Exploring the critical care nurses ’ experiences regarding moonlighting

While moonlighting is so prevalent amongst critical care nurses, there are no documented facts in this country about how it affects the nurses and the hospital management, considering the nature of their work that is both physi­ cally, mentally and emotionally strenuous. The aim of this study was to explore the critical care nurses’ rationale and experiences regarding holding a second job (moonlight­ ing). A non-experimental exploratory study was done us­ ing focus groups. Many positive and less positive experi­ ences were revealed, for example, economical, educational, and psychosocial ones. Participatory control of moon­ lighting activity was suggested involving both manage­ ment and staff at functional level. Sam evatting Terwyl ’n tweede werk onder kritiese sorg verpleegkund iges aan die orde van die dag is, is daar geen gedokumenteerde feite in hierdie land oor hoe dit verpleegkundiges en die hospitaalbestuur beinvloed nie met in agneming van die feit dat die aard van die werk fisies, geestelik en emosioneel veeleisend is. Die doel van hierdie studie is om die kritiesesorgverpleegkundige se rasionaal en ervarings met betrekking tot ’n tw eede w erk te ondersoek. ‘n Nieeksperimentele ondersoekende studie deur middel van fokusgroepe is gedoen. Baie positiewe en minder positiewe ervarings, byvoorbeeld, ekonomiese opvoedkundige en psigososiale faktore is geidentifiseer. Deelnemende beheer van die tweede werk deur beide verpleegbestuur en personeel op die funksionele vlak word voorgestel.


Introduction
Holding a second job or moonlighting has become prevalent amongst nurses especially critical care nurses.Half of the four hundred and sixty nine (469) nurses on the register of one of the four nursing agencies recruiting and supplying nurses for moonlighting in Durban are identified as critical care nurses, because of the demand for the nurses of this specialty in the private hospitals.It is also reported that some nurses apply directly to these hospitals as session workers while others leave their primary jobs and freelance through the agencies.The pool of nurses that are in the register in these agencies are predominantly from the public hospitals, (personal interview, member, Nursing Services of S.A, 1999).

The Problem Statem ent
While moonlighting is so prevalent amongst nurses, there are no documented facts in this country about how it affects the nurses and the hospital management, considering the na ture of their work that is both physically, mentally and emo tionally strenuous.Instead there is increased demand for nurs ing staff in private hospitals which are now more accessible with the increase in the medical aid provision to the previ ously underprivileged.The private institutions find it more economical to work with skeleton staff and call additional staff when the need arises.The pool of nurses that moonlight comes from the public sector.The government, as the em ployer in the public sector, is not being ready to compete with the private institutions in terms of incentives to retain nurses in the public sector (Sunday Tribune, 1999:2).Instead, like in other developing countries, further cuts in government spending on salaries are inevitable either through retrench ments or freezing of posts (Van der Gaag, Selcner & Vijverberg, 1989:V).It is postulated that there is a relation ship between holding a second job and absenteeism in the public sector.It is also reported that some spend extraordi narily long hours in the second job to the detriment of their health (Van der Gaag, Selcner &Vijverberg, 1989:30; Cohen, 1990:529 & Urbach, 1994:797).

The Purpose and Objectives of the study
The purpose of this study was to explore the critical care nurses' rationale and experiences regarding holding a sec ond job (moonlighting).The objectives were to: • establish the critical care nurses' rationale for accepting and holding a second job; • explore the critical care nurses' experiences of the second job and • establish from the critical care nurses the need to support engagement in the second job and the way this should be done.

The Significance of the study
The prevalence of holding a second job especially, among critical care nurses, whose nature of work is so strenuous, has raised concern.The reported relationship between moonlight ing and absenteeism including the effect of this activity on the physical health are also cause for concern both from the employee's and the management's perspective ( Van der Gaag, et al, 1989:30;Cohen, 1990:529 & Urbach, 1994:797).Therefore exploring the critical care nurses' rationale for and their experiences of a second job could enable cooperation and understanding of all parties involved in balancing serv ice, quality of care and education while limiting risk expo sure.The benefit of guided moonlighting to the post graduate students could also be explored and taken advantage of.

Definition of Terms
Moonlighting is, according to Van der Gaag et al (1989:30), a second income earning activity in addition to the primary job, also called "double jobbing".Barnhart and Barnhart (1989) define it as the practice of holding or working at a second job, usually at night, in addition to a regular daytime job.It seems that the definition depends on the context in which it is used because Urbach (1994:794) defines it as an extracurricular employment in relation to academic pro grammes.In this study both versions were used.
Session work describes that type of moonlighting by nurses who are not recruited by nursing agencies but are listed di rectly in the hospital for call on a regular basis, according to need.These nurses may be part of the hospital staff doing something like overtime or may also be listed with the agen cies (Personal interview, SA Nursing Services: 1999).
Freelance describes a type of work in which one performs or offers a service without being regularly employed (Mackwardt, Cassidy, Hayakawa & McMillan: 1973).Critical Care Nurses are all registered nurses working in Critical Care Units who have had experience with moonlight ing either directly or indirectly.

Literature review
Existing literature on moonlighting focuses on resident doc tors outside this country.The only nursing literature avail able expresses concern about the hospital malpractice insur ance or physician insurance cover for moonlighting nurses (Muir, 1988).However, exposure to liability is a problem at any workplace, therefore in South Africa the insurance cover embraces all settings in which the insured is covered by a professional body or union.According to the member of the nursing agency that was visited, recruits for moonlighting are required to produce indemnity from a professional body or union.Secondly nurses are concerned about the legal duty to report this practice to management (Regan, 1981).Muir (1988), as an industrial relations consultant, advises the nursemanagers on facts to consider when they discover that a nurse is engaged in a second job, as follows: • The impingement of the second job on the efficiency of the organisation or business interests of the princi pal job.In nursing this may imply sacrificing the qual ity of patient care when the nurse comes to the princi pal employment tired physically and mentally.

•
The existence of competition between the primary and the second jobs may be unlikely with nurses although nurses can also set up a private nursing home which may bring about conflict of interests.

•
Whether a clause in the contract of employment exists that forbids taking up a second job and whether this condition is absolute or conditional on the nurse seek ing permission.This places the management in a bet ter position to base their discipline on some tangible concrete facts.

•
Common law which implies an unwritten contract of loyalty, fidelity, trust and confidentiality; is also sug gested for consideration by the management when dis ciplinary action is taken.• However, Muir (1988) also warns that a person has a right to work for whosoever he/she chooses and use the spare time to his/her advantage.This being all that nurses have to say about moonlighting, the author decided to look for the subject under study among other health professionals.Literature on moonlighting among resident doctors indicates that moonlighting is a widespread practice so much that its prevalence is rated at 30%-60%.This activity also varies among specialities with 6% among pathology, anaesthesiology, radiology, gynaecology and ob stetrics; 30% in internal medicine and 70% in paediatrics.(Gullup & Schnittling, 1991:387;Urbach, 1994:795).How ever, in nursing the register of the employment agency indi cates that most moonlighting nurses are critical care nurses.

M o tiv e s fo r m o o n lig h tin g
The main motive for moonlighting among other health work ers was economic indebtedness related to salaries failing to keep pace with inflation, high interest rates and dependants (Cohen, 1990(Cohen, :1065;;Gullup & Schmittling, 1991: 387;Urbach, 1994:795).Studies also revealed that debts correlated with decision to moonlight and that higher resident salaries de crease the probability of moonlighting (Urbach 1994:795).

B e n e fits o f M o o n lig h tin g
There are various benefits to moonlighting, for example, ad ditional income that enables repayment of massive student loans thus improvement of the standard of living (Cohen & Leeds, 1989:529).Education is also enhanced through exposure to other treat ment environments, promotion of self confidence to practise independently, promotion of ability to take responsibility, ex ploration of career opportunities with an experienced eye (Stange & Sutherland, 1987;Urbach, 1994: 795).Provision of an exciting change from one's daily work was seen to be an additional advantage to moonlighting (McCue, Janiszewski & Stickley 1990:512).

C o n c e rn s a b o u t m o o n lig h tin g
Many studies reveal a number of concerns about moonlight ing in relation to competing needs, rights and principles as will be discussed hereunder.Exhaustion is one important factor that causes concern as it affects efficiency in the performance of the job (Muir, 1988:34).Furthermore, a survey by Cheng (1991Cheng ( :1105) ) in California revealed that fatigue threatened medical judgement and com passion for patients, qualities that are so important for criti cal care nurses.Although a second job takes place after hours, Van der Gaag et al (1989:30) have made casual observation on absenteeism, suggesting that some of the moonlighting may be taking place during the day thereby enchroaching on the primary job.Malpractice liability is of concern especially because some health workers have limited knowledge about liability insur ance, to the extent that some may find out about it only after a lawsuit has been filed (Gullup & Schmittling, 1991: 387 388;Urbach et al 1994Urbach et al : 1512)).As alluded to earlier, conflict of interests and competition between the primary and secondary jobs may be a problem, for example, competition for specialised staff and well pay ing clientele in the health care setting.Hence the observation that moonlighting varies with the area of specialisation (Urbach & Richmond, 1994:1512).Authors suggest that moonlighting be regulated in terms of duration, reporting, monitoring and/or approval.To achieve this authors recommend Peer Review Committees for colle gial discipline and awareness workshops on professional li ability insurance for moonlighters, including developing a policy to address moonlighting and handling situations with moonlighting employees.However, concern exists to the ef fect that regulation of moonlighting may suggest approval and supervisory responsibility for this activity (Urbach, 1994:796;Gullup & Schm ittling, 1991:389;Yingling, Hattemer, Rouan & Luke 1991:705;Lycos, 2000).Whichever way is taken, regulatory measures to restrict or eliminate moonlighting practice, Cohen, & Leeds (1989:531); Piening (1990:454) suggest that they must be balanced with the academic, clinical and financial realities.

Research Methodology
A non -experimental exploratory study was used to analyze the critical care nurses' rationale for and experiences of hold ing a second job.Twenty four (24) registered nurses working in the critical care units in two public hospitals in the Durban Functional Region were formed into four focus groups repre senting both shifts (day and night duty) according to their willingness to participate.The focus group discussions were conducted in the context of their primary jobs.For ethical reasons the participants were not selected according to whether they were moonlighting or not and they remained anonymous.A semi structured interview guide was used to trigger the discussions.(See table 1).

Data Analysis
A content analysis of data was done manually whereby the data was formed into categories, namely, the extent of the moonlighting activity, positive and less positive experiences which were further categorized into economic, educational, psychosocial ones including physical health.

Trustworthiness
To ensure accuracy of fieldnotes and objectivity the focus group discussions were tape-recorded and transcribed verbatim with the permission of the participants.The analyzed data was shared with an experienced researcher and some of the re search participants to verify the accuracy of the analyzed data.

Findings
The findings are presented according to the categories based on the interview guide.
T h e e x te n t o f th e a c tiv ity All participants were moonlighting or had moonlighted in the recent past.
T h e ra tio n a le fo r m o o n lig h tin g All groups agreed that they moonlighted for economic rea sons; " to augment the minimal government salaries"' , " NPA salaries cannot carry you to month end".One group pointed out that they were networking or explor ing with an aim of changing to the private hospital; " if you have an interest o f ending up working in private sector to orientate yourself'.The other group admitted that it was out of curiosity; as peo ple talk about moonlighting more people want to experience it." To experience what people talk about".

Cost awareness and cost containment
All groups agree that moonlighting made them aware how expensive equipment and supplies are in hospital and em barked on cost containment even in their own hospitals, thus saving one's own hospital.This is illustrated in responses such as "charging in private hospitals makes you think how much we waste in the government hospitals not knowing how much things cost"or "Now I see to it that unused gauze is sent back to CSD".

Personal financial improvement
The participants in all groups felt that they had gained financially because they could then make ends meet, and could afford to educate their children and avoid buying on account.
P o s itive Ex p e rie n c e s :

E d u c a tio n a l
According to the participants, moonlight ing fosters independence, self-confidence and responsibility through: • exposure to a variety of diseases and technology to learn • update with new technology and drugs which the pub lic hospitals cannot afford to buy.Therefore moonlighting improves performance in their pri mary jobs.This is indicated by statements like; '7 thought that after I had done an ICU course I was the b est..., I only realized after I went to other hospitals that I did not have enough experience".

P o s itiv e E x p e rie n c e s : P s y c h o s o c ia l
The participants stated that the nurse-patient relationship and patient co-operation are facilitated by the fact that admission for patients in private hospitals are most of the time elective therefore patients are conscious and able to communicate.

1.
Tell me, have you moonlighted in the past three years?2.
Would you share with me the reason(s) that made you moonlight?3.
What do you think the effect of moonlighting is: 4.1.In your work life?4.2.In your private life? 5. Can moonlighting be made user friendly?
These patients are also well prepared for admission into ICU while those in public hospitals are usually admitted uncon scious and often in an advanced stage of the disease to be able to communicate and co-operate, "in private patients are ori entated and they are told that they will end up in ICU and this is what they will find therefore they are co-operative".Moonlighting has further allowed mixing of different racial and cultural groups which has established trust relationships and fostered mutual respect and understanding in these groups."We get a chance to work with other races, they learn your culture and you learn theirs".According to the participants moonlighting boosts people's morale and motivates them in their primary job because of: • Exciting change from routine.The overtime that was offered at the government sector at some stage does not take you out of routine, "in your hospitalthere is no change: same hospital, same work, same people, everything is the same".

•
Appreciation by their authorities and incentives offered at secondary jobs, "in public one is never thanked and if things go wrong they are up in a r m s " you only see when you sign the report ".All groups of participants agree that moonlighting improves their quality of life because of the economic improvement in their households.

L e s s p o s itiv e e x p e rie n c e s : P h y s ic a l h e a lth
Participants claimed that moonlighting can be very tiring and exhausting therefore may tempt people to go off sick espe cially those that overdo it.This they confirmed by saying that "there is no rest; people get tired and would go off sick".

Le s s p o s itiv e e x p e rie n c e s : Ec o n o m ic
The participants assert that moonlighting tempts people to live beyond their means therefore leads to a person wanting to moonlight more.This temptation encourages moonlight ers to leave the country for more money thus contributes to brain drain from public to private hospitals and finally out of the country."You feel moonlighting money in South Africa is not enough and get motivated to leave to work outside the country to make more money".The participants were concerned that in private hospitals cost takes precedence over life." I could not insert a naso-gastric tube to protect the patient from aspiration because o f addi tional cost and, indeed, the patient did aspirate and was re intubated".

Racism and Ethnocentrism
According to the participants, language differences and lack of communication and trust among the different racial and ethnic groups threaten care."Some speak Sotho, others Afrikaans and you can' t understand"', "Sometime they write care plans in Afrikaans so that one cannot understand what happened during the day therefore they make the patient suf fer"."White patients used to have negative attitudes and make you wonder if your nursing care will be sufficient or o f ac ceptable standard'.
rest hence the temptation to go off sick when due to come back to the primary job.Statements that confirmed such a habit were; "Some work a few days in the shift and go off sick because the pay is not going to be affected', "It must ". "We will not deny that some people go off sick whenever they are supposed to come back from days off" It must also be noted though, that even those that do not moonlight do develop a tendency to go off sick".

Differential Behaviour
Participants stated that some of their colleagues work differ ently in the two jobs, for example, drag their feet in the pri mary job to save their energy for the secondary job."Some time people work differently, drag their feet, save their en ergy for moonlighting''."You'll be surprised when you see people as they massage patients and smile, coming close to kissing them in the sec ond job".

Tension, fear and anxiety
The participants maintain that they work under tension, fear and anxiety because of language differences, impatient doc tors, ethnocentrism and lack of orientation in the secondary jobs.These further threaten patient care as alluded to, earlier."When you come to a unit they just say 'here is the patient' and no one says anything (orientates you), you see to finish because you have come to make money"."Some feel you are worrying them if you ask".

Jealousy bv permanent staff
The participants interpret the questioning by the permanent staff as jealousy, for example; "when do you get time to rest?How do you manage to work so much?You must be having a car now! " The participants have observed that most private hospitals depend totally on moonlighters to an extent of leaving the ICU with strangers only."They leave the ICU totally to stran gers ".Stereotyping has also been observed if a nurse has made a mistake at some stage."Sometime they undermine some hospitals if one nurse made a mistake from that hospital".

Neglect of family
The participants have found that they cannot schedule their time because they are expecting calls anytime to go moon lighting.They also found that they have neglected their fami lies: "we miss out on homework for kids".

Exploitation bv family members
The husbands of moonlighters have been observed to exploit their wives and the whole family taking the moonlighter in the family for a money-maker and literary budgeting for them."Husbands start making profit out óf you, budget for you ". "Kids look at you as money maker".

Habitual Moonlighting
Participants claim that some of the moonlighters develop 'ha bitual moonlighting' by working almost continually without Family disorganisation Families of moonlighters have been observed to behave irre sponsibly in the absence of their wives/mother."He has an other life when you are gone; children start doing their own things; no discipline".This is usually the beginning of a rift between husbands and wives.

Inevitability of Moonlighting
The participants suggested that the management in the pub lic sector must acknowledge that moonlighting is inevitable because of the need to earn extra cash and the demand for moonlighters in the private sector."The management must accept that somehow everybody will need extra cash as long as there are no incentives with the public sector"."Nobody in her good senses would leave the comfort o f her bed and go to work without a reason.We do like to be with our families"."Private hospitals do not employ a full complement of staff, they rely on moonlighters".

Need to control
The need to control moonlighting met with mixed feelings because two of the groups agreed that there is a need to have a policy such as restriction regarding the number of days or hours allowed to moonlight per certain period.However for bidding it would cause problems as quoted in one institution where it was forbidden and the staff resigned.

Confrontation of habitual moonlighters
The participants have observed that the people in charge of units tend to generalise about the problem of habitual moon lighters instead of just confronting them because the pattern is usually recognisable, yet if they report the sister may not be tactful."Sisters in charge must not turn a blind eye"; "As long as you don't call my name I don't care "If you report, the sister in charge will say, 'so and so came and complained"'

Self Discipline
The participants agreed that moonlighters must set their own limits and give themselves rest together with setting realistic goals in terms of budget.This is summarised in statements such as: "Set your own limits, give yourself rest; do not set high unrealistic goals; moonlighting is good for you if you have a conscience".

Peer Group Discipline
They also suggested that they could discipline each other though this seemed to be a source of other problems espe cially if peers are junior to the culprit or the latter is an ag gressive person."Talk to each other; some are aggressive; would not accept correction.But it is possible".

Co-operation between the private and the public sector
One group suggested the need for co-operation between the public and private hospitals to check if a person was officially off.How this could be done, needs to be worked out.They had no suggestions.

Discussion and recommendations
From the above findings it appears that moonlighting is much more prevalent than was anticipated as all participants were moonlighting.It also appears that moonlighting does not only affect the nurse employees but also management, whether positively or negatively.This compares with studies among medical residents who were pushed to moonlight by economic indebtedness as the salaries were failing to keep up with the inflation rate while their education was enhanced through varied and rich exposure (Stange and Sutherland 1987:64;Gullup & Smittling 1991:387;Cohen 1990:1065and Urbach 1994:795).The physical and mental health of the critical care nurses is of much concern especially when fatigue from moon lighting is associated with poor mental judgement and loss of compassion (Cheng, 1991(Cheng, :1105)).It seems that the moonlight ers are pointing fingers at the hospital management for the flaws in how they moonlight.The overtime that was once introduced by the Department of Health seemed to have some benefit but the problems with it was that there was no change from routine as also observed by McCue, Jaiszewski & Stickley (1990:1512).There were also restrictions like in one hospi tal, for example, when on leave one would not be allowed to moonlight in one's own hospital.With this overtime they would only get paid after three months yet they needed im mediate cash.The participants also claimed that they were tempted to misbehave when moonlighting in their own hos pital, for example, they would remind colleagues that they were moonlighting therefore needed not to be overworked.It may be important to take the participants' recommendations seriously to regulate moonlighting, for example, this issue may need to be discussed openly in climate meetings.Moon lighting policy may need to be developed jointly between management and the nurses.Lycos (2000) recommend a m oonlighting policy that does not necessarily regulate employees'off-duty conduct nor forbid them from having other jobs but focuses on issues like interference with the primary job, conflict of interest and approval of the additional em ployment.Peer Review Committees may have to be formed also as suggested by the m oonlighters them selves and Yingling, Hattemer Rouan & Luke (1991:705) to monitor and discipline moonlighters.It seems that the private hospitals where nurses moonlight need to develop clinical guidelines to ensure safety of patients in the hands of strangers (moon lighters), who are also exposed to malpractice liability.Af filiation to a union or professional society seems inevitable if one has to moonlight safetly.

Further study
The researcher suggests another study to explore the percep tions of the hospital management on moonlighting and their experiences with moonlighting activity among nurses in their hospitals.

Lim itations to the study
Because of the small size of the sample in qualitative research one cannot generalise beyond the context of this study.Most of the available literature on the subject is old and not nurs ing as mentioned earlier probably due to the activity having assumed large proportions only recently.

Conclusion
This research has indicated that moonlighting is prevalent.It has also shown that moonlighting has some benefits.How ever, the disadvantages have pointed out that there is need to co-operate between the critical care nurses and the manage ment regarding control of moonlighting.Whatever way is taken to regulate moonlighting, it is important to balance the academic, clinical and financial realities (Piening 1990:454).
P o s itiv e e xp e rie n c e s : Ec o n o m ic Le s s p o s itive e xp e rie n c e s : P a tro n a g e for/ D e p e n d e n c e on M o o n lig h te rs Le s s p o s itive e x p e rie n c e s : P e rs o n a l and fa m ily d is o rg a n is a tio n

Table 1 :
Interview Guide