A large part of the health and care services are carried out by temporary workers and employees with short working hours. This has been the case for a long time. In this study, we show the extent to which temporary workers are used in these services, how and why this practice varies, and the experiences of managers and other employees. The project is financed by the Norwegian Directorate of Health’s Competence Boost 2025 (Kompetanseløft 2025) programme. This is the government’s action plan for skills enhancement, recruitment and professional development in the primary care service. The health authorities are also encompassed within this study.
In writing this report, we used data from national registers on education, sickness absence, employment and salaries, as well as accounting data from the KOSTRA Municipality-State-Reporting system collected by Statistics Norway. We also used statistics on temporary workers from the Norwegian Hospital Procurement Trust, the local authorities’ online newspaper Kommunal Rapport and Burson Cohn & Wolfe (BCW). Data from BCW were shared with us by the Norwegian Nurses Organisation. In addition, we conducted a survey of managers and trade union representatives in the local authorities and health authorities, and conducted qualitative interviews with managers and other employees in the sector.
Transient workforce
The study shows that a large and increasing part of the health and care services are being performed by temporary workers and permanent employees who work extra shifts. Some of this is planned, but much is ad-hoc as a result of vacant positions and sickness absence among permanent employees. In 2022, the use of temporary workers accounted for approximately 20 per cent of total wage costs. This figure is significantly higher in periods when sickness absence levels are high, as well as holiday periods and weekends, and in areas with multiple vacant positions. If we also consider that around one in ten work in an FTE of 0.25 or less, the scope of what we call a transient workforce is even greater.
Use of temps
In 2021, the local authorities and health authorities spent NOK 3.4 billion on hiring health personnel from agencies that provide temporary staff (temping agencies). The use of temps measured per NOK spent on agency temps has doubled since 2012, and accounted for an estimated 1.8 per cent of wage costs and temp costs combined in the primary care service, and a corresponding share in the health authorities. Use of agency temps is not a widespread practice, but it is on the rise.
All regional health authorities use temping agencies, and although this is not widespread, the use varies. Central Norway Regional Health Authority does not hire temps to any great extent, but the practice is more common in northern and western Norway. The situation is the same in local authorities, with almost one in four not using temping agencies at all. The variations are especially great among smaller municipalities.
The cost of an agency temp is roughly 2.5 times as much as a permanent employee. This means that temping agencies accounted for one in every ten NOK spent on temporary workers as well as one in every 25 hours of all temporary work.
Who hires temps and who hires them out?
As a proportion of all employees in the sector, the percentage who work in temping agencies is low. However, the number has increased somewhat in recent years. As of the fourth quarter of 2021, temping agencies were the main source of employment for 3050 healthcare workers. Sixty per cent of outsourced health personnel are nurses. This is followed by nursing associates (25 per cent), unskilled workers (7 per cent), doctors (5 per cent) and others (3 per cent). In addition, some temps are self-employed or hire themselves out via other businesses that we have no precise information about. People who work as temps normally have many years of work experience.
Why are temporary workers used?
The need for temporary workers arises because permanent employees cannot cover all shifts, and because few tasks can be postponed out of consideration for vulnerable patients and service users. The explanations for the large demand for temporary workers can be divided into three main groups: firstly, there are many vacant positions and shifts as a result of recruitment problems. This is highlighted in the survey as the factor that explains most of the demand for temporary workers. Many places of work have low basic staffing levels, and the need for temps can quickly be triggered by the absence of permanent employees. Many also have rotating weekend shifts, which leads to extensive use of temporary workers. Last but not least, the absenteeism rate is fairly high. In the period 2020 to 2022, the extreme pressure of dealing with the pandemic and pandemic-related sickness absence among employees increased the demand for temporary workers.
Temporary workers and temping agencies have an important role to play
The use of temporary staff, including agency temps, is important for maintaining sufficient staffing levels. It will also have a positive impact on the working environment compared with the alternative: having permanent employees work extra shifts or shifts that are understaffed.
Challenging for managers and permanent employees
Many of the managers describe staffing levels as a problematic aspect of their work, with a large number of part-time employees who do not want to work longer hours, a high demand for temporary workers and problems in maintaining sufficient staffing levels at weekends and during holiday periods. Much of their working day is spent trying to find staff to cover extra shifts, managing the high staff turnover, and recruiting and training new temporary workers and permanent employees – all of which reduces the time they can spend on managerial and professional development tasks. The large number of personnel that managers are responsible for and the high staff absence levels lead to communication problems and reduce the continuity of the service delivery.
Some permanent employees also have similar tasks to the managers in terms of the training and ongoing supervision of on-call workers and agency temps. The reduction in permanent employees and the number who can take responsibility for professionally demanding tasks also creates challenges.
The ideal distribution of permanent employees and temporary workers
Most of the informants believe that the overall use of temporary workers is currently higher than it ought to be. This is based on how service quality and the working environment for managers and other employees are affected. According to the responses in the survey, the ideal distribution would be 88 per cent permanent employees, 11 per cent on-call workers and 1 per cent agency temps.
Measures
If local authorities and health authorities are to reduce the use of temporary workers so that this amounts to 10 per cent or less of labour costs, they will need to implement more extensive measures than simply reducing the use of agency temps. They must develop rotas in which weekend shifts have more permanent employees who work full-time or near full-time hours, and more robust staffing plans where most absences can be managed without hiring temps. So-called over-coverage, where some of the temporary workers are transferred to permanent positions without this leading to overstaffing, is entirely possible. Implementing annual shift rotas could facilitate staff planning, while long shifts would mean more hours for part-time staff and make recruitment easier whilst also retaining older workers.
Some of the vacant positions that create a need for temporary workers can, following a job analysis and a subsequent redistribution of tasks where appropriate, be replaced by other occupational groups. This also lays the foundation for developing an ‘ideal shift’. This ideal shift can be found at places of work that have developed an operation with competent employees who know their duties, HSE routines, colleagues and the service users, and who have established a culture of good working practices and a high standard of services. This provides a basis for high-quality services and a better quality of life for service users. Uncooperative service users become more cooperative, passive service users become more active, and their families respond more positively. This creates a better working environment for the employees and reduces stress. The knock-on effects of this could be less sickness absence and a solid foundation for active management and service development.
Temporary staff will always be needed
Many places of work could make better use of their temporary workers and could reduce the use of random and unknown temporary workers. Where it is relevant to use temping agencies, a closer cooperation should be developed between the client and the agency. Agency temps should be well known at the place of work and recognised as qualified by managers and other employees. If temps are to have the opportunity to attain such a position, there needs to be a certain regularity in the use of temping agencies in the form of a framework agreement with a small number of agencies and sufficient scope and frequency in the use of temps to enable a relationship to be developed.
This also applies to the use of on-call workers. Firstly, the number of on-call workers and people on zero-hours contracts must be reduced considerably. In addition, those who remain must be given more training and put to better use. The latter can entitle temporary workers to a permanent position or a position with longer hours (Section 14 of the Working Environment Act). Many of these may lack healthcare qualifications, in which case the employer should implement skills-enhancing measures.
