International Journal of Nursing Practice 2001; 7: 104–108

INTRODUCTIONNursing care delivery is subject to the same fiscal con-straints as other areas of the health system. There is a growing focus on the need for efficiency and cost-effectiveness at a service delivery level, together with anemphasis on professional accountability. Nursing as a sub-group within the health system represents the singlelargest body of staff and, consequently, represents a highproportion of budget expenditure.

One response taken to reduce costs associated withnursing budgets is the increased use of ‘casual’ nursingstaff. This phenomenon is evident internationally and

appears unlikely to be reversed in the immediate future.There is considerable debate regarding the efficacy of thismove. In order to ensure that safe, efficient and effectiveservice continues to be provided, nurses must recognizethe potential risks associated with this practice, and iden-tify ways to address these.

DEVELOPMENT OF CASUALIZATIONIN THE WORKFORCE

Casualization can be described as the systematic replace-ment of permanent full-time and part-time staff with staffemployed on an ad-hoc basis.1 Regular work is not guar-anteed but the casual worker is expected to be availablewhen required. Theoretically, the operating costs of theorganization are reduced while increased flexibility of thework force is achieved.

✠ R E S E A R C H P A P E R ✠

Casualization of the nursing workforce:

A New Zealand perspective on

an international phenomenon

Sandra Richardson BA, RGON, DipSocSci(PG), DipHealSciNurse Practitioner, Emergency Department, Christchurch Hospital, New Zealand

Jan Allen BSc, RGONDuty Patient Care Manager, Christchurch Hospital, New Zealand

Accepted for publication March 2000

Richardson S, Allen J. International Journal of Nursing Practice 2001; 7: 104–108Casualization of the nursing workforce: A New Zealand perspective on an international phenomenon

A discussion of the increased use of ‘casual’ nursing staff (those nurses employed on a casual or ‘per diem’ basis) is pre-sented. Reference is made to related literature, together with consideration of the implications associated with this trend.This issue has international significance, with the increased use of casual staff being widely recognised. A New Zealandperspective is included, with the provision of nursing care at Christchurch Hospital presented to illustrate certain aspectsof the discussion.The impact of changing health-care systems and increased emphasis on efficiency and accountability areidentified.This change to workplace practice will inevitably affect nursing; possible future developments are considered.

Key words: casualization, New Zealand, nursing workforce.

Correspondence: Ms S Richardson, 18 Warner Pl., Heathcote,

Christchurch 2, New Zealand. Email: sandy-nick@xtra.co.nz

Casualization of the nursing workforce 105

Casual workers have traditionally been used in situa-tions where production is subject to arbitrary and unpre-dictable short-term fluctuations in demand. This methodof production was initially introduced as an employer-led trend, rather than worker choice.2 In 1989, the NewZealand Employers Federation3 called for ‘restraints onnon-standard work forms, such as part-time work, jobsharing and casual work’(p. 3) to be lifted to create greaterflexibility in the labour market. Nursing is a predomi-nantly female profession and child-care is a significantissue for many workers. As a result, part-time work is arealistic response for many staff, as well as meeting theneeds of employers.4,5 Current ideals associated with therecognition of nursing as a profession, include the goal ofa permanent, stable and organized nursing work force.These ideals encompass such concepts as continuity ofcare, primary nursing, clinical career pathways and spe-cialist nursing practice.6,7 These objectives may, however,prove to be unattainable in the reality of economicallyconstrained workplaces. Given the introduction of a fluidand changing workforce, it becomes questionable whetherthese ideals are in fact attainable, and indeed whether they are appropriate within the reality of nursing serviceprovision.

Casual nurses, agency nurses and part-timers are nowintegrated into the nursing work force, both within NewZealand and on an international scale.There remains con-siderable blurring of the definitions and scope of practiceassociated with such positions. In New Zealand, the intro-duction of the Employment Contracts Act (1991) servedto break the historic link between union membership andnegotiating authority in New Zealand, by making unionmembership optional. One of the policy objectives of thislegislation was to enhance flexibility in the workforce.8

The proliferation of individual contracts that resulted pro-vided the impetus for an expansion in the employment ofcasual staff. Recent changes in the New Zealand govern-ment have seen the introduction of a Labour-led coalition,and subsequent withdrawal from some aspects of market-led health care. This has also been associated with theintroduction of legislation to overturn the EmploymentContracts Act. The impact of this on the nursing work-force remains to be seen.

THE CASUAL NURSE: A DEFINITIONThere is a lack of clear conceptual and operational defini-tions of the term ‘casual nurse’. There are a number ofpreconceptions and assumptions associated with such

roles, and many different titles, often reflecting aspects ofthe work. Nurses occupying these roles are varyinglyreferred to as ‘float’, ‘pool’, ‘bank’ and ‘agency’ nurses, inaddition to the term casual. Casual nurses have the samebasic nursing education, and have frequently had similarbackground experiences as their colleagues who are per-manently employed. Batten5 emphasizes that the termcasual is used to denote the employment status of a nurse,not their approach to nursing. These nurses may beemployed through organisations separate from the health-care facility, such as agencies and bureaus, or secondedfrom established positions within the wider health-careorganization. Additionally, many hospitals have specific‘pool’ staff, orientated to working in a variety of areas,and assigned on the basis of need. There is considerableflexibility in the scope of practice associated with thecasual nursing role. Some staff employed in this way areexpected to take on the same level of responsibility as apermanent employees, despite having little or no orienta-tion to the specific area.9

Despite the increased use of casual nurses, little isknown about their characteristics and how they differfrom permanent staff members.10,11 Many nurses activelychoose to work casually due to increased flexibility ofhours and settings.This allows the nurse, not the hospital,to choose the day, the shift and the workplace.12 A studyof English nursing graduates no longer working full-timeshowed that the need to maintain employable skills wasalso recognized as an important factor.13 In the UnitedKingdom, agency and bank work is often the only way anurse with family commitments can continue to work,given the inflexible working patterns offered by theNational Health Service.14,15 Many nurses rely on casualor temporary employment until full-time work becomesavailable, and at times when their circumstances limit theirability to undertake full-time work. Included in this groupare experienced nurses undertaking postgraduate study.12

Christchurch Hospital is an acute-care facility servicingthe upper half of the South Island of New Zealand. It is atertiary level teaching hospital, offering a number of specialized services, including a cardiothoracic unit andhyperbaric chamber. The hospital draws on a regionalpopulation of 447 667, and hosts the largest emergencydepartment in Australasia, with an annual throughput of approximately 65 000 patients (P. O’Donovan, pers.comm., 2000).

In 1998, the New Zealand Health and Disability Com-missioner, Robyn Stent, undertook an investigation into

106 S. Richardson and J. Allen

the actions of Canterbury Health Ltd, the Crown HealthEnterprise responsible at the time for the operation ofChristchurch Hospital.16 This came in response to a seriesof concerns raised by the staff and public regarding con-ditions at this facility. One area of concern identified wasthat inexperienced new graduates were working in a casualnursing capacity. The Commissioner stated ‘. . . newgraduates found the role of casual nurse difficult.The roleof the casual nurse requires experience, confidence, and awide range of skills that new graduates do not yet have’ (p.92).16 The casual nurses who were the subjects of Batten’sthesis also questioned the appropriateness of employingnew graduates in this role.7 Their main concern was a lackof professional support, which they felt would have asevere impact on inexperienced nurses.

THE NEW ZEALAND EXPERIENCEWithin New Zealand, as internationally, the challenge to health managers is to provide staffing levels that main-tain quality, while responding to fluctuations in patientnumbers and acuity.17

Casualization is seen as providing a solution to bur-geoning nursing costs, as staff can be deployed at shortnotice to cope with peaks in workload.18

The growth of casualization within nursing in NewZealand was concurrent with the Governments introduc-tion of wide ranging health reforms in 1991, designed tocreate a more efficient and effective public health service.Evidence in the literature shows that there has been a sig-nificant increase in the use of casual staff throughout NewZealand hospitals since 1990. McKillop reported thatAuckland Hospital increased its use of casuals from 36shifts in January 1991 to 1246 shifts in February 1993.17

These figures parallel overseas statistics although the trendfor increased use of casual staff commenced a decadeearlier in both the United Kingdom and the United Statesof America.

The Health and Disability Commissioners Report16

supports these findings with evidence gathered at Christ-church Hospital. In the early 1990s only one to two casualnurses were employed in Christchurch Hospital on eachshift.16 This increased significantly in 1994, with two tothree per ward each shift. In real terms, this meant thatbetween 30% and 50% of the staff at any given time werecasuals. Stent also noted that Unit Nurse Managers wereencouraged to use casual nurses rather than part-timestaff, to reduce the accrual of annual leave.

High levels of casual staff can have a major impact on aunit or ward, the smaller and more specialized the area,

the greater the impact. Casual staff are usually called in attimes of peak workload, when there is both high acuityand patient volume. Often they are used when permanentstaffing numbers are inadequate to cope with the work-load through sickness, injury or attrition. Napthine notedthat in Australian Hospitals, it is no longer the norm for award or unit to be staffed with its own integrated team ofnurses.17 Stent reported that casuals in Christchurch Hos-pital were often sent to different wards each shift worked,which compounded the problems they faced in copingwith a heavy patient load.16 As a result, many casual nurseswere placed in a position where they did not know thepatients, the medical teams, the procedures of the wardor the location of equipment, potentially compromisingthe care and safety of the patients.

Castledine states that there is no doubt that casualnurses put themselves and their patients at risk; the degreeof that risk varies and is dependent on several factors: thenurse’s commitment to clinical updating, the level ofresponsibility s/he accepts and the management of theenvironment in which s/he is working.6

IMPLICATIONS ASSOCIATED WITHCASUALIZATION

There is little research based information concerning theeffect of casualization on the quality, continuity and safetyof care given to patients, or the impact this trend has onthe permanent staff in a ward or unit. Anecdotal evidencesuggests that permanent hospital staff perceive a greaterburden of patient care when working alongside casualnurses. Permanently employed nurses typically assumethe care for the most critical and complex cases, whilecasual staff are assigned patients requiring less skill andcare.10

Anecdotal evidence is cited by Dickson who states:‘. . . the employment of casual nurses in large numbersaffects the stress levels of permanent full-time and part-time staff. Permanent nursing staff have to orientate andoversee casual nursing staff who do not carry full work-loads (p. 12)’. However, he does qualify these statementsby acknowledging the level of efficiency is dependent onthe employment status not the individual nurses’ compe-tency.The discontinuous nature of casual work means thatthese nurses are unlikely to develop either specialist skillsor a support network among their peers.

Internationally, similar concerns are being voiced.19–21

A survey comparing perceptions of the practice of agencynurses and ward staff, showed that 42% of respondentsbelieved agency nurses provided a lower standard of

Casualization of the nursing workforce 107

nursing care than their permanently employed colleagues.Concern has also been expressed that nursing routines areoften planned as if all the nurses coming on duty werefamiliar with the unit.19 The drive toward specialization ofnursing skills has also been questioned, together with thepromise to patients of continuity of care, and the alloca-tion of tasks with the assumption that all nurses are equallyknowledgeable, and skilled in, the procedures specific toa particular ward. This raises concerns about the implica-tions for the education of student nurses when their workexperience may place them alongside nurses who do nothave the specialist knowledge of an area.

Casual nurses and the casualization of the nursing workforce are often cited in the literature in a negative context.There are concerns about the impact on patient safety,15–22

the quality of nursing care23 as well as the associated con-cerns about the increased risk of legal liability.24,25 Identi-fication is also made, however, of the benefits to individualnurses, as well as to institutions, of introducing more flexible working patterns.10,17 This suggests that perhapsnurses are focusing on the outcome of a problem, ratherthan the problem itself. The question must be asked,whether nurses have unrealistic expectations of casualstaff, triggered by the staffing constraints present in manyworkplace settings. Issues associated with this includeconcern with staffing levels, skill mix, nurse to patientratios and the loss of expert practitioners. Further dis-cussion on these issues is beyond the scope of this article,but it is important to acknowledge the need for furtherresearch in these areas.

NURSING RESPONSE TOCASUALIZATION

It is unlikely that the trend toward casualization will bereversed, which gives rise to concerns about the best waysof utilizing casual nurses.18 The challenge for nursing is toutilize the abilities of the various casual nurses within an unfamiliar environment, with Styles, noting ‘. . . ourresponsibility as a profession is to ensure that the rightnurse is at the right place at the right time with the rightknowledge and skills and the right motivation’ (p. 354).25

If nurses are to work together for the good of the profes-sion, the provision of quality nursing care, and the benefitof both nurses and the recipients of care, then somemiddle ground must be reached.

Orientation of casual nurses has been discussed in theliterature, although research on the effectiveness of suchprogrammes appears scarce. Temporary employees, suchas agency or casual nurses, have special needs regarding

orientation and with today’s emphasis on safety, compe-tence and accountability it is disconcerting to find such apaucity of concrete data.

Stent identified that casual nurses at Christchurch Hospital found their role stressful and difficult, oftenreceiving little or no orientation to wards and protocols,insufficient structured support or guidance, and wereunfamiliar with the ward, its procedures and the locationof essential equipment.16 As a result of this report it is nowa requirement that casual staff employed at ChristchurchHospital attend a paid 2-day orientation programme.

Cushing promotes the idea of a readily availableresource person or buddy to be allocated to each casualworker in the ward or unit.26 This person would be avail-able if help was needed in identifying patient problems orfor the provision of specialized technical skills in whichthe casual nurse lacks expertise. In the United States ofAmerica, collective bargaining agreements have includeda clause that no nurse may be floated to a hospital unitunless s/he has been orientated to that unit.

When 159 hospitals orientation programmes were sur-veyed in three separate States of America, it was found thatall covered the same basic material: emergency proce-dures, location of supplies and unit routines. However, thelength of orientation time varied from 15 min to 40 h; theaverage being 8 hours.This suggests a substantial differencein the extent to which the content was covered.11

Meyer and Siegel noted that a large hospital in themidwest of America provided an orientation for perma-nent nurse employees but this option was consideredimpractical for casual nurse personnel.27 The time, effortand expense involved were not considered an efficientinvestment of resources when some nurses may only worka single eight hour shift once or twice per year. In thisinstance, staff development specialists designed a timeconscious, low budget and low labour intensive, casualnurse orientation package. The nurse is also required tocomplete a skills checklist which is filed to provide a database for future employment. No casual nurses are able towork at the hospital without completing this process.28

Other hospitals have adopted a method called crosstraining to enable not only their pool of casual nurses, butalso permanent staff to function competently on a multi-tude of nursing units. Cross training serves two purposes:it familiarizes the nurse with unit layout, equipment, typesof patients, and staff also helping to alleviate any anxietya nurse may have about being asked to ‘float’. It ultimatelymakes the nurse a more valuable resource by virtue ofexpanding his/her experience base.

108 S. Richardson and J. Allen

Cross training or cross utilization of staff is achieved bygrouping similar wards or units into clusters. The nursesare then able to confidently provide care to all patientswithin the cluster. As a result, staff can then be flexed andassigned within the cluster to meet changes in census,acuity, or to relieve other staff. The American Organiza-tion Of Nurse Executives believes that cross utilizationwill prove not only to be a valuable management strategy,but will also provide nurses with the opportunities tobroaden the scope of their practice, thereby ensuring ahigh standard of patient care and safety.28

CONCLUSIONThe existence of casual nurses is recognized, in much of the literature, as a sign of the detrimental changesoccurring in our health system as a result of world-wide,cost-driven health reforms. Current nursing research rec-ognizes that high use of casual staff has potentially detri-mental implications for patient safety and care. It alsoplaces limitations on professional specialization and devel-opment. However, many nurses accept casual work eitherthrough choice, to enable them to integrate other respon-sibilities; or necessity, due to the dearth of available per-manent positions.

Health care is likely to remain cost driven, and casualnurses will continue to meet a need within the healthsystem, providing a cost-effective means of responding to changing staffing needs. Greater effort must be madeto ensure that casual staff are enabled to contribute fullyand effectively in the work environment. Nurses musttake the initiative in developing systems, such as cross utilization, orientation programmes, and providing sup-portive environments for all staff. Further research isneeded, not only looking at the impact of casualization onhealth-care outcomes, but also considering the underlyingcauses of staff shortages, skill-mix and patient-to-nurseratios.

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