Chapter 27. Temporary, Agency, and Other Contingent 

Workers 

Ann E. K. Page 

Background 

The Institute of Medicine (IOM) report, Keeping Patients Safe: Transforming the Work 

Environment of Nurses,1 determined that the use of temporary nursing staff or staff from 

agencies external to the health care organization to provide care threatens patient safety. 

Involving personnel with less knowledge of the nursing unit and larger organizational care 

policies—and interrupting the continuity of patient care—increases the risk to patients’ safety. In 

its report, the IOM recommended that health care organizations avoid using nurses from external 

agencies. 

In 2004, 2.3 percent of registered nurses (RNs) provided their services through a temporary 

agency, as opposed to being employed by the organization or organizations through which they 

delivered care.2

 This was an increase from the 1.8 percent of RNs working in their principal 

nursing position through a temporary employment service in 2000, which itself was a 36 percent 

increase over that reported in 1996, reversing a declining trend between 1988 and 1996.3 

Although this proportion continues to represent a minority of the nurse workforce, the increase 

mirrors workforce trends occurring globally across many industries.4, 5 Temporary workers, 

contract employees from external agencies, intermittent workers, “casual” workers, and other 

types of workers without a standard employer-employee relationship with the organization in 

which they provide services are together referred to in the United States as “contingent 

workers.”6 In other counties, such arrangements are sometimes referred to as “precarious 

employment,” the terminology used in the European Union, for example. 

Although use of nurses from external agencies can increase the number of staff available for 

patient care, threats to patient safety are theorized to arise, in part, because temporary staff are 

less familiar with a nursing unit and a health care organization’s overall structure, policies, 

practices, and personnel—including information systems, facility layout, critical pathways, 

interdependency among work components, ways of coordinating and managing its work, and 

other work elements.4, 7 This can be compounded when temporary workers do not receive the 

same level of orientation and training from the organization in which they provide care as do the 

organization’s employees. Studies in industries outside of health care have found that increased 

use of contingent workers can result in higher accident rates and other adverse effects.4

 The 

International Atomic Energy Agency, for example, cites use of contract personnel to replace 

traditionally hired employees as a symptom of incipient weakness in an organization’s safety 

culture.8

 Health care researchers find similar results. 

Research Evidence 

Searching health care literature for the effects of contingent nursing staff on patient safety 

and other quality of care outcomes is difficult because of the various terminologies used to refer 

to such workers: for example, temporary, float, casual nursing, contingent employment, or 

precarious employment. Moreover, health care research, unlike research on the impact of 

1 
Patient Safety and Quality: An Evidence-Based Handbook for Nurses

temporary employees across a variety of other industries, typically has not exclusively examined 

the effects of temporary workers on patient safety and care quality. Findings are typically 

embedded in studies of more comprehensive issues such as the effects of nurse staffing or health 

care organization practices. 

The search strategy (see below) resulted in finding seven observational studies; of which six 

studies reported adverse patient outcomes associated with the use of contingent nurses7, 9–13 (see 

evidence table). The seventh study, which did not find adverse patient outcomes,14 did not 

measure patient outcome directly, but rather examined nurses’ documentation of their own 

performance of activities related to patient safety and better quality of care—the lowest level of 

outcome measured for all seven studies. The findings of the seventh study also were confounded 

by the provision of specialized training in the legal ramifications of documentation to only two 

of the three groups under study—the groups that subsequently performed at the highest level. 

Although it is possible that the findings of six of seven studies showing adverse effects of 

using agency nurses are a manifestation of reporting bias (i.e., multivariable studies that did not 

find a difference in the use of contingent nurses might not report the finding of no difference), 

the evidence cited in these studies does not support this possibility. Five of the seven studies 

examined variables in addition to staffing composition and their effects on bloodstream 

infection, 30-day mortality, medication errors, and violence committed by psychiatric patients. 

All five of these identified and reported on variables for which “no difference” in patient care or 

outcomes was found. 

Evidence-Based Practice Implications 

The IOM report identified the need for all health care organizations to have in place 

mechanisms to achieve “flexible” staffing in instances when the patient census, acuity, or both 

demand staffing at a higher level than anticipated. However, the research included in the 

aforementioned analysis reaffirms the importance of avoiding the use of nursing staff from 

external sources as a mechanism to provide such flexible staffing. The IOM recommends using 

internal nursing “float pools” composed of nurses employed by the health care organization. 

Although using floating nurses may still result in nurses being assigned to patient care units with 

which they are less familiar, using an organization’s own float pool of employed nurses at least 

assures that these nurses have received the same orientation and in-house training as other 

nursing staff permanently assigned to specific nursing units. Float pools would also assure that, 

even if the floating nurses are not familiar with policies and procedures unique to individual 

patient care units within the organization, the nurses would be familiar with organization-wide 

policies and practices pertaining to patient safety, such as an organization’s error reporting 

system, decision-support systems, and information technologies. 

Research Implications 

Research on temporary and agency nurses could benefit from a meta-analysis to determine 

how strong the effect may be between using external nurses and patient safety and outcomes. 

Additional research could be conducted to further build the evidence base pertaining to the effect 

on patient care outcomes of using contingent nurses to meet staffing demands. However, 

research is also needed to understand the reasons for the use of contingent workers in health care 

in the first place. Such research can inform policy decisions by health care organizations and 

2
Temporary & Agency Nurses

other entities affecting workforce deployment. Are contingent workers preferred by health care 

organizations? If so, why? To what extent is increasing use of contingent nursing staff caused by 

the same factors leading to increased use of contingent workers globally across myriad 

industries, or are there unique factors at play in nursing? Do nurses employed by temporary 

agencies prefer this type of employment? If so, why? Can these factors be replicated in health 

care organizations to bring contingent workers into standard employer–employee relationships 

with health care organizations? If nursing staff employed by temporary agencies do not prefer 

this employment, why are nurses so employed in the face of a widely cited nursing shortage? 

Conclusions 

Whether temporary workers or float pools are used to meet staffing shortfalls, hospital 

managers and leaders are challenged to ensure patient safety by matching the available skill mix 

of nurses to the needs of patients. The flexibility offered by temporary workers may address 

staffing gaps, but it is important to have effective communication, education, and orientation 

mechanisms to enable comprehensive, safe patient care by outside nursing staff. More research is 

needed on the effects of contingent nursing staff on patient safety and the reasons for the use of 

contingent workers. 

Search Strategy 

A search of MEDLINE®, CINAHL®, the Cochrane Registry of Controlled Trials, and the 

Cochrane data base of systematic reviews for the period January 1990–March of 2006 using the 

search terms (temporary OR contingent) AND (staff OR personnel OR nurs$) in all fields for 

human studies and English-language articles yielded 809 articles. Five of these titles or abstracts 

described a research study that included measures of the effects of contingent nurses on patient 

safety or clinical quality outcomes.7, 9–11, 14 A repeat of this search using (float OR casual) in 

place of (temporary OR contingent) generated 181 references, which yielded an additional 

research study with these variables.12 A similar search within PychoINFO yielded 178 

references, of which one was a previously undetected research study examining use of temporary 

nurse staffing and patient outcomes.13 All searches were mediated through the OVID search 

engine. Studies measuring only nurse outcomes (e.g., occupational injuries, job satisfaction, or 

features of work design) were excluded, although there is literature showing adverse outcomes in 

these areas as well. 

Author Affiliation 

Ann E. K. Page, R.N., M.P.H., senior program officer, Institute of Medicine. E-mail: 

aekpage@NAS.edu. 

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Patient Safety and Quality: An Evidence-Based Handbook for Nurses

References 

1. Committee on the Work Environment for Nurses and 

Patient Safety, Board on Health Care Services, Page 

A, ed. Keeping patients safe: transforming the work 

environment of nurses. Washington, DC: National 

Academies Press; 2004. 

2. U.S. Department of Health and Human Services. 

Unpublished data from the 2004 National Sample 

Survey of Registered Nurses. Rockville, MD: 

Author; 2006. 

3. Spratley E, Johnson A, Sochalski J, et al. The 

registered nurse population March 2000: findings 

from the National Sample Survey of Registered 

Nurses. Rockville, MD: Division of Nursing, Bureau 

of Health Professions, Health Resources and Services 

Administration; 2001. 

4. Quinlan M, Mayhew C, Bohle P. The global 

expansion of precarious employment, work 

disorganization, and consequences for occupational 

health: a review of recent research. Int J Health Serv 

2001;31(2):335-414. 

5. Connelly CE, Gallagher DG. Emerging trends in 

contingent work research. J Manage 2004;30(6):959-

83. 

6. Stagg S. The impact of contingent workers on the 

workplace. AAOHN J 2004 Sep;52: 412. 

7. Alonso-Echanove J, Edwards JR, Richards MJ, et al. 

Effect of nurse staffing and antimicrobialimpregnated central venous catheters on the risk for 

bloodstream infections in intensive care units. Infect 

Control Hosp Epidemiol 2003 Dec; 24(12):916-25. 

8. Carnino A. Management of safety, safety culture and 

self assessment: international atomic energy agency. 

Available at: http://www.iaea.org/ns/nusafe/publish/ 

papers/mng_safe.htm. Accessed January 15, 2003. 

9. Estabrooks C, Midodzi W, Cummings GG, et al. The 

impact of hospital nursing characteristics on 30-day 

mortality. Nurs Res 2005; 54(2): 74-84. 

10. Roseman C, Booker JM. Workload and 

environmental factors in hospital medication errors. 

Nurs Res 1995;44(4):226-30. 

11. Bourbonniere M, Zhanlian F, Intrator O, et al. The 

use of contract licensed nursing staff in U.S. nursing 

homes. Med Care Res Rev 2006 Feb;63:88-109. 

12. Robert J, Fridkin SK, Blumberg HM, et al. The 

influence of the composition of the nursing staff on 

primary bloodstream infection rates in a surgical 

intensive care unit. Infect Control Hosp Epidemiol 

2000 January;21(1):12-7. 

13. James DV, Fineberg NA, Shah AK, et al. An increase 

in violence on an acute psychiatric ward: a study of 

associated factors. Br J Psychiatry 1990 June; 156: 

846-52. 

14. Strzalka A, Havens DS. Nursing care quality: 

comparison of unit-hired, hospital float pool, and 

agency nurses. J Nurs Care Qual 1996 Jul;10(4):59-

65. 

4
Evidence Table

5

Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design, 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Find

AlonsoEchanove 20037

Use of float nurses – agency nurses or nurses from other hospital areas who had been working in the unit under study for less than a year. 

Prospective cohort 

Level 3 study design. Level 1 outcome measure: central venous catheter (CVC) bloodstream infections (BSIs) 

4,535 adult patients admitted for at least 24 hours in 1997–1999 to eight Intensive care units at six geographically distinct hospitals 

Observational study – no intervention 

Of more thfactors stucared for only six st<.005) vawith the din patientsRisk of CVtimes highfloat nursetime. 

Bourbonniere 200611 Use of a high proportion of 

contract nurses (RNs and LPNs combined) to fill nurse staffing positions.  High proportion was defined as 5 percent or more of total full-time equivalent nursing positions. 

Cross-sectional, time series 

Level 4 study design. Level 3 or higher outcome measures; i.e., study measured health care quality deficiencies detected in nursing homes as part of their State ‘s annual survey and certification inspection process. 

15,717 freestanding nursing homes (facilities) in urban and rural counties in the United States between 1992 and 2002. 

Observational study – no intervention 

Annually, more contdisproporttop quartilranked in health carduring anncertificatioFor each cdifferencesignificant

Estabrooks 20059

Use of temporary or casual nurses in hospital staffing. 

Cross-sectional Level 4 study 

design. Level 1 outcome measure: 30-day mortality following admission 

18,142 patients discharged from 49 of 109 acute care hospitals in Alberta Province, Canada 

Observational study – no intervention 

Hospitals casual anhigher ratemortality (confidenc
6

Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design, 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Find

James 199013 Use of agency 

(temporary ) nursing staff 

Retrospective cohort 

Level 4 study design. Levels 1 and 2 outcome measures: any act of violence, defined as physical aggression involving physical contact directed at fellow patients, staff, self, or property. 

All acts of violence occurring in a 12-bed “high dependency” ward within a 60-bed psychiatric unit in a district general hospital in London, England, during January 1986 through March 1987 (15 months). 

Observational study – no intervention 

A greater violent incperiod waa decline permanenby the hosthe use of the mainteof nurse spositive conumber of of agency 

agency nuand a negthe numbeof perman

0.0007). 

Robert 200012 Use of nurses 

from an external agency or from a hospital pool compared to nurses permanently assigned to the surgical intensive care unit (SICU) 

Case-control study 

Level 4 study design. Level 1 outcome measure: nosocomial bloodstream infections (BSIs) 

28 patients with BSIs and 99 randomly selected controls in a 20-bed SICU in a 1,000 bed, universityaffiliated, inner-city, public teaching hospital. Cases were any patient hospitalized in the SICU for 3 or more days from June 1994 to June 1995 in whom a primary BSI was identified. 

Observational study – no intervention 

BSIs were more freqhigh use oagency or use of pernursing stThe pool nsignificant(P < 0.001Conversepatient ratinfection wcase patie(P < 0.001
7

Source Safety Issue 

Related to Clinical Practice 

Design Type Study Design, 

Study Outcome Measure(s) 

Study Setting & Study Population 

Study Intervention Key Find

Roseman 199510

Use of temporary nurses 

Cross-sectional Level 4 study 

design. Level 2 outcome measure: medication errors 

All medication errors reported in a 140-bed acute care medical center in Alaska from 1984 to1989. 

Observational study – no intervention 

Number otemporary statisticallwith medic1.15). Errors decnursing stratio = 0.8

Strzalka 199614 Use of nurses 

from external agencies, compared to internal float pool nurses and nurses hired by the organization to staff a specified nursing unit under study (unit-hired nurses) 

Prospective cohort 

Level 4 study design. Level 3 outcome measure: Nurses’ documentation that they performed nine activities determined by the facility as related to patient safety (e.g., side rails raised, assessment of mental status, vital signs, etc.) and related to bowel management. 

All agency nurses and two randomly selected comparison groups of internal float and unit-hired nurses providing care on one nursing unit in a large teaching hospital in the United States over an 8-month period. 

Observational study – no intervention 

Nursing gvaried from with interngenerally highest leperforming agency nuDifferencewere stati

< 0.05 levdocumentAgency nusignificantnurses on items.