How do nurse managers describe clinical nurses' work arrangements? A qualitative study

Abstract Aim The researcher sought to understand how nurse managers describe nurses in alternative work arrangements. Design The researcher conducted this study using grounded theory. Method Semi‐structured interviews. A theoretical sample of 26 baccalaureate‐prepared nurse managers located across the United States participated in the study. Results A typology of five work arrangements provides descriptors that contribute toward greater conceptual clarity on nurses' work arrangements. The data reveal that the typology is fluid because nurses can easily switch across work arrangements. Because the rise in alternative work arrangements means that nurses can leave permanent positions—or explore different work arrangements—when circumstances permit or necessitate, nurses who do not receive continued mentoring will likely bring their deficiencies in skill and/or knowledge to facilities where they find future employment. Hence, inadequate mentoring at the unit level has practical consequences for the quality of patient care at the institutional level.


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GAN 2 | BACKG ROU N D Adjustments to work schedules are a concern for major stakeholders-facilities, nurses and patients-because scheduling affects cost containment, work-life balance and the quality of care delivery (Kossek, Rosokha, & Leana, 2019;Thériault, Dubois, Borgès da Silva, & Prud'homme, 2019). Indeed, staffing issues are stressors for nurse managers globally (Fast & Rankin, 2018;Gantz et al., 2012). As patient acuity and census change, nurses on various work arrangements help units maintain nurse-to-patient ratios. Nurses who work alternative work arrangements give nurse managers staffing options that they could schedule in advance or on short notice. Without such options, nurse managers oftentimes must multitask between supervisory and clinical roles when their units are direly understaffed (Kossek et al., 2019); the prioritization of patient care is necessary yet it can also draw nurse managers away from their managerial tasks. Although such real-time staffing changes are a common phenomenon, scholars note the paucity of research on the employment of temporary nurses and the implications of nursing shift work (Dall'Ora et al., 2016;Harris et al., 2015;Rodwell & Fernando, 2016;Simpson & Simpson, 2019). This knowledge gap limits scholars' capacity to discuss practical managerial consequences of the rise in alternative work arrangements. Because alternative work arrangements reshape employment relations in the nursing profession (Baumann, Hunsberger, & Crea-Arsenio, 2013) and have the potential to affect how nurse managers work, the following research question guided this research study: How do nurse managers describe nurses in different work arrangements?

| Design
The relative lack of knowledge on nurse managers' work experience in general (Paliadelis & Cruickshank, 2008) and their description of their nurses in varied work arrangements in particular warranted an exploratory study. The researcher used semi-structured interviews because 'individuals have unique and important knowledge about the social world that is ascertainable and that can be shared through verbal communication' (Hesse-Biber & Leavy, 2011, p. 94). The consolidated criteria for reporting qualitative research and standards for reporting qualitative research guided this research study (O'Brien, Harris, Beckman, Reed, & Cook, 2014;Tong, Sainsbury, & Craig, 2007).

| Reflexivity
The researcher conducted the interviews between June 2016-November 2017 as an advanced doctoral student. Prior to conducting this research, the researcher received advanced methodological training in field methods and interview techniques. Other credentials that added depth to his approach to the research design and data collection include professional experience as a former combat medic as well as his present research interest in contemporary career sensemaking. Self-reflexivity is an important ethical and epistemological consideration because the researcher's personal assumptions provide a lens through which he interprets his participants' lived experiences. As a result, researchers' participation in qualitative research yields different socially constructed meanings as they make sense of their participants' notions of reality (Hesse-Biber & Leavy, 2011). This coconstruction of subjective realities is a sensemaking process that builds on the researcher's ontological view of multiple versions of 'truths' as experienced by the participants.

| Data collection
In accordance with the approved institutional review board procedure, colleagues at nurses' professional organizations in the United States disseminated the call for research participants to their members. The researcher did not have a prior relationship with the participants before the interviews, although they knew of his interest in the research topic. The participants were recruited through theoretical sampling until theoretical saturation, where additional participants no longer contribute new information to the conceptual categories (Glaser & Strauss, 1967). The participants scheduled their interviews based on their availability. One-time, one-on-one interviews took place over the telephone without the presence of other individuals. Participants gave written informed consent, and they understood how the researcher would use the data and protect participants' identities. The researcher used the approved interview guide and audio recorded all but one of the interviews. Audio recordings were transcribed verbatim. He took detailed notes throughout and immediately after the interviews.
This study had a sample of 26 participants and an unknown non-participation rate because the researcher did not have access to the number of potential participants who received the official recruitment statement and those who heard about the study through word-of-mouth recruitment. The inclusion criteria required that participants must be registered nurses with clinical management experience and had directly supervised clinical nurses. Participants had an average of 25 years of experience as registered nurses and had on average almost 11 years of experience as nurse managers; their educational background was at least a Bachelor of Science in Nursing.
The interviews averaged 47 minutes each. The participants in this article are referred to by assigned pseudonyms.

| Data analysis and data trustworthiness
The researcher employed the constant-comparative method to inductively analyse the data throughout the data collection phase (Strauss & Corbin, 1990). He read the transcript line-by-line and used open coding to identify concepts of similar meanings.
Subsequently, the researcher conducted axial coding to develop specific open-coded categories, which came from grouped categories of initial concepts, based on emerging relationships among the concepts. Selective coding transpired through iterative readings of the interview transcript and revisions to the categories, which finally yielded the themes (Strauss & Corbin, 1990). To enhance data trustworthiness, the researcher: (a) discussed emerging patterns in the data with fellow field researchers (Creswell & Miller, 2000); (b) used member checks to verify emerging themes (Miles & Huberman, 1984); (c) used quotations that provide thick, rich descriptions (Creswell & Miller, 2000); and (d) exercised researcher reflexivity.

| RE SULTS
One of the first questions on the interview guide was to help the researcher learn what temporary nurses meant to the participants. They collectively described temporary nurses as nurses who 'are not part of our core team' (Elizabeth) 'but they come in to fill holes' (Emma). Lily, a paediatric oncology nurse manager with 36 years of registered nurse experience, put it succinctly, 'Having travellers go in while you're trying to look for permanent employees [is a strategy that] helps your permanent staff'. Participants' definition mirrored the increasing prevalence of team-based care observed in international healthcare systems (Norful, Martsolf, de Jacq, & Poghosyan, 2017). The similar ways that the participants categorized their nurses in terms of teams created a permanent-temporary distinction by referencing to their units' staff nurses, nurses' tenure and anticipated tenure on their units.
Intuitively, participants viewed temporary nurses as non-staff nurses.
The permanent-temporary distinction became most salient when participants talked about their expectations of temporary nurses. Charlotte, who has 22 years of nurse manager experience and works at a 500+-bed teaching hospital, had this expectation, 'They need to view their role as being part of a team, whether it's for a day or for a year'. Michelle, a Millennial in her second year as a nurse manager, narrated her recollection of a travel/agency nurse when she was a nurse assistant: We had an agency nurse who worked in our unit for a long time. Her contract was up and they renewed it so she was there. Everyone respected her. She really became part of the team because she was there for several months and that's how I knew she was an agency nurse.
Productive temporary nurses must not only want to 'be a part of the team' (Emma; Erin), but must also onboard quickly to become 'part of the team' (Heather). Thus, the participants instinctively classified temporary nurses as those who do not originally belong to their units and whose purpose is to serve immediate needs.
Participants acknowledged that 'to bring everyone together as a team to work is a challenge' (Erin). One way that nurse managers onboard temporary nurses was to treat and communicate with them like their staff nurses: We have huddles every shift so we bring them in where we can introduce them to all the people on their team that are coming on right then. And then give them assignments and so that they can all work out there as a team. And we include them, you know, wearing an emergency department jacket is a feather in their caps. They get things like that to be part of the team.

(Emma)
The quotations considered so far reveal that nurse managers view patient care delivery as a collective team effort. Nurse managers and their nurses work toward that goal when staff nurses welcome the help that temporary nurses bring to their units while temporary nurses adapt quickly and perform tasks diligently.
Since permanent/staff nurses and temporary/non-staff nurses support one another in different ways, this insight suggests that different work arrangements have different features. The next section illustrates the representative features of different work arrangements that make them uniquely attractive to nurses.

| Distinguishing different types of temporary and permanent work arrangements
The second part of the analysis builds on the permanent-temporary distinction and presents Table 1 as a visual summary of the distinction between different types of permanent and temporary nurses as well as their similarities and differences. This typology highlights two considerations that the participants used to differentiate among different types of work arrangements. The vertical axis represents a continuum of shorter-term nurses (who may work a complete shift or a part of it) to longer-term nurses (whom facilities have scheduled to work for a specified duration or on a permanent basis). The horizon- . Money refers to differential allowances given to nurses in alternative work arrangements but not to permanent or staff nurses. Flexibility refers to both employment flexibility (i.e., the many configurations of work schedules in which facilities can employ nurses) and nurses' flexibility (to adapt to the challenges they find at work). Illustrative quotations for these five work arrangements will be provided below.

Rooted
Like per diem nurses, staff nurses opt for a work arrangement that keeps them in their communities. Although nurses know that they can earn differential allowances by picking up additional shifts as per diem nurses or by signing contracts as travel nurses, Ella (who works on a 42-bed post-operative joint-replacement unit) said that some nurses preferred permanent positions chiefly because family responsibilities kept them rooted in their local areas. Sophia, who works at a 900+-bed non-profit acute care hospital, shared her analysis with me, 'Travellers are the ones who don't have family obligations at home because it's very difficult when you've children …Usually, travelling's seen as an early job entry or work after kids are grown'.
Emma, employed at a large level-1 trauma tertiary care centre, recognized the same reasons and disclosed the curiosity that almost every nurse whom she had met had about the adventures of travel nursing:  Consistent work environment has eight years of nurse manager experience, discerned these relational differences: You tend to know your permanent employees better.
A permanent employee is more likely to tell you things than the temporary [employee]. The temporary people don't know you; they're only there for a short period of time, so they might not be as forthcoming. You also don't know their background as well, you don't know their personalities as well.
Nevertheless, Ashley said, 'When they wanted to join us, it was because they recognized that the teaming and the culture we had on our units was something that they wanted to be a part of'. The right work culture keeps nurses and cultivates relationships.
The relationships that nurse managers foster with their staff nurses have a greater social and personable element, in contrast to the more transactional approach usually observed with temporary workers (Van Breugel et al., 2005). Nurse managers relate to their staff nurses better because they view staff nurses as integral members of their teams' core.

Vested
Because of their rootedness and relationships, staff nurses have a stake in their organizations and they voluntarily articulate ways that their units can change or improve. Lily explained: They sometimes raise more things that have to do with the unit and the team and they look at issues in the unit… because they're going to be there for the long haul, if there's something that's frustrating in the workflow… they're more engaged at trying to improve those things, whereas the traveller knows that he or she will be gone in 13 weeks.
Staff nurses' commitment reveals their high member identification with their organizations (Van Breugel et al., 2005). They communicate their thoughts more frequently because they take ownership of the concerns that they have-or problems that they observe-in their work environments. If they remain silent, they must then accept the consequences and the work conditions. This descriptor indicates that the anticipated permanence of one's job will make the employee more vocal about improvements as compared to more itinerant employees and those with less frequent or shorter footholds.

Consistent work environment
Finally, staff nurses find comfort in familiarity. Abigail categorized them this way: They don't like to get outside of their box. They're very comfortable in their geographical location, they've four walls, they know the patient population that they're dealing with, they know their coworkers, they know where their stuff is, they know predictably what's going to happen on any given day; they may have a busy day or a slow day, but the days are pretty much the same and that comfort level is good for some people. Some people like that, some people need that.
This final descriptor ties together the preceding descriptors and provides an overarching explanation as to why permanent nurses stay as permanent nurses, despite the attractive features of other work arrangements.

| Staff-floaters
Staff-floaters are a subset of staff nurses who are functionally temporary nurses who fill gaps in understaffed units (top-right quadrant of Michelle also gave a similar account based on her experience with temporary nurses in general and per diem nurses in particular, 'Their husbands are working so they're kind of bringing in extra income but they don't have to work full-time and they need the flexibility to work around child care'. Per diem nurses cherish flexibility because they prioritize their non-work lives; they prefer to dedicate their energies to family responsibilities and to participate in personal activities meaningful to them.
Nurse managers construed per diem nurses' rootedness more positively than how they characterized staff nurses' rootedness. Rooted presence in the local community makes proximity less of an issue.

Consistent work environment
They not only get to choose when they work but also where they work. Tiffany, who works on an intensive care unit at a level-1 trauma teaching hospital, analysed, 'PRNs usually tend to fall into two different groups. There're nurses that only work for us and they're PRN for us, or they're nurses who've another full-time job and they'll work PRN for us'. Michelle also gave an example, 'I've one who's a nurse practitioner who wants to stay on in our unit after she has finished nurse practitioner school'. Nurses may also view per diem nursing as a way 'to get their foot in the door', as Erin told me about a nurse who worked a once-a-week schedule for her even though this nurse had a full-time position at a hospital closer to where she lived.
Per diem nurses commonly want a consistent work environment because they value familiarity with their employers, colleagues and community. They also work per diem so that they increase their access to future employment opportunities.

Task-oriented
Participants complimented travel nurses as competent and independent. However, they noticed that travel nurses had less interest in cultivating relationships with patients than nurses in other work arrangements. Stephanie, who has 40 direct reports and works in a neurosurgery department at a level-1 trauma hospital, remarked, 'They're not very concerned about individual care of patients. They do the orders. They follow the orders but …they know they're just there a short time. They're not very attached to the patients at all'. This criticism seems largely consistent among other participants. Lily praised travellers as 'relatively good nurses' but they only 'do their job on the unit' and not engage with others as much as permanent nurses. Abigail had an explanation as to why travellers kept mostly to themselves, 'Some of them are very gregarious but some of them are rather quiet, and they may have been burned somewhere else, and so they sort of stay to themselves until they know that they're welcomed'. It seems plausible that travel nurses focus mostly on completing tasks because they fill staffing gaps at their temporary units.

Money
Because travel nurses possess sought after expertise, they seek employment opportunities that will pay them well. Charlotte works for a hospital network in an urban but rather isolated Northeastern region that has difficulty retaining nurses: We don't typically get local nurses, we get nurses that like to travel home for a week at a time. … They want to go back home and to their families, which we completely understand …they're really doing it financially, because maybe there aren't local opportunities, or the salaries locally are so low. These are primary breadwinners.
Similarly, Olivia qualified the perception that travellers 'make a lot more money, because they're willing to go at a moment's notice'.
However, to earn that higher remuneration, they must have the tenacity to adapt quickly to different geographical and work environments.

Flexibility
Olivia stated, 'They tend to be very well-trained, they can jump right in', meaning that travel nurses do not get the lengthier orientation that new graduate nurses typically receive. Evelyn, a nurse manager at an orthopaedic hospital, agreed, 'They're expected to adapt really quickly to their roles. They don't need a lot of orientation. They've learned how to get you through a rough patch in your staffing'. Much of their flexibility comes from having gained exposure to and experience in different settings.

Experience
They travel and work as a lifestyle choice. Lily outlined two types of travel nurses, 'The two groups of travellers-there's the one that travels for money and the one that travels so that they can travel.
They go to places that they wouldn't ordinarily be able to go to'.
This descriptor shares similarities with the same namesake for float nurses: travel nurses thrive in geographically dispersed locations while float nurses thrive in different units in their organizations.

Task-oriented
Participants generally had a positive impression of float nurses' competency, but they also remarked that float nurses seemed less inter- observed that float nurses must adapt quickly to new environments, 'When you're a float nurse, you should have the ability to step into any situation, orient quickly and be able to take over the job'. This descriptor connects back to the earlier descriptor because differential allowances partly compensate nurses for their flexibility in meeting units' pressing needs.

Experience
Jessica continued, 'They like the excitement of going from place to place. They enjoy the mix of patients: taking care of a transplant patient one day, a neuro patient another day and a cardiology patient another day'. Float nurses look forward to the daily challenge of working with a different patient mix and applying different skills.
They also get to experience novel settings and in this sense are adventurous like travel nurses: they get to explore different clinical specialties in their hospitals without travelling afar.

| D ISCUSS I ON
This study unearths nurse managers' conception of the permanenttemporary distinction of nurses. Participants' definition of temporary nurses offers three fundamental insights into how they view their nurses. First, nurse managers view permanent nurses as those who work exclusively/mostly for their units; they express a degree of belongingness of permanent nurses as members who provide dependable and long-term stability to their respective units. By implication, individuals share common work identities (Van Breugel et al., 2005), appreciate one another's personalities and foster workplace relationships developed over time and into the future as they anticipate continued interactions as colleagues on the same unit.
Second, nurse managers shoulder the responsibility of finding replacement nurses-whether temporary or permanent-for their understaffed teams. The second insight reinforces the previous insight regarding the seriousness of nursing work. It also underscores key managerial tasks of maintaining nurse-to-patient ratios and human resource functions such as recruitment and retention (Kortbeek et al., 2015;Larson et al., 2012;Thériault et al., 2019). A wise reminder from Kimberly: [What] I don't always remember is that the people are first. We always get caught up in the processes and in the payments, but it's all about the people. And if I can remember that, my team will do very well.
The two-dimensional framework depicts nurse managers' categorization and perception of nurses' work arrangements. Participants expect temporary (or non-permanent) nurses to be highly competent and that they will 'hit the ground running' (Amanda; Avery; Isabella; Lily). Because of their clinical proficiency and flexibility, nurses in alternative work arrangements typically receive differential allowances (and, therefore, higher salaries) than staff nurses.
Highly productive temporary nurses 'blend in with the rest of the Therefore, whenever possible, nurse managers interview temporary nurses carefully to ascertain candidates' personalities and they assign incoming nurses (when within their control and when circumstances permit) to work with nurses whom they envision will work well together.

| An applied recommendation
This study's analysis offers a framework to understand how nurse managers describe nurses' work arrangements. The data reveal that the typology is fluid because nurses can switch among work arrangements to achieve what they desire from working as nurses.
That insight empirically supports the notion that work arrangements can reflect work motivations, which may influence whom and how nurse managers mentor (Gan, 2019a). Nurse managers invest much of their time and resources in mentoring nurses (Kodama & Fukahori, 2017;Sveinsdóttir, Ragnarsdóttir, & Blöndal, 2016 is about raising the overall quality of care delivery by addressing inadequate mentoring. Because nurses who do not receive continued mentoring will likely bring their deficiencies in skill and/or knowledge to facilities where they find future employment (Gan, 2019b), inadequate mentoring at the unit level has practical consequences for the quality of patient care at the institutional level.
The above recommendation is distinct from merely stating that the employment of temporary nurses in itself-without considering the quality of the employed temporary nurses-will affect patient care. Indeed, as the employment of temporary nurses to maintain adequate staffing implies staffing instability (Thériault et al., 2019), healthcare administrators are typically concerned about whether increased employment of nurses in alternative work arrangements will adversely affect the quality of patient care (Morelock & Kirk, 2019); however, this instinctive concern is largely unsupported by empirical studies (Simpson & Simpson, 2019). Recent studies indicate that the resources-such as time-that nurses have, nurses' work experience and nurse-to-patient ratios affect the extent to which nurses complete patient care tasks such as the monitoring of patients' fluid intake (Litchfield, Magill, & Flint, 2018) and the taking of patients' vital signs (Recio-Saucedo et al., 2018). The delivery and monitoring of these tasks are important because they are within nurses' scope of practice and they directly affect patients' health outcomes (Stalpers, De Vos, Van Der Linden, Kaljouw, & Schuurmans, 2017). Such nuances in nurses' work, nurses' qualifications and motivations as well as the challenges that nurses confront daily highlight salient factors that facilities must constantly evaluate as they ascertain and manage the staffing mix appropriate for their respective circumstances.
These factors are especially crucial as the cost and the quality of patient care can create competing interests, complicating the allocation of mentoring resources.

| CON CLUS ION
Alternative work arrangements both complement and challenge the conventional or 'standard' boundaries of work and personal time as variations in work arrangements shape nurses' experience of work time and structures such as schedules. Nurse managers who understand the varied motivations undergirding their nurses' preference for particular work arrangements are better equipped to mitigate staffing challenges, manage the potential impact that staffing mix has on patient care and effectively fulfil their mentoring responsibility.
The study's sample is a limitation because staffing demands and licensing requirements differ from state to state and from other international jurisdictions. Participants' broad clinical backgrounds may limit transferability of findings. However, the consistent themes reported by the participants ring true despite their diverse clinical settings.
Future studies should seek greater insights into alternative work arrangements' impact on nurses' careers. As temporary arrangements increase the likelihood of temporary employees developing transactional rather than relational interactions with their employers (Van Breugel et al., 2005), nurses' experience of work time shapes the way they relate to their colleagues and vice versa. For instance, although nursing researchers have studied mentoring extensively and have reported that Millennial nurses in particular want ongoing mentoring and flexible careers (Hale, 2018;Jamieson, Kirk, Wright, & Andrew, 2015), the nursing scholarship sheds limited light on how alternative work arrangements affect mentoring as a communicative behaviour (Gan, 2019a). As Millennial nurses will have increasingly diverse nursing career options (Jamieson et al., 2015), researchers should invest greater effort into understanding Millennial nurses' thoughts about alternative work arrangements.

ACK N OWLED G EM ENT
The author is indebted to the participants of this study.

E TH I C A L A PPROVA L
The Texas A&M University IRB approved this study.

CO N FLI C T O F I NTE R E S T
No conflict of interest has been declared by the author.