Despite federal regulation and extensive state oversight, many of the nation’s 17,000 nursing homes still provide poor quality of care (Institute of Medicine, 2001). No panacea likely exists for improving this, but most experts in this area would cite nursing home staff as essential change agents. However, our understanding of what staff are needed to help provide high-quality care is still underdeveloped; for example, the impact of agency staff is unknown. Our understanding in this area consists almost entirely of the effects of staffing levels (Harrington & Swan, 2003) and turnover (Castle & Engberg, 2007). That is, high staffing levels and low turnover are associated with high quality of care. Our understanding of what staff are needed to help provide high-quality care may be further improved by examining agency staff. Agency staff are used by many nursing homes, yet few studies have examined the impact of agency staff use.
Agency staff are workers who belong to a firm that subcontracts their services to another firm, including nursing homes, assisted living, and home care. These firms are often called staffing agencies, or more simply, agencies (Ward, Grimshaw, Rubery, & Beynon, 2001). Agency staff are hired by nursing homes to work on a temporary basis. Agency staff can be useful for nursing homes. For example, a nursing home experiencing an unexpected shortage of staff, due to turnover or absenteeism, can use agency staff to quickly fill these available positions. In addition, agency staff could influence quality of care. However, to date, little research has examined why nursing homes use agency staff and their relationship with quality of care.
Following a general perception in the literature, some recent research has shown that higher numbers of agency staff are associated with low quality of care (Castle & Engberg, 2007). The findings of this prior empirical study need to be interpreted carefully. The association with low quality identified was for very high use of agency nurse aides (NAs) only. No significant findings were observed for licensed practical nurses (LPNs), and contrary findings were observed for RNs, with more agency RNs associated with high quality. These findings may represent the complexity of agency staff use in nursing homes.
In the current research, using responses from several thousand nursing homes and the hospital-based literature, the advantages and disadvantages of using agency staff are examined, and a conceptual model showing potential reasons for the relationship between agency use and quality is described.
Proposed Conceptual Model
No previous conceptual model was identified in the literature specific to agency staff use in nursing homes. Therefore, the current conceptual model was constructed using information from the literature. A limited amount of this literature exists for nursing homes, so the more extensive hospital literature was also used in developing this conceptual model. Using the hospital literature in this way has some limitations because hospital staffing levels, care processes, and patients can be very different from those in nursing homes. Nevertheless, in both settings, agency staff and permanent staff have to work together, and some of the interactions may be similar. In addition, in both hospital and nursing home settings, facility operations may be influenced in the same way via the use of agency staff (e.g., agency staff may have lower productivity). The proposed conceptual model showing potential reasons for the relationship between agency use and quality is shown in the Figure. The model shows that agency staff likely influence other staff, facility operations, and residents.
Figure. Conceptual Model Showing Potential Reasons for the Relationship Between Agency Use and Quality of Care in Nursing Homes. + = Advantages; – = Disadvantages.
Influence on Other Staff
Most nursing homes use consistent staff assignments, whereby staff consistently work on the same unit (National Center for Health Statistics, 2004). This can promote familiarity with residents and teamwork among staff. Regarding the influence agency staff have on other staff, one common theme in the literature was that an increase in the number of inexperienced workers may decrease teamwork (Bloom, Alexander, & Nuchols, 1997; Deitzer, Wessell, Myles, & Trimble, 1992; Elson, 1995; Manias, Aitken, Peerson, Parker, & Wong, 2003). As Manias et al. (2003) described, it is “hard for them [agency workers] to belong to a team because they are not always there” (p. 464).
Agency staff may also increase the workload for remaining staff (Amenta, 1977). This is because agency staff may not be able to perform all of the same tasks as permanent staff. As Manias et al. (2003) reported, “the agency nurse cannot do 100% of the work that a normal permanent staff member might do” (p. 464), or as Amenta (1977) reported, “two temporaries equal one regular” (p. 25). Agency staff, for example, may not be familiar with equipment to lift residents or with specific routines preferred by some residents. For several reasons, such as reassignment of permanent staff or permanent staff’s receiving lower pay than agency staff, morale of the permanent staff may also be lowered (Deitzer et al., 1992). In these cases, Schubert (1995) found indifference of permanent staff for the facility and the work.
Agency workers, because of their unfamiliarity with the organization and residents, also need increased supervision (Deitzer et al., 1992; Wu & Lee, 2006). Further, because agency workers are frequently replaced, their use is associated with inconsistent work groups (Jones, Yancer, McGinley, & Galbraith, 1990).
Influence on Facility Operations
For the facility, important operational considerations include costs, staff productivity, administrative burden, staff turnover, and staff absenteeism. The use of agency staff can be expensive, as facilities pay a premium for using agency workers (Bird, 2000; Braddy, Washburn, & Carroll, 1991; Daniel, Garman, Grady, & Phillips, 2006; Deitzer et al., 1992; Merolle, 1988; Spetz, 2005). As Bird (2000) noted, “They [agency staff] are now an expensive but essential part of the workforce” (p. 27). This expense can divert dollars from care, or from the facility’s hiring more staff.
A hidden cost may also be lower overall productivity (Bloom et al., 1997; Jalonen, Virtanen, Vahtera, Elovainio, & Kivimaki, 2006; Sayer, 1990). Using agency staff can be convenient for a facility. However, in many cases, temporary staff reassignments occur when agency staff are used. That is, agency staff are often placed on units where the resident case mix is lowest (Bliss & Alsdorf, 1992; Hass, Coyer, & Theobald, 2006). In turn, facility staff ordinarily working in these positions are given other resident assignments (Bliss & Alsdorf, 1992). This continuous reassignment of staff can add to the administrative burden of the facility (e.g., for the director of nursing) and can stress permanent staff (Bliss & Alsdorf, 1992). Overall, this can lead to decreased staff commitment (Prescott & Langford, 1981), disrupted routines (Merolle, 1988), and lower professionalism (Manias et al., 2003). As noted above, agency workers also need increased supervision (e.g., by unit directors and shift supervisors). This overall influence on permanent staff, as a result of using agency staff, may also predispose the facility to higher permanent staff turnover (Jones et al., 1990; Prescott, 1986; Wu & Lee, 2006) and higher absenteeism rates (Jones et al., 1990).
Influence on Residents
Several potential limitations of using agency staff are also evident for resident care, including interference with continuity of care, unfamiliarity with care practices, and resident psychological distress. Agency staff are often not familiar with the residents, which can interfere with continuity of care and lead to adverse resident outcomes or errors in providing care (Buchan & Seccombe, 1995; Deitzer et al., 1992; Grinspun, 2002; Hughes & Marcantonio, 1991; Inman, Blumenfeld, & Ko, 2005; Jones et al., 1990). In addition, agency staff are likely unfamiliar with at least some facility practices, which can weaken standards of care (Sayer, 1990). Care by unfamiliar agency staff may also cause psychological distress for some residents (Inman et al., 2005). Stable staff relationships with residents are beneficial to resident health (Maas et al., 2004; Pennington, Scott, & Magilvy, 2003). Resident relationships with staff have been shown to be associated with quality of life and care (Gaugler & Ewen, 2005).
Market and organizational characteristics were added to this conceptual model. These factors are included because they have shown an extremely robust association with quality of care in prior nursing home studies, including those examining staffing characteristics, and as some authors have argued, influence the context of care (Castle & Engberg, 2005). Despite the disadvantages of using agency staff, they do increase the number of caregivers in a facility (Lemow, 2004). Although these additional caregivers may not provide the same care as permanent staff, this care still may be better than not having these workers at all. This is also shown in the conceptual model. Both advantages (shown as +) and disadvantages (shown as –) are shown in the model (Figure).
Data and Methods
Source of Data
Data used in this investigation came from a survey of nursing home administrators conducted during January-March 2007. This survey was sent to 6,000 nursing homes, with 3,946 returned (66% response rate). This large sample was used to increase the representativeness of the findings.
The mailing sample was created by using information from the Online Survey, Certification, and Recording (OSCAR) data. (These data are described in detail by several authors, including Castle and Engberg, 2005, and Harrington and Swan, 2003). Small nursing homes (fewer than 30 beds) and hospital-based facilities were excluded from the sample because their staffing characteristics are often highly variable and differ from other kinds of nursing homes (Castle & Engberg, 2007). However, with the exception of these exclusions, all nursing homes in the United States were included in the sampling frame. From this sample, facilities were randomly selected to receive a questionnaire.
The survey was short, focused, and primarily collected information on agency staffing characteristics for NAs, LPNs, and RNs. The survey was pilot tested through in-person interviews with 5 nursing home administrators. These administrators agreed the survey items were relevant and could be completed easily. Nevertheless, they did suggest several wording changes for a few items. After making these wording changes, the survey was mailed to 100 nursing home administrators, and the returned surveys were examined for nonresponse to items and for any possible misinterpretation of items. The good response rate achieved can be attributed to the short and focused nature of the survey.
In the questionnaire, the first section asked background questions, such as the gender and age of the nursing home administrator (5 items). The next section asked about aggregate facility-level staffing levels and turnover rates (7 items). It then asked about the use of agency staff (i.e., whether or not the facility had used any agency staff during 2006) and the degree of agency staff use (i.e., if used, the average number of full-time equivalent [FTE] staff used in 2006) (7 items). Finally, two open-ended questions asked administrators to list advantages and disadvantages of using agency staff.
Descriptive analyses are presented for the facility characteristics of the sample (e.g., mean bed size). Descriptive analyses are also presented for aggregate facility-level staffing levels, turnover rates, and use of agency staff. The descriptive information was also used to examine nonresponse bias and sample representativeness. These analyses were conducted using Stata® (2005) version 8.2 computer software.
Advantages and disadvantages of using agency staff are presented; that is, comments provided by administrators to the open-ended survey questions asking for advantages and disadvantages of using agency staff are listed. Due to the large number of comments received, all comments are not listed. Rather, the author selected text that was representative of all of the comments received. The comments provide descriptive information on administrators’ opinions of using agency staff.
In addition, all of the comments received were used by the author to examine the tenability of the proposed conceptual model, described above. The concepts included in the conceptual model were listed (e.g., decreased teamwork), and all comments received from the surveys were examined to determine whether they reflected the concepts of the model. The determination of whether the comments reflected concepts in the model was made by the author.
The staffing and facility characteristics of the sample of 3,946 returned nursing home surveys are shown in Table 1. The reported average staffing levels (i.e., average FTE regular RNs, LPNs, and NAs) were not significantly different from those found in the National Nursing Home Survey (National Center for Health Statistics, 2004). The average facility characteristics of respondent facilities (e.g., average daily occupancy rate) were also not significantly different from those in the national OSCAR data. Likewise, using the OSCAR data, respondent facilities were not found to be significantly different from nonrespondent facilities. In general, most items on the questionnaire were answered.
Table 1: Staffing and Facility Characteristics of Nursing Homes Examined (N = 3,946)
Agency staffing characteristics are reported in Table 2. On this questionnaire, 59% of administrators answered “yes” to the question asking if any agency staff (RNs, LPNs, or NAs) were used by the facility in 2006. Overall, average agency staffing use by all nursing homes was low, with rates of 1.2, 1.4, and 2.6 for FTE agency RNs, LPNs, and NAs, respectively, per 100 beds. However, when those facilities that did not use any agency staff in 2006 were excluded, the rates of FTE agency use per 100 beds were 2.3, 3.1, and 4.9, for RNs, LPNs, and NAs, respectively.
Table 2: Agency Staffing Characteristics of Nursing Homes Examined (N = 3,946)
Of the 3,946 surveys returned by administrators, 3,215 (81%) provided comments to the open-ended questions. Some of these administrator comments are listed in Table 3. Almost all administrators providing comments listed both advantages and disadvantages of using agency staff, with 433 (13%) providing only disadvantages and 112 (3%) providing only advantages of using agency staff. However, in almost all cases, the number of disadvantages listed were greater than the number of advantages (i.e., the median number of disadvantages listed was 3, and the median number of advantages listed was 1). No significant differences existed on any variables listed in Table 1 between administrators providing and not providing comments.
Table 3: Comments Provided by Administrators Listing Advantages and Disadvantages of Using Agency Staff
The concepts included in the conceptual model were listed and reconciled with each comment received from the surveys. The results are shown in Table 4. Few advantages of using agency staff were identified by administrators. That is, many administrators reported advantages of using agency staff, but the number of advantages listed was often low. The most commonly reported advantage was to maintain compliance with staffing levels (26% of survey respondents), followed by maintain staffing levels (12%) and have staff available when needed (5%).
Table 4: Advantages and Disadvantages of Using Agency Staff
Regarding the disadvantages of using agency staff identified by administrators, many supported the conceptual model described above. Regarding the potential influence on other staff, increased supervision was listed most often (38%), followed by indifference (37%). Regarding the potential influence on facility operations, expense was listed most often (42%), followed by decreased commitment (26%). Regarding the potential influence on residents, psychological distress was listed most often (23%), followed by continuity of care (18%).
Almost all of the comments received from the administrators supported the proposed conceptual model. One additional area that was mentioned was safety concerns for the residents (13%). Some other comments (<1%) were general statements (e.g., do not like using these staff) and did not support the proposed conceptual model. No other additional comments were made by administrators that were not captured by the proposed conceptual model.
Discussion and Implications
Using the existing literature, including the literature providing general perceptions of agency staff use across care settings, the conceptual model presented (Figure) was developed to represent some of the complex interactions that could occur by using agency staff. Using responses from 3,946 nursing home administrators, the validity of this conceptual model was further examined.
The survey results indicated that administrators view agency staff as having both positive and negative influences on care in nursing homes. However, the negative influences were described more fully in the survey responses. Expense was the most frequently reported disadvantage of using agency staff. Agencies typically charge a premium for using these staff. That is, the nursing home pays extra for the convenience of a quick staffing fix when they are short staffed. Given the comments received on this survey, administrators seemed to think it was necessary to use agency staff to increase staffing levels, but one could speculate that their own cost-benefit calculations concluded that the costs were high, relative to the benefits.
The second most frequently reported disadvantage of using agency staff was increased supervision. This would appear to be the conundrum involved with using agency staff. In most cases, these staff are needed because the facility is short staffed, but using agency staff further increases the burden on regular staff. Thus, it is not surprising that a negative “tone” exists in the literature when regular staff describe agency staff. For example, they are described as “rivals” (Charnley & Arnold, 2006, p. 34) and as increasing “tension” (George, 2003, p. 387).
Overall, the survey results seemed to fit the conceptual model very well. One unexpected finding was the issue of resident safety. Further feedback was not elicited in the survey, but this concern would seem warranted. A worker unfamiliar with a resident may be more prone to medication errors, for example. Thus, to refine the conceptual model, safety should be added to the Residents column.
Of note, examining the results overall, it would appear that it is the use of agency staff that is seen as problematic, and not necessarily the agency staff themselves. It would appear that it is how agency staff are used and the circumstances under which they are used that are most problematic (Stiehl, 2004). The characteristics of agency staff were not examined, but this finding would seem intuitive. It is likely that agency staff differ very little from permanent nursing home staff in terms of experience.
No existing literature has reported on the degree of agency staff use using a large sample of nursing homes. Nevertheless, the large number of facilities that used at least some agency staff was somewhat surprising. This finding is probably a testament to the staffing shortage currently being experienced by all health care facilities. However, the actual use of agency staff is relatively small. The results suggest that nursing homes sporadically use agency staff, and few rely extensively on these staff.
A caution is that the opinions of nursing home administrators should be substantiated in empirical research. However, the study findings suggest that some practice implications may be important. For example, an orientation program for agency staff may be an effective way to help a facility mitigate some of the potential negative influences of using agency staff (i.e., increased supervision, lower productivity, disrupted routines, unfamiliar practices). Careful consideration of agency staff assignment may also be helpful in lowering administrative burden.
As a further practice implication, the findings suggest that continuity of resident care suffers when agency staff are used. Thus, using the same agency staff and consistently assigning them to the same residents may be useful. Still, the additional expense of using agency staff is difficult to mitigate, and as such, a reevaluation of staffing patterns of permanent staff may be a beneficial investment for many facilities.
One limitation of this analysis is that it presents the opinions of nursing home administrators only. Other opinions may come from directors of nursing, permanent staff, and residents themselves. Including these opinions may further refine the conceptual model. A further limitation is that the opinions presented are just that—opinions.
The proposed conceptual model also reflects some of the complexity involved in using agency staff. Nevertheless, the relative weights of the disadvantages (–) and advantages (+) are likely different for different staff (NAs, LPNs, RNs). That is, it may serve us well to move beyond generalizing to all “agency staff” and being more specific to the kind of agency staff used.
This study found that many nursing homes use at least some agency staff. Nursing home administrators view the advantages of agency staff primarily as meeting staffing requirements. Numerous disadvantages were cited, the most common of which is the expense associated with using these staff. Moreover, agency staff may also influence quality of care. If these disadvantages noted by nursing home administrators are verified in empirical analyses, then nursing homes may benefit from more judicious use of agency staff. For example, some benefits may be achieved by reducing reassignment of permanent staff, and some facilities may benefit by decreasing their use of agency staff.
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Staffing and Facility Characteristics of Nursing Homes Examined (N = 3,946)
|Variable||Definition||Mean (or Percent [N])||Standard Deviation|
|RN regular staffing||FTE regular RNs per 100 residents||12.5||9.1|
|LPN regular staffing||FTE regular LPNs per 100 residents||11.2||6.8|
|NA regular staffing||FTE regular NAs per 100 residents||24.8||7.3|
|RN turnover||RN departures for 1 year as a percentage of total positions||33.4% [1,318]||34.2|
|LPN turnover||LPN departures for 1 year as a percentage of total positions||38.9% [1,535]||32.1|
|NA turnover||NA departures for 1 year as a percentage of total positions||63.8% [2,517]||55.2|
|Organizational size||Number of beds||131||91|
|Ownership||For profit or not for profit||58% [2,289]||—|
|Chain membership||Member of a nursing home chain or not||54% [2,131]||—|
|Occupancy||Average daily occupancy rate||87% [3,433]||15|
|Private-pay occupancy||Average daily private-pay occupancy rate||18% ||16|
|Medicaid occupancy||Average daily Medicaid occupancy rate||58% [2,289]||22|
Agency Staffing Characteristics of Nursing Homes Examined (N = 3,946)
|Variable||Definition||Mean (or Percent [N])||Standard Deviation|
|Any use of agency staff|
|RN agency||Used any agency RNs in 2006||28% [1,105]||—|
|LPN agency||Used any agency LPNs in 2006||19% ||—|
|NA agency||Used any agency NAs in 2006||42% [1,657]||—|
|Any agency use||Used any agency staff in 2006 (RN, LPN, NA)||59% [2,328]||—|
|Average agency staffing (all facilities)|
|RN agency||FTE agency RNs per 100 beds||1.2||1.2|
|LPN agency||FTE agency LPNs per 100 beds||1.4||1.6|
|NA agency||FTE agency NAs per 100 beds||2.6||4.2|
|Average agency staffing (including only facilities that used agency staff)|
|RN agency||FTE agency RNs per 100 beds||2.3||1.1|
|LPN agency||FTE agency LPNs per 100 beds||3.1||1.5|
|NA agency||FTE agency NAs per 100 beds||4.9||3.8|
Comments Provided by Administrators Listing Advantages and Disadvantages of Using Agency Staff
|Dependable||Sometimes necessary to keep the doors open|
|Director of nursing does not have to work to fill in.||If you have the same agency, they learn the routine.|
|Available when needed||Meets licensure requirements|
|Replacement for sick staff||Decreased workers comp liability|
|There when you need someone in a pinch||Meeting state staffing levels|
|Keeps us in compliance||No benefit calculations needed|
|Simple charge structure||Can be used on short notice|
|Can become a future employee||Reduces overtime|
|Lack of team cohesion||Behave as though they are unaccountable|
|Poor attitude towards coworkers||Lack of continuity of care|
|Held hostage by agency workers||Do not know the “little” things about residents|
|Lack of caring||Jump in without much training or orientation|
|Cost||Do not have the buy in to our “mission”|
|Customer friendliness||Inconsistent staff|
|Do not know the residents||Not well trained|
|Poor efficiency||Safety concerns|
|Not knowledgeable about the facility||Don’t know families|
|Don’t know staff||Poor documentation|
|Do not know the job||Training for one-time use|
|Higher staff turnover||Don’t know what to do|
|Lack of personal investment||Unreliable, often do not show up|
|Decrease morale of regular staff||No teamwork|
Advantages and Disadvantages of Using Agency Staff
|Maintains compliance||1,026 (26)|
|Maintains staffing levels||474 (12)|
|Available when needed||197 (5)|
| Increased supervision||1,500 (38)|
| Indifference||1,461 (37)|
| Decreased teamwork||1,078 (27)|
| Inconsistent work groups||987 (25)|
| Increased workload||830 (21)|
| Decreased morale||671 (17)|
| Expense||1,660 (42)|
| Decreased commitment||1,024 (26)|
| Disrupted routines||909 (23)|
| Lower productivity||475 (12)|
| Administrative burden||396 (10)|
| Professionalism||395 (10)|
| Absenteeism||316 (8)|
| Turnover||199 (5)|
| Psychological distress||910 (23)|
| Continuity of care||712 (18)|
| Unfamiliar practices||554 (14)|