About the assignment and its methodology
This is a study of measures that have been enacted at Østfold Hospital to increase the volume of more substantial full-time equivalents (FTE) among nurses and healthcare workers. The study was commissioned by the Spekter employers’ association. The underlying data consist of interviews with 14 managers, 13 employees and six trade union representatives in the hospital located at Kalnes. The interviews have been conducted both individually and in groups of two or three persons. The informants were selected according to the following criteria:
- managers from both the staffing unit and the inpatient units[1] (wards)
- trade union representatives from relevant unions
- former and present participants in the trainee programme
- employees with experience of split positions
- employees in the grey area between voluntary/involuntary part-time and full-time work
In addition, registry data from the regional health authorities were used. These consisted of aggregated data on all salaried employees in Norwegian hospitals.
Opportunities and limitations of the main approach
In 2012, Østfold Hospital established a separate staffing unit, partly with a view to reducing the volume of involuntary part-time work, partly to increase the proportion of full-time employment among the staff, and partly to reduce the use of extra shifts. These measures were also thought to provide a possible advantage in the competition for recruitment of nurses.
These staffing measures are mainly permanent schemes for permanent employees. For the management, the use of staffing units is a way to reduce the challenges associated with traditional shift rosters, which will only function as intended with a high proportion of full-time staff and extensive use of extra shifts. By using staffing units, the extra personnel can be replaced by permanent, skilled personnel, who are frequently employed in full-time or substantial part-time positions. This is considered to be a better solution than extra shifts in short part-time positions. According to the hospital, the objective of the staffing unit is to ‘ensure service quality, quality of patient treatment and patient safety, and in principle, all staff at Østfold Hospital should work full-time’.
One of several shift roster models
To implement these ideas, Østfold Hospital has introduced two types of shift roster. The first dictates that the staff should work more weekends, preferably an extra four per year on top of every third weekend in the basic shift roster. The second involves establishment of multi-ward positions whereby a staff member could have, for example a 75 per cent FTE in one ward, supplemented by a 25 per cent FTE in the staffing unit. Personnel in the staffing unit perform work in multiple secondary wards. The department to which employees are mainly affiliated and where they have the most substantial FTE is frequently referred to as the primary ward, mother unit or mother ward.
In Chapter 2 we review a number of shift roster solutions and conclude that the basic roster schedule (Model 1) which is used for nurses and healthcare workers at Østfold Hospital (and in the Norwegian healthcare system in general) is a poor basis for achieving gains beyond small increases in position sizes. The following six roster models, each with their own variants, are reviewed:
Model 1: every third weekend, traditional shift length on all days
Model 2: every third weekend, long shift on weekends and weekdays
Model 3: every fourth weekend, long shift on weekends and weekdays
Model 4: every fourth weekend, long shift on weekends, traditional shift length on weekdays
Model 5: every other weekend, traditional shift length on all days
Model 6: every fourth weekend, traditional shift length on all days
Model 1: traditional shift length, work every third weekend, 24 employees, 12–24 FTEs, much part-time work
This is the main model applied at Østfold Hospital. It is also widely used in other hospitals and the municipal health and care services. Irrespective of which variant is chosen, Model 1 (which is based on 7–8 hour day and evening shifts, and work every third weekend) can never be used if the goal is to develop a system where more than 80 per cent of the healthcare workers and nurses work full time. If chosen, it will be extremely costly. This applies even if the staff were willing to work four extra weekends during the year, in addition to the 17 weekends that are usually included in this basic shift roster.
Model 2: long shifts, work every third weekend, 12 employees, 10–12 FTEs, no part-time work necessary
Model 2 is a pure and simple long-shift roster. It has the advantage of requiring few staff members and few FTEs to cover service needs. The roster can be filled without resorting to short part-time positions. All staff can be offered a full-time position without any need to work extra weekends or in other wards. Seen from behind a desk, this is the best solution. Because of the long shifts, there is a large number of weekend hours, making this shift roster less attractive for some employees as well as among the trade unions.
Model 3: long shifts, work every fourth weekend, 16 employees, 10–16 FTEs, little need for part-time
Model 3 is also a pure long-shift roster, but here, the staff work only every fourth weekend. This permits an institution to achieve a staff presence which is so high that the aim of establishing a full-time employment culture is within reach. If the goal is to achieve a significant increase in the number of full-time positions, this appears to be the most realistic model.
Model 4: long shifts every fourth weekend, traditional shifts on weekdays, 16 employees, 12–16 FTEs
Model 4 is one of the most common measures that are implemented in order to operate institutions with more substantial FTE percentages. This measure is suited for approaching the goal of a full-time employment culture. However, to fully achieve this goal, some staffing increase will be required.
Model 5: traditional shift length, work every other weekend, 16 employees, 12–16 FTEs
The variants of Model 5 include no long shifts and may represent a step towards a full-time employment culture. However, this entails a large amount of weekend work. Compared to Models 2, 3 and 4, the full-time staff have little time off. This shift roster is therefore unattractive for full-time employees, even though it complies with the provisions in the Working Environment Act.
Model 6: traditional shift length, work every fourth weekend, 32 employees, 12–32 FTEs
Model 6 represents a basic shift roster that has been preferred by many permanent employees in substantial FTE positions, but has been abandoned by many institutions because it gives rise to many short part-time positions/vacancies. This is a costly shift roster, unless it includes an unacceptably high number of short part-time positions.
Extra weekends
In some cases, four extra weekends per year may make it easier to offer employees a full-time position, but it will not bring the institution closer to the goal of a full-time employment culture. If these four extra weekends are worked at the mother unit, that unit will be able to provide services with slightly fewer staff. This could mean better continuity and somewhat better services for the users. On certain conditions, this weekend measure may help increase the average FTE by approximately 10 percentage points.
Staffing units and multi-ward positions
The use of resource units, often referred to as temporary staff pools, is organised in various ways across municipal and hospital services in Norway (Ingstad and Moland 2016). A common feature is that the employer should have reserve capacity available to cover a varying need for manpower at the lowest possible cost. At Østfold Hospital, the staff members in the reserve manpower pool who have multi-ward positions are employed in permanent and relatively substantial FTE positions, and they are well qualified for the job. In other words, they are versatile and can be flexibly deployed. So when and how can an effect be obtained from having staff working 25 per cent in another ward?
Their own department will have a continuous need for temporary staff because of illness, leave, time off in lieu and holidays amounting to 15–20 percent of all FTEs. Shift rosters without any long shifts may make it difficult to cover holiday shifts with internal resources. This also applies to the need for temporary staff on weekends if a cap on weekend work has been set to every third weekend. Depending on such choices, the need for manpower in their own department indicates that most of the part-time employees will be able to increase their FTE from approximately 75 per cent to approximately 80 per cent. It thus appears to be economically ‘harmless’ to transfer approximately 10 per cent of the non-earmarked funds to permanent positions. The remaining need to cover vacant shifts (including vacant positions) can be met by temporary staff.
Since an employee’s weekend shifts are included in his or her 75-per cent FTE, the 25 per cent proportion cannot automatically be used for weekend shifts. This solution will therefore not be seamless either, and many weekend shifts will continue to be covered by staff working extra shifts.
Even if all units have an optimal shift roster version (of Model 1), they would still be unable to fill 10–15 per cent of all shifts with staff in substantial part-time positions. With a theoretical result that provides for an FTE percentage of nearly 85 in many wards, this would be a considerable step forward for Østfold Hospital and all municipalities. If the ambition is to achieve an average FTE of 90 per cent or more, further measures will be called for.
Operation with a staffing unit and multi-ward positions
The use of multi-ward positions has a bearing on the FTE sizes and the organisation of work. In turn, this will affect the working environment and competence level.
Stability, predictability and competence
The question of how substantial a position needs to be for an employee to feel job satisfaction and social belonging varies with individual experience, skills and personal characteristics. The staff at Kalnes communicated to us that a 50 per cent position in the primary unit is too little, and many consider 75 per cent to be a minimum. Many, and especially the younger staff, find it difficult to develop sufficient professional confidence without working in a nearly full-time position in a single department. For them, 75 per cent is also too little, and the managers largely agree.
Potential gains from full-time employment remain unrealised
Full-time work and substantial FTEs enhance service quality as well as the working environment. The reason, however, is not that employees are formally employed in more substantial FTE positions, but that they are sufficiently present in a workplace to enable them to become familiar with the tasks, procedures, colleagues etc. and thereby do a good job and feel that they cope. The measures that have been enacted at Kalnes and are described in this report do not help meet these expectations. The logic according to which it is assumed that staff in 80–100 per cent FTEs do a better job than their colleagues who are working part-time will thus be seriously compromised if parts of the substantial FTE percentage consist of multiple small ones.
The managers who were interviewed also generally agreed that full-time positions in single departments would be preferable both for the individual employee and for the professional community. They regard full-time positions as the best solution for operations and service quality, but impossible partly because of the costs incurred by current practices, which limit weekend work to every third weekend, and partly because of the lack of interest in full-time positions among the staff.
Many employees and managers also pointed out that the use of these multi-ward positions undermined the development of specialist skills. The current use of the specialist skills available was also criticised, frequently by using the deployment of midwives to completely different wards as a hypothetical example.
Hard to meet the considerable need for training
Staff who work in several of the hospital’s departments need to have broad familiarity with different clinical specialties, tasks, procedures, colleagues and patients. This exposes those in multi-ward positions to greater professional and social challenges than normal. This also makes for a considerable need for training, especially for those who are relatively new to the job. Some report to have received adequate training, others do not. Although the situation has recently improved, a more systematic approach to training is called for.
The trainee programme
The hospital has a trainee programme for nurses and healthcare workers. The study shows that the participants are divided in their opinions about the implementation of the programme. Many of them are glad to have been hired in a full-time position, but find it arduous to work in multiple wards, especially those who feel that they have been insufficiently prepared. This applies to the secondary position in particular, where the training period is significantly shorter than in the mother unit. Many of the recently graduated nurses whom we interviewed also felt that because they were less frequently present in the secondary ward, they were not fully included in the working environment.
Just temps
The narratives provided to us by full-time, multi-ward employees are quite similar to the experiences communicated to us by part-time staff members. More specifically, a full-time employee with two combined positions sounds more like two part-time employees. Many find that even a 75 per cent position in the mother unit is insufficient to develop adequate professional skills, to feel socially included and to have a sense of continuity in their work.
Managers and staff members agree that multi-ward positions may prevent some of the staff from becoming sufficiently familiar with their colleagues, routines and procedures. Things tend to work out in the mother unit, where they have their main position, but less so in the secondary unit, where they ‘just drop by’. This is also an issue for the permanent staff at the secondary unit, who need to relate to the fact that many who work there drop by only occasionally. Many of the staff members from the staffing unit may therefore easily be seen as ‘just temps’. This is an issue both for the permanent staff at the unit and for those who feel that they are ‘just temps’.
Reducing risk
In many of our interviews, the staff members and trade union representatives note that in practice, many part-time employees work so many hours in a specific department that they fill a full-time position. A recruitment practice that involves hiring someone in a part-time position in order to be able to assign him or her later to extra shifts, means that the economic risk is transferred to the employee. There are complex reasons for engaging in this practice, but it represents a kind of employer-friendly flexibility that has been described and criticised in a number of studies. The establishment of the staffing unit at Østfold Hospital is a measure to guarantee full-time salaries to former part-time employees by supplementing the part-time job in a department with a part-time job in the staffing unit. They can thus avoid the uncertainty that comes with having to chase extra shifts. The staff will thereby no longer have to accept the economic risk that follows from a varying need for manpower, and it is difficult to fill the shift rosters without shifting personnel between departments. Furthermore, the management can reduce the economic risk by avoiding overstaffing of some shifts.
Most of our interviewees report that the hospital is now advertising more full-time vacancies than previously, but it is also noted that the number of full-time positions has fallen. This gave rise to the following questions:
- What kinds of full-time vacancies are advertised?
- Is the full-time vacancy split into part-time positions during the recruitment process?
- Are new staff hired in full-time positions before changing to part-time after a while?
The answer to these questions is that as a rule, full-time vacancies are advertised as multi-ward positions. The new employee is free to choose whether or not to accept the part of the position linked to the staffing unit. Some new staff members in full-time multi-ward positions gradually sign up for single-ward positions internally or externally, other resign from the small FTE position linked to the staffing unit, while others choose to remain in their multi-ward positions. The proportions represented by each of these groups have not been quantified.
Both trade union representatives and staff members report that there is little interest in joining the staffing unit, and that those who apply for combined positions do so as a last resort to earn a full salary. It is thus hardly surprising to see that many seek other solutions when the opportunity arises.
If the staffing unit offers a job to recently graduated staff, whereby they can develop professionally and become familiar with a broad range of the hospital’s services before being permanently hired in a single department, the staffing unit has benefited both the individual employee and the hospital as a whole. In this case, the staffing unit will have functioned almost as a recruitment and training agency.
Part-time positions as a recruitment strategy
In line with other studies, the managers whom we interviewed at Kalnes answer that most of the part-time work is voluntary. They highlight the employees’ wish to reduce work pressure and have more time for family life as the main explanation why many choose to work part-time. The managers have difficulty envisaging a working environment where full-time employment is a desire and a real opportunity for significantly more employees than those they currently have. Advertising of part-time vacancies therefore continues to be regarded as an important recruitment strategy.
Forms of full-time and part-time work
Multi-ward positions as systemised part-time work
Østfold Hospital’s HR policy means that staff members (with some exceptions) need to work in multiple departments in order to have an FTE percentage in excess of 75. Conversely, this means that the management caps the FTE percentage (in a single department) at 75. With rota model 1 as a restrictive premise, this will be the least ineffective operational solution. This HR policy can thereby be interpreted as systemising part-time employment. Seen in a more positive light, the policy could be said to use the practice of multi-ward positions as an instrument to promote larger FTE percentages. The argument would be that an employee who works, for example, 75 + 15 per cent formally, would be regarded as hired in a 90 per cent position, and that the employee in fact has increased his or her part-time percentage from 75 to 90 per cent.
From involuntary part-time to involuntary full-time, mostly voluntary part-time
In recent years, representatives of the social partners have highlighted the volume of part-time work as a problem, and that voluntary part-time work is the greatest barrier to developing a culture of universal full-time employment in the health and care sector. This view is corroborated by research. However, we believe that it will be wrong to see this as an argument to stop using the notion of involuntary part- time.
Our informants at Kalnes disagreed strongly as to what should be considered voluntary or involuntary part-time. The latter is a form of partial unemployment that can be serious for employees who remain in part-time positions over time, but would prefer a larger FTE percentage or a full-time job. A formal distinction between involuntary and voluntary part-time work can be drawn from their respective definitions. Statistics Norway uses the concept of ‘underemployed persons’, who are defined as part-time employees who have attempted to seek longer contractual working hours and are able to start working longer contractual hours within one month.
In cases where staff members work additional weekends in order to expand their FTE percentage, many of our informants question whether they perceive this as voluntary. The same applies to their descriptions of the combined positions. This is not far removed from the somewhat neglected phenomenon that can be referred to as ‘involuntary full-time work’.
If someone is working in a reduced FTE position because of heavy work pressure or because they are unwilling to work in multiple wards, managers in the health and care sector will tend to say that it is voluntary to reduce the FTE to a percentage that the person in question can cope with. Trade union representatives, on the other hand, will argue that this reduction is involuntary, because it could have been avoided if the employer had ensured better facilitation of the workload. The same difference of opinion between the parties emerges at Kalnes in situations where a multi-ward position or an extraordinary number of weekend shifts is given as a precondition for full-time employment.
There are undoubtedly some grey areas between voluntary and involuntary part-time work. A wish for more leisure time, concerns for the family and heavy workloads are common explanations for choosing part-time work, irrespective of whether these options and choices are considered voluntary or involuntary.
The need for professional development and strong professional communities is a frequently used argument in favour of full-time positions. In this study, however, the need for professional development is given as an argument among employees who turn down offers of 100 per cent FTEs. The underlying argument is that the 100 per cent FTEs at Kalnes are divided up in such a way that parts of the time are dedicated to one or more secondary posts. According to many of our informants, this split is not conducive to the development of more specialised skills. It will therefore be rational to keep a part-time job in the mother unit and turn down the part-time job in the full-time pool. The time freed up can be spent on working more hours in the mother unit (which has a constant need for extra shifts). In this perspective, shopping for shifts in your own department in fact appears to be a good solution – for the head of department and for the individual employee.
More full-time work or less?
In a procedure document for positions that are split between the staffing unit and the clinical sections, the hospital notes: ‘To ensure service continuity, quality of patient treatment and patient safety, full-time positions should be the main rule in Østfold Hospital’.[2] Since positions in the staffing unit provide many part-time staff members with an option for full-time employment, the hospital is expected to increase its proportion of full-time posts as a result of this measure.
Statistics on full-time work
Chapter 1 shows figures for the proportion of full-time employment and average FTE size for 20 health trusts. When the health trusts’ figures for full-time and part-time employment are presented, only permanent staff members are included. As a result, the health enterprises’ overviews of their proportions of full-time employees are 20–25 higher than what the actual staffing would indicate. Multi-ward positions that add up to 100 per cent are registered as full-time positions.
When ranked according to the proportion of full-time employees, Østfold Hospital comes in 19th place. However, the figures show that the hospital has progressed somewhat in recent years. The proportion of full-time work among the permanent staff has increased to 60 per cent in 2019. On the other hand, with the exception of Akershus and Oslo University Hospitals, all the other health trusts have progressed to the same extent. We can also observe the same trend in approximately 190 municipalities. This could be due to wider trends in society that manifest themselves in employees wanting more working hours, but could also be a result of targeted efforts by the health trusts.
Østfold Hospital reports that among the staff that work shifts, full-time employees account for 39.1 per cent, i.e. 20 percentage points less than when only permanent employees are included.[3] Most of the participants in the trainee programme or those who are employed in the full-time or staffing pool work full time. If we regard these measures in isolation and evaluate them exclusively based on the volume of full-time positions achieved, they have been successful. When regarded on the basis of service quality and working environment concerns, the degree of success declines.
No more full-time positions after all?
When we ask managers and staff members at Kalnes to describe the trend in the proportion of full-time and part-time positions, the responses vary considerably. According to the numbers in Figure 1.2, the proportion of the staff that work full time has increased. According to managers and staff members, on the other hand, the proportion has decreased. This apparent contradiction may occur because our informants are mistaken or else the figures give a wrong impression of the situation in the (inpatient) wards. Some respondents also consider a multi-ward position to include two part-time posts.
Our informants refer to the increasing pace of work as an important reason for many to choose part-time rather than full-time employment. When we ask why the pace of work has increased, many different answers are given. Issues such as a growing number of patients, more complex diagnoses, more serious illness and longer hospitalisation periods before discharge are the most frequently cited reasons. Many interviewees report consistent hospital overcrowding and mercantile (frequently ICT-related) time thieves. Managers and staff members are largely in agreement in this regard, and their descriptions are confirmed by the Norwegian Hospital Construction Agency (2020) and the top management of Østfold Hospital.
An increased workload in combination with poor shift rosters creates increasing workplace pressure. This trend is reinforced by the use of multi-ward positions. These factors all help make part-time work a logical solution for a growing number of employees. In other circumstances, a large proportion of them would prefer a full-time position.
Conclusion
The measures that have been trialled in Østfold Hospital have the potential to increase the proportion of full-time positions, but will be unable to establish a culture of full-time work, if this should be the objective. The reason is that that the measures are implemented within the framework of what we have referred to as shift roster Model 1, i.e. the traditional shift roster that involves 7–8 hour daytime and evening shifts and work on every third weekend. More frequent weekend work for a few employees appears to be a patched-up solution more than anything else. Nor will the establishment of staffing units lead to a culture of full-time employment. The fundamental reason is that the ‘75 + 25’ solutions cannot ensure adequate operations with almost exclusively full-time positions. The 25 per cent FTE can cover for sickness absence and other gaps in the shift roster on weekdays, but this does not eliminate the need for short part-time positions that results from a ‘dearth’ of weekend work in the basic shift roster (cf. Chapter 2). Moreover, few staff members choose to remain in a multi-ward position over time, and many regard this as a collection of part-time jobs, with negative repercussions for professional development, the sense of coping and belonging to a familiar work community.
Opportunities for improvement
This review has shown that the hospital has a number of areas for improvement, both large and small. Here, we highlight the three main areas:
- Assess the basic shift roster: The traditional shift roster used for nurses and healthcare workers, involving work every third weekend (called Model 1), alone generates a large need for extra shifts, multi-ward positions and staffing units. Furthermore, this basic shift roster sets a cap on the number of full-time positions that can be established without significant extra cost, since it requires a considerable increase in manpower.
- Include more participants in the measures: Avoid having many employees in short FTE positions, irrespective of whether these are primary or secondary. The more staff members who have substantial FTE percentages and are familiar with their ward(s), the easier the running of the hospital. This reduces the workloads and reinforces the development of skilled professional communities.
- Measures to improve coping: The current multi-ward concept gives rise to an increased need for systematic competence enhancement. Burdens on the staff and the institution can be reduced by measures that ensure better continuity, such as reducing the number of different wards where the individual staff members need to perform their duties.
[1] Departments with wards that are staffed around the clock are called inpatient units, as opposed to day wards and outpatient clinics.
[2] Procedure document: Kombinasjonsstillinger mellom bemanningsavdelingen og kliniske seksjoner, Sykehuset Østfold. Dokument-ID: D29263. Versjonsnummer: 6.00 Gjelder fra: 02.12.2019.
[3] The figures for part-time staff also include approximately 100 apprentices and student nurses.
