Voice through exit: Changing working conditions by independent contractors’ participation

Abstract

In the course of worldwide reforms in health care systems, flexible employment is of increasing relevance in medicine and also includes the highly skilled workforce of hospital physicians. With reference to Hirschman’s seminal work on exit, voice and loyalty, this article analyzes the phenomenon of deploying locum tenens physicians as independent contractors in hospitals. The results of two qualitative empirical studies drawing on 30 qualitative interviews show conditions and consequences of exit–voice–loyalty behavior on different levels. On the meso level of organizations, locum tenens physicians help to enforce improvements in everyday hospital practices because as independent contractors, they gain a new, more autonomous position – they receive voice through exit.

Keywords

Employee voice independent contractor health care organizations profession working conditions

Introduction

Worldwide, health care systems are undergoing various processes, reforms and policy initiatives intended to decrease expenditures by making health care providers more cost-effective (Kikuzawa et al., 2008). In these attempts, efficiency in patient care becomes essential and thus has an impact on medical practice. In Germany, fundamental reforms in the health care sector have led to major changes that physicians and other hospital staff commonly perceive as unsatisfactory (Figueras et al., 2004; McKee et al., 2002; Saltman et al., 2007). As a result, some physicians decide to leave the organization, quitting their jobs to work instead as locum tenens physicians. As such, they are self-employed independent contractors who work in various hospitals for a limited time.

Perceiving deterioration in their work environment, these physicians have responded with exit (Mattei et al., 2013; Mitlacher and Welker, 2012). However, we suggest that this step can also be conceptualized as voice, since their departure is perceived as an attempt to change the working conditions in hospitals for both dependent and independent physicians. In view of their orientation toward professional standards, locum tenens physicians are particularly willing to disagree with organizational activities since their loyalty is to their profession rather than to a specific organization. Against this background, we refer to Hirschman’s (1970) seminal work on exit, voice and loyalty to analyze the phenomenon of deploying locum tenens physicians as independent contractors in hospitals, and we consider its conditions and consequences on different levels.

Our data emerge from two qualitative empirical studies comprising a total of 30 interviews with locum tenens physicians, permanently employed physicians, and chief physicians in hospitals as well as intermediary actors in medicine. The analysis shows that locum tenens physicians help to maintain professional standards in hospitals because they are not bound by organizational directives, allowing patient care to remain at the center of their medical practice regardless of a hospital’s economic, bureaucratic and hierarchical requirements or hospital-specific routines. As solo self-employed workers, locum tenens physicians have a greater autonomy within the hospital setting. They have the opportunity to enforce improvements in everyday hospital practices and to compensate for shortcomings in the working conditions. They have achieved voice through exit.

Our article makes three important conceptual contributions. We examine independent contracting as a means of changing work in the health care sector by (1) discussing the interrelationship of exit, voice and loyalty with regard to this special form of employment, (2) showing new forms of worker participation to exercise voice in the organizational context, and (3) pointing to the relevance of structural conditions on the macro and meso levels to understand exit–voice–loyalty behavior and its consequences.

In the next sections, we first briefly introduce regulatory changes in the German health care system, describe related developments in the hospital context and working conditions as well as changing employment relationships of physicians over recent decades, and discuss the phenomenon of locum tenens physicians with regard to the literature on highly skilled independent contractors. We then introduce Hirschman’s concepts of exit, voice and loyalty. We subsequently present our qualitative studies and describe the methods applied, and follow with a discussion of our empirical findings. Finally, we develop conclusions and put forward implications for further research.

The German health care system in transformation

Regulatory changes in the German health care system

Over the past decade, the German health care system has been moving from a traditional welfare state model to a more regulatory state model to save expenditures on health. Rising expenditures were mainly caused by (1) the unification of the two postwar German states, (2) the aging population, and (3) advances in medical sciences (Hogwood, 2016). In particular a major reform in the year 2000 – which aimed to increase the efficiency through the so-called Diagnosis Related Groups (DRG) system – has led to profound changes in the German hospital sector (Hogwood, 2016; see also Ferlie et al., 1996; McLaughlin et al., 2001; Noordegraaf and Burns, 2017). This broader movement encompasses managerially oriented re-stratification processes and is also known as New Public Management (NPM). This effort can be observed all over Europe, although the implications and patterns vary from one country to another.

In the German health care sector, the main objectives for introducing NPM lie in reducing treatment costs and the average length of stay per patient, in cultivating cost transparency, and in promoting competition in the hospital market (Bode and Märker, 2014; Ernst and Szczesny, 2005). The increased competition among hospitals has led to an overall decrease in the number of hospitals between 2003 (N = 2197) and 2015 (N = 1956). Perhaps more importantly, a change in the ownership of hospitals has occurred. The total number of non-profit hospitals, which are charitable hospitals operated by churches or welfare services, continuously decreased (2003: n = 856; 2015: n = 697), as did the number of public state hospitals (2003: n = 796; 2015: n = 577). In contrast, the number of for-profit hospitals that are operated by private companies continuously increased (2003: n = 545; 2015: n = 700).

The Federal Hospital Act, passed in 2009, provided the impetus for this structural change. As a consequence of this, the federal states (Bundesländer) are now allowed to transfer the entire investment funding to the hospitals as a lump sum so that hospitals can make nearly autonomous investment decisions. Therefore, the influence of banks is becoming increasingly important in hospital investment and privately owned hospitals can arrange loans much more easily than public or non-profit hospitals (Mattei et al., 2013). At the same time, owing to changed legal regulations, a growing number of people work in medical services. In 2004, the European Court of Justice adopted new labor legislation (EuGH 09.09.03; C-151/02) that imposed new daily and weekly hour maximums that led to increasing demand for medical personnel and changes on the organizational meso level of hospitals.

Changes in the German hospital context

As a result of the health care reforms sketched above, incentive and reimbursement schemes of hospitals were modified to be more efficient, more utility-oriented, and more business-like in their practices and attitudes (Ferlie et al., 1996; McLaughlin et al., 2001; Noordegraaf and Burns, 2017). Mainly because of these structural changes, between 1991 and 2015 the average length of stay in German hospitals decreased from 14.0 days to 7.3 days (Destatis, 2017). In addition, since NPM created the opportunity to generate profits or losses, hospitals stepped up their efforts to attract lucrative treatment cases. The result is an increasing selection of patients and treatments according to profit criteria.

Not surprisingly, the introduction of NPM has fostered contradictory practices in hospitals in terms of managerial and professional logics (Bode and Märker, 2014). As in other companies, labor costs are hospitals’ largest expenditures, and hospitals now pursue increased cost flexibility and decreased fixed salary costs by paying low wages in relation to workload and by consistently requiring overtime. This practice frequently results in a negative work climate and lower levels of job satisfaction (Mitlacher and Welker, 2012). Moreover, these negative organizational outcomes also have an impact on the relationship between the organization and physicians as members of a profession. While the medical profession has traditionally been the most powerful group within hospitals, a shift is now occurring because some managerial targets (e.g., cost reduction, quantity targets for medical treatments) conflict with professional standards (e.g., medically indicated autonomous decisions) (Ruiner et al., 2017).

In this sense, the reorganization of organizational processes and structures and a higher degree of standardization introduced by NPM affect professional standards as well. Under new labor regulations, the physician’s entire on-call time in hospitals is to be counted as working time, obliging hospitals to introduce new working time models. The physician shortage resulting from the new labor legislation modifying working time in hospitals currently yields a high demand for doctors helping out in daily business, at least temporarily. This development creates the need for more personnel, which is met by hiring external physicians and deploying locum tenens physicians.

Changing employment relationships of physicians

As noted above, Germany presently faces a shortage of physicians. Following an oversupply of physicians and a resulting high risk of physicians’ unemployment in the 1990s, the number of unemployed doctors has steadily decreased so that today, the number of physician vacancies is higher than the number of physicians seeking employment.

Customarily, physicians are permanently employed in German hospitals and receive a fixed salary. Since 2007, however, hospitals have been allowed to deduct costs for physicians who serve as temporary substitutes for the permanently employed doctors (Mitlacher and Welker, 2012). This opportunity is particularly important if vacancies cannot be filled. The legal change regarding cost deduction is a result of hospitals’ need for greater flexibility, especially with respect to the massive labor shortages of physicians that occur in rural areas. The new legislation allows these hospitals to pay external specialists somewhat more highly to mitigate this shortage. The increased flexibility also attracts physicians who demand more flexible working hours, better quality of life, better income opportunities, better work–life balance.

The transformation processes described above have been accompanied by an outflow of medical personnel from hospitals as some physicians quit their jobs to become locum tenens physicians, working independently as freelancers (Alonzo and Simon, 2008). As locum tenens physicians, they are deployed by various hospitals on a temporary daily or weekly and sometimes recurring basis, and typically serve as short-term substitutes for permanently employed physicians (Alonzo and Simon, 2008; Simon and Alonzo, 2004). German locum tenens physicians characteristically have diverse and complex employment biographies that often reflect hybrid stages of employment, in which permanent employment alternates with fully self-employed work or independent contracting. This form of employment is highly dynamic, as self-employed locum tenens physicians find the current market situation to be quite beneficial to them since they are less affected by the disadvantages of typical self-employment, are better compensated than permanently employed physicians, and importantly are not bound by directives, as permanently employed physicians are (De Ruyter et al., 2008; Gallagher and Sverke, 2005; Kalleberg et al., 2000; Kirkpatrick and Hoque, 2006; Ward et al., 2001).

So far, research is scarce regarding locum tenens physicians, their intentions to quit permanent employment, and the consequences of redeploying them as solo self-employed physicians. A single study of 764 locum tenens physicians found that they leave their jobs because they are dissatisfied with the working conditions in hospitals (Teske et al., 2010) – a finding in line with Hirschman (1970), who defines this reaction as exit.

Notably, the decision to leave the organization is only an option if a physician has already finished specialized training and has been awarded a Certificate of Completion in Specialist Training (CCT, or Facharztanerkennung). During the training period, interns depend heavily on their superior in the hospital because the acquisition of such a certificate is bound to hospitals. However, for physicians who have completed their training, the combination of more attractive working conditions and mounting performance pressures makes the exit option quite appealing – as evidenced by the rising number of locum tenens physicians in Germany who have left the organization. In 2009, about 1879 locum tenens physicians worked in hospitals. By 2015, this figure had risen to 3034 (Figure 1).

Figure 1.

Number of physicians in hospitals without direct employment relationship.

Indeed, physicians’ acceptance of this new form of employment is relatively high, as emphasized in a study of chief physicians (Bundesärztekammer und Kassenärztliche Bundesvereinigung, 2011). One-third of the respondents confirmed that they would consider positions as a locum tenens physician if they were compelled to quit their current jobs. In view of their employment status and educational level, locum tenens physicians can be regarded as highly skilled independent contractors.

Locum tenens physicians as highly skilled independent contractors

So far, most research on independent contracting focuses on individual motives. Independent contractors prefer their work arrangement over that of permanent employees (Kalleberg, 2000), especially as the decision to work as an independent contractor may be induced by a feeling of entrapment in a dull, bureaucratic environment and a wish for more variation and challenge (Connelly and Gallagher, 2004). Moreover, highly skilled independent contractors prefer contracting and consciously accept its risks in the hope of making more money while escaping the constraints of organizational life, thus gaining independence as well as freedom to express opinions and distance from organizational politics (Kunda et al., 2002). Other research found that independent contractors have strong preferences for autonomy and a distaste for direction, supervision and formal organizational processes (Von Nordenflycht, 2010). Beyond these studies, highly skilled independent contractors have not been studied thoroughly even though they are likely to operate at the core of organizations and may be concerned with sensitive organizational issues (Bidwell and Briscoe, 2009; Connelly and Gallagher, 2004; Gallagher and Sverke, 2005; Kunda et al., 2002; Matusik and Hill, 1998).

However, existing research on employment change and professions in general suggests that, apart from these individual motives, structural factors such as skill scarcity in the external labor market and organizations’ reaction to these factors in their internal labor markets are relevant for understanding employment strategies (Grimshaw and Rubery, 1998). In the case of health care in Germany, the hiring of locum tenens physicians appears to be supply-led and a strategy of increasing importance. In addition, of particular importance in the institutional context is the transferability of skills of physicians as members of an established profession (Freidson, 1970a). Accordingly, professional skills may play a key role in the workers’ strategies for coping with and negotiating their status within a nonstandard employment relationship, and professional workers might take advantage of this form of employment (Acar, 2016). However, in this case, the loyalty to a profession and to colleagues in the hospital as a professional organization (Mintzberg, 1979) might also counteract the tendency to seek improved working conditions as an independent contractor.

In addition to the consideration of individual motives and structural conditions that facilitate the expansion of independent contracting in a professionalized workforce, a critical factor is the organizational effect of deploying locum tenens physicians in hospitals. A relevant study explored the consequences to the organizational core of using professional agency workers (Hoque and Kirkpatrick, 2008). In supply-led expansions of nonstandard work, in increasingly tight labor markets, and when faced with problems of staff recruitment and retention, employers have to use nonstandard workers in their core business because not enough qualified workers are willing to be employed. Where organizations are understaffed, agency workers may boost morale and relieve pressure (Feldman et al., 1994). However, the use of agency workers might also result in a contagion, in that permanent employees seek to exit the organization as well (Houseman et al., 2003; Purcell et al., 2004). In any case, the physicians’ actions can be seen as a response to perceived deterioration of working conditions in hospitals in the context of changes in organizations, skill shortages and loyalty to professions. Against this background and to link the micro, meso and macro levels, we refer to the well-established concepts of exit, voice and loyalty (Hirschman, 1970).

Exit, voice and loyalty in Hirschman’s perspective

Hirschman’s theoretical concept

Hirschman (1970) systematized responses to organizational decline. Although he focused on firms producing saleable goods for customers and organizations providing services to their members, such as political parties and volunteer associations, his model is also applicable to employment relationships. Essentially, people who are dissatisfied with their job can respond with exit, voice, loyalty, or neglect.¹ Through exit, people quit their job and search for a new one, whereas through voice people stay and try to improve the situation.

Voice is here defined as any attempt at all to change, rather than to escape from, an objectionable state of affairs, whether through individual or collective petition to the management directly in charge, through appeal to a higher authority with the intention of forcing a change in management, or through various types of actions and protests, including those that are meant to mobilize public opinion. (Hirschman, 1970: 30)

Hirschman argues that voice can be a residual of exit – that is, voice is the only way to express dissatisfaction when the exit option is unavailable. However, voice can also be an alternative to exit because only if people stay with the organization they have the chance to change something (Bogenrieder and Nooteboom, 2004; Courpasson and Dany, 2003). Importantly, the decision between exit and voice also depends on the availability and attractiveness of alternatives.

The relationship between voice and exit has now become more complex. So far it has been shown how easy availability of the exit option makes the recourse to voice less likely. (Hirschman, 1970: 83)

People who respond with loyalty also stay and support their organization to improve the situation. Loyal employees are willing to tolerate a higher level of disagreement with organizational activities and actively contribute to changing the situation by speaking out. According to Hirschman, loyal employees will try all alternatives before they painfully decide to withdraw from the organization. In this sense, loyalty is an attitude that promotes organizational development ‘by working for it, fighting for it and – where one thinks it has gone astray – seeking to change it’ (Barry, 1974: 98). That is, as long as people believe in the possibility of improvement, they will stay (Barry, 1974). Otherwise, they will exit (Kolarska and Aldrich, 1980).

As a result, loyalty can prevent workers and customers from prematurely turning away from an organization when they realize shortcomings in the relationship, since loyalty represents a feeling of attachment to an organization to which one belongs. Further, loyalty prevents labor turnover by activating voice: ‘the likelihood of voice increases with the degree of loyalty … loyalty holds exit at bay and activates voice’ (Hirschman, 1970: 77). Finally, people can respond with silence and do nothing about the dissatisfying situation. This response would reflect inner resignation and lead to reduced work efforts, less attention to quality, and increased absenteeism and lateness (Turnley and Feldman, 1999).

Early studies included only absenteeism and turnover as responses to low job satisfaction. Hirschman is the first to suggest at least three possible options (Farrell, 1983; Rusbult et al., 1988; Whitey and Cooper, 1989). However, Hirschman has been criticized for treating exit and voice as mutually exclusive alternatives, holding that loyalty causes non-exit and that non-exit stimulates voice (e.g., Barry, 1974; Kolarska and Aldrich, 1980). Under certain circumstances, loyalty can also be manifested by voice. In addition, as noted above, people can choose to remain with the organization and do nothing, which ‘is probably the most common response by discontented members’ (Kolarska and Aldrich, 1980: 44). Consequently, employees must choose between exit (leaving) and non-exit (staying) and between voice (activity, participation) and silence (inactivity, non-participation).

Hirschman in research

Hirschman’s concept has been the starting point for considerable interdisciplinary research. Many studies have focused on individual expectations with regard to costs and consequences of individual behavior, and on individual characteristics and personality traits. Included, for example, are studies on employee retention (De Vos and Meganck, 2009; Spencer, 1986) and on the changing of both formal and psychological contracts (Turnley and Feldman, 1999; Watson and Shepard, 2000). Two longitudinal studies examined when dissatisfied employees respond with exit, voice, loyalty or silence (Whitey and Cooper, 1989). Exit was more likely when its costs were low and the costs of voice were high, as well as when satisfaction was low and individuals did not believe that the organization would improve, and a better alternative was available. Loyalty resembled entrapment in the organization more than a supportive allegiance to it. The group of voicers was diverse, perceived voice as having low costs, believed that improvement would be possible, and had no better alternatives. People responding with silence perceived especially high voice and exit costs.

A study testing Hirschman’s assumption that loyal employees tend to complain and raise their voice and less loyal employees tend to choose to exit found that less loyal employees do both: they raise their voice and complain and also choose to exit the organization. Loyal employees who have experienced unfair treatment suffer quietly: ‘we conclude that employee loyalty translates into “silence” ’ (Boroff and Lewin, 1997: 60). Most likely these people hope for an improvement of the situation. Consequently, depending on tolerance, patience and confidence in leadership, the relationship may be shorter or longer – a condition that can also hold true in the case of interns who want to achieve the Certificate of Completion in Specialist Training. They have to be silent until they have completed their vocational training.

Other studies are more open to connecting structural factors such as labor market conditions to voice, exit and loyalty by relating individual characteristics and behavior to work supply and demand. More specifically, studies on voice behavior have analyzed the antecedents of speaking out and challenging the status quo with the intent of improving the situation with respect to organizational or work-related problems (Detert and Edmondson, 2011; LePine and Van Dyne, 1998; Milliken and Morrison, 2003; Morrison, 2011). In this sense, voice is more than organizational dissent and complaining, which merely reflect an expression of dissatisfaction and do not necessarily include suggestions for change (Kowalski, 1996). These studies reveal that in predicting voice behavior the amount of dissatisfaction is less important than demographics, since employees who are more tenured and educated and who hold supervisory and professional jobs are more likely to engage in voice behavior. Moreover, individuals who are highly employable are more likely to use voice and thereby gain greater control over their working life (Berntson et al., 2010).

In addition, the changing employee–employer relationship during downsizing has varying effects on loyalty (Watson and Shepard, 2000). An important factor is the organization’s ideological orientation toward either individualism or communitarism. Individualism holds that the individual’s freedom or responsibility to construct and sustain a fulfilling life is a central value that takes precedence over collective interests. In contrast, communitarism holds that institutions play an important role in preserving values that elevate the importance of collective action above absolute individual liberty and autonomy. The organization’s ideological orientation and human resource policies during downsizing events have significant direct effects on indicators of loyalty.

A rare study considered the role of employment relationships with a focus on the organizational level, examining how a blended workforce comprising groups of standard and nonstandard workers affected exit, voice and loyalty among standard employees (Davis-Blake et al., 2003). Through a quantitative analysis, the researchers show that the use of temporary and contract workers negatively affected the relations between managers and employees, and partly decreased the standard employees’ loyalty. Specifically, the use of temporary workers increased exit among permanent employees while reducing voice and loyalty, although the use of contractors had no effect – a result traced back to the fact that they work rather independently.

Little research has studied exit–voice–loyalty behaviors in the context of hospitals. Especially neglected is the aspect of professionalism (Evetts, 2009; Freidson, 1970b, 2001; Holvast and Doornbos, 2015). Since most functions in the medical sector require extensive expertise and knowledge, obtained via a necessary university degree and specialized training, working as a physician entails a large degree of autonomy. For example, analysis of the relationship between employees’ opportunities to voice dissatisfaction and employee turnover of registered nurses in general care hospitals showed that having numerous mechanisms for employee voice decreases turnover rates (Spencer, 1986). In the case of physicians in hospitals, only one study has analyzed factors affecting physician loyalty and exit (Burns and Wiholey, 1992). Study results underline that given their training and socialization, physicians’ loyalty can be expected to be influenced less by organizational factors such as decision-making involvement or role conflict and more by factors such as time and convenience.

This review points to both empirical and theoretical lacunae. Empirically, the effects of organizational decline and health care reforms and the resulting employee behaviors have not yet been analyzed. Moreover, research is lacking regarding locum tenens physicians in general and in the German hospital context specifically. In addition, theoretical questions remain. Since the application of Hirschman’s theory mostly focuses on the organization on a meso level, we assume that this framework can also be directed on the macro level of profession and market conditions. To date, however, previous research has been primarily concerned with individual expectations, calculations and perceptions as causes of exit, voice and loyalty. Some studies at least implicitly relate to organizational characteristics and labor market conditions. Missing so far is an explicit analysis and discussion of professionalism in the sense of facilitating labor market closure and thus influencing labor market conditions of voice, exit and loyalty, and in the sense of transmitting certain values and loyalties through professional socialization.

Therefore, we take the dynamic development of economization in the health care sector and the resulting organizational changes as a starting point in applying Hirschman’s work on exit, voice and loyalty to analyze the deployment of locum tenens physicians as independent contractors in hospitals. In contrast to other studies, which conceptualize exit–voice–loyalty behavior with regard to individual factors such as personality, experience and tenure, we also take into account structural factors on the macro and meso levels, such as organizational, labor market and institutional conditions. These can also be relevant since they affect organizational structures and workload as well as the attractiveness and availability of alternatives and costs of exit.

Methods and data

To explore the relationship between independent contracting and forms of exit, voice and loyalty as well as conditions and consequences on different levels, we took a qualitative empirical approach. Our empirical findings emerge from two separate projects. We first refer to a qualitative study on incentive structures in the health care sector in which we conducted 21 semi-structured interviews in 2014 to explore the ramifications of health care reforms on hospitals and related changes in employment structure. We interviewed 13 locum tenens physicians, five permanently employed physicians and three organizational representatives, such as chief physicians and executive directors of hospitals. We complemented these data with a second qualitative study in 2015 that analyzed the role of intermediaries in negotiating working conditions from the perspective of both intermediary actors and independent contractors. In this second study, we interviewed three locum tenens physicians and six intermediary actors, such as representatives of trade unions, professional associations, works councils and staffing agencies in the German health care sector.

In both projects, the interviewees were accessed through gate-keepers, calls in relevant newsgroups and telephone acquisition. The interviewed physicians were predominantly male, between 31 and 70 years old, and represented the following fields (in order of frequency): anesthesia, emergency medicine, critical care, internal medicine, psychiatry and psychotherapy, gynecology, surgery and radiology. The locum tenens physicians interviewed have an average work experience of 21 years. Before they worked as locum tenens physicians, they were employed in various hospitals in Germany. Since becoming self-employed, they have been deployed in hospitals throughout Germany and have worked in five to 40 different organizations. We aimed at triangulating perspectives to enhance credibility of the findings (Miles et al., 2014). In our sample of, in total, 16 locum tenens physicians and 14 organizational representatives, we achieved informational redundancy and theoretical saturation, leading us to decide not to acquire more interviewees.

The interview guidelines we used in both projects started with a narrative stimulus such as the following: ‘In our project we analyze increasing employment flexibility in the context of a changing health care environment, which is why we are particularly interested in your professional experience. Perhaps we can start with your occupational biography: How did you come to be working as a locum tenens physician?’ We addressed the respondents’ experiences with regard to the cooperation between locum tenens physicians and permanently employed physicians in hospitals, and we particularly asked about the cooperation with chief physicians and the physician–patient relationship. Finally, we questioned changing the status of employment and the related opportunities and risks. The interviews took on average 50 minutes. Four interviewers participated, of which only one was present in a given interview. The interviewees had the choice of a face-to-face or telephone interview. Altogether, 10 interviews were conducted by telephone.

All interviews were audio-recorded, transcribed and anonymized. Data analysis relied on qualitative content analysis (Mayring, 2000), which is an approach of systematic, rule-guided qualitative text analysis. We included a deductive application and an inductive development of codes. Initially, we derived codes from theory and the interview guide and applied these to the interview material. Examples of codes are ‘occupational biography’, ‘physician–patient relationship’ and Hirschman’s categories of exit, voice and loyalty. Codes were also developed inductively as key issues were discussed. Examples of inductive codes are intentions to become self-employed and effects of interviewees’ deployment in hospitals. Finally, we formulated definitions for each code, found examples, and defined coding rules (for examples of codes, see Appendix 1, in online article only). We encoded the transcripts primarily individually and subsequently compared and discussed the codes and codings in several team sessions. Correspondingly, the code system was constantly checked and modified, inductively expanded, and revised. Rater influence was controlled by having at least three people participate in the data interpretation process and by discussing the match of codings in teams to further develop the code system (for an overview of the coding process, see Appendix 2, online). Through permanently reflecting the data evaluation and jointly developing the code system, we minimized potential inconsistencies in coding the data.

Empirical findings

Hospital physicians between voice and exit

In their former work as permanently employed physicians, locum tenens physician were dissatisfied with the working conditions in hospitals, which changed in the course of profound health care reforms (Chandler et al., 2002; McGivern and Ferlie, 2007). Structural changes and changes in the hospital context can exert pressure to achieve specific economic goals. Consequently, permanently employed physicians perceive an increasing power of management, resulting in an emphasis on bureaucratic structures that undermine their professional freedom: ‘Administrators are increasingly taking the reins – one has too little to say, too little leeway’ (permanently employed physician_01-20: 8). Although hospitals have institutionalized mechanisms of voice like works councils, unions and professional associations, physicians perceive themselves as not being able to improve the organization and its routines either because they are not able to raise their voices or because they are not being heard. This lack of empowerment is mainly due to the perception that actions such as strikes do not have much impact (Janus et al., 2007). Moreover, since permanently employed physicians are integrated into hierarchical relationships, they are dependent on supervisors, for example, to gain professional training. In the perception of locum tenens physicians, those working permanently in a hospital do not usually question these hierarchies.

There are significant hierarchies in the hospital, which are enacted [by everyone], no matter if young or old, everyone lives these presumable laws. (Locum tenens physician_02-01: 83)

In, supervisors influence working conditions by deciding about assignments and shifts, resulting in restricted possibilities of voice. However, as soon as permanently employed physicians gain their CCT, they have the possibility to become self-employed.

Hospital physicians choose the exit option and become self-employed as a locum tenens physician mainly when they experience the everyday working situation in hospitals as being characterized by a work overload – not least because of the shortage of physicians – and when they are expected to do overtime, night and weekend shifts, and on-call duties free of charge. A locum tenens physician’s description of these consequences of health care reforms and organizational changes in the hospital is typical:

The economization of health care increased in a way that it is hardly about good medical work anymore. We still have good medical work, but in fact most hospitals are about controlling costs or making profits. This is a catastrophe … there are many physicians working up to the point of complete exhaustion, many go abroad, become locum physicians. (Locum tenens physician_01-04: 162)

Moreover, managerial controls lead to a massive and exhausting workload. Looking back at their time as permanently employed, locum tenens physicians especially criticized perceived economic incentives and an increasing dominance of market logic as being more important in hospitals than the patient’s well-being, and that endanger physicians’ medical autonomy.

The locum tenens physicians in our studies consistently stated that these excessively controlling and exhausting conditions led them to quit their positions as permanent employees because they felt restricted in their professional behavior. Particularly important to understanding the situation of permanently employed physicians and the decisions of locum tenens physicians to become self-employed is that they decided to exit after their attempts to improve working conditions failed. The interviewees emphasized that they used voice when they were permanently employed in hospital, but became even more dissatisfied when they realized that nothing was changing and that support by worker representatives was lacking.

We met many physicians who justified becoming self-employed with their long-term engagement, also in relation to their professional community and unions, but experienced their limits as nothing ever changed. So these are people who are frustrated by their lack of interest representation and are also disappointed by the union, because they do not represent their interests in decisive ways. (Intermediary actor_02-01: 32)

Obviously, locum tenens physicians are not loyal to the hospitals in which they were previously employed, but they are very loyal to their professional values. With regard to the organization, they exert voice and exit. However, the exit option differs from that conceptualized by Hirschman since physicians quit their hospital jobs to be deployed in various hospitals and still do the same job in the same profession. Considering their employment status, the voice option slightly differs as well.

Voice of locum tenens physicians in German hospitals

In contrast to their authority when permanently employed in hospitals, locum tenens physicians perceived that they can potentially make autonomous medical decisions. Since they are not formally integrated into hierarchical organizational structures, they are not bound by directives and instead meet colleagues and superiors on the same level.

I can decide what I want, because I am not subject to any economic constraints of the hospital or anything else, but I’m practicing medicine really well and I do it for the patients. (Locum tenens physician_01-01: 159)

I am not under economic or other constraints. And also not under hierarchical constraints and feel truly free to make my decisions, what’s best for the patient. (Locum tenens physician_01-02: 143)

Since locum tenens physicians are oriented toward patients’ well-being, they argue that their lack of familiarity with organization-specific standards and routines (Hoque and Kirkpatrick, 2008) promotes their awareness of inefficiencies and weaknesses in organizations and thus their ability to challenge an organization’s internal processes.

The greater independence of locum tenens physicians has another important consequence for their professional practice: It allows them to prioritize the latest scientific findings over organization-specific requirements or instructions from superiors. As a consequence, they refer to their expertise and practical knowledge to influence the provision and quality of medical services in hospitals. Locum tenens physicians are therefore more willing to report any unprofessional behavior and mistakes they may observe. They use voice, and are heard.

[Being a locum physician] makes it easier to say ‘I am not contributing to what is going on here, because I do not want to.’ And then I go. This is why I am a locum physician. (Locum tenens physician_01-01: 175)

When I notice that, for instance during the resuscitation of a patient, something went wrong … then I go to the chief medical officer another day to suggest resuscitation should be practiced more often. Without saying names or giving examples. (Locum tenens physician_01-02: 59-61)

The permanently employed physicians we interviewed support these views and emphasize the function of locums as educators. As the locum tenens physicians have already completed their specialist training, permanently employed junior physicians in particular profit from their colleagues’ advice when supervision from the regular superiors is missing.

So we had actually quite positive experiences because the benefit is that locum physicians are often specialists, and otherwise many colleagues are freshmen. … On the one hand, locum physicians are of course novices in terms of organizational structures, but on the other hand you can learn a lot … that’s why I find it really positive. (Permanently employed physician_01-01: 31)

An interviewee who functioned both as an intermediary actor and as a locum tenens physician observed that locum tenens physicians are in a comparatively better position to exert voice individually when working in hospitals as independent professionals.

I arrive at a hospital and the room [in which he spends time for on-call duties] was not renovated since the 1950s … and sometimes you can achieve more improvements in two weeks as a locum physician, saying, ‘Nobody will stay here’, than the permanently employed [can achive] by complaining for 20 years. … [The permanently employed physician] cannot bang on the table as he wants, because he is dependent. (Intermediary actor_02-01: 32)

This example illustrates how locum tenens physicians align their own interests with those of their permanently employed colleagues. Another potential alignment of interests, which was described by both permanently employed and locum tenens physicians, is the possibility of relieving time pressure and workload by deploying locum tenens physicians temporarily to allow permanent employees to take time off for recreation or further training.

In the end, we are thankful because locum physicians take much of the load off. (Permanently employed physician_01-03: 30)

In sum, locum tenens physicians return to hospitals virtually in a new form. As independent contractors, they have more autonomy within the organization and can use this position to exert voice in their own interest (e.g., to negotiate better pay and better accommodation during on-call duties) as well as to contribute to improvements in everyday hospital work and serve as a role model for permanently employed physicians. These activities are supported by professional associations. In 2011, the Federal Chamber of Physicians and the National Association of Statutory Health Insurance Physicians presented a position paper that highlighted the benefits of the rise of locum tenens physicians and attributed the decline in the attractiveness of the medical profession to the lack of professional autonomy and inflexible working time models (Mischkowsky, 2012). Our study also found various instances in which locum tenens physicians not only compensate for shortcomings in working conditions but also have the power to use voice to improve both the working conditions for their permanently employed colleagues and the quality of patient care. Examples include pointing to instances of malpractice and training needs, sharing new knowledge and professional experience, defending professional standards against hierarchical orders, and alleviating work pressure through their flexible availability.

Discussion and conclusion

Summary of findings

Our study analyzed the phenomenon of deploying locum tenens physicians as independent contractors in hospitals with reference to Hirschman’s concepts of exit, voice and loyalty, thereby linking the micro, meso and macro levels. Our analysis shows that locum tenens physicians become self-employed because of their dissatisfaction with the working conditions in hospitals, which have changed due to profound health care reforms To express dissatisfaction with these working conditions, permanently employed physicians use the exit option, which is available owing to a labor shortage and high demand for physicians in German hospitals. Being deployed as self-employed physicians in different hospitals helps them to maintain professional standards because they are not bound by directives and, thus, patient care stays at the center of their medical practice regardless of economic, bureaucratic and hierarchical requirements as well as hospital-specific routines.

In all, as independent contractors, they gain a new, more autonomous position in the hospital. Therefore, they have the opportunity to enforce improvements in everyday hospital practices and to compensate for shortcomings in the working conditions – they obtain voice through exit.

Conceptual contributions

Our study makes three important conceptual contributions. We explore independent contracting as a means of changing the form of work in the health care sector, first by discussing the interrelationship of exit, voice and loyalty with regard to this comparatively new form of employment, and second by showing new forms of worker participation in the organizational context. We additionally point to the relevance of structural conditions at the macro and meso levels for voice, such as the degree of professionalization, existing career paths and labor market shortages.

Studies referring to Hirschman’s work have discussed exit–voice–loyalty behavior mainly with regard to individual factors and have paid less attention to structural preconditions such as organizational, labor market and institutional conditions.

As a result, voice and exit are not mutually exclusive alternatives since highly skilled workers can gain voice through exit. In applying Hirschman’s concept to locum tenens physicians we show that before these individuals decided to quit their jobs, they were permanently employed in hospitals and tried to improve the organization. Thus, during their previous employment in hospitals, locum tenens physicians tried to raise their voices to improve organizational structures and routines. When they were not heard and no organizational improvement occurred, they exited the organization and changed their employment status because of being loyal to professional values.

Although locum tenens physicians perceived the exit option as readily available, which ‘makes the recourse to voice less likely’ (Hirschman, 1970: 83), they first tried to alter the situation and left only after nothing had changed. Thus locum tenens physicians do not merely exit, they also exercise voice. As it is the case in Hirschman’s argumentation, loyalty is an attitude that promotes organizational development. However, in the perspectives of the physicians interviewed, organizational improvement can be fostered only by changing employment status. Loyalty causes exit and exit stimulates voice. In Hirschman’s view, loyalty represents a feeling of attachment to an organization to which one belongs. However, physicians are not only loyal to hospitals as organizations but also are loyal to their profession. Thus, to promote professional values, they decide to withdraw from the organization. Importantly, in the case of locum tenens physicians a slightly different understanding of exit is implied since they still do the same job in the same profession but in different hospitals.

The findings of this study also point to a significant change in participation and possibilities of voice in the context of organizational restructuring processes aimed at increasing efficiency and reducing costs in a non-market environment such as health care. The intention of individual voice is not only to improve personal working conditions but to better the working conditions of permanently employed colleagues and conditions of patient care in hospitals. In this sense, loyalty to the profession is likely to activate voice in organizations (see Figure 2). Locum tenens physicians decide to be self-employed to remain independent and to reinforce their ideas and demands. They do not exit the hospital with the intent of being employed in another one. Instead, they use the market situation to ensure the possibility of voice.

Figure 2.

Conditions and consequences of exit–voice–silence–loyalty behavior.

However, locum tenens physicians’ reason for exit and voice potentially comes from the fact that physicians are members of a profession (Freidson, 1970a). As such, they are committed to a professional ethos and patient care and orient themselves to core ethical values (e.g., do no harm, help patients) instead of to a specific hospital organization. In contrast to their formal socialization – which comes through pursuit of the university degree – their professional socialization takes place within the clinical practice in hospitals – that is, at the organizational level (Becker et al., 1961). Whether physicians respond with silence and do nothing about the dissatisfying situation is not presently known, and finding the answers would require an in-depth study of permanently employed physicians and their coping strategies. At this point, we would expect that silence behaviors, such as reduced work effort, less attention to quality and increased absenteeism and lateness (Turnley and Feldman, 1999), would be less likely for physicians than for other groups of workers considering their loyalty to their profession. Employees with a high investment in a job are more likely to show voice and loyalty and less likely to choose exit and silence (Morrison, 2014; Rusbult et al., 1988).

As committed professionals, locum tenens physicians seem to engage in a mixture of individualistic and collectivistic behavior to represent their interests (Watson and Shepard, 2000). While locum tenens physicians’ interests are not purely individualistic, their means of exerting voice – through individual exit – potentially competes with collective forms of voice, such as works councils, unions and professional associations, in addressing problematic working conditions. Likewise their use of voice shows that informal patterns of worker participation (Townsend et al., 2012) also involve independent contractors.

Limitations and implications for future research

Our findings must be considered in light of our studies’ limitations. First, although we gained valuable insights into a previously under-researched topic of locum tenens physicians in German hospitals, these insights emerged from a highly specific sample that may especially include those locum tenens physicians who are ideologically driven. Future studies should validate the insights through a quantitative study and replicate the results with regard to independent contractors in industries and organizational contexts with comparable structural conditions, since similar interrelationships of exit, voice and loyalty can be expected.

Second, to become self-employed, physicians must have their Certificate of Completion in Specialist Training and must be willing to cope with risks such as limited access to jobs. Because career paths in hospitals can make them dependent on hierarchies that combine professional and managerial logics, permanently employed physicians at early career stages are restricted from voicing complaints or suggesting changes. Moreover, physicians may stay employed in hospitals when they have the chance to change something or when the alternatives are not attractive. For example, physicians may expect the situation in other hospitals to be similar, or may prefer not to be self-employed.

Third, our examination was affected by the special situation of a labor shortage, which implies a lower risk to becoming self-employed and limits the potential downsides of self-employment and exerting voice in organizational contexts. Future studies should refer to longitudinal data to identify labor market effects. Since the rise of locum tenens physicians is a recent phenomenon, whether this effect leads to a broader re-professionalization of physicians in hospitals can be only conjecture. What is certain is that recent health care reforms affect organizational decision-making and control processes, which currently result in a stronger restriction on the professional autonomy of physicians.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

This work was supported financially by the non-profit foundation Stiftung Mercator (GYF_2013/15) and Mercator Research Center Ruhr (Pr-2014-0041).

Notes

Author biographies

Caroline Ruiner is a sociologist and economist and currently is a stand-in professor at Ruhr-University Bochum in Germany. Her areas of research include sociology of work and organization, new employment relationships in knowledge-intensive fields of work as well as the effects of increasing flexibility and challenges for the management of human resources.

Maximiliane Wilkesmann is an assistant professor at the Faculty of Business and Economics at the TU Dortmund University in Germany. Her research interests include (medical) professions, knowledge transfer, organization studies, industrial relations and new forms of employment.

Birgit Apitzsch is a postdoctoral researcher at the Sociological Research Institute in Göttingen, Germany. Her areas of research are the sociology of work, organizations and labor markets, industrial relations, institutional theory, comparative and transnational sociology. Recent research centers on consequences of informalized and nonstandard employment with a focus on regulation and institutional change, migration, industrial relations, professions and service work.

References

Acar

(2016) Variation in worker responses to subcontracted employment: A qualitative case study. Economic and Industrial Democracy 37(1): 1–25.

Alonzo

Simon

(2008) Have stethoscope, will travel: Contingent employment among physician health care providers in the United States. Work, Employment and Society 22(4): 635–654.

Barry

(1974) Review article: ‘Exit, voice and loyalty’. British Journal of Political Science 4(1): 79–107.

Becker

Geer

Hughes

Strauss

(1961) Boys in White: Student Culture in Medical School. Chicago: University of Chicago Press.

Berntson

Näswall

Sverke

(2010) The moderating role of employability in the association between job insecurity and exit, voice, loyalty and neglect. Economic and Industrial Democracy 31(2): 215–230.

Bidwell

Briscoe

(2009) Who contracts? The determinants of the decision to work as an independent contractor among information technology workers. Academy of Management Journal 52(6): 1148–1168.

Bode

Märker

(2014) Management in medicine or medics in management? The changing role of doctors in German hospitals. International Journal of Public Sector Management 27(5): 395–405.

Bogenrieder

Nooteboom

(2004) Learning groups: What types are there? A theoretical analysis and an empirical study in a consultancy firm. Organization Studies 25(2): 287–313.

Boroff

Lewin

(1997) Loyalty, voice, and intent to exit a union firm: A conceptual and empirical analysis. Industrial and Labor Relations Review 51(1): 50–63.

10.

Bundesärztekammer und Kassenärztliche Bundesvereinigung (2011) Honorarärztliche Tätigkeit in Deutschland. Positionsbestimmung der Bundesärztekammer und der Kassenärztlichen Bundesvereinigung. Available at: www.bundesaerztekammer.de/fileadmin/user_upload/downloads/honoraraerzte_26052011.pdf.

11.

Burns

Wiholey

(1992) Factors affecting physician loyalty and exit: A longitudinal analysis of physician–hospital relationships. Health Services Research Journal 27(1): 1–24.

12.

Chandler

Barry

Clark

(2002) Stressing academe: The wear and tear of the New Public Management. Human Relations 55(9): 1051–1069.

13.

Connelly

Gallagher

(2004) Emerging trends in contingent work research. Journal of Management 30(6): 959–983.

14.

Courpasson

Dany

(2003) Indifference or obedience? Business firms as democratic hybrids. Organization Studies 24(8): 1231–1260.

15.

Davis-Blake

Broschak

George

(2003) Happy together? How using nonstandard workers affects exit, voice, and loyalty among standard employees. Academy of Management Journal 46(4): 475–485.

16.

De Ruyter

Kirkpatrick

Hoque

, et al. (2008) Agency working and the degradation of public service employment: The case of nurses and social workers. International Journal of Human Resource Management 19(3): 432–445.

17.

De Vos

Meganck

(2009) What HR managers do versus what employees value: Exploring both parties’ views on retention management from a psychological contract perspective. Personnel Review 38(1): 45–60.

18.

Destatis (2017) Durchschnittliche Verweildauer in deutschen Krankenhäusern in den Jahren 1990 bis 2015 (in Tagen). Destatis. Available at: www.destatis.de/DE/ZahlenFakten/GesellschaftStaat/Gesundheit/Krankenhaeuser/Tabellen/KrankenhaeuserJahreOhne100000.html;jsessionid=E6E89EF765797BD9F4B9A5C0F6A85FFC.cae2.

19.

Detert

Edmondson

(2011) Implicit voice theories: Taken-for-granted rules of self-censorship at work. Academy of Management Journal 54(3): 461–488.

20.

Ernst

Szczesny

(2005) Cost accounting implications of surgical learning in the DRG era: Data evidence from a German hospital. Schmalenbach Business Review 57(2): 127–166.

21.

Evetts

(2009) New professionalism and new public management: Changes, continuities and consequences. Comparative Sociology 8(2): 247–266.

22.

Farrell

(1983) Exit, voice, loyalty and neglect as responses to job dissatisfaction: A multidimensional scaling study. Academy of Management Journal 26(4): 596–607.

23.

Feldman

Doerpinghaus

Turnley

(1994) Managing temporary workers: A permanent HRM challenge. Organisational Dynamics 23(2): 49–63.

24.

Ferlie

Ashburner

Fitzgerald

Pettigrew

(1996) The New Public Management in Action. Oxford: Oxford University Press.

25.

Figueras

McKee

Cain

Lessof

(2004) Health Systems in Transition: Learning from Experience. London: World Health Organization.

26.

Freidson

(1970a) The Profession of Medicine. New York: Mead and Company.

27.

Freidson

(1970b) Professional Dominance: The Social Structure of Medical Care. New York: Atherton.

28.

Freidson

(2001) Professionalism, the Third Logic: On the Practice of Knowledge. Chicago: University of Chicago Press.

29.

Gallagher

Sverke

(2005) Contingent employment contracts: Are existing employment theories still relevant? Economic and Industrial Democracy 26(2): 181–203.

30.

Grimshaw

Rubery

(1998) Integrating the internal and external labour markets. Cambridge Journal of Economics 22(2): 199–220.

31.

Hirschman

(1970) Exit, Voice and Loyalty. Cambridge, MA: Harvard University Press.

32.

Hogwood

(2016) German healthcare in transition: A ‘paradigm shift’? In: Mattei

(ed.) Health Care Governance and Accountability. Oxford: Palgrave Macmillan, pp. 13–35.

33.

Holvast

Doornbos

(2015) Exit, voice, and loyalty within the Judiciary: Judges’ responses to new managerialism in the Netherlands. Utrecht Law Review 11. Available at: www.utrechtlawreview.org/articles/10.18352/ulr.317/galley/318/download/.

34.

Hoque

Kirkpatrick

(2008) Making the core contingent: Professional agency work and its consequences in UK social services. Public Administration 86(2): 331–344.

35.

Houseman

Kalleberg

Erickcek

(2003) The role of temporary agency employment in tight labour markets. Industrial and Labor Relations Review 57(1): 105–127.

36.

Janus

Amelung

Gaitanides

Schwartz

(2007) German physicians ‘on strike’: Shedding light on the roots of physician dissatisfaction. Health Policy 82(3): 357–365.

37.

Kalleberg

(2000) Nonstandard employment relations: Part-time, temporary and contract work. Annual Review of Sociology 26(1): 341–365.

38.

Kalleberg

Reskin

Hudson

(2000) Bad jobs in America: Standard and nonstandard employment relations and job quality in the United States. American Sociological Review 65(2): 256–278.

39.

Kikuzawa

Olafsdottir

Pescosolido

(2008) Similar pressures, different contexts: Public attitudes toward government intervention for health care in 21 nations. Journal of Health and Social Behavior 49(4): 385–399.

40.

Kirkpatrick

Hoque

(2006) A retreat from permanent employment? Accounting for the rise of professional agency work in UK public services. Work, Employment and Society 20(4): 649–666.

41.

Kolarska

Aldrich

(1980) Exit, voice, and silence: consumers’ and managers’ responses to organizational decline. Organization Studies 1(1): 41–58.

42.

Kowalski

(1996) Complaints and complaining: Functions, antecedents, and consequences. Psychological Bulletin 119(2): 179–196.

43.

Kunda

Barley

Evans

(2002) Why do contractors contract? The experience of highly skilled technical professionals in a contingent labor market. Industrial and Labor Relations Review 55(2): 234–261.

44.

LePine

Van Dyne

(1998) Predicting voice behavior in work groups. Journal of Applied Psychology 83(6): 853–868.

45.

McGivern

Ferlie

(2007) Playing tick-box games: Interrelating defences in professional appraisal. Human Relations 60(9): 1361–1385.

46.

McKee

Healy

Edwards

Harrison

(2002) Pressures for change. In: McKee

Healy

(eds) Hospitals in a Changing Europe. Buckingham: Open University Press, pp. 36–58.

47.

McLaughlin

Osborne

Ferlie

(eds) (2001) Book New Public Management: Current Trends and Future Prospects. New York: Routledge.

48.

Mattei

Mitra

Vrangbaek

, et al. (2013) Reshaping public accountability: Hospital reforms in Germany, Norway and Denmark. International Review of Administrative Sciences 79(2): 249–270.

49.

Matusik

Hill

CWL

(1998) The utilization of contingent work, knowledge creation, and competitive advantage. Academy of Management Journal 23(4): 680–697.

50.

Mayring

(2000) Qualitative content analysis. Qualitative Social Research. Available at: www.qualitative-research.net/index.php/fqs/article/view/1089/2385.

51.

Miles

Huberman

Saldana

(2014) Qualitative Data Analysis: A Methods Sourcebook. Thousand Oaks, CA: Sage.

52.

Milliken

Morrison

(2003) An exploratory study of employee silence: Issues that employees don’t communicate upward and why. Journal of Management Studies 40(6): 1453–1476.

53.

Mintzberg

(1979) The Structuring of Organizations: A Synthesis of the Research. Englewood Cliffs, NJ: Prentice Hall.

54.

Mischkowsky

(2012) Spannungsverhältnis Chefarzt-Geschäftsleitung. Ergebnisse einer Befragung bei Deutschen Chefärzten. BDC Online. Available at: www.bdc.de/document.jsp?documentid=525D104D718F9932C12579D500482B96&form=Dokumente&print=1&parent=null.

55.

Mitlacher

Welker

(2012) Who called the physician? HR risks and challenges for German hospitals using locum tenens. International Journal of Employment Studies 20(2): 56–74.

56.

Morrison

(2011) Employee voice behavior: Integration and directions for future research. Academy of Management Annals 5(1): 373–412.

57.

Morrison

(2014) Employee voice and silence. Annual Review of Organizational Psychology and Organizational Behavior 1(1): 173–197.

58.

Noordegraaf

Burns

(2017) The paradoxes of leading and managing healthcare professionals: Toward the integration of healthcare services. In: Hoff

Sutcliffe

Young

(eds) The Healthcare Professional Workforce: Understanding Human Capital in a Changing Industry. Oxford: Oxford University Press, pp. 107–142.

59.

Purcell

Tailby

(2004) Temporary work agencies: Here today, gone tomorrow? British Journal of Industrial Relations 42(4): 705–725.

60.

Ruiner

Apitzsch

Hagemann

, et al. (2017) Locum doctors – Curse or blessing for hospital’s performance? International Journal of Employment Studies 25(2).

61.

Rusbult

Farrell

Rogers

Mainous

III (1988) Impact of exchange variables on exit, voice, loyalty, and neglect: An integrative model of responses to declining job satisfaction. Academy of Management Journal 31(3): 599–627.

62.

Saltman

Bankauskaite

Vrangbaek

(2007) Decentralization in Health Care: Strategies and Outcomes. Maidenhead: Open University Press.

63.

Simon

Alonzo

(2004) The demography, career pattern, and motivation of locum tenens physicians in the United States. Journal of Healthcare Management 49(6): 363–375.

64.

Spencer

(1986) Employee voice and employee retention. Academy of Management Journal 29(3): 488–502.

65.

Teske

Schäfer

Ollenschläger

(2010) Honorarärzte in Deutschland – Demographie, Rahmenbedingungen und Motivation – Erste Ergebnisse der Honorararztstudie, Manuskript Honorararztstudie für das Deutsche Ärzteblatt. Available at: www.aerzteblatt.de/download/files/2010/06/down146385.pdf.

66.

Townsend

Wilkinson

Burgess

(2012) Filling the gaps: Patterns of formal and informal participation. Economic and Industrial Democracy 34(2): 337–354.

67.

Turnley

Feldman

(1999) The impact of psychological contract violations on exit, voice, loyalty, and neglect. Human Relations 52(7): 895–922.

68.

Von Nordenflycht

(2010) What is a professional service firm? Towards a theory and taxonomy of knowledge-intensive firms. Academy of Management Review 35(1): 155–174.

69.

Ward

Grimshaw

Rubery

Beynon

(2001) Dilemmas in the management of temporary work agency staff. Human Resource Management Journal 11(4): 3–21.

70.

Watson

Shepard

(2000) Disaffected loyalties in a changing contractual environment. International Journal of Value-Based Management 31(2): 123–140.

71.

Whitey

Cooper

(1989) Predicting exit, voice, loyalty, and neglect. Administrative Science Quarterly 34(4): 521–539.