tasks. Even agency nurses with significant years of experience felt at sea within their allocated ICUs:
Fortunately, several agency nurses also had positive experiences with their ICU managers:
‘I have past paediatric ICU knowledge, so I have some experience, but I don’t have in-depth knowledge of adult ICUs. I’m just starting to build up that knowledge’ (Mariam, RN). ‘They leave me just because I’m an experienced nurse. But I don’t know everything in ICU’ (Cecilia, EN).
‘I had a needle prick incident and the manager organised everything and even checked up on me weeks’ later’ (Beauty, ENA). ‘He’s very patient: he’s a top guy. He walked me through the procedure step-by-step. I was very happy. I asked him: ‘‘Can I please, please come back here tomorrow?”’ (Hayley, EN). ‘Most managers are fantastic because they ask you ‘‘Have you been here before? Can you do certain things? If not, you can just ask”’ (Redi, EN).
Agency nurses, with a keen sense of their own limitations, had also indicated explicitly to the ICU manager when they felt out of their depth professionally: ‘They allocated me to a very sick patient and I said to the manager ‘‘this is outside my scope of practice. I don’t know how to use the machines that they need”. Then they took me off that patient’ (Elsie, EN). However, the strategy of simply removing an agency nurse from a patient because she had no prior knowledge of the procedural process to be followed had an unintended negative consequence: ‘I asked what I must do as I haven’t ever taken someone off dialysis. The manager said ‘‘fine, just leave it”. So, now I still don’t know what to do or where to start’ (Thato, RN). Despite the experience levels of some of the older participants, the skills gap between agency and permanent ICU nurses in this study was acknowledged and apparent to all. As this deficit was difficult to address – and made more so given the relentless work demands – agency staff experienced an ongoing erosion of their self-belief in their ability to perform the required tasks. Feedback and support As agency nurses report directly to the ICU managers after being allocated to the specific ICU, the interactions between these two parties set the tone for what would follow. When asked what role ICU managers should play, agency nurses replied that visibility, availability and on-the-job training were key elements: ‘The role of the manager is make sure that everyone is happy when they’re working. When staff ask questions, they must be able to explain to them rather than saying ‘‘you’re asking too much”’ (Noni, EN). ‘They need to be working alongside the nurses. This can help a lot, to be hands-on. If there’s new equipment, you need to know how it works. As an agency nurse, I go to the manager to find out as she’s the first port of call’ (Mariam, RN). ‘The manager should take me around and explain the status of the patients. She should show me things I’m supposed to know’ (Elsie, EN). ‘It is their role to motivate staff. When you get those comments: ‘‘study further”, ‘‘you did well today”, it boosts your self-esteem’ (Redi, EN). Actual on-the-job experiences between agency nurses and ICU managers painted a somewhat mixed picture. There were reported instances of extremely demotivating interactions, such as public reprimands and lack of professional support: ‘[When she is] shouting at you – ‘look here, what have you done?’ – you feel like you want to leave what you’re doing. They let you down by not encouraging you’ (Betty, ENA). ‘One time I was working night shift and instead of guiding me with the critically ill patient whose vital signs were very low during the day, I got shouted at and went home very dejected. The next day I didn’t come to work’ (Hayley, EN).
As difficult as it might be for agency staff who do not have a sense of permanent placement or the requisite skills to work in ICU, it appeared to be an environment where they had the prospect of acquiring the knowledge of new processes and procedures. However, the opportunity to learn and remain motivated was influenced by the workplace culture – as shown in the examples of feedback and support – that was created by ICU managers. Being the outsider Just as ICU managers often set the tone for the level of collaboration with agency nurses in their ICUs, so the work relationships between agency and permanent nurses typically followed suit. It was in these day-to-day interchanges that agency nurses felt the lack of inclusion most keenly. These experiences centred on three aspects: trust, belonging and acceptance: ‘At the beginning, the permanents monitor you all the time because they don’t really trust you. I understand you’re new but how committed can you be if you feel you’re not trusted?’ (Thato, RN). ‘I get treated different because I’m an agency. You feel you don’t belong in the team’ (Dorothy, EN). ‘The permanents shouldn’t look down upon us, like we don’t know anything. Talk to us as human beings. Talk to us, tell us what to do. We do have feelings’ (Lily, EN). ‘The senior nurses, they were junior nurses before, so they know what it’s like to be in my shoes. Maybe they would treat me differently if I was permanent. I wouldn’t do that to anyone else if I was permanent’ (Noni, EN). As is clear from the excerpts, the feeling of being an outsider had an impact on the self-esteem of the agency nurse. These instances are likely to undermine the confidence of the affected staff and may potentially affect the level of patient care. Where interactions between agency and permanent nurses were more effective, agency nurses felt a sense of fitting in: ‘We are working as a team, and you can ask questions if you want to. Teamwork is very important’ (Dorothy, EN). ‘Positive ones make you feel like you belong. I pray almost every day to get someone who is helpful’ (Noni, EN). Issues of inclusivity and teamwork surfaced in the accounts of agency nurses in terms of their relationships with permanent ICU nurses. There appeared to be a perception among the sample that, due to their very status as temporary workers, agency nurses were discounted from being accepted as part of the team. Discussion Findings from the study showed that the inherent challenges of the agency nurses’ experiences of the ICU were haphazard clinical allocation, perceived unfair task allocation, a lack of requisite skills, the absence of formal ICU experience and feelings of exclusion from the ICU team. Positive aspects of the agency nurse experience
Please cite this article as: L. Ronnie, Us and them: Experiences of agency nurses in intensive care units, Intensive & Critical Care Nursing, https://doi.org/ 10.1016/j.iccn.2019.102764
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included feedback and support from permanent staff including ICU managers and instances of belonging and acceptance. These findings are important for ICU managers and nurse managers as they provide insights for the improvement of agency nurses’ training and development, workplace relationships, and engagement. A common finding, confirmed in this study, has been the need for ongoing training and professional development of ICU agency nurses (Hass et al., 2006; Matlakala et al., 2015). Indeed, Rispel and Moorman (2015) found that while ICU managers would complain about the sub-optimal performance of their temporary staff, they spent little to no time on induction processes to orientate or prepare agency nurses, which Manias et al. (2003) discovered to be vital to patient care. Although mixed findings regarding relationships between agency nurses and ICU managers were reported in this study, the recommendation to implement orientation programmes appears pertinent and would be welcomed by agency nurses. During these sessions, agency nurses should be reminded about potentially unsafe practices when functioning beyond the scope of their own practice. This discussion would be particularly pertinent for the more junior nurses who, under normal circumstances, would be precluded from working in an ICU. These suggestions, however, do not absolve nurse placement agencies of their responsibility for the training and ongoing development of their nursing staff. Members of the Allied Healthcare Association of South Africa (AHASA), the association body for nurse placement agencies, must ensure that their staff are fully trained and registered with the SANC. Furthermore, as Manias et al. (2003) argued, there is a need to build collaborative relationships between hospitals, staffing agencies, and agency nurses to address and resolve issues of concern such as these. This study highlighted that even experienced nurses require ongoing education and training to keep up to date with medical knowledge, specialised technology and processes. One of the underlying reasons for the predominantly poor interactions between agency and permanent nurses may be the responsibility laid on nurses with ICU qualifications and experience to supervise nurses without the relevant ICU experience, such as the agency nurses in this study. This creates a further burden for ICU personnel tasked with critical care responsibilities (Matlakala and Botha, 2015). Another factor linked to training and development was the process of clinical allocation which, in this research context, meant that agency nurses experienced ostensibly random assignment to units resulting in a lack of continuity that affected skills development and relationships. Where it is commonplace for agency nurses to work in many different units and hospitals for short spaces of time, they have reported concerns of ‘‘de-skilling”. Hass et al. (2006) identified that agency nurses believe they lose technical competence because they are assigned the simplest tasks that require minimum input. Although participants in this study did not allude to the loss of their skills, they experienced frustration at being assigned menial tasks without the necessary explanatory communication. This discomfort was mostly keenly felt by the three agency nurses with more than 25 years of experience. This practice of preventing non ICU-trained nurses from performing more complex tasks, although entirely consistent with patient care responsibilities in the ICU, has consequences for morale and the professional development of individual nurses and has the potential to negatively impact on the provision of quality healthcare and compromise continuity of care over the medium to long term (Morse et al., 2005). The frequent use of temporary workers adds an element of complexity to the working environment as agency nurses have little time to acclimatise to the culture of the organisation of a particular ICU unit. In addition, the use of ad hoc agency workers can create instability within the nursing team as the relationship
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dynamics constantly change (Chênevert et al., 2016). Savjani et al. (2018) pointed to the environment and culture as the ultimate determinants of quality care in ICUs. Difficult though they may be to quantify, adverse workplace culture and processes may negatively affect nurses, as they are seen to do in this study, in addition to the unique stressors of being temporary staff members. In her critique of ICU leadership where poor participation from leaders featured as the central issue, Rouse (2009) discussed the importance of mentorship and role modelling mechanisms by senior nurses and managers in order to in improve employee morale. Strategies for managing agency staff in similar ways are needed. As confirmed by the findings of this study, agency nurses often report feelings of isolation, of not being part of the team (Hass et al., 2006). Lapalme and Doucet (2018) suggested that nurse managers who want to create more collaboration within their blended workforce, containing temporary and permanent staff, must create a shared identity among the group. This can be effected by leader inclusiveness, distributive justice and nurses’ perception of similarity. Furthermore, they reported that the establishment of a common identity led to increased knowledge sharing among the group. This suggestion is crucial in an environment, such as this research setting, where agency nurses lack the requisite skills and experience to function optimally in the ICU.
Limitations Due to the study’s qualitative design, participants were limited in number. The precarious nature of agency nurses’ employment may have meant they were reluctant to participate in the study. As noted, the role of the agency itself is not a focus of the study. The findings regarding the responsibilities of agency nurses is primarily discussed with regard to ICU managers and nurse managers in the research setting.
Conclusion Hospitals often turn to agency nurses as a means of cost-saving and improved efficiency, trying to align the supply to demand on a daily or weekly basis. The findings of this study, which focussed on the work experiences of agency nurses, point to the importance of their relationships with ICU managers and fellow permanent nurses. ICU managers and nurse managers are therefore encouraged to navigate the nursing shortage in ways that enable quality care for patients, maintain a healthy working environment for staff and are cost effective for hospitals. It is insufficient to employ agency nurses to merely fill employment gaps without addressing the needs of this group. To ensure that patient care is not compromised, ICU managers and nurse managers have a responsibility to ensure a welcoming, inclusive, and nurturing environment for all staff tasked with ICU responsibilities.
Declaration of Competing Interest The author declares that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper
Acknowledgments The author would like to thank Grace Cairns for her assistance during the access and data management phases.
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Funding There were no funding or sources of support for this study. Ethical approval The University of Cape Town Faculty of Health Sciences’ Human Research Ethics Committee granted ethical approval for the study. Ethical approval number: HREC 682/2016. References Allied Healthcare Association of South Africa (AHASA). 2019. About us. http://ahasa. org/about/ (accessed 2019-04-07). Bazeley, P., 2013. Qualitative Data Analysis: Practical Strategies. Sage Publications, London. Berg Jansson, A.B., Engström, A., 2016. Working together: critical care nurses experiences of temporary staffing within Swedish health care. Intensive Crit. Care Nurs. 41, 3–10. Chênevert, D., Jourdain, G., Vandenberghe, C., 2016. The role of high-involvement work practices and professional self-image in nursing recruits’ turnover: a three-year prospective study. Int. J. Nurs. Stud. 53, 73–84. https://doi.org/ 10.1016/j.ijnurstu.2015.09.005. De Beer, J., Brysiewicz, P., Bhengu, B.R., 2011. Intensive care nursing in South Africa. S. Afr. J. Crit Care 27, 6–10. Hass, H., Coyer, F.M., Theobald, K.A., 2006. The experiences of agency nurses working in a London teaching hospital. Intensive Crit. Care Nurs. 22, 144–153. Jakimowicz, S., Perry, L., Lewis, J., 2018. Compassion satisfaction and fatigue: a cross-sectional survey of Australian intensive care nurses. Aust. Crit. Care 31, 396–405. Lapalme, M., Doucet, O., 2018. The social integration of healthcare agency workers in long-term care facilities: a cross-sectional study. Int. J. Nurs. Stud. 82, 106–112. Makombo, T., 2018. Health, in: South Africa Survey. South Africa Institute of Race Relations, Pretoria, pp. 617–736.
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Please cite this article as: L. Ronnie, Us and them: Experiences of agency nurses in intensive care units, Intensive & Critical Care Nursing, https://doi.org/ 10.1016/j.iccn.2019.102764