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1. International Journal of Nursing Studies 40 (2003) 269–279
Agency-nursing work: perceptions and experiences of
agency nurses
Elizabeth Maniasa,
*, Robyn Aitkena
, Anita Peersonb
, Judith Parkera
, Kitty Wonga
a
School of Postgraduate Nursing, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Level 1, 723
Swanston Street, Carlton Vic. 3053, Australia
b
Education Centre, The Prince Charles Hospital, Rode Road, Chermside Ql 4032, Australia
Received 21 March 2002; received in revised form 2 September 2002; accepted 26 September 2002
Abstract
This paper explores agency-nursing work from the perspective of agency nurses to gain in-depth understanding of
their clinical practice, their relationships with the employing agency, hospitals and permanent nurses, and their
professional status. For this study, individual interviews were conducted with ten agency nurses who were registered
with one of three nursing agencies in Melbourne, Australia. Five major themes emerged from interview data:
orientation, allocation of agency nurses, reasons for doing agency-nursing work, experiences with hospital staff, and
professionalism. The findings reveal that the primary reason for nurses engaging in agency-nursing work is for the
flexibility it offers. While agency nurses described a commitment to professionalism, the findings emphasise the need to
establish effective communication networks between agency nurses, nursing agencies and hospital institutions. Such
communication between stakeholders is important to facilitate discussion of issues such as appropriate notification of
shift availability, appropriate assignment of work and recognition of the agency nurse as a valuable member of the
health care team. In particular, the findings highlight the importance of comprehensive orientation and education for
agency nurses to shift the focus of their daily work from task completion to more comprehensive patient care.
r 2003 Elsevier Science Ltd. All rights reserved.
Keywords: Agency-nursing work; Agency nurses; Nursing agencies; Work experiences; Work perceptions
1. Introduction
The perennial shortage of nurses combined with an
increased demand for their services have contributed to
a greater reliance on agency nurses. Despite continued
use and considerable cost of temporary nursing services,
little is known about agency nurses’ perceptions and
experiences of their clinical practice, of their relation-
ships with the employing agency, hospitals and perma-
nent nurses, and of their professional status. This study
was conducted as part of a larger project that examined
agency-nursing work from the perspectives of agency
nurses, agency nurse providers, hospital nursing
managers and senior clinical nurses, in Melbourne,
Australia. This paper reports on the first component of
the project; which specifically sought information from
agency nurses about their experiences and perceptions of
working on a casual contracted basis in acute care
hospitals.
2. Literature review
For this study, agency nurses are defined as those who
‘‘have their working life organised by a private
contractor, known generally as an agency, to carry out
work within any number of hospitals within any one
working week’’ (Bates, 1998, p. 140). Agency-nursing
work refers to the nursing services provided by agency
*Corresponding author. Tel.: +613-8344-0778.
E-mail address: emanias@unimelb.edu.au (E. Manias).
0020-7489/03/$ - see front matter r 2003 Elsevier Science Ltd. All rights reserved.
PII: S 0 0 2 0 - 7 4 8 9 ( 0 2 ) 0 0 0 8 5 - 8

2. nurses employed on a casual contracted basis. Notwith-
standing the growth of casual employment in female-
dominated work environments (Burgess and MacDo-
nald, 1990), the majority of literature on agency nurses
involves personal accounts of nurses’ experiences with
agency work (Chellel, 1987; Grau and Willens, 1989;
Gunn, 1983; Mack, 1988; Phillips, 1983; Ward and
Moore, 2000) and commentaries that compare perma-
nent and agency work (Brooks-Shaverin, 1995; Duns-
more and Houston, 1990; Elson, 1995; Jones et al., 1990;
Leigh, 1996; LeRoy, 1986; Roy and Runge, 1983;
Watson, 1998).
Most research studies on agency nurses have ad-
dressed reasons for choosing this type of work (Braddy
et al., 1991), recruitment, retention and compensation of
agency and hospital nurses (Hughes and Marcantonio,
1991), and evaluations of orientation programs designed
for agency nurses (Bliss and Alsdorf, 1992; Leidy, 1992).
Following an extensive survey of agency nurses ðn ¼
3360Þ and hospital nurses ðn ¼ 3535Þ; Hughes and
Marcantonio (1993) reported interesting comparisons
of work schedules and clinical practice between these
two groups. In response to work schedules, agency
nurses were less likely to work day shifts and more likely
to work afternoon and night shifts. They were also more
likely to work more weekend shifts and fewer hours each
week. With respect to clinical practice, agency nurses
reported performing more physical and psychosocial
examinations on their patients. They also reportedly
evaluated clinical outcomes, and devised nursing diag-
noses and therapeutic plans for more patients than their
hospital counterparts. Furthermore, agency nurses
indicated they had good opportunities to use their
clinical skills in the ward setting compared to hospital
nurses. Unfortunately, as Hughes and Marcantonio
(1993) did not seek the perceptions and experiences of
agency nurses, it is difficult to determine the various
complexities underlying their clinical work. This lack of
comprehensive exploration of agency-nursing work
typifies the research conducted in this area.
On the other hand, two studies have sought to provide
an in-depth analysis of agency-nursing work from the
agency nurses’ perspective. In an Australian study, Bates
(1998) conducted individual interviews with 12 agency
nurses to explore their contractual work arrangements
in hospital settings. While Bates questioned their
experiences, the focus was not on issues facing agency
nurses at the local level of clinical nursing practice.
Instead, Bates’s analysis emphasised the role of manage-
rial strategies and labour market structures in shaping
temporary employment processes. While these wider
social and political forces are intrinsic in how work is
organised and defined within hospitals, a dependence on
these aspects in Bates’s analysis meant that the nurses’
views about their agency-nursing work were either
obscure or overlooked.
In another Australian study, Schubert (1995) inter-
viewed four agency nurses about professional relation-
ships with their current agency and the processes of
agency-nursing work. In contrast to Bates’s (1998) work,
Schubert’s exploratory study provided some under-
standing of nurses’ experiences of agency-nursing work.
Nurses identified control over work scheduling as a
major reason for undertaking agency-nursing work.
However, they also indicated a lack of professional
autonomy and isolation in their practice. Issues such as
access to continuing education and the maintenance of
clinical skills were identified as problems associated with
their practice. While Schubert’s study provided valuable
insight on agency-nursing work from the agency nurses’
perspective, it had some limitations. The research was
carried out using a small number of participants who
were currently registered with the same agency. All
participants were female and aged in their thirties. With
such similarities in socio-demographic profiles, the
participants’ experiences may not necessarily reflect
those of other agency nurses.
In summary, previous studies on the perceptions and
experiences of agency nurses have not considered
adequately the context in which agency-nursing work
occurs. Aside from the studies conducted by Bates
(1998) and Schubert (1995), there has been little attempt
to determine the nature of agency-nursing work by
detailing the context from the particular viewpoint of
the agency nurse. Therefore, this exploratory study was
conducted to examine agency-nursing work in acute
metropolitan hospitals from the perspective of agency
nurses. The aim of the study was to gain an in-depth
understanding of agency nurses’ clinical practice, their
relationships with the employing agency, hospitals and
permanent nurses, and their professional status. This
paper describes:
* Agency nurses’ perceptions and experiences of work-
ing through a nursing agency; and
* Agency nurses’ perceptions and experiences of work-
ing in acute care hospital settings.
3. Method
This qualitative research design used the interview
technique in order to explore perceptions and experi-
ences about agency-nursing work. A semi-structured
interview schedule included questions that were designed
to record the participants’ descriptions and explanations
about their world (Gillis and Jackson, 2002). This
information was sought from agency nurses who were
registered with a nursing agency in Melbourne, Aus-
tralia. Ethics approval was sought from the university
ethics committee to conduct individual interviews with a
representative sample of agency nurses who participated
E. Manias et al. / International Journal of Nursing Studies 40 (2003) 269–279
270

3. in the larger project. Following ethics approval, the
investigators provided information about the interviews
in a mail-out to 100 active agency nurses. These nurses
were registered with one of three major nursing agencies
in metropolitan Melbourne. Together, these three
agencies supply more than 50% of the agency nurse
requirements for the acute care hospitals of metropoli-
tan Melbourne. An active agency nurse was classified as
one who had worked at least one agency shift in the
previous three months. Agency nurses were invited to
indicate their willingness to complete an individual
interview by providing contact details to the investiga-
tors. Following receipt of this information, agency
nurses were selected by means of a stratified sampling
technique based on age, gender, number of years of
experience as a registered nurse, and number of years of
experience as an agency nurse. The final sample included
ten agency nurses. The size of this sample was
determined by the data analysis and ceased when no
new themes arose from the interview questions and
when all demographic characteristics were represented.
Four nurses were registered with the first nursing
agency, three nurses were registered with the second
agency and the remaining three with the third agency.
Participation was voluntary and confidentiality was
assured.
Interviews, which were approximately 60–90 min
long, were tape-recorded to enable the interviewer to
focus on responses and to guide the interview. In asking
questions, the interviewer probed for depth and variety
of responses and did not constrain the participants’
ability to put forward their own views. The interviewer
provided clear instructions to ensure that variation in
responses did not result from participants’ varied
understandings of what was asked of them (Gillis and
Jackson, 2002). For example, it was ensured that
questions did not have more than one meaning. The
semi-structured interview included questions relating to:
employment conditions, the nature of interactions with
agency company representatives, hospital staff and
patients, recognition of professional knowledge and
skills by agency nurses and other health care profes-
sionals, and perceived career opportunities and limita-
tions.
Following verbatim transcription of interviews, data
were subjected to the ‘framework’ method of analysis
(Ritchie and Spencer, 1994). This method of analysis
provided a systematic, comprehensive and structured
approach that also enabled data to be reworked and
reconsidered because the analytical process was docu-
mented clearly and was therefore accessible. Such an
approach facilitated the identification of themes in
order to delineate participants’ perceptions and experi-
ences of agency-nursing work. The framework com-
prised the following five stages: familiarisation,
identification of a thematic framework, indexing, chart-
ing, and finally, mapping and interpretation. Familiar-
isation involved gaining a thorough overview of the
interview transcripts. For developing the thematic
framework, data were analysed to determine key
issues. Indexing involved labelling the data into
manageable units. For the charting stage, the transcript
data were examined and a summary of the agency
nurses’ perceptions and experiences was entered onto a
chart. The mapping and interpreting stage involved
comparing and contrasting participants’ comments,
and searching for connections and explanations. To
ensure rigour, two investigators conducted data
analysis independently to determine the emerging
themes, the results of which were compared and
scrutinised.
4. Findings
Demographic details for the ten agency nurses who
participated in interviews are shown in Table 1. The
participating nurses ranged in age from 25 to 46 years,
with an average age of 33 years. While their length of
nursing experience as a registered nurse varied from 4 to
25 years, their length of experience as an agency nurse
ranged from 1 to 14 years. Five major themes were
derived from interviews: orientation, allocation of
agency nurses, reasons for doing agency-nursing work,
experiences with hospital staff, and professionalism
(Table 2). These themes are presented below, incorpor-
ating examples from the data.
Table 1
Demographic profile of agency nurses ðn ¼ 10Þ
Gender Age Years of nursing experience
as a registered nurse
Total years of experience as
an agency nurse
Female 9 20–29 years 5 4–6 years 1 1–3 years 4
Male 1 30–39 years 2 7–9 years 4 4–6 years 2
40–49 years 3 10–12 years 1 7–9 years 1
13–15 years 1 10–12 years 2
> 15 years 3 13–15 years 1
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4. 4.1. Orientation
Orientation was an important consideration for
agency nurses. Participants referred to the orientation
provided by their agency and by a particular hospital.
Nursing agencies prepared nurses for their role by
communicating information at interview and by written
handouts. Most participants indicated that the agencies
provided information about a professional code of
conduct, fees, uniforms, and agency regulations for
working and cancelling shifts. Details about pay and
superannuation were also generally given. Surprisingly
few participants knew whether they were covered for
professional indemnity, or about the process to follow if
an incident involving serious misconduct occurred
during their course of duty. The following comments
were typical of the type of orientation nurses received
from their agency:
There was a police check. There was nothing asked
about my level of competency. She [the agency nurse
provider] also looked at my CV [curriculum vitae]
and spoke with me about it. She decided then and
there that I could start work y There was a brief
statement about the code of conduct but there was no
orientation about the hospitals. It was mostly about
fees and uniforms.
Only one participant commented that the agency
provided comprehensive information about hospitals,
including geographical location, car parks, patient
system of care, and procedures to follow for emergency
situations. Similarly only one participant indicated that
a comprehensive assessment and analysis was carried
out of her competencies at the time of her agency
interview.
The participants also commented about their orienta-
tion experiences from hospitals, which tended to be quite
varied. Agency nurses received some form of orientation
on their first visit to a particular hospital. Thereafter,
hospital employees assumed that agency nurses were
familiar with an environment if they returned to work
there, for example:
Usually you get an orientation the first time you go
there [to the hospital]. Some places give you a
fabulous orientation so you know where all the fire
exits are, and what the emergency procedures are, the
people you are responsible to and the codes y Every
hospital has a different code y and they don’t tell
you every time. I was at a hospital that I work at a lot
quite recently and they devised an orientation
checklist for staff y but during my shifts I was
lucky to fill out half of it and I have worked at that
hospital on and off for six years.
Furthermore, all agency nurses agreed that the
hospital employees should make available a written
orientation package for their ward setting. This package
could be then taken away for future reference, for
example:
In the written package there should be the mission
statement of the hospital. I think they should have
objectives of what they want the nurse to achieve for
the day. They should have something written about
the legalities of documentation and a section about
nurse registration y They should also have their fire
drills and their code for resuscitation. If there are any
problems or if there is a lack of support, agency
nurses should have the contact names of hospital
people they can contact.
4.2. Allocation of agency nurses
Another theme to emerge was the allocation of agency
nurses in particular hospitals and practice settings,
Table 2
Themes from interviews with agency nurses
Orientation Allocation of agency
nurses
Reasons for doing
agency work
Experiences with
hospital staff
Professionalism
By the agency Notification about a
working shift
Flexibility Level of welcoming,
friendship and
belonging
Career development
By the
hospital
Cancellation of a shift Personal development Support Educational provision
by the agency
Being sent to a
particular ward area
Stress of permanent
work
Abuse by hospital staff Educational provision
by the hospital
Lack of respect in
permanent work
Communication of
information
Individual
responsibility to
address educational
needs
Politics of the clinical
setting
Enhancement of
clinical skills
E. Manias et al. / International Journal of Nursing Studies 40 (2003) 269–279
272

5. which involved the notification and cancellation of a
working shift, and the allocation to a specific ward area.
Generally, participants considered that they received
adequate notification about a forthcoming shift. They
all mentioned that they were often notified a few hours
beforehand about the possibility of a working shift.
However, four participants commented they sometimes
received short notice between notification of an agency
shift and working in the clinical area. One participant
who had experienced problems with shift allocation
related the following poignant narrative:
I had to be prepared to wait for the phone to ring, be
it 6 a.m. for a morning shift or 11 a.m. for an
afternoon shift. That took me weeks to just get the
feel of it, and not to have a big anxiety attack that I
wasn’t going to get any work. But you get used to
that, you go with it and you need to be flexible. What
was needed was psychological preparation.
However, whilst participants’ comments suggested the
need to be psychologically prepared in the notification
process, some expressed difficulties in coping, for
example:
I only do night duty. Over 12 years I have dealt with
that problem [of insufficient time for notification] by
only doing night duty. I got to the stage where I
became paranoid on the early morning calls. I don’t
like that. I can deal with a phone call at 10.30 at
night—I can deal with that better than at 6 o’clock in
the morning.
Participants’ comments highlighted that permanent
staff in hospitals sometimes blamed agency nurses if
they arrived late for their shifts. At times, permanent
nursing staff did not accept the lateness of agency nurses
was due to insufficient notification by the agency, as
stated by the following participant:
This girl [nurse] was in charge but she was only a
junior. It was a medical ward. It started badly
because I was called in late. Nursing administration
hadn’t called in to say that the associate charge nurse
was off sick. So I wasn’t phoned until after 9 p.m.
This girl couldn’t deal with the fact that suddenly I
was arriving late. It was not my fault. I got there as
soon as I could after the phone call.
The cancellation of a shift, which was initiated by
hospitals and communicated through agencies to the
nurses, caused much anxiety for participants. Agency
nurses not only missed out on payment following a shift
cancellation, but they also had spent time reorganising
other commitments to make space for the proposed
shift, for example:
What is very annoying is that I do get a shift booked
and the family gets all rigged up to function without
me for the day and then they [the agency] ring me up
half-an-hour before the shift and cancel.
Participants also seemed wary of certain hospitals
having a reputation for cancelling shifts. Agency nurses
developed an understanding about which hospitals
tended to cancel shifts, and have refused to work there
as a result.
When asked about the appropriateness of allocated
ward areas, participants believed they asserted them-
selves if these settings were unsuitable. However, most of
the time, participants indicated they felt satisfied about
their ward allocation. The allocation of a ward area
tended to be a two-stage process: the agency provider
made initial contact to the nurses about the ward setting
and then the hospitals confirmed this allocation upon
their arrival. At either point, the initial ward allocated
may have been changed by the agency or the hospital.
Despite their expressions of assertiveness, such changes
caused enormous anxiety for participants if they felt
compelled to work in inappropriate settings. The
following interview excerpt demonstrates a participant’s
experience of being reallocated to intensive care follow-
ing her arrival at the hospital:
I said to the allocation officer that I wasn’t happy to
go to intensive care because I am not ICU trained
and I can’t look after that kind of patient. I was told,
‘Now will be a good time to learn.’ I said, ‘No, it
wouldn’t,’ and said that if they didn’t allocate more
appropriately, then I would have to go home. In
the end, I still went to ICU but they reallocated the
patients. They [nurses] basically ignored me for the
shift and didn’t treat me very nicely.
There were also occasions when agency providers
themselves had organised inappropriate ward alloca-
tions, for example:
I have been sent to places where I am really not
competent. The worst time was once when I was
given a shift in the emergency department of y
hospital. I said, ‘I’m not competent to work there.’
They [the agency nurse provider] said, ‘It’s okay,
you only have to do obs. [observations]. You
won’t have to assess patients.’ They sent me there
and I got four cubicles and I had to assess patients.
I should have left, I really should have. They [the
nurses] got so frustrated and angry with me. I had no
idea what I was doing y I told the person in charge
and then rang my agency, and they said, ‘Oh, we
can’t do anything about it.’ They really washed
their hands.
E. Manias et al. / International Journal of Nursing Studies 40 (2003) 269–279 273

6. 4.3. Reasons for doing agency work
Participants spoke animatedly about their reasons for
undertaking agency-nursing work. The most common
reason was the flexibility. Other reasons included
personal development, the stress associated with perma-
nent work, lack of respect of nurses in permanent roles
and the politics of the clinical setting.
Flexibility was the most common reason provided by
participants for carrying out agency-nursing work. They
needed flexible work hours, which were not accommo-
dated by rigid hospital routines. Several participants
reported their current work schedule enabled them to
address social and personal commitments, which in-
cluded time spent with partners, children and friends,
volunteer work, church attendance, weekend retreats
and informal outings, for instance:
Work is important, sure, but I am not allowing work
to encroach on my other activities. I do voluntary
work inside my parish. I also participate in a couple
of retreat programs and I go away to the country on
weekends. With agency now I fit work around my
own life.
Some participants had health problems that tended to
be aggravated by the inflexibility of permanent work
schedules, as mentioned by the following nurse:
Since starting agency work I haven’t worked night
duty for 18 months, and I haven’t been sick for 18
months. That makes a big difference. I used to get
sick once every four to six weeks with the cold or the
flu because I was on night duty.
Other participants had additional study or job
commitments that demanded flexible work routines,
for example:
The one really big advantage of working agency is
the flexibility. I’m a midwife, and I do home births
and I’ve got my own clients. That way I’ve got the
freedom to schedule my appointments and also to
cancel some shifts if I’ve got a birth.
Another reason provided by nurses for undertaking
agency-nursing work involved increased opportunities
for personal development. While nurses were able to
pursue other areas of interests, they cultivated a more
positive attitude to patient care, for example:
I can do the work when I want for myself. I am sure
that benefits me as a person. It enables the patient to
benefit because I have got a better attitude to care.
Participants associated permanent work with stress.
On the other hand, agency-nursing work provided
greater levels of autonomy and independence, for
example:
I want to work for myself. I’m sick of tailing after
people. That’s what I had to do all my life as a
permanent nurse. I’ve never actually been one of
those people who got promotion easily, so what’s the
point of staying?
Some nurses also felt that proponents of the health
care system did not respect permanent hospital employ-
ees. According to participants, this lack of respect was
evidenced by inadequate levels of pay and inappropriate
working conditions. As mentioned by one participant:
That side of nursing [permanent] is not highly valued.
It is not something that I could do y I couldn’t do it
because you just don’t get the respect. You don’t get
the professional feedback, you are treated poorly y
It is too demoralising.
Finally, participants referred to hospital politics as
being a major deterrent to undertaking permanent work,
for example:
Agency nursing trains my mind to assess things
properly y because you don’t have all the political
blockages. I found that I was so much in the politics
of the system [when I was a permanent staff member]
that I ended up nursing the staff more than the
patients that were there y The obstructions between
me and my patient have been a lot less during agency.
4.4. Experiences with hospital staff
Another theme to emerge from participants’ com-
ments concerned their experiences with hospital ward
staff. There were four key aspects to these comments:
agency nurses’ views about the level of welcoming,
friendship and belonging, support provided by perma-
nent nursing staff, abuse directed at agency nurses, and
communication of information. With respect to experi-
ences of welcoming, friendship and belonging, partici-
pants expressed fairly similar views. When agency nurses
were allocated to new environments, they had to
struggle against a feeling of wariness from permanent
nurses. Associated with this wariness was the partici-
pants’ belief that they did not experience a sense of
belonging to the health care team of the ward setting.
Permanent nurses were also upset when their comple-
ment of nursing staff for a particular shift comprised
agency nurses. As mentioned by the following partici-
pant:
As much as you try to feel part of the team it is like a
‘us and them’ type thing. You feel sometimes a bit
left out, a bit cold. In some places I work they are
quite business-like, they don’t make you feel parti-
cularly welcome y In fact, they’re quite upset by the
fact they have got agency nurses.
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274

7. For some participants, this lack of belonging extended
to perceptions of isolation and difference. These
perceptions were difficult to resolve because agency
nurses were unable to develop adequate camaraderie
during their infrequent encounters, for example:
The working relationship is separate and isolated. I
usually always feel different. Part of your working
time within such an area is social contact with other
nurses, camaraderie, that feeling of give and take
with humour and information exchange. You don’t
get any of that when you are doing agency.
However, there was also a general view that agency
nurses were able to establish a sense of belonging and
friendship if they worked in one specific environment
over a defined period. Participants also felt that
permanent nurses treated them with respect if they had
worked most of their shifts in the one unit.
In relation to nursing support, participants believed
they received adequate help during their working shift.
At times, however, agency nurses did not feel well
supported in the clinical area. Interestingly, this situa-
tion occurred in settings where they had regularly
worked in an environment, and permanent staff
perceived that agency nurses were relatively familiar
with policies and protocols.
Participants also felt that they were inadequately
supported in extremely busy situations because perma-
nent nurses had exorbitant workloads despite agency
allocation, for example:
Sometimes the [permanent] nurses haven’t got the
time or the resources to have someone around to ask
questions. They are just too busy y Sometimes the
person-in-charge has got their own workload and
that is where you get problems with support because
there is no one around.
Occasionally permanent nurses ignored participants’
requests for help, especially if they involved procedures
that disrupted particular ward routines, for example:
On this aged care rehab. [rehabilitation] setting I felt
that I was disrupting the nurses’ routines. Three staff
had gone to dinner so that left me with two other
nurses. The two other nurses were going around
together putting patients to bed. They were not
answering any buzzers—I was answering the buzzers
y I would say, ‘Can I have some help, this patient
needs to go to the toilet.’ And they would say, ‘Oh
no, I am putting these patients to bed.’ It was just
inappropriate.
Three participants commented on experiences of
abuse by permanent nurses, which had a profound
effect on their confidence and demeanour. For one
participant, experiences of abuse were physical in
nature, for example:
The worst experience I had [as an agency nurse] was
only a few weeks ago where another nurse actually
physically shoved me out of the way to attend to a
client that I was about to attend to. I’m not sure why.
I had to inform the person-in-charge of the unit, and
she told the nurse supervisor on that shift, and I
believe the woman was spoken to but I didn’t get any
feedback on it.
For two participants, experiences of abuse tended to
be verbal in nature. For one participant, she had the
following to say:
I was there to help the nurse in charge but she was
very unprepared for the job. I happened to ask her
for help with a patient during the night. It was an
unfortunate circumstance as this patient had extreme
diarrhoea and had to be changed many times. This
girl [nurse] happened to say, ‘Well, he can lie in it.’ I
took exception to that, so I had my say to her about
that standard of care. She took exception to me. In
the end she abused me, shouted at me. I said, ‘Look
that’s fine, you will never see me again.’ I spoke to the
agency and said, ‘I don’t want to go back to that
ward again.’
In these situations of abuse, the agency nurses contacted
their employing agency to complain. However, aside
from refusing to send the agency nurses back to these
ward settings, there was no further follow-up with the
hospitals.
Notably, some participants also made comments that
highlighted communication of information in the
clinical setting. Communication concerned mainly dia-
logue between the permanent hospital nurses and agency
nurses about professional issues and patient care
information. Since agency nurses were not present in
the setting for a prolonged period, they all experienced a
sense of urgency about voicing any concerns with
permanent staff, for example:
In the couple of places where I’ve had really bad
experiences, I have told the person-in-charge y If by
the end of the shift they haven’t done anything to
help me or resolve the issue, I would usually say to
them that I was very disappointed in this and for this
reason, and that I won’t return to the unit.’
Participants also perceived that communicating about
patient care information tended to focus on tasks
requiring completion rather than on the holistic needs
of patients, for example:
When I ask for information about a patient’s past
history so I can care for them better, I usually don’t
get the right information. I usually just get the
E. Manias et al. / International Journal of Nursing Studies 40 (2003) 269–279 275

8. comment, ‘You just have to do this thing,’ rather
than answer my question so I can make my own
decision on what I am going to do. I feel that they
don’t really to let me know the patient’s holistic
picture because they want me to do a series of tasks.
4.5. Professionalism
Agency nurses spoke about professionalism, which
could be broadly divided into five major aspects. These
aspects involved the following: career development with
agency-nursing work, educational provisions by agen-
cies, educational provisions by hospitals, individual
responsibility in addressing educational needs, and
enhancement of clinical skills. Participants were divided
in their opinions about whether agency-nursing work
assisted their career development as a nurse. Some
nurses felt that agency-nursing work did not facilitate
career progression because they focused on completing
tasks rather than improving their knowledge and skills.
Nursing agencies were also regarded as corporate
entities, which were more concerned about cost efficien-
cies and addressing personnel shortfalls rather than
focusing on the professional needs of their nurses. The
following participant highlighted her difficulty in career
progression because of her stressful work experiences:
The experiences of most agency nurses working are
‘come in and go out’. It’s a stressful full-on day and if
they haven’t worked there before they’re just
extremely anxious most of the day and can’t wait
to get out the door. So I can’t see it as an enriching
professional experience at all. There is very little time
in the day to devote to extra-curricular things like
education or updating skills. It’s just not done y I
see this job as a short time-filler.
Other participants believed their careers were affected in
a positive way by agency work. Their wealth of
experience in a variety of settings allowed them to
consolidate their skills to the point where they could
provide high quality patient care.
Issues were also raised about the educational provi-
sion by the nursing agency. Some participants commen-
ted about the benefits associated with the education
programs provided by their respective agency. Some
nursing agencies conducted regular in-service sessions
that were readily utilised by nurses. However, there also
appeared to be some ambivalence about their value
because of associated cost, lack of accessibility and lack
of relevance, for example:
I also don’t have the opportunity to attend courses
when I am doing agency. I have to make my own
time to attend the courses. Often you have to pay for
the courses yourself y whereas if you are working in
a hospital, you have the opportunity of attending
ongoing in-service education for free.
Another participant commented about the possible
relevance of educational sessions delivered by agencies:
I am a midwife, and my agency doesn’t do that
many midwifery in-services. If you are permanently
working in a hospital you would have more access to
the midwifery in-services.
For other participants who were associated with a
smaller agency, no education was offered at all, for
example:
The unit that I have been working on provides a
continuous update for staff about new equipment y
But my agency has never offered me any education
y If I have any clinical questions I just ask at the
hospital.
All participants agreed unanimously that they would
have benefited from participating in hospital in-service
sessions. However, they reported that there was a
general feeling of negativity from permanent nurses if
agency nurses attempted to attend these sessions.
Agency nurses were expected to remain at the bedside
because these sessions were only devised for permanent
staff, for example:
There would be some hospitals I work at frequently
where an extra person [an agency nurse] y at an in-
service wouldn’t bother them. But most places would
look at that as taking up a space that someone else
could use. They’re [permanent nurses] not necessarily
going to get benefits of knowledge if they went
instead of you. This is wrong.
Aside from education provided by agencies and
hospitals, participants commented on the importance
of being individually responsible for maintaining current
knowledge. As already addressed previously, educa-
tional sessions conducted by agencies were not always
relevant and participants often experienced difficulties in
making time available to attend these sessions. Partici-
pants addressed their knowledge needs in a number of
ways, including subscribing to professional journals,
attending nursing conferences, accessing the Internet,
and completing courses conducted by private providers.
This reliance upon self-education and individual respon-
sibility appeared to be related to nurses’ perceptions
about their knowledge deficits, for example:
I think it’s your own responsibility to make sure you
are on top of things, and if you are not then to find
out or access people who can get you up-to-date.
Only you would know what your deficits are.
When asked about their professional development,
participants believed their clinical skills were enhanced
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276

9. since commencing agency-nursing work. The major
reason for skill enhancement related to the various
clinical settings in which tasks were practised. However,
some participants conceived their skills were not
improved because they felt stressed and sometimes
lacked experience in the practice areas to which they
were allocated. For one participant, her enhancement of
clinical skills was compared to the nurse practitioner
role:
My clinical skills were very much enhanced by the
variety of work. You become more of a nurse
practitioner because you are standing alone. If you
take the job seriously you have to know your limits
very carefully, and you have to know your assess-
ment and procedures very well y You are going
from one patient to another, and going to different
hospitals. It really makes you grow y It has opened
my eyes a lot.
For another participant, she developed an appreciation
of how particular tasks could be completed in a number
of different ways and became more flexible in how she
carried out clinical procedures:
It [agency-nursing work] has given me an incredible
ability to enhance my performance and skills. That
has been really positive. It has given me a good
understanding of how some hospitals are so adamant
that things are done one way and their way is best. In
another hospital they do something totally different
and they’re just as adamant that their way is best. So
it has given me an understanding that there isn’t just
one way of doing things—there are as many different
ways as there are hospitals.
5. Discussion
This research provides valuable insight into the
demands of agency-nursing work from the perspective
of agency nurses. Nurses were concerned about shift
allocation, which involved notification about a working
shift and ramifications for being late. They also
emphasised the importance of work flexibility, develop-
ing positive experiences with permanent staff, commu-
nicating about patient care activities, and maintaining
clinical skills.
Agency nurses were concerned about hospital and
ward allocation, which included the notification of a
working shift and the assignment to a particular ward
area. While participants believed that they had adequate
notification about a forthcoming shift, nearly half the
participants had experienced receiving short notice
about the availability of a particular shift. The perceived
flexibility of agency work could be threatened if these
nurses continued to experience difficulties with balan-
cing other commitments if inadequate time was available
to plan for working shifts.
Furthermore, participants perceived that hospital
nurses sometimes blamed them if they arrived late for
a shift. Often lateness was beyond the control of the
agency nurses because it occurred if there was insuffi-
cient notification about a forthcoming shift by the
nursing agency or hospital. Lateness may cause con-
siderable anxiety for agency nurses as well as permanent
staff. For agency nurses, the amount of time available
for orientating about patient care needs and the nuances
of the environment may be limited. For permanent
nurses, they are required to address the additional
workload until the agency nurses’ arrival. This situation
of lateness also affects permanent nurses’ perceptions of
professional commitment by agency nurses, and as
found by Burda (1992) it may lead to decreased hospital
staff morale.
The assignment to a particular ward area was another
concern relating to allocation. Participants felt able to
self-regulate and refuse to work in particular work
settings if these placements were viewed as unsuitable to
their skill level. Despite their perceived assertiveness,
participants were extremely anxious if they felt com-
pelled to work in inappropriate settings. While agency
nurses’ refusal to work in a particular setting may be
viewed as a form of control over work placements, it
could reduce their choices of future work opportunities
and employment prospects (Schubert, 1995). Further-
more, in order to obtain the goodwill of the agency,
temporary workers could feel obliged to accept assign-
ments that do not necessarily suit them (Merolle, 1988).
The flexibility of agency employment was the most
common reason voiced by participants for doing
agency-nursing work. They needed flexible work hours,
which were not addressed by the rigidity of permanent
hospital routines. Similarly, Braddy et al. (1991)
reported that flexible scheduling was the most frequently
listed reason among nurses for undertaking agency
work. The reluctance of hospitals to structure flexible
work patterns in female dominated professions, espe-
cially in those professions where shiftwork is the
accepted pattern of employment, hinders greatly wo-
men’s participation in the workforce and capacity to
balance other commitments.
Interestingly, while low pay and inadequate promo-
tional opportunities have been found to influence nurses’
dissatisfaction with hospital employment (Bates, 1998;
Braddy et al., 1991; Huey and Hartley, 1988), partici-
pants did not comment about financial remuneration as
a reason for undertaking agency-nursing work. This lack
of influence of financial incentives was also supported by
the work of Braddy et al., which indicated the promise
of a better salary would influence only 39% of the nurses
surveyed to leave their agency work and return to
permanent hospital employment.
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10. Another significant issue was agency nurses’ experi-
ences with hospital staff. Although some participants
enjoyed supportive relationships that served to enrich
their practice, others described a lack of supportive
consultation especially in settings where they worked
regularly and in relatively busy situations. Again, it
appeared as though the temporary nature of employ-
ment influenced how permanent hospital nurses per-
ceived the agency nurse and the degree of support they
gave or withheld (Bates, 1998). The withholding of
support may serve to minimise the agency nurses’ work
autonomy in patient decision-making. In view of the
complex and changing nature of clinical work, agency
nurses depend on support from the health care profes-
sionals with whom they are working. If this support is
not provided, agency nurses may experience professional
isolation and deliver poor patient care (Schubert, 1995).
Gunn (1983) encountered a similar situation when
agency nurses found themselves isolated from the
decision making process within the area they were
working.
Communication about the completion of patient tasks
was another important aspect of agency nurses’ experi-
ences with permanent staff. Participants perceived that
their communication was orientated towards the need to
complete tasks within tight time frames rather than to
develop a comprehensive, holistic understanding of
patient care needs. While the findings indicated that
the level of communication from permanent nurses may
be limited, Bates (1998) reported in her study that
agency nurses had few opportunities to access the
necessary information from medical records because of
constant interruptions, a lack of familiarity with the
ward environment, and the immediacy of patient needs.
Task completion could be difficult when information,
either oral or written, is not always readily accessible. As
a result, agency nurses may feel compelled to develop a
rapid problem solving or ‘quick fix’ response to
completing tasks and addressing patient problems
(Street, 1992). However, this form of response tends to
focus on the immediate concerns of the patient, such as
resuscitation emergencies and vital sign assessment,
while other, less valued concerns, such as family support
and spiritual needs, go unnoticed. Furthermore, the lack
of appropriate communication about patient care may
necessitate the need for decisions to be passed on to
permanent staff, thereby decreasing agency nurses’
autonomy (Bates, 1998).
With respect to professionalism, participants com-
mented on their responsibility in maintaining and
updating clinical skills through continuing education.
While permanent nurses had access to educational
opportunities in the workplace, agency nurses were
expected to maintain their own professional develop-
ment. In Schubert’s study (1995), agency nurses
commented on the cost of continuing education, and
felt they were missing opportunities to update their
knowledge and skills that were readily available to
hospital employees. The temporary nature of employ-
ment may motivate hospital employers to extract the
maximum labour power for the duration of the work
assignment (Bernstein, 1986). Subsequently, employers
could be reluctant to include agency nurses in educa-
tional sessions normally meant for permanent nurses.
The limitations of this study concern the small
number of individual interviews conducted with agency
nurses who worked in Melbourne, Australia. Due to the
voluntary means of participation, it may be assumed
that the findings reveal the perceptions and experiences
of agency nurses who had a strong interest in their work.
Nevertheless, the comprehensive findings, which repre-
sent the views of ten individuals with varying levels of
experience in agency-nursing work, are likely to resonate
with other agency nurses in similar positions.
6. Conclusion and implications
The findings of this study make a unique contribution
to knowledge about agency nurses’ perceptions and
experiences of their work in acute care hospital settings.
While these participants had undertaken agency nursing
to maintain flexibility and control in their practice, their
relationships with nursing agencies and hospitals meant
that they were left with little opportunity to obtain
adequate hospital orientation, negotiate allocation of
shifts, communicate in a supportive manner with
permanent staff and experience professional advance-
ment. The findings reinforce the need to create strong
collaborative networks between agency nurses, nursing
agencies and hospital institutions, in which all stake-
holders could discuss issues of concern and negotiate an
agreed position. In particular, as agency nurses now
comprise a significant portion of nurses who work in
hospital settings, they need to be orientated adequately,
and to have some sense of belonging and autonomy in
the workplace.
Further research could involve an exploration of the
experiences of agency nurses who are employed in
different health care institutions, including long-term
care, aged care, community health and psychiatric
settings. While this research focused on participants
employed in the metropolitan area, it would also be of
interest to consider if agency nurses’ views differ
between metropolitan, regional and rural areas. Another
neglected area concerns the views of permanent nurses
who work with agency nurses. It is vital that compre-
hensive understandings of different perspectives of
agency-nursing work are sought to enhance professional
nurses’ satisfaction with their practice and to facilitate
quality patient care.
E. Manias et al. / International Journal of Nursing Studies 40 (2003) 269–279
278

11. Acknowledgements
The authors wish to acknowledge the Nurses’ Board
of Victoria that provided financial assistance to support
the study upon which this paper is based.
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