The last resort? Similarities and differences between contingent ‘agency’ employment practices in social work and nursing

Introduction

Largely due to politically motivated and market-led reforms, one of the most extensive cultural changes experienced within international key public sectors in recent years has been the increased reliance upon temporary workers recruited and supplied by independent employment agencies. As Allan (2000: 189) notes, this trend fits with wider changes pioneered in the business sector that question the feasibility of relying solely upon full-time permanent staff:

Employers are seeking greater responsiveness, flexibility and cost-effectiveness from their human resources as a result of intensified competitive pressures, greater market uncertainty, the availability of new technologies and a more deregulated labour market … [they] are re-evaluating the efficacy of full-time, typical employment.

Subsequently, since the 1990s both social work and nursing sectors in the UK – and elsewhere in the case of nursing – have increased their dependence upon contingency or temporary agency staff. This trend contrasts sharply with any previous public-sector rationale or philosophy, which sought to prioritize permanency and loyalty from professional staff. Indeed, as Maggs (2004: 154) highlights in his discussion of nursing in England, sustained pressures to move away from over-reliance upon casual labour in the latter half of the 19th century were driven as much by ethical as by economic motives:

The move to a larger and permanent workforce was seen as much a moral issue as one of efficiency and good economic management. In the process, this aided the recruitment of women to the nursing profession, as it gained ‘respectability’, and threw off the images conjured by Dickens and his contemporaries.

Such reform was also a response to union activism and labour resistance offered by other reform-minded groups (Baines, 2004).

The recent reversal of this century-long trend, however, in which ‘re-casualization’ has occurred, has subsequently generated numerous ethical as well as professional and organizational concerns. For example, some apprehension has been expressed that over-reliance upon agency social workers can pose significant risks to the safety of vulnerable service users, many of whom require the stability and longer-term assurance that permanency encourages (Carey, 2008; TUC, 2009). In contrast, precedence continues to be given to market- and supply-led priorities that seek to encourage choice, the more fluid movement of labour, efficiency and the containment of costs, etc., in countries as diverse as the UK, Canada, Taiwan, Australia and elsewhere (Baines, 2004; De Ryter, 2003; Yeh et al., 2007).

However, for both social work and nursing contingent employees can offer important benefits, including not least an essential and rapid response to the endemic staff shortages that have overwhelmed many sectors of social work and nursing in the UK and elsewhere since the 1990s (De Ryter, 2003; Hoque and Kirkpatrick, 2008; Hurst and Smith, 2010). In their study of 151 staff involved in the recruitment, supply and practice of agency social workers (including 45 qualified agency social workers), Cornes et al. (2010: 10) also highlight additional benefits:

Once on placement, good agency social workers were thought to be able to get through high volumes of work and could refresh teams by bringing in new skills and insights from other areas.

The previous Labour government in the UK, however, recognized some of the implicit dangers as well as the substantial financial cost of any over-reliance upon locum staff within the public sector. Within Options for Excellence it initiated reforms (including the introduction of locally authority run Vendor Management Schemes) that were intended to reverse, and eventually end, the reliance upon agency staff within social work by 2020 (DES/DOH, 2006). As Cornes et al. (2010) reflect, initial evidence suggests that the decade and a half surge in private sector agency staff since the 1990s has now begun to gradually recede within social work.

This article draws from a literature-based survey to detail some of the similarities and differences regarding the use of agency employees within social work ¹ and nursing sectors. It highlights that with any over-reliance upon ‘flexible’ labour the risks tend to outweigh the benefits, including for practitioners, employers and service users. It also highlights the increasing emphasis now placed upon the ‘scientific management’ of contingent employees within both sectors. Finally, it is noted that although offering some discretion to locum employees, disadvantaged labour market groups may suffer further forms of prejudice when they enter the contingency labour market.

Methodology

The aim of the research was to identify and explore some of the similarities and differences experienced with the use of agency employees within social work and nursing. Specifically, evidence was sought to explore previous and current trends and policies as well as the potential risks and benefits following the use of ‘flexible’ labour within both formal care sectors.

A critical interpretive synthesis (CIS) was utilized which followed iterative and reflexive phases that included: formulating the review question, searching the literature, identifying relevant literature and studies, determining quality, extracting information and conducting an interpretive synthesis. Through interpretive synthesis the generation of concepts of analysis are pursued alongside a more precise understanding of initial research objectives (Dixon-Woods et al., 2006). The benefits of CIS include its capacity to overcome some of the limitations of a standard review: for example, any tendency to prioritize things that can be measured rather than identify concepts that are considered important by the researcher (or participants), or privilege ‘answerable’ rather than ‘useful’ research questions. A CIS can also encourage us to theorize findings or question taken-for-granted research assumptions (Dixon-Woods et al., 2006).

The literature search was carried out relating to the role and impact of agency social work and nursing since 1980 within the databases of the Social Science Citation Index (SSCI), Social Science Research Network, Medline, Social Care Online and the British Nursing Index. Key words and search terms used included: agency and/or contingency social work and nursing; temporary and/or non-traditional social work and nursing; independent social care or nursing work, and so on. Specific terms were also later used for emerging analytical sub-themes that included those that link to deskilling, isolation, training, Vendor Management, and so forth. The majority of sources were drawn from academic journals, although some of the ‘grey literature’ – including commissioned reports and articles on relevant websites – were also drawn upon.

The research sought to take an international perspective, although it became apparent at an early stage that any empirical research undertaken regarding agency social work had predominantly been undertaken in England, and mostly during the past decade. In contrast, a significantly higher proportion of studies into agency nursing had been undertaken in all continents and many countries. This bias is recognized as possibly influencing the analysis and recommendations of this article. Early on in the research it was decided to use England as a case study but also to draw upon key international studies for comparison (see the Notes section for further relevant discussion).

Supply, deskilling and isolation

As well as reflecting neo-liberal demands for less-regulated quasi-markets of social and health care provision, significant reductions in direct state care and greater use of private sector service provision, expansion of contingent employees also reflects the related ideological and hegemonic demands of employers and senior managers. In particular, these include a desire to ‘externalize employment’ in order to encourage greater flexibility, extend managerial control and reduce the overall cost of staffing. For both social work and nursing there has, however, also subsequently occurred a chronic shortage of staff in such key public sector posts; the reasons for which vary, yet include employee disenfranchisement due to deskilling, the encroachment of highly regulated practices, the intensification of workloads, bureaucracy and targets, fewer resources and increased expectations and surveillance from management, and, in the case of social work, a lack of support or appreciation from many sections of the general public (Audit Commission, 2002, among others). In the case of nursing, Tailby (2005: 372) also highlights the impact of demographic influences:

By the end of the 1990s many [Health] Trusts were finding it hard to fill vacancies. Some reported high attrition rates, and the proportion of nurses at or nearing retirement age had risen. Rates of ill health and early retirement also showed an increase.

There is also evidence to suggest that many social workers and nurses pursue agency employment because they cannot find a permanent job (Tailby, 2005). For social work at least this can be especially prevalent following graduation or in the early stages of a career (Carey, 2008). However, differences persist between social work and nursing regarding how agency employment is utilized. Most notably within nursing, agency work is regularly used by staff alongside other sources of employment, in particular longer-term and permanent nursing work undertaken elsewhere – that is, contingency nursing pursued through an employment agency not unusually provides additional income or experience rather than a main or long-term source of employment, and may represent something to occasionally ‘dip into’ (Tailby, 2005). In contrast, agency social work often provides the main source of employment and income for those involved, and is more often than not pursued full time and for at least six months at a time (Carey, 2006, 2008).

Deskilling remains a relatively common experience for contingency employees once in post. For example, Hass et al. (2006: 147–8) draw from in-depth interviews with eight full-time agency nurses working in intensive care in a London hospital to highlight their shared experience of deskilling. Examples included being allocated patients ‘with low clinical acuity’, receiving a lack of feedback on performance and, significantly, ‘not being able to undertake the registered nursing role of medication administration’. As one nurse stated:

I found I was getting fairly low acuity types of patients, you know easy ones, and that concerned me. Then I thought that’s what it’s going to be like. I don’t get patients where I have to constantly think … I can just slip into cruise control and get through twelve and a half hours.

The nursing staff also explained that deskilling tended to impact upon their competence, such as due to being over-reliant upon permanent colleagues who were required to assist in core tasks that they were not allowed to perform. Within social work the evidence is less certain, and perhaps more of a concern. For example, agency social workers are sometimes allocated more complex cases, including those that permanent staff may refuse. Agency staff may also be expected to accept difficult and crisis-related work that absent staff whom they are replacing were previously allocated (Carey, 2008; Cornes et al., 2010). Inevitably, this can pose potential risks to vulnerable service users, especially if a contingent employee is new or inexperienced in work with a specialist service user group or within a new community-based location.

De Ryter’s (2003: 3) case study research undertaken with managers in a University hospital in New South Wales, Australia, discovered that agency and other temporary staff nurses (or ‘casuals’) were largely excluded from the core training that permanent staff received. Indeed, as the author explains:

The perception from management is that it is not worth investing in someone who might not be around for long. If casuals want to attend courses that are not deemed necessary to perform their duties, they generally have to pay for it themselves.

Carey (2006, 2008) discovered a similar trend among qualified agency based care managers in the northwest of England. Here staff induction tended to be brief and limited – with most locum staff expected to ‘hit the ground running’ – and although training was never paid for it was only offered sporadically.

Isolation or collegial exclusion has also been acknowledged as a problem for agency employees in both social work and nursing. For example, Cornes et al. (2010: 90) discovered that agency social workers ‘often find it difficult to integrate fully within the team and can also face resentment and hostility from colleagues’. Resentment may also be felt towards temporary employees by front-line workers, senior managers or indeed other representatives of a regional employing authority. This specifically relates to concerns or bitterness regarding the relatively high cost of the temporary service being provided, especially during periods when redundancies are evident elsewhere or if support services are being refused or withdrawn from potential users or informal carers. Despite this, Cornes et al. (2010: 90) discovered that some employees also recognized that they were more likely to receive a warm welcome ‘where they were visibly seen to be helping relieve pressure on a team’. Service users or their relatives may resent or refuse the allocation of a locum social worker: this is more prominent regarding child support and family-related work where longer-term contact is often the norm (TUC, 2009).

Regarding contingency nursing, Hass et al. (2006: 148–9) discovered that isolation was identified as a significant drawback to agency employment. In particular, ‘not feeling part of the team and not participating in ongoing education’ was a regular complaint made by contingent nurses. Tailby (2005: 376) also notes the views of one ward manager to explain the view from above: ‘It is always easier for smooth working if you’ve got all your own [permanent] staff on duty because … they know each other and, more importantly, you know what skills they do or don’t possess.’ Yeh et al. (2007: 119) draw conclusions from questionnaire-based responses received from 249 nurses working in two hospitals in northern Taiwan. The authors note the high proportion of temporary nurses employed since 1995, with an average of 28.7 percent now employed in the health sectors of Taiwan. Their quantitative research discovered that agency nurses on fixed-term contracts typically experience greater ‘job stress’ than their permanent counterparts and a ‘lower level of occupational commitment’. The authors also recommend that personnel managers ‘need to be aware of important psychological differences between temporary and permanent workers’. This includes the often negative impact that temporary work status can have upon an employee’s identity. In relation any short-term status can determine how employees are treated by colleagues within an organization and this can inevitably influence the personal responses of contingent employees themselves, including worker performance and competency. A lack of job security, as well as limited receipt of ‘better compensation and other rewards’, were also identified as discouraging employee commitment and performance.

Allan (2000: 195) interviewed 29 members of staff responsible for recruiting and managing nursing and administrative staff within a 200-bed hospital in Sydney, Australia. The author highlights the various standards of staff supplied by employment agencies and concludes that ‘permanent staff often had to work harder to cover for [contingency workers] shortcomings’. These findings, however, are not supported in all of the available literature. As Hoque and Kirkpatrick (2008: 334) maintain, there is evidence to suggest that ‘over time, agency workers often do seek to forge relational contacts in organizations, often to satisfy deeper psychological needs for security or a sense of belonging’. Horning et al. (1995) argue that agency staff may suffer less fatigue or can be less complacent once in post, often in contrast to some permanent workers. They can therefore revitalize or bring new and more positive energy to an organization besieged by low morale. Cornes et al. (2010: 113) also note that within social work, employment agencies are viewed as providing an essential service by team managers because they help to ‘keep the show on the road’. In practice, employee commitment and competency are likely to vary according to factors such as the work setting, prior experience, role and attitude.

Vendor management, rewards and risks

As stated earlier, there are different ways by which social work and nursing staff engage with agency employment. Agency nursing tends to be provided alongside ‘Bank’ recruitment which is typically represented by ‘in-house organizations that seek to match the desire of nurses to work shifts with wards and departments in need of shift workers’. Bank employees are also more likely to be familiar with local procedures and some staff. As Cornes et al. (2010) note, in the UK at least, there has recently emerged growth within some local authorities of similar in-house ‘social work banks’. The advantage of this service remains not only the more controlled elements of recruiting more familiar staff, but also the lower cost. Another development in again first nursing and then more recently social work, remains Vendor Management Schemes (VMSs). Briefly, this is where a Trust or Local Authority employs a ‘third party organization or broker to enter into contracts with a wide range of supply agencies, re-negotiating charges and rates and undertaking monitoring and inspection’ (Cornes et al., 2010: 40). Potentially at least, VMSs can significantly cut the cost of agency employment for a Trust or Local Authority as well as provide greater consistency and security by encouraging competition, vetting and inspection processes. Nevertheless, VMSs do not guarantee that associated risks posed by agency employment – such as the lack of stability or familiarity for users and colleagues or limited training offered to agency staff – are subsequently reduced.

As well as potential problems there are also notable advantages or perks experienced by agency employees themselves within both social work and nursing. In particular, agency employment will often tend to allow greater choice and discretion for employees, especially those who require more flexibility with regard to their lifestyle. This is perhaps most pronounced for parents who may struggle to cope with the traditional ‘9 to 5’ routine (most prominently working mothers). However, although the ‘pay by the hour’ tradition within agency employment may suit workers and employers, not all employers will necessarily wish to agree to ‘flexi-time’ as part of any contract. Usually working hours are determined by the purchaser of agency care, but at times some negotiation may be possible. Within intense areas of social work such as child or adult protection it may also be difficult to predict the times when employees are most required. Another possible concern remains that any absenteeism during periods of high demand or crisis may generate resentment from permanent staff or employers. Under such circumstances disadvantaged groups such as mothers in the workplace may suffer further prejudice or discrimination when employed through an agency.

Although deskilling is recognized as being significant within agency nursing – especially with regard to (lower-need) patient allocation and the removal of key roles such as the giving of medication – there are still aspects of the contingent role which stand to counter, or even usurp, this process. This is most apparent due to the variety of placements that a locum employee will typically experience over a relatively short period of time. Drawing from interviews with 23 qualified agency care managers in England, Carey (2006) discovered that most employees benefited significantly from the different fields of social work practice they engaged with and the varied environments they migrated between (social work departments, hospitals, clinics, etc.). This was especially the case for newly qualified practitioners. Hoque and Kirkpatrick (2008: 333) add that for employers, agencies can provide an efficient means of supplying ‘access to specialist skills as opposed to developing them ‘‘in-house’’’. In addition, a moderate amount of labour turnover can stimulate the ‘learning needs’ and morale of an organization, yet there are also risks associated with this. For example, some employment agencies in their pursuit of profit may exaggerate the capabilities, experience or even qualifications of contingent employees supplied.

De Ruyter et al.’s (2008: 440) interviews with 15 nurses and 20 social workers supplied by employment agencies in England revealed that a key motive for employees entering contingency employment remained the poor and deteriorating conditions of employment within the public sector. Indeed, as one employee and manager respectively argued:

… that’s one of the things that’s quite nice about being an agency nurse, you don’t have to deal with the office politics and bureaucracy; you just go and do your job and you don’t have to hear it. I mean it’s certainly there and it is certainly a problem the [permanent staff] nurses have.

… a large number of social workers used to come to us for reasons of low morale … You would have a significant group of people who were disenchanted with the grind and the awfulness of child protection work, the bureaucracy, and would actually dip in and out of work to suit themselves.

De Ruyter et al. (2008: 441), however, also note that for a significant minority of their sample a ‘sense of professionalism and desire to contribute to their work team over-rode any desire to escape’. This was also more likely to be the case for contingent employees on longer-term contracts within work placements. However, in again echoing Carey’s (2006) findings, Cornes et al. (2010) highlight the potential risks within social work of allocating cases to agency staff that permanent employees refuse. This tendency was not apparent in any of the studies of nursing, and indeed the strict ruling on the allocation of low-level patients to agency employees appears to offer protection to patients.

Discussion: ‘Flexible’ care in context

The expansion of ‘flexible care’ services by independent employment agencies to key public health and social care sectors has been propelled by trends such as new organizational demands within more complex ‘post-Fordist’ political economies and greater ‘lifestyle’ discretions demanded by some employees. However, of particular influence following extensive neo-liberal inspired (structural and cultural) organizational reforms such as in the UK remains the effect of poor working conditions within public sector organizations. Deteriorating conditions of employment that have encouraged migration out of the public sector have generated staff shortages in key sectors such as ‘child protection’ in social work or intensive care in nursing, which ‘for profit’ employment agencies and corporations have been quick to exploit. Paradoxically, many employees discover that their ‘escape’ into agency employment may be short-lived, since deskilling or work intensification can increase further once new employment is found through an agency.

Although they often provide an essential service by helping to keep ‘the show on the road’ during difficult times, the majority of empirical studies uncovered as part of this research indicates that risks tend to outweigh any benefits following any over-reliance upon ‘flexible’ agency labour within both social work and nursing. This is especially the case if service-user or patient needs remain an organizational priority. For example, with reference to nursing in the UK, the Audit Commission (2001: 3) concluded that:

The ways in which some bank and agency staff are recruited, inducted and carry out their duties are less than ideal. They may be unfamiliar with those in their care, with local procedures, practices and equipment, with their surroundings and with their colleagues. Combined with lower participation in mandatory training and continuing professional development, and the general absence of performance review, these factors increase the chances of patients receiving care of a poorer quality.

Similar concerns have been expressed about agency social work provision (DES/DOH, 2006; Carey, 2008, among others). It would therefore be fair to conclude that employment agencies and their respective employees provide an important service to call upon when policies or organizational strategies have failed. For example, Cornes et al. (2010: 42–3) note the great efforts now made by some Local Authorities in England to discourage reliance upon employment agencies for supply of contingent staff. Strategies include increasing the recruitment of permanent staff, making greater attempts to retain such staff and promoting the use of in-house relief pools, among others. The clear message from such findings is that agency employment within social work and nursing is now for the most part treated as a service of last resort, one to be called upon only in an emergency and over a short period of time if possible. This general attitude and strategy contrasts with a decade ago when demand for and recruitment of agency employees was continuing to grow significantly and was quickly becoming a core part of public sector service provision. Since working conditions in the public sector still appear to be poor however (Hoque and Kirkpatrick, 2008), this trend may return at some point.

When agency employees are called upon it is apparent that some lessons can be learnt from previous research. For example, there remain concerns regarding the generic capabilities assumed or permitted to agency social workers. In particular, inexperienced practitioners can be expected to undertake intense casework, including in relation to child or adult protection. Similar scenarios are less likely within nursing due to tighter organizational controls which restrict what roles agency nurses are allowed to undertake. In addition, within more controlled clinical environments such as a hospital (as opposed to a more open ‘community’ setting) greater monitoring of contingent staff will be evident. Clearly, social work can learn from some the safer practices evident within nursing. For both professions, however, it is apparent from the available research that more emphasis needs to be placed upon providing temporary staff with better training, induction and general support.

The past decade, however, has witnessed gradual yet significant changes in the ways by which agency employees in both social care and health are recruited and managed. In particular, there has been a move away from the almost casual and spontaneous attitude of hiring and monitoring agency staff towards the development of much greater regulation and careful management. As Hoque et al. (forthcoming) recently discovered, Local Authorities and Trusts have become much better organized, strategic and, paradoxically, less ‘flexible’ regarding the recruitment of contingent labour. Alongside the growth of expert Vendor Management Systems and in-house Banks there has also occurred more reliance upon Information Technology, including prediction of future sector demands and needs.

What is also apparent, however, is that the underlying structural causes that have generated the high demand for contingent staff – in particular, the poor and deteriorating working conditions within the public sector for social care and nursing staff, and subsequent destabilized and ever more fragmented services for users and carers – are largely ignored as priority in favour of further supply- and market-led solutions. The evidence suggests that such reforms do little to confront the many structural and ‘street level’ problems generated by a push for more flexible services and labour; indeed, quite often they can make matters worse. Most notably, service users and practitioners require reliability and stability, rather than more fragmentation and uncertainty. There is also clearly a need for more policy-related and legal protection of agency employees, especially those from traditionally disadvantaged groups such as mothers, disabled people and members of minority ethnic communities.