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Beauvais B, Pradhan R, Ramamonjiarivelo Z, Mileski M, Shanmugam R. When Agency Fails: An Analysis of the Association Between Hospital Agency Staffing and Quality Outcomes. Risk Manag Healthc Policy 2024; 17:1361-1372. [PMID: 38803621 PMCID: PMC11129761 DOI: 10.2147/rmhp.s459840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Accepted: 05/02/2024] [Indexed: 05/29/2024] Open
Abstract
Introduction Staffing is critical to hospital quality, but recent years have seen hospitals grappling with severe shortages, forcing them to rely on contract or agency staff for urgent patient care needs. This shift in staffing mix has raised questions about its impact on quality. Consequently, this study investigated whether the increased use of agency staff has affected healthcare quality in hospitals. Given the limited recent research on this topic, practitioners remain uncertain about the effectiveness of their staffing strategies and their potential impact on quality. Methods Drawing from agency theory, data were obtained from Definitive Healthcare which consolidates information from numerous public access databases pertaining to hospitals such as the American Hospital Association Annual Survey (hospital profile) and the Hospital Value-Based Purchasing Program (quality data). We conducted a cross-sectional study using a multivariable linear regression model (2021-2022) with appropriate organizational and market- level control variables. Quality was measured across eight variables while the independent variable of interest was agency labor cost ratio operationalized as the percentage of net patient revenue consumed by agency labor expense. Results Our results suggested that the employment of agency staff was significantly and negatively associated with six of eight quality measures tested, including the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) star rating, Hospital Compare rating, the hospital Total Performance Score (TPS), and three of the four sub-domains that comprise the TPS: clinical domain score, person and community engagement domain score, and the efficiency and cost reduction score. Discussion Our results indicated that the increased use of agency labor may have a significant negative influence on quality outcomes at the hospital level. Our findings support the premise that interventions that promote full-time staffing may be more supportive of the quality of care delivered as well as patients' perceptions of care.
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Affiliation(s)
- Bradley Beauvais
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Rohit Pradhan
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Zo Ramamonjiarivelo
- School of Health Administration, Texas State University, San Marcos, TX, USA
| | - Michael Mileski
- School of Health Administration, Texas State University, San Marcos, TX, USA
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Djukanovic I, Fagerström C, Schildmeijer K, Tuvesson H. Taking command of continuity-An interview study with agency nurses. Nurs Open 2023; 10:2477-2484. [PMID: 36448325 PMCID: PMC10006664 DOI: 10.1002/nop2.1504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 10/03/2022] [Accepted: 11/16/2022] [Indexed: 12/03/2022] Open
Abstract
AIM The aim of the study was to describe continuity from the perspective of working as an agency nurse (AN). DESIGN Qualitative design was applied using individual semi-structured interviews. METHOD Individual interviews with fifteen registered nurses working at agency companies were conducted in 2020. The interviews were analyzed with thematic analysis. The study followed the guidelines addressed in the COREQ (Consolidated Criteria for Reporting Qualitative Research) framework. RESULTS Thematic analysis yielded one theme - standing strong and taking command - and four categories: being competent and experienced, being prepared and at ease, ensuring an unbroken chain of care, and belonging on my own terms. The categories illustrated the engagement, professionalism, and natural leadership showed by the ANs to uphold quality and continuity.
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Affiliation(s)
- Ingrid Djukanovic
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden
| | - Cecilia Fagerström
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden.,The Research Section, Region Kalmar County, Kalmar, Sweden
| | | | - Hanna Tuvesson
- Faculty of Health and Life Sciences, Linnaeus University, Kalmar, Sweden.,Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
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Berg Jansson A, Engström Å. Working together: critical care nurses experiences of temporary staffing within Swedish health care: A qualitative study. Intensive Crit Care Nurs 2017; 41:3-10. [PMID: 28209430 DOI: 10.1016/j.iccn.2016.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 07/18/2016] [Accepted: 08/19/2016] [Indexed: 11/17/2022]
Abstract
OBJECTIVES The aim of this study is to describe critical care nurses (CCN's) experiences of working with or as temporary agency staff. RESEARCH METHODOLOGY This explorative qualitative study is based on interviews with five agency CCNs and five regular CCNs, a total of ten interviews, focusing on the interviewees' experiences of daily work and temporary agency staffing. The interviews were analysed manually and thematically following an inductive approach. FINDINGS Four themes that illustrate both similarities and differences between regular and temporary agency CCNs emerged: "working close to patients versus being responsible for everything", "teamwork versus independence", "both groups needed" and "opportunities and challenges". CONCLUSION The study findings illustrate the complexity of the working situation for agency and regular staff in terms of the organisation and management of the temporary agency nurses and the opportunities and challenges faced by both groups.
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Affiliation(s)
- Anna Berg Jansson
- Division of Industrial Work Environment, Department of Human Work Science, Luleå University of Technology, Sweden
| | - Åsa Engström
- Division of Nursing, Department of Health Science, Luleå University of Technology, SE-971 87 Luleå, Sweden.
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Cozad MJ, Lindley LC, Mixer SJ. Using Agency Nurses to Fill RN Vacancies Within Specialized Hospice and Palliative Care. Policy Polit Nurs Pract 2016; 17:147-155. [PMID: 27683508 PMCID: PMC5127722 DOI: 10.1177/1527154416671711] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of agency nurses offers flexibility in filling registered nurse (RN) openings during times of shortage, yet little is known about their use in specialized palliative care. In an effort to fill this knowledge gap, this study determined whether significant relationships existed between full-time and part-time RN vacancies and the use of agency RNs within specialized hospices that deliver perinatal end-of-life care to women and their families in the event of miscarriage, ectopic pregnancy, or other neonatal complications resulting in death. This study used data from the 2007 National Home and Hospice Care Survey and multivariate regression methods to estimate the association between RN vacancies and agency RNs use. Approximately 13% of perinatal hospices in 2007 used agency nurses. Increases in full-time RN vacancies are associated with a significant increase in the use of agency RNs, while part-time RN vacancies are associated with a significant decrease in agency RNs. These results suggest that full-time agency RNs were used as a supplemental workforce to fill vacancies until the full-time position is recruited. However, for part-time vacancies, the responsibilities of those positions shifted onto existing staff and the position was not filled.
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Affiliation(s)
- Melanie J. Cozad
- Assistant Professor, Department of Health Services Policy and Management, Center for Effectiveness Research in Orthopedics, University of South Carolina, 915 Greene Street, Columbia, SC 20687, Primary Phone: 757-613-1569, Alternate phone: 803-777-9331
| | - Lisa C. Lindley
- Assistant Professor, University of Tennessee, College of Nursing, 1200 Volunteer Blvd., Knoxville, TN 37996, (865) 974-0653
| | - Sandy J. Mixer
- Associate Professor, University of Tennessee, College of Nursing, 1200 Volunteer Blvd., Knoxville, TN 37996, (865) 974-0653
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Kehyayan V, Hirdes JP, Tyas SL, Stolee P. Predictors of Long-Term Care Facility Residents’ Self-Reported Quality of Life With Individual and Facility Characteristics in Canada. J Aging Health 2015; 28:503-29. [DOI: 10.1177/0898264315594138] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: Identify predictors of long-term care (LTC) facility residents’ self-reported quality of life (QoL). Method: QoL of a convenience sample of 928 residents from 48 volunteer LTC facilities across six Canadian provinces was assessed using the inter–Resident Assessment Instrument (interRAI) Self-Report Nursing Home Quality of Life Survey. Multivariate regression models were used to identify predictors. Results: In logistic regression modeling, residents who were religious and socially engaged, had a positive global disposition, or resided in rural, private, or municipal facilities were less likely to report low QoL. Those with post-secondary education and who were dependent on activities of daily living were more likely to report low QoL. These factors, except for religiosity and residence in municipal facilities, were significant in generalized estimating equation (GEE) modeling. Discussion: QoL is significantly associated with select resident and LTC facility characteristics with implications for improving residents’ QoL and LTC facility programming, and guiding future research and social policy development.
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Rispel LC, Moorman J. The indirect costs of agency nurses in South Africa: a case study in two public sector hospitals. Glob Health Action 2015; 8:26494. [PMID: 25971399 PMCID: PMC4430684 DOI: 10.3402/gha.v8.26494] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 02/17/2015] [Accepted: 02/17/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Globally, flexible work arrangements - through the use of temporary nursing staff - are an important strategy for dealing with nursing shortages in hospitals. OBJECTIVE The objective of the study was to determine the direct and indirect costs of agency nurses, as well as the advantages and the problems associated with agency nurse utilisation in two public sector hospitals in South Africa. METHODS Following ethical approval, two South African public sector hospitals were selected purposively. Direct costs were determined through an analysis of hospital expenditure information for a 5-year period from 2005 until 2010, obtained from the national transversal Basic Accounting System database. At each hospital, semi-structured interviews were conducted with the chief executive officer, executive nursing services manager, the maternity or critical care unit nursing manager, the human resource manager, and the finance manager. Indirect costs measured were the time spent on pre-employment checks, and nurse recruitment, orientation, and supervision. All expenditure is expressed in South African Rands (R: 1 USD=R7, 2010 prices). RESULTS In the 2009/10 financial year, Hospital 1 spent R38.86 million (US$5.55 million) on nursing agencies, whereas Hospital 2 spent R10.40 million (US$1.49 million). The total estimated time spent per week on indirect cost activities at Hospital 1 was 51.5 hours, and 60 hours at Hospital 2. The estimated monetary value of this time at Hospital 1 was R962,267 (US$137,467) and at Hospital 2 the value was R300,121 (US$42,874), thus exceeding the weekly direct costs of nursing agencies. Agency nurses assisted the selected hospitals in dealing with problems of nurse recruitment, absenteeism, shortages, and skills gaps in specialised clinical areas. The problems experienced with agency nurses included their perceived lack of commitment, unreliability, and providing sub-optimal quality of patient care. CONCLUSION Hospital managers and policy-makers need to address the effective utilisation of agency nurses and quality of patient care in tandem.
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Affiliation(s)
- Laetitia C Rispel
- Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
| | - Julia Moorman
- Department of Community Health, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Olojede OI, Rispel LC. Exploring the characteristics of nursing agencies in South Africa. Glob Health Action 2015; 8:27878. [PMID: 25971401 PMCID: PMC4430690 DOI: 10.3402/gha.v8.27878] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2015] [Revised: 03/23/2015] [Accepted: 03/24/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Nursing agencies are temporary employment service providers or labour brokers that supply nurses to health establishments. OBJECTIVE This study was conducted to determine the characteristics of nursing agencies and their relationship with clients in the health sector. METHODS During 2011, a cross-sectional national survey of 106 nursing agencies was conducted. After obtaining informed consent, telephone interviews were conducted with a representative of the selected nursing agency using a pretested structured questionnaire. Questions focused on the following: ownership, date of establishment, province of operation, distribution of clients across private and public health facilities; existence of a code of conduct; nature of the contractual relationship between nursing agencies and their clients, and numbers and cadres of nurses contracted. The survey data were analysed using STATA(®) 12. RESULTS Fifty-two nursing agencies participated in the survey, representing a 49% response rate. The study found that 32 nursing agencies (62%) served private-sector clients only, which included private hospitals, homes for elderly people, patients in private homes, and private industry/company clinics, and only four (8%) of the agencies served the public sector only. Twenty-seven percent of nursing agencies provided services to homes for elderly individuals. Nursing agencies were more likely to have contracts with private-sector clients (84%) than with public-sector clients (16%) (p = 0.04). Although 98% of nursing agencies reported that they had a code of conduct, the proportion was higher for private-sector clients (73%) compared to public-sector clients (27%). In terms of quality checks and monitoring, 81% of agencies agreed with a statement that they checked the nursing council registration of nurses, 82% agreed with a statement that they requested certified copies of a nurse's qualifications. Only 21% indicated that they conducted reference checks of nurses with their past employers. CONCLUSIONS Nursing agencies should enhance their quality assurance mechanisms when engaging contracted staff. Overall, the study findings suggest the need for improved governance and management of nursing agencies in South Africa.
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Affiliation(s)
- Omolola I Olojede
- Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Laetitia C Rispel
- Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
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Rispel LC, Angelides G. Utilisation and costs of nursing agencies in the South African public health sector, 2005-2010. Glob Health Action 2014; 7:25053. [PMID: 25537936 PMCID: PMC4275649 DOI: 10.3402/gha.v7.25053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 08/23/2014] [Accepted: 08/26/2014] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Globally, insufficient information exists on the costs of nursing agencies, which are temporary employment service providers that supply nurses to health establishments and/or private individuals. OBJECTIVE The aim of the study was to determine the utilisation and direct costs of nursing agencies in the South African public health sector. DESIGN A survey of all nine provincial health departments was conducted to determine utilisation and management of nursing agencies. The costs of nursing agencies were assumed to be equivalent to expenditure. Provincial health expenditure was obtained for five financial years (2005/6-2009/10) from the national Basic Accounting System database, and analysed using Microsoft Excel. Each of the 166,466 expenditure line items was coded. The total personnel and nursing agency expenditure was calculated for each financial year and for each province. Nursing agency expenditure as a percentage of the total personnel expenditure was then calculated. The nursing agency expenditure for South Africa is the total of all provincial expenditure. The 2009/10 annual government salary scales for different categories of nurses were used to calculate the number of permanent nurses who could have been employed in lieu of agency expenditure. All expenditure is expressed in South African rands (R; US$1 ∼ R7, 2010 prices). RESULTS Only five provinces reported utilisation of nursing agencies, but all provinces showed agency expenditure. In the 2009/10 financial year, R1.49 billion (US$212.64 million) was spent on nursing agencies in the public health sector. In the same year, agency expenditure ranged from a low of R36.45 million (US$5.20 million) in Mpumalanga Province (mixed urban-rural) to a high of R356.43 million (US$50.92 million) in the Eastern Cape Province (mixed urban-rural). Agency expenditure as a percentage of personnel expenditure ranged from 0.96% in KwaZulu-Natal Province (mixed urban-rural) to 11.96% in the Northern Cape Province (rural). In that financial year, a total of 5369 registered nurses could have been employed in lieu of nursing agency expenditure. CONCLUSIONS The study findings should inform workforce planning in South Africa. There is a need for uniform policies and improved management of commercial nursing agencies in the public health sector.
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Affiliation(s)
- Laetitia C Rispel
- Centre for Health Policy & Medical Research Council Health Policy Research Group, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa;
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Seo S, Spetz J. Demand for Temporary Agency Nurses and Nursing Shortages. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2014; 50:216-28. [DOI: 10.1177/0046958013516583] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There is an ongoing debate about the reasons for the growth of temporary employment of registered nurses (RNs). Some argue that efficiency incentives to increase flexibility and reduce labor costs are the principal cause, while others point to shortages of RNs as the stronger determinant. Using hospital-level data from California’s Office of Statewide Health Planning and Development, we find a significant trend of increasing demand for agency nurses during the years of RN shortage. Demand rose with inpatient days, patient demand fluctuation, and the level of fringe benefits. Competition between hospitals and unionization, however, did not affect hospitals’ demand for temporary RNs.
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Affiliation(s)
- Sukyong Seo
- Department of Health Policy Research, Korea Institute for Health and Social Affairs, Seoul, South Korea
| | - Joanne Spetz
- University of California, San Francisco, CA, USA
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Abstract
Use of outsourced nurses is often a stop-gap measure for unplanned vacancies in smaller healthcare facilities such as long-term acute-care hospitals (LTACHs). However, the relationship of utilization levels (low, medium, or high percentages) of nonemployees covering staff schedules often is perceived to have negative relationships with quality outcomes. To assess this issue, the authors discuss the outcomes of their national study of LTACH hospitals that indicated no relationship existed between variations in percentage of staffing by contracted nurses and selected outcomes in this post-acute-care setting.
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HENNERBY CATHY, JOYCE PAULINE. Implementation of a competency assessment tool for agency nurses working in an acute paediatric setting. J Nurs Manag 2011; 19:237-45. [DOI: 10.1111/j.1365-2834.2011.01223.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Use of temporary nurses and nurse and patient safety outcomes in acute care hospital units. Health Care Manage Rev 2010; 35:333-44. [DOI: 10.1097/hmr.0b013e3181dac01c] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Castle NG. Use of Agency Staff in Nursing Homes. Res Gerontol Nurs 2009; 2:192-201. [DOI: 10.3928/19404921-20090428-01] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Accepted: 03/17/2009] [Indexed: 11/20/2022]
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Castle NG. Perceived Advantages and Disadvantages of Using Agency Staff Related to Care in Nursing Homes: A Conceptual Model. J Gerontol Nurs 2009; 35:28-36. [DOI: 10.3928/00989134-20090101-03] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Jackson D. Editorial: Organising care delivery: facilitator or impediment to supportive working relationships in nursing. J Clin Nurs 2008; 17:701-2. [DOI: 10.1111/j.1365-2702.2007.02246.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Castle NG, Engberg J, Aiju Men. Nurse Aide Agency Staffing and Quality of Care in Nursing Homes. Med Care Res Rev 2007; 65:232-52. [DOI: 10.1177/1077558707312494] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Data from a large sample of nursing homes are used to examine the association between use of nurse aide agency staff and quality. Agency use data come from a survey conducted in 2005 ( N = 2,840), and the quality indicators come from the Nursing Home Compare Web site. The authors found a nonlinear relationship between nurse aide agency levels and quality; however, in general, higher nurse aide agency levels were associated with low quality. The results have policy and practice implications, the most significant of which is that use of nurse aide agency staff of less than 14 full-time equivalents per 100 beds has little influence on quality, whereas nurse aide agency staff of more than 25 full-time equivalents per 100 beds has a substantial influence on quality.
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Affiliation(s)
| | | | - Aiju Men
- University of Pittsburgh, Pittsburgh, Pennsylvania
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FitzGerald M, McMillan M, Maguire JM. Nursing from the casual pool: Focus group study to explore the experiences of casual nurses. Int J Nurs Pract 2007; 13:229-36. [PMID: 17640244 DOI: 10.1111/j.1440-172x.2007.00632.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The use of flexible non-contract nursing staff is increasing in Australia and in other countries where there is currently a nursing shortage. There is sparse empirical evidence relating to the experience of these nurses. This focus group study with six groups of enrolled and registered nurses in one regional health authority in New South Wales reports on the challenges and rewards of working through the casual pool. The textual data were coded and reported in themes and subthemes; the overarching theme is balance of social and professional life, while subthemes are social politics, nursing work and professional performance. The results reveal that nurses who work from the casual pool have insight into the work environment and culture of clinical teams that is untapped formally. They have little or no chance to provide clinical teams with feedback or receive feedback on their own performance. The consequence of this study has been the development of a two-way performance intervention to promote high standards of care from nurses who work from the casual pool and the promotion of safe clinical environments and cultures.
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Stone PW, Clarke SP, Cimiotti J, Correa-de-Araujo R. Nurses' working conditions: implications for infectious disease. Emerg Infect Dis 2005; 10:1984-9. [PMID: 15550212 PMCID: PMC3328993 DOI: 10.3201/eid1011.040253] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Staffing patterns and nurses' working conditions are risk factors for healthcare-associated infections as well as occupational injuries and infections. Staffing shortages, especially of nurses, have been identified as one of the major factors expected to constrain hospitals' ability to deal with future outbreaks of emerging infections. These problems are compounded by a global nursing shortage. Understanding and improving nurses' working conditions can potentially decrease the incidence of many infectious diseases. Relevant research is reviewed, and policy options are discussed.
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Affiliation(s)
- Patricia W Stone
- Columbia University School of Nursing, New York, New York 10032, USA.
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