Journal of Gerontological Nursing

Feature Article 

Perceived Advantages and Disadvantages of Using Agency Staff Related to Care in Nursing Homes: A Conceptual Model

Nicholas G. Castle, PhD

Abstract

Data from 3,946 nursing homes (66% response rate) were used to examine the advantages and disadvantages of using agency staff. A conceptual model showing potential reasons for the relationship between agency use and care quality was also developed. Fifty-nine percent of nursing homes used some agency staff (i.e., RNs, licensed practical nurses, nurse aides) in 2006. The conceptual model and empirical analyses show that agency staff likely influence other staff, facility operations, and residents. Administrators listed more disadvantages than advantages of using agency staff.

Abstract

Data from 3,946 nursing homes (66% response rate) were used to examine the advantages and disadvantages of using agency staff. A conceptual model showing potential reasons for the relationship between agency use and care quality was also developed. Fifty-nine percent of nursing homes used some agency staff (i.e., RNs, licensed practical nurses, nurse aides) in 2006. The conceptual model and empirical analyses show that agency staff likely influence other staff, facility operations, and residents. Administrators listed more disadvantages than advantages of using agency staff.

Dr. Castle is Professor, University of Pittsburgh, Department of Health Policy and Management, Pittsburgh, Pennsylvania.

Address correspondence to Nicholas G. Castle, PhD, Professor, University of Pittsburgh, Department of Health Policy and Management, A649 Crabtree Hall, 130 DeSoto Street, Pittsburgh, PA 15261; e-mail: CASTLEN@Pitt.edu.

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.

© istockphoto.com

© istockphoto.com

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.

Conceptual Model Showing Potential Reasons for the Relationship Between Agency Use and Quality of Care in Nursing Homes. + = Advantages; – = Disadvantages.

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.

Data Analyses

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.

Results

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.

Staffing and Facility Characteristics of Nursing Homes Examined (N = 3,946)

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.

Agency Staffing Characteristics of Nursing Homes Examined (N = 3,946)

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.

Comments Provided by Administrators Listing Advantages and Disadvantages of Using Agency Staff

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%).

Advantages and Disadvantages of Using Agency Staff

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.

Conclusion

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.

References

  • Amenta, MM1977. Staffing through temporary help agencies. Supervisor Nurse, 8(12), 19–20, 23, 25–26.
  • Bird, M. 2000. Do the locomotive. Health Service Journal, (September), 26–30.
  • Bliss, JB & Alsdorf, P1992. Geriatric orientation for agency nurses. The Journal of Continuing Education in Nursing, 23, 60–62.
  • Bloom, JR, Alexander, JA & Nuchols, BA1997. Nurse staffing patterns and hospital efficiency in the United States. Social Science & Medicine, 44, 147–155. doi:10.1016/S0277-9536(96)00063-9 [CrossRef]
  • Braddy, PK, Washburn, TA & Carroll, LL1991. Factors influencing nurses to work for agencies. Western Journal of Nursing Research, 13, 353–362. doi:10.1177/019394599101300305 [CrossRef]
  • Buchan, J & Seccombe, I1995. Managing nurse absence. Health Manpower Management, 212, 3–12. doi:10.1108/09552069510085852 [CrossRef]
  • Castle, NG & Engberg, J2005. Staff turnover and quality of care in nursing homes. Medical Care, 43, 616–626. doi:10.1097/01.mlr.0000163661.67170.b9 [CrossRef]
  • Castle, NG & Engberg, J2007. The influence of staffing characteristics on quality of care in nursing homes. Health Services Research, 42, 1822–1847. doi:10.1111/j.1475-6773.2007.00704.x [CrossRef]
  • Charnley, D & Arnold, J2006. Work relationships between agency and permanent staff. Nursing Times, 10235, 34–38.
  • Daniel, L, Garman, A, Grady, J & Phillips, M2006. E-bidding and hospital agency usage. Journal of Nursing Administration, 36, 173–176. doi:10.1097/00005110-200604000-00005 [CrossRef]
  • Deitzer, D, Wessell, J, Myles, K & Trimble, P1992. Agency nurses: The right solution to staffing problems?The Journal of Long Term Care Administration, 203, 29–33.
  • Elson, L1995. Agency advantages. Nursing Standard, 109, 46.
  • Gaugler, JE & Ewen, HH2005. Building relationships in residential long-term care: Determinants of staff attitudes toward family members. Journal of Gerontological Nursing, 319, 19–26.
  • George, E2003. External solutions and internal problems: The effects of employment externalization on internal workers’ attitudes. Organization Science, 14, 386–402. doi:10.1287/orsc.14.4.386.17488 [CrossRef]
  • Grinspun, D2002. A flexible nursing work-force: Realities and fallouts. Hospital Quarterly, 61, 79–84.
  • Harrington, C & Swan, JH2003. Nursing home staffing, turnover, and case mix. Medical Care Research and Review, 60, 366–392. doi:10.1177/1077558703254692 [CrossRef]
  • Hass, H, Coyer, FM & Theobald, KA2006. The experience of agency nurses working in a London teaching hospital. Intensive & Critical Care Nursing, 22, 144–153. doi:10.1016/j.iccn.2005.09.007 [CrossRef]
  • Hughes, KK & Marcantonio, RJ1991. Recruitment, retention, and compensation of agency and hospital nurses. Journal of Nursing Administration, 2110, 46–52. doi:10.1097/00005110-199111000-00007 [CrossRef]
  • Inman, RR, Blumenfeld, DE & Ko, A2005. Cross-training hospital nurses to reduce staffing costs. Health Care Management Review, 30, 116–125.
  • Institute of Medicine. 2001. Improving the quality of long-term care. Retrieved October 28, 2008, from the National Academies Press. Web site: http://www.nap.edu/catalog.php?record_id=9611
  • Jalonen, P, Virtanen, M, Vahtera, J, Elovainio, M & Kivimaki, M2006. Predictors of sustained organizational commitment among nurses with temporary job contracts. Journal of Nursing Administration, 36, 268–276. doi:10.1097/00005110-200605000-00020 [CrossRef]
  • Jones, K, Yancer, DA, McGinley, SJ & Galbraith, P. 1990. An agency-staffed nursing unit project. Nursing Management, 21(10), 36–37, 40.
  • Lemow, J2004. Measuring the competence of agency nurses. Nursing New Zealand, 107, 12–14.
  • Maas, ML, Reed, D, Park, M, Specht, JP, Schutte, D & Kelley, LS et al. . 2004. Outcomes of family involvement in care intervention for caregivers of individuals with dementia. Nursing Research, 53, 76–86. doi:10.1097/00006199-200403000-00003 [CrossRef]
  • Manias, E, Aitken, R, Peerson, A, Parker, J & Wong, K2003. Agency nursing work in acute care settings: Perceptions of hospital nursing managers and agency nurse providers. Journal of Clinical Nursing, 12, 457–466. doi:10.1046/j.1365-2702.2003.00745.x [CrossRef]
  • Merolle, DL1988. The nuts and bolts of agency nursing. RN, 511, 37–39.
  • National Center for Health Statistics. 2004. National Nursing Home Survey. Retrieved October 28, 2008, from the Centers for Disease Control and Prevention. Web site: http://www.cdc.gov/nchs/nnhs.htm
  • Pennington, K, Scott, J & Magilvy, K2003. The role of certified nursing assistants in nursing homes. Journal of Nursing Administration, 33, 578–584. doi:10.1097/00005110-200311000-00007 [CrossRef]
  • Prescott, PA1986. Uses of nurses from supplemental services: Implications for hospitals. Nursing Administration Quarterly, 111, 81–88.
  • Prescott, PA & Langford, TL1981. Supplemental agency nurses and hospital staff nurses: What are the differences?Nursing & Health Care, 2, 200–206.
  • Sayer, W1990. Comparing hospital and agency nurses. Nursing Times, 8629, 51.
  • Schubert, S1995. “You’re more your own boss”: Nurses’ experience of agency work”. Contemporary Nurse, 4, 166–173.
  • Spetz, J2005. The cost and cost-effectiveness of nursing services in health care. Nursing Outlook, 53, 305–309. doi:10.1016/j.outlook.2005.05.006 [CrossRef]
  • Stata® (Version 8.2) [Computer software]. 2005. College Station, TX: StataCorp LP.
  • Stiehl, RR2004. Quality assurance requirements for contract/agency nurses. JONA’s Healthcare Law, Ethics, & Regulation, 6, 69–74. doi:10.1097/00128488-200407000-00005 [CrossRef]
  • Ward, K, Grimshaw, D, Rubery, J & Beynon, H2001. Dilemmas in the management of temporary work agency staff. Human Resource Management Journal, 114, 3–21. doi:10.1111/j.1748-8583.2001.tb00048.x [CrossRef]
  • Wu, SH & Lee, JL2006. A comparison study of nursing care quality in different working status nursing staffs: An example of one local hospital. Journal of Nursing Research, 14, 181–189.

Staffing and Facility Characteristics of Nursing Homes Examined (N = 3,946)

VariableDefinitionMean (or Percent [N])Standard Deviation
Regular staffinga
RN regular staffingFTE regular RNs per 100 residents12.59.1
LPN regular staffingFTE regular LPNs per 100 residents11.26.8
NA regular staffingFTE regular NAs per 100 residents24.87.3
Turnovera
RN turnoverRN departures for 1 year as a percentage of total positions33.4% [1,318]34.2
LPN turnoverLPN departures for 1 year as a percentage of total positions38.9% [1,535]32.1
NA turnoverNA departures for 1 year as a percentage of total positions63.8% [2,517]55.2
Facility characteristicsb
Organizational sizeNumber of beds13191
OwnershipFor profit or not for profit58% [2,289]
Chain membershipMember of a nursing home chain or not54% [2,131]
OccupancyAverage daily occupancy rate87% [3,433]15
Private-pay occupancyAverage daily private-pay occupancy rate18% [710]16
Medicaid occupancyAverage daily Medicaid occupancy rate58% [2,289]22

Agency Staffing Characteristics of Nursing Homes Examined (N = 3,946)

VariableDefinitionMean (or Percent [N])Standard Deviation
Any use of agency staff
RN agencyUsed any agency RNs in 200628% [1,105]
LPN agencyUsed any agency LPNs in 200619% [750]
NA agencyUsed any agency NAs in 200642% [1,657]
Any agency useUsed any agency staff in 2006 (RN, LPN, NA)59% [2,328]
Average agency staffing (all facilities)
RN agencyFTE agency RNs per 100 beds1.21.2
LPN agencyFTE agency LPNs per 100 beds1.41.6
NA agencyFTE agency NAs per 100 beds2.64.2
Average agency staffing (including only facilities that used agency staff)
RN agencyFTE agency RNs per 100 beds2.31.1
LPN agencyFTE agency LPNs per 100 beds3.11.5
NA agencyFTE agency NAs per 100 beds4.93.8

Comments Provided by Administrators Listing Advantages and Disadvantages of Using Agency Staff

Advantages
DependableSometimes 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 neededMeets licensure requirements
Replacement for sick staffDecreased workers comp liability
There when you need someone in a pinchMeeting state staffing levels
Keeps us in complianceNo benefit calculations needed
Simple charge structureCan be used on short notice
Can become a future employeeReduces overtime
Disadvantages
Inconsistent careExpensive
Lack of team cohesionBehave as though they are unaccountable
Poor attitude towards coworkersLack of continuity of care
Held hostage by agency workersDo not know the “little” things about residents
Lack of caringJump in without much training or orientation
CostDo not have the buy in to our “mission”
ReliabilityDon’t care
KnowledgePoor dedication
Customer friendlinessInconsistent staff
Do not know the residentsNot well trained
Poor efficiencySafety concerns
Not knowledgeable about the facilityDon’t know families
Don’t know staffPoor documentation
Do not know the jobTraining for one-time use
Higher staff turnoverDon’t know what to do
Lack of personal investmentUnreliable, often do not show up
Decrease morale of regular staffNo teamwork

Advantages and Disadvantages of Using Agency Staff

Advantagesn (%)
Maintains compliance1,026 (26)
Maintains staffing levels474 (12)
Available when needed197 (5)
Disadvantages
Other Staff
  Increased supervision1,500 (38)
  Indifference1,461 (37)
  Decreased teamwork1,078 (27)
  Inconsistent work groups987 (25)
  Increased workload830 (21)
  Decreased morale671 (17)
Facility Operations
  Expense1,660 (42)
  Decreased commitment1,024 (26)
  Disrupted routines909 (23)
  Lower productivity475 (12)
  Administrative burden396 (10)
  Professionalism395 (10)
  Absenteeism316 (8)
  Turnover199 (5)
Residents
  Psychological distress910 (23)
  Continuity of care712 (18)
  Unfamiliar practices554 (14)
Other Concerns
Safety512 (13)

Use of Agency Staff

Castle, NG. (2009). Perceived Advantages and Disadvantages of Using Agency Staff Related to Care in Nursing Homes: A Conceptual Model.Journal of Gerontological Nursing, 35(1), 28–36.

  1. Use of some agency staff is a widespread practice among nursing homes.

  2. High levels of agency staff use by nursing homes is not common.

  3. Use of agency staff is generally viewed as having more disadvantages than advantages.

Authors

Dr. Castle is Professor, University of Pittsburgh, Department of Health Policy and Management, Pittsburgh, Pennsylvania.

Address correspondence to Nicholas G. Castle, PhD, Professor, University of Pittsburgh, Department of Health Policy and Management, A649 Crabtree Hall, 130 DeSoto Street, Pittsburgh, PA 15261; e-mail: .CASTLEN@Pitt.edu

10.3928/00989134-20090101-03

Sign up to receive

Journal E-contents