Clark (2009:327) states that the shortage of nurses places a burden on every clinic, hospital and community agency. The shortage of nurses in health care facilities is a global problem, especially in specialised areas such as ICUs and theatres. According to Hopkins (2002:18), patients who undergo high-risk surgeries are more likely to experience postoperative complications if the ICU is not sufficiently staffed by competent nurses. As a result of the nursing shortages, some hospitals are using nursing agencies in order to augment and enhance the efficiency, productivity and cost-effectiveness of their nursing resources and in this way they are endeavouring to meet the acute staffing needs that are caused by fluctuating patient numbers. A nursing agency service identifies, screens and provides qualified nurses to healthcare organisations at short notice. The use of nursing agencies has become an international trend (Hopkins 2002:18).

The use of nursing agencies varies from country to country. De Ruyter (2007:1666) maintains that expenses for the use of agency nurses have increased threefold in the United Kingdom from 1997 and 1998 to 2002 and 2003. In Australia, the use of agency nurses increased from 23% in 1994 to 26% in 2004 (Fitzgerald, McMillan & Maguire 2007:229). It is known that there are recruitment and retention problems in key high-skill areas, such as theatres, ICUs and neonatal units.

There are various reasons why the use of nurses from a nursing agency is not a wholly satisfactory way of filling vacant full-time positions. In view of the fact that the agency nurses’ affiliation with the hospital is short-term, such nurses could lack a strong commitment to the goals, personnel and clients of the hospital (Burgess & Connell 2006:131; Hall 2006:175). It may happen that departments and units take on any agency nurse because they are of the opinion that any caregiver is better than no caregiver at all. However, managers complain when these nurses fail to meet the nurse managers’ work requirements (De Ruyter 2007:1667–1681). Fitzgerald et al. (2007:230) also indicate that nurses prefer to work in areas in which they have experience and which they recognise as their speciality, for example ICU.

Fitzgerald et al. (2007:230) state that little has been written about the relationship between agency nurses and standards of care and that it constitutes a problem in the health care environment, which relies heavily on agency nurses.

Nevertheless, the use of agency nurses has benefits for health organisations. In a survey conducted in England, it was found that the most important advantages of using agency nurses included the operational and numerical flexibility of these agency nurses, as well as cost savings (Branine 2003:53–68). In South Africa the trend over the last five years has been that nurses prefer to work through nursing agencies, because they are not prepared to commit themselves to working at one hospital only. In this way, they have the freedom to choose when and where they want to work. It would seem as if the nursing agencies in South Africa are able to satisfy the staffing needs of the nurses, whilst patient satisfaction in South Africa increased from 87.5% in 2002 to 89.1% in 2008 (Poo 2009:7).

It is essential that each patient care unit has a staffing master plan that includes the basic personnel needed to cover the unit for each shift. Basic staff refers to the minimum number of nurses needed to staff a unit and it includes fully orientated full- and part-time employees (Roussel & Swansburg 2008:341).

A framework of agreement with preferred nursing agencies across the country imposes minimum standards. An important feature of these agreements is that only agencies that signed the agreement might supply staff to National Health Systems hospitals (De Ruyter 2007:1667). Zuzelo (2010:347) mentions that hospitals make use of agency nurses to meet a shortfall in nursing staff, especially in specialised units like ICUs. It is a global trend to use agency nurses in ICUs when there is a shortage of nursing staff in these units.

According to Armstrong (2007:384), agency nurses on average remain detached from a continuous relationship with the hospitals where they work. Huber (2006:740) recommends that nurse managers should take into account skills, competencies and knowledge when delegating tasks to agency nurses and when supervising their actions. It is essential that the nurse manager ensures that the agency nurse is aware of the relevant policies, procedures, resource materials and documentation procedures. However, there is also the opinion that appropriate staffing involves more than just numbers. It is important to select staff with the appropriate skills and competencies, and it includes agency nurses. Thungjaroenkul et al. (2008:31–36) agree that the increase in workload along with a decline in the number of registered nurses impact the quality of patient care, as well as patients’ safety. Accordingly, the planning of a health organisation’s human resources should include an anticipation of labour shortages and surpluses (Muller, Bezuidenhout & Jooste 2006:245).

The main objectives of ANASA include:

• Provide a service to and represent all nursing agencies in South Africa.
• Provide a service to the public through competent nurses.
• Ensure credibility and recognition by healthcare institutions that use agency nurses.
• Improve the standards for nursing agencies in order to provide an adequate and competent nursing workforce to hospitals.

These objectives of ANASA are intended to facilitate effective staffing of South African hospitals by agency nurses. In 1999, Professor M.E. Muller undertook a study on behalf of ANASA to develop standards for nursing agencies.

These standards addressed the following aspects with which a nursing agency should comply (Muller 2009:21–36):

• The nursing agency should be managed as a business to ensure quality nursing service delivery to the clients (hospitals).
• The nursing agency is responsible for the temporary staffing of agency nurses who are appropriately licensed with regulatory bodies.
• There should be evidence of contractual agreements between the nursing agency and the agency managers, as well as clients (hospitals) and other relevant stakeholders.
• A system reflecting the channels of communication, both internally and externally with hospital managers, should be available to ensure the adequate functioning of the nursing agency.
• There should be written quality improvement management programme in the nursing agency.

These standards indicate the importance of collaboration between agencies and hospitals for the provision of adequate nursing staff by the agencies. Hospitals might assume that the nursing agencies conform to these standards and that the agencies provide agency nurses to them in accordance with the abovementioned standards. There are no completed research studies available in South Africa about the management of nursing agencies or about the staffing of agency nurses at hospital units, such as ICUs.

Agency workers are classified as temporary workers because their tenure within a hospital is for a limited period of time only. Agency nurses are part of a triangular relationship involving the nursing agency manager who hired them, the hospital for which they work (nurse manager) and the agency nurses themselves (Biggs & Swailes 2006:130–143). It is unclear how these role players (the nursing agency manager, the ICU nurse manager and the agency nurse) perceive the staffing of agency nurses in ICUs at private hospitals in Pretoria.

• Staff productivity in the unit might decrease as a result of the incompetency of the agency nurses.
• Conflict might develop in the unit when full-time nurses become frustrated with the lack of knowledge of agency nurses.
• Both incompetent agency nurses and agency nurses who did not show up for work might hold financial implications for the hospital.

The effective provision of agency nurses (staffing) might avert a negative scenario. The International Council of Nurses (ICN 2006:5) states that research increasingly demonstrates that the level of staffing has an impact on patient outcomes, such as mortality and morbidity.

In terms of the scenario described above and the implications such as poor patient outcomes, the following research question arose:

What factors guide nurse managers in the staffing of agency nurses in ICUs at private hospitals in Pretoria?

• Explore and describe the perceptions of nursing agency managers, nurse managers and agency nurses regarding the factors involved in staffing agency nurses in intensive care units (ICUs) at private hospitals in Pretoria.

Professional nurse: According to section 31 of the Nursing Act (Act. 33 of 2005) ‘a professional nurse is a person who is qualified and competent to independently practice comprehensive nursing in the manner and to the level prescribed and who is capable of assuming responsibility and accountability for such practice.’

Agency nurse: Agency nurses are regarded as nurses who were hired as independent contractors for a shift, a week, or a longer period.

Staffing: Muller (2009:300) defines staffing as a process that involves the determination of positions, the recruitment of personnel, the advertisement of positions, as well as the selection, appointment and placement of personnel.

Nursing agency: According to Wikipedia, a nursing agency is a staffing agency that provides nursing personnel to hospitals, medical offices and individuals.

Nursing agency manager: In this study, the nursing agency manager is the person in charge of the nursing agency that is providing agency nurses to private hospitals.

Nurse manager: In this study, the term ‘nurse manager’ refers to a professional nurse who is the manager responsible for the general unit management of the ICU, for maintaining contact with the nursing agency managers and for the staffing of the ICU.

• The first group of respondents included all the nursing agency managers who were working at the nursing agencies registered with ANASA and who provided agency nurses to private hospitals in the Pretoria region (n = 7).
• The second group of respondents comprised the nurse managers of the ICUs at the seven private hospitals in Pretoria who were working either day or night shifts (n = 138).
• The third group of respondents included all agency nurses who were working for the nursing agencies (on their agency employee lists) and who delivered nursing care to ICUs at private hospitals in Pretoria (n = 220).

According to Polit and Beck (2010:307), sampling refers to the process of selecting a portion of the population to represent the entire population. At the time of the study, there were seven nursing agency managers (first group) in the Pretoria region who provided agency nurses to ICUs. A probability total sampling method was used and the researcher selected all seven nursing agency managers, since they were all typical of the population in question (Babbie 2009:196; LoBiondo-Wood & Haber 2009:268). Two of the nursing agency managers later took part in the pre-testing of the instrument and were excluded from the main study. Five nursing agency managers therefore served as the sample.

An equal-probability systematic sampling technique was utilised to select every 4k respondent of the nurse managers and agency nurses (Burns & Grove 2005:350). A representative sample of 69 nurse managers (second group) was systematically obtained from the private hospitals staff lists in Pretoria and a sample of 55 agency nurses (third group) was systematically selected from the agency staff lists. In total, 129 respondents served as the study sample of agency managers, nurse managers and agency nurses.

A self-administered structured questionnaire was used to obtain information on the factors that guide nurse managers regarding the staffing of agency nurses in ICUs at private hospitals in Pretoria. The questionnaire included both open-ended and closed-ended questions. A 5-point Likert scale was used with responses ranging from ‘Totally disagree’, ‘Disagree’, ‘Agree’, ‘Totally agree’ to ‘Do not know’ (Polit & Beck 2008:418–420). The questionnaire had background information and four sections on: determining posts, recruitment and advertising, selection and appointment of agency nurses to ICUs (Table 1). Participants took 30 minutes to complete the questionnaires. The collected data were analysed by a statistician using both descriptive and inferential statistics. The questionnaire was pre-tested. Fowler (2009:124) maintains that the pre-testing of a questionnaire is crucial in order to obviate ambiguity in the items and to eliminate errors. The population in the pre-testing possessed similar characteristics to the accessible research population and, because of some suggested changes to the instrument, they were not included in the main study.

Reliability was enhanced by internal consistency through the Cronbach’s alpha (α) test for internal consistency. Cronbach’s alpha (α) reliability coefficient of > 0.7 was deemed acceptable (Gliem & Gliem 2003:84). The Cronbach’s alpha values for each of the factors from the factor analysis conducted (Table 1).

FIGURE 1: The relationships of participants in the Intensive Care Unit setting.

Ward (2005:399–400) reported that the United States of America (USA) introduced a bill (Registered Nurse Safe Staffing Act 2005) to support staffing ratios and patient acuity levels. In terms of that bill, hospitals are required to put a staffing system in place that provides the appropriate number of nursing personnel for each shift and each unit. The lack of nursing expertise experienced in the ICU nurses should be the determining factor when ascertaining the competencies that the nursing agency manager had to address when selecting agency nurses (Item 13: x̄ 2.93, s.d. 0.860). The skills mix available for a shift in ICU determines the number of agency nurses needed for that shift (Item 12: x̄ 2.95, s.d. 0.926). According to Hart (2006:219), a strategic assessment of a number of factors should be made when recruiting nurses.

The hospital should take shortages of skilled ICU nurses into consideration when determining posts for the ICU (Item 6: x̄ 2.56, s.d. 1.029). Daly, Speedy and Jackson (2007:10–11) maintained that nursing shortages were experienced in a broad range of specialisations, including critical and/or intensive care nursing, and raised critical questions for nurse leaders and managers with regard to the deployment of scarce resources and the recruitment and retention of competent staff. Buerhaus et al. (2007:854) indicate that prolonged shortages of nursing staff might reduce the quality of patient care and decrease the efficiency and effectiveness of the care provided. Hospital managers should evaluate nurse shortages in terms of vacant budgeted positions, as well as the influence of vacancies on costs and revenues.

Armstrong (2007:420) indicates that the cost of advertising could be considerable (Item 19: x̄ 2.46, s.d. 1.080). Harris (2009:507–508) maintains that employment agencies assume advertising and recruitment costs and would produce applicants who have been screened, presumably according to the employer’s specifications. The fee for such services is usually a percentage of the salary. Armstrong (2007:367) holds the opinion that businesses might benefit from aspects of human resource planning concerned with policies for recruiting and retaining staff (Item 14: x̄ 2.39, s.d. 0.948). Muller, Bezuidenhout & Jooste et al. (2006:262) indicate that a recruitment policy should be designed according to the objectives of the hospital by stating the method of recruitment and the recruitment source to be used.

There are various methods to recruite personnel. Muller et al. (2006:264) indicate that advertisements form part of external recruitment. The most popular method for recruiting nurses is advertising (Item 16.1: x̄ 2.64, s.d. 0.932). Advertising is traditionally done in newspapers and magazines. However, internet advertising is cost-effective and more nurses are using the internet to look for work (Cleary & Rice 2005:265). Advertisements should specify the speciality areas in which agency nurses are needed (Item 22: x̄ 2.53, s.d. 0.942). Arthur (2006:5) and Armstrong (2007:417) indicate that an advertisement should contain the name of the hospital, the job specification, the type of person required and the qualifications and experience necessary for the job. The job specification of such a nurse should be stated in the advertisement (Item 21: x̄ 2.38 s.d. 0.968 in order to reduce the number of inappropriate candidates.

Armstrong (2007:383–384) reveals that the recruitment policy provides broad guidelines and procedures for the way in which nurses should be recruited for the ICU, as well as for the use of agency nurses. This document should reflect the views of the hospital in relation to recruitment (Item 15: x̄ 2.18, s.d. 0.861).

The nursing agency manager should make their appointment policy known to the agency nurse during the selection process (Item 24: x̄ 2.47, s.d. 0.867). Compton, Morrissey and Nankervis (2009:49) indicate that the recruitment policy should be made known to all employees since it relates to the sourcing of employees. The appointment of suitable agency nurses by the nursing agency manager to an ICU setting should be based on the nurses’ qualifications (Item 29.2: x̄ 2.44, s.d 0.897). Job specifications indicate the knowledge, qualifications, skills, abilities and other characteristics required for a person to be qualified to perform a job successfully (Noe et al. 2004:73). Agency nurses should be appointed to an ICU setting based on the extent to which their profiles suit the job description of an ICU nurse (Item 29.1: x̄ 2.27, s.d. 0.886). Zimmerman (2002:95) indicates that a job description is important and useful during the selection process. A role profile, listing the competencies, skills, educational and experience requirements, produces job criteria against which candidates should be assessed during the interview (Armstrong 2007:410).

The nursing agency manager should verify the references stated on the application form of candidates applying for ICU posts (Item 26: x̄ 2.55, s.d. 0.905). Arthur (2006:253), Muller et al. (2006:267) and Armstrong (2007:435) indicate that the information provided by the candidate nurse is usually checked and verified. Good (2008:82) and Fernandez-Araoz, Groysberg and Noharia (2009:80) agree that reference checks are an absolute requirement of the selection process.

The nursing agency manager should also try to accommodate the agency nurses’ preferences by appointing them according to choice of a particular ICU (Item 34.3: x̄ 2.65, s.d. 0.726), since it could be seen as contributing to job satisfaction (Swansburg & Swansburg 2002:309). Cherry and Jacob (2008:567) suggest that, if the speciality preference is not available, it would be wise to accept an alternative position. Item 29.3 (x̄ 2.21, s.d. 0.958) states that the nursing agency manager appoints a suitable agency nurse to an ICU setting according to the nurse’s practical experience. Nurse managers should provide the agency with details of the demand for nurses, their qualifications, amount of work experience and particular skills required (Compton et al. 2009:9).

The nursing agency manager should appoint a suitable agency nurse to an ICU setting based on the feedback about the past performance of the nurse (Item 29.4: x̄ 2.31, s.d. 0.958). Armstrong (2007:435) stated that it would be unwise to make a final decision without first checking an applicant’s references and conducting a thorough background check.

The nursing agency should provide a choice on the application form of where an appointment is preferred (Item 25: x̄ 3.00, s.d. 0.753). Roussel and Swansburg (2008:270) are of the opinion that candidates should have a choice of units to which they would be assigned.

When an agency nurse is required to work in a specific ICU on a busy day, the profile of the permanent staff working on that day determines the required experience level of the agency nurse (Item 33: x̄ 8 1.82, s.d. 0.850. In ICUs, patients who are very ill and unstable need more experienced personnel than patients who are stable. Zuzelo (2010:346) points out that the skills mix should be determined by examining the patient population being served and identifying the skills and tasks required to provide care. To determine the skills mix one should look at several aspects, such as how care is being delivered, who is best suited for delivering the care, how the care should be divided between the caregivers and what skills mix is the safest (Dunham-Taylor & Pinczuk 2009:777).

The nursing agency should have a large pool of ICU nurses to choose from when selecting a nurse (Item 31: x̄ 1.82, s.d. 0.899). Nursing shortages are a global problem and create stress and tension in the ICU. Huber (2006:587) indicated that this shortage seriously affects nurses and the provision of patient care. Clark (2008:10–11) indicates that a job description clearly defines the job beforehand in writing, and by using this document candidates know exactly what the job entails. From the employer’s perspective, written job descriptions could serve as a basis for minimising misunderstandings around job requirements that occur between managers and their subordinates (Bohlander & Snell 2010:158).

Item 35 (x̄ 1.82, s.d. 0.850) states that before the nursing agency manager appoints nurses to specific ICU settings, they should be provided with a job description outlining the required duties for that ICU. Clark (2008:10–11) indicates that a job description clearly defines the job in writing and, therefore, that document should be used to ensure that candidates are aware of what the job entails.

Staffing levels are influenced by many factors, such as the budget, nurse-to–patient ratios, nursing competencies and skills mix (Elliot, Aitken & Chaboyer 2007:18). According to hospital policy and guidelines, the hospital determines the number and qualifications of the nurses needed in the ICU (Zuzelo 2010:344–345). The permanent personnel working in the ICU should mentor the agency nurses (Item 48: x̄ 2.95, s.d. 0.808), who should be supervised and helped in the ICU, especially if they are working in an ICU for the first time. Huber (2006:740) suggests that a mentor should be assigned to agency nurses to help prevent potential problems from occurring because of a lack of familiarity with the unit routine.

Agency nurses are usually placed by the hospital according to the expectations spelt out by them (Item 41: x̄ 2.48, s.d. 0.849). Fernandez-Araoz et al. (2009:83) support the view that nurse candidates should be given realistic information about the job so that they can decide whether they are suitably matched for the position. The job description provided by the nursing agency and the nurse manager should be similar (Item 38: x̄ 2.08, s.d. 0.802). The hospital should inform the nursing agency manager of the job specifications and the duties that the agency nurse would be required to perform in the ICU. Muller et al. (2006:255) define a job description as a written statement explaining the purpose, scope, duties and responsibilities of a specified job. Compton et al. (2009:64) indicate that agencies would only be successful in locating the right applicant if it is equipped with accurate job descriptions and job specifications.

Nurse managers should take into account a number of internal hospital variables when deciding on the staffing needs of specific units. These variables include the staffing policies of the hospital and the structure and philosophy of the nursing department. The findings indicated that the nurse manager requires judgement, experience and a thorough knowledge of the requirements of the organisation, for example the different policies and guidelines of the organisation, when planning for staffing. It is essential that a recruitment policy be designed in accordance with the objectives of the hospital. Such a recruitment policy should include broad guidelines and procedures for recruitment. In addition, the hospital recruitment policy should state the method of recruitment and the recruitment source to be used.

The recruitment of qualified nurses is critical for the establishment and maintenance of both the ICU and the nursing agency. The findings indicated that information about the jobs to be filled, the ratio of job openings to the number of applicants and as much relevant information as possible about the applicants themselves are essential for making sound decisions in selcting agency nurses to work in ICUs. In order to place a nurse within a hospital, it is essential to follow an introduction process that include induction and orientation in respect of the hospital concerned.

It was difficult to calculate the number of agency nurses who were working in the different ICUs at private hospitals in Pretoria, as permanently employed nurses working in ICUs also worked overtime as agency nurses in the hospitals in which they were permanently employed. There were agency nurses who worked for more than one nursing agency and it was found that permanent staff in hospitals might also act as agency nurses.

Regarding the determining of posts for agency nurses in an ICU, specific issues to be taken into account include nurse-to-patient ratios, nursing competencies and the skills mix (Elliot, Aitken & Chaboyer 2007:18). The hospital policy should address the nurse-to-patient ratios when determining the staffing levels within an ICU setting. The nurse manager should inform the nursing agency about the hospital’s equity policy. In South Africa there is a law that addresses equity in the workplace (Employment Equity Act [Act 55 of 1998]). Patient acuity levels should be ascertained before determining the number of agency nurses needed to work in an ICU. Some patients in ICU need more care than other patients. Thungjaroenkul et al. (2008:31–36) agree that both increased workloads, as well as declining numbers of nurses have an impact on the quality of patient care and safety. Therefore, the nurse manager must implement a staffing plan that addresses patient acuity. This staffing plan should specify the number of each category of staff needed according to the patients’ acuity. Staffing plans promote increased consistency.

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