The health system consequences of agency nursing and moonlighting in South Africa

Figures & data

Table 1 Health system consequences of moonlighting and agency work

			Felt too tired to work while on duty		Paid less attention to nursing work while on duty		Took sick leave when not actually sick		Stayed away from work without authority		Involved in a medico-legal incident		Any of these		Composite Consequence Index 1 (MCA*)
Variable		n	%	p	%	p	%	p	%	p	%	p	%	p	Mean	p
Total		3708	51.5		11.5		10.9		5.6		2.9		55.8		0.761
Moonlighting or agency	No	2143	52.2	0.442	10.3	0.035	9.7	0.011	4.9	0.090	2.6	0.169	56.5	0.463	−0.018	0.138
nursing	Yes	1473	50.5		13.2		12.9		6.5		3.4		55.0		0.032
Province	Gauteng	1638	55.6	0.005	13.6	0.049	13.2	0.018	6.9	0.012	3.1	0.299	59.5	0.007	0.197	<0.001
	Eastern Cape	945	54.6		10.6		10.4		6.0		2.4		59.4		0.001
	Western Cape	800	44.2		9.2		9.3		3.3		2.7		48.1		−0.102
	Free State	325	40.5		9.4		5.5		4.3		4.4		45.6		−0.135
Sex	Male	289	53.4	0.621	14.4	0.135	14.8	0.090	6.7	0.416	3.5	0.579	58.6	0.447	0.230	<0.001
	Female	3412	51.3		11.2		10.6		5.5		2.9		55.5		−0.013
Age group	<25 years	139	54.5	<0.001	14.3	0.017	14.8	<0.001	7.2	<0.001	4.0	0.290	60.4	<0.001	0.183	<0.001
	25–34 years	926	59.4		15.1		16.6		9.5		4.0		63.9		0.235
	35–44 years	1024	52.4		11.0		11.0		5.2		2.9		56.6		0.026
	45–54 years	1060	50.0		10.4		8.9		4.4		2.3		54.4		−0.094
	55+ years	430	35.8		8.3		3.5		1.7		1.9		40.3		−0.315
Marital status	Married/living together	1667	51.9	0.011	11.5	0.513	11.0	0.231	4.8	<0.001	3.2	0.509	56.5	0.004	−0.021	0.007
	Single	1495	53.3		10.9		11.6		7.4		2.4		57.7		0.071
	Divorced/widowed	530	44.7		13.1		8.2		3.2		3.3		47.9		−0.070
Any children?	No	619	56.6	0.084	15.6	0.012	13.2	0.099	4.9	0.457	4.1	0.129	62.3	0.016	0.120	0.002
	Yes	3089	50.5		10.7		10.5		5.8		2.7		54.5		−0.019
Sector	Public	2692	54.3	<0.001	11.0	0.012	11.5	0.011	5.8	0.002	2.4	0.041	58.3	<0.001	0.078	<0.001
	Private	681	46.5		15.1		7.1		2.9		4.2		51.9		−0.075
	Agency	259	35.3		8.7		12.7		9.1		3.6		39.7		−0.113
Nursing category	Professional nurse	1759	57.4	<0.001	15.2	<0.001	12.3	0.134	5.5	0.526	3.9	0.010	61.5	<0.001	0.110	<0.001
	Enrolled nurse	740	52.1		9.1		10.6		6.6		2.2		56.3		−0.038
	Nursing assistant	1209	42.3		7.4		9.1		5.2		2.0		47.0		−0.162
Unit	General wards	1160	51.3	0.482	12.1	0.134	11.1	0.962	6.1	0.258	3.1	0.632	56.1	0.305	−0.007	0.355
	Maternity	599	52.5		8.9		11.2		4.2		2.8		55.7		−0.044
	ICU	536	50.5		14.7		11.8		4.1		3.2		56.4		0.062
	Theatre	570	55.2		11.6		10.1		7.5		1.9		59.7		0.039
	Other	834	49.1		10.5		10.6		5.7		3.1		52.3		−0.012
Years working at	Less than 1 year	404	47.2	0.257	10.7	0.146	8.4	0.005	4.8	0.389	2.3	0.005	50.6	0.310	−0.047	<0.001
primary job	1–4 years	982	53.2		10.3		11.6		6.9		4.0		57.4		0.054
	5–9 years	675	55.3		14.5		15.8		6.3		2.1		59.2		0.097
	10–14 years	339	54.9		13.1		13.4		4.5		4.6		58.5		0.037
	15–19 years	312	53.0		13.5		8.4		3.8		4.6		57.9		−0.029
	20 or more years	904	49.0		10.2		7.6		4.9		1.3		54.3		−0.106

Type 1 indicators in all nurses; Statistically significant relationships in bold.

*Multiple correspondence analysis.

Table 2 Health system consequences of moonlighting and agency work

			Argued with doctors or other nurses		Conflicting schedules between primary and secondary jobs		Took vacation leave to do agency work or moonlighting		Took sick leave to do agency work or moonlighting		Stayed away without authority to do agency work or moonlighting		Treated patients differently in primary vs. secondary job		Any of these		Composite Consequence Index 2 (MCA)
Variable		n	%	p	%	p	%	p	%	p	%	p	%	p	%	p	Mean	p
Total		1473	19.6		9.8		11.9		2.8		1.6		2.3		33.7		0.422
Province	Gauteng	897	23.2	<0.001	12.1	<0.001	13.9	0.011	3.2	0.204	2.4	0.475	3.4	0.002	38.5	<0.001	0.218	<0.001
	Eastern Cape	122	24.1		6.4		11.2		2.8		0.0		0.2		34.3		−0.102
	Western Cape	334	11.4		4.3		6.5		2.7		0.0		0.6		20.7		−0.205
	Free State	120	12.1		11.9		13.9		0.6		1.8		1.7		34.7		−0.047
Sex	Male	107	25.3	0.042	13.2	0.188	16.8	0.140	1.6	0.372	2.1	0.579	1.2	0.459	39.9	0.211	0.219	0.015
	Female	1362	19.1		9.6		11.6		2.9		1.6		2.4		33.2		−0.014
Age group	<25 years	51	15.0	0.651	8.8	0.397	2.4	0.070	3.5	0.521	3.4	0.500	3.5	0.718	22.9	0.123	0.036	0.035
	25–34 years	402	21.6		10.7		11.2		3.8		2.0		3.3		36.4		0.039
	35–44 years	463	20.1		11.9		15.4		2.7		1.3		2.2		37.2		0.075
	45–54 years	377	18.1		7.2		11.3		2.7		0.9		1.5		29.6		−0.080
	55+ years	114	16.2		9.9		8.6		0.0		0.0		3.5		28.7		−0.181
Marital status	Married/living together	648	19.1	0.971	9.7	0.523	12.3	0.336	3.0	0.661	1.7	0.978	1.8	0.247	32.9	0.541	−0.011	0.832
	Single	613	19.8		9.1		10.8		2.9		1.6		2.3		33.2		0.002
	Divorced/widowed	199	19.7		11.7		14.9		1.5		1.5		4.4		37.7		0.033
Any children?	No	232	22.2	0.305	9.6	0.886	10.9	0.623	2.2	0.592	1.2	0.671	2.0	0.751	33.9	0.920	−0.023	0.657
	Yes	1241	19.0		9.9		12.1		2.9		1.7		2.4		33.6		0.007
Sector	Public	823	20.1	0.134	9.9	0.916	12.7	0.001	3.1	0.191	1.2	0.004	3.4	0.151	34.8	0.019	0.116	0.001
	Private	413	21.1		9.3		15.1		1.7		0.7		0.9		35.8		−0.091
	Agency	203	12.6		9.8		2.2		3.7		6.0		1.5		22.6		0.017
Nursing category	Professional nurse	735	22.7	0.068	9.5	0.543	17.9	<0.001	2.5	0.114	1.2	0.547	2.7	0.284	38.7	0.003	0.049	0.109
	Enrolled nurse	315	15.2		11.5		8.3		4.5		1.9		1.0		27.9		−0.024
	Nursing assistant	423	17.0		9.1		3.7		2.0		2.2		2.8		28.7		−0.081
Unit	General wards	386	17.7	0.239	10.2	0.167	6.3	<0.001	3.3	0.605	1.8	0.290	1.6	0.296	29.3	0.009	−0.043	0.014
	Maternity	274	18.0		6.5		6.9		1.4		0.0		2.1		25.6		−0.139
	ICU	372	17.9		11.1		20.9		3.7		2.1		3.3		39.3		0.129
	Theatre	207	26.3		14.8		12.1		2.0		1.2		3.7		43.0		0.031
	Other	234	21.3		6.7		12.9		3.1		2.8		1.1		33.5		0.001
Years working at	Less than 1 year	180	12.6	0.186	10.3	0.428	8.6	0.047	5.0	0.154	2.0	0.360	2.6	0.240	27.6	0.157	−0.011	0.878
primary job	1–4 years	448	21.8		7.8		8.7		3.4		2.9		3.0		32.3		0.028
	5–9 years	290	18.7		12.4		13.7		2.2		0.9		0.9		36.8		−0.023
	10–14 years	170	21.9		12.4		17.7		4.6		1.2		1.7		39.1		0.070
	15–19 years	125	24.7		9.1		18.1		0.0		0.0		1.1		41.5		−0.038
	20 or more years	205	19.0		7.7		13.4		0.7		0.7		4.8		32.6		−0.021

Type 2 indicators in moonlighting nurses only; Statistically significant relationships in bold.

Table 3 Multiple logistic regression of predictors of health system consequences

		Felt too tired to work while on duty	Paid less attention to nursing work while on duty	Took sick leave when not actually sick	Stayed away from work without authority	Involved in a medico-legal incident	Any of these
Variable		OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Moonlighting or	No	–	–	–	–	–	–
agency nursing in	Yes	0.97	1.19	1.36	1.31	1.01	0.99
the past 12 months		(0.79–1.19)	(0.88–1.62)	(0.95–1.94)	(0.86–1.98)	(0.63–1.62)	(0.81–1.20)
Province	Gauteng	–	–	–	–		–
	Eastern Cape	0.95	0.87	1.02	1.03		1.02
		(0.60–1.51)	(0.59–1.28)	(0.72–1.45)	(0.65–1.63)		(0.64–1.62)
	Western Cape	0.65**	0.67**	0.84	0.54***		0.64**
		(0.49–0.85)	(0.52–0.85)	(0.53–1.36)	(0.40–0.75)		(0.49–0.83)
	Free State	0.58***	0.71*	0.44***	0.74		0.60***
		(0.42–0.78)	(0.51–0.98)	(0.29–0.68)	(0.49–1.11)		(0.45–0.80)
Sex	Male		–	–
	Female		0.78	0.76
			(0.50–1.21)	(0.47–1.23)
Age group	<25 years	–	–	–	–		–
	25–34 years	1.32	1.10	0.88	1.30		1.27
		(0.77–2.27)	(0.63–1.91)	(0.46–1.65)	(0.66–2.55)		(0.83–1.95)
	35–44 years	0.94	0.62	0.45*	0.69		0.89
		(0.55–1.61)	(0.34–1.13)	(0.24–0.87)	(0.32–1.48)		(0.57–1.39)
	45–54 years	0.83	0.60	0.37*	0.71		0.81
		(0.47–1.49)	(0.35–1.02)	(0.18–0.79)	(0.31–1.60)		(0.51–1.29)
	55+ years	0.47*	0.45*	0.15***	0.19*		0.46**
		(0.24–0.91)	(0.22–0.93)	(0.06–0.38)	(0.04–0.97)		(0.27–0.80)
Marital status	Married/living together	–			–		–
	Single	0.95			1.21		0.93
		(0.79–1.13)			(0.83–1.78)		(0.78–1.11)
	Divorced/widowed	0.99			0.84		0.94
		(0.77–1.26)			(0.48–1.48)		(0.74–1.20)
Any children?	No	–	–	–		–	–
	Yes	0.86	0.79	0.94		0.65	0.78
		(0.63–1.16)	(0.57–1.11)	(0.64–1.38)		(0.35–1.19)	(0.58–1.03)
Sector	Public	–	–	–	–	–	–
	Private	0.68**	1.30*	0.49**	0.50*	1.32	0.73*
		(0.53–0.89)	(1.02–1.66)	(0.32–0.75)	(0.30–0.86)	(0.79–2.21)	(0.57–0.94)
	Agency	0.50***	0.79	1.27	1.40	1.56	0.50***
		(0.38–0.66)	(0.48–1.31)	(0.80–1.99)	(0.82–2.40)	(0.80–3.04)	(0.37–0.67)
Nursing category	Professional nurse	–	–	–		–	–
	Enrolled nurse	0.77	0.57**	0.73		0.58	0.77
		(0.56–1.04)	(0.39–0.83)	(0.52–1.04)		(0.31–1.06)	(0.58–1.04)
	Nursing assistant	0.52***	0.44***	0.71		0.50*	0.54***
		(0.41–0.66)	(0.30–0.65)	(0.49–1.04)		(0.26–0.93)	(0.42–0.69)
Unit	General wards		–
	Maternity		0.63*
			(0.43–0.93)
	ICU		0.91
			(0.62–1.33)
	Theatre		0.89
			(0.63–1.25)
	Other		0.82
			(0.56–1.20)
Years working at	Less than 1 year		–	–		–
primary job	1–4 years		0.93	1.57*		1.82
			(0.63–1.37)	(1.00–2.46)		(0.90–3.68)
	5–9 years		1.45	2.88***		0.95
			(0.97–2.16)	(1.80–4.63)		(0.38–2.38)
	10–14 years		1.40	2.71**		1.89
			(0.89–2.20)	(1.43–5.12)		(0.69–5.16)
	15–19 years		1.56	1.79		2.14
			(0.94–2.60)	(0.85–3.79)		(0.80–5.76)
	20 or more years		1.45	2.00		0.58
			(0.89–2.37)	(0.88–4.55)		(0.21–1.59)
Constant		2.36**	0.38*	0.21***	0.07***	0.04***	3.09***
		(1.42–3.94)	(0.17–0.82)	(0.10–0.47)	(0.03–0.21)	(0.02–0.09)	(2.16–4.44)
Observations		3357	3277	3281	3354	3401	3375
Model p value		<0.001	<0.001	<0.001	<0.001	<0.001	<0.001

Type 1 indicators in all nurses.

***p<0.001, *p<0.01, *p<0.05.

Table 4 Multiple logistic regression of predictors of health system consequences

		Argued with doctors or other nurses	Conflicting schedules between primary and secondary jobs	Took vacation leave to do agency work or moonlighting	Took sick leave to do agency work or moonlighting	Stayed away without authority to do agency work or moonlighting	Treated patients differently in primary vs. secondary job	Any of these
Variable		OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)	OR (95% CI)
Province	Gauteng	–	–	–	–		–	–
	Eastern Cape	1.01	0.49	0.70	0.82		0.04**	0.79
		(0.58–1.75)	(0.23–1.05)	(0.32–1.55)	(0.31–2.17)		(0.00–0.36)	(0.45–1.40)
	Western Cape	0.45***	0.34***	0.46**	0.95		0.17*	0.45***
		(0.29–0.68)	(0.23–0.51)	(0.27–0.80)	(0.48–1.88)		(0.04–0.71)	(0.32–0.65)
	Free State	0.44***	1.01	1.12	0.24*		0.56	0.83
		(0.29–0.66)	(0.60–1.70)	(0.63–1.99)	(0.07–0.83)		(0.13–2.39)	(0.56–1.24)
Sex	Male		–	–
	Female	0.82	0.73	0.68
		(0.53–1.27)	(0.39–1.37)	(0.36–1.27)
Age group	<25 years			–				–
	25–34 years			3.95				1.68
				(0.71–21.86)				(0.51–5.53)
	35–44 years			4.08				1.51
				(0.74–22.46)				(0.49–4.64)
	45–54 years			2.69				1.02
				(0.46–15.71)				(0.36–2.89)
	55+ years			2.18				0.99
				(0.36–13.29)				(0.28–3.48)
Sector	Public	–		–	–	–	–	–
	Private	1.16		1.09	0.44*	0.63	0.26	1.01
		(0.75–1.79)		(0.69–1.71)	(0.21–0.95)	(0.15–2.67)	(0.05–1.32)	(0.70–1.45)
	Agency	0.54*		0.20***	0.72	5.44*	0.44	0.49*
		(0.32–0.93)		(0.10–0.39)	(0.28–1.88)	(1.31–22.63)	(0.07–2.99)	(0.28–0.85)
Nursing category	Professional nurse	–		–	–			–
	Enrolled nurse	0.65		0.61*	1.66			0.69
		(0.38–1.13)		(0.40–0.94)	(0.75–3.68)			(0.47–1.01)
	Nursing assistant	0.86		0.28**	0.46			0.79
		(0.50–1.47)		(0.13–0.62)	(0.18–1.18)			(0.51–1.22)
Unit	General wards		–	–				–
	Maternity		0.64	0.94				0.70
			(0.23–1.75)	(0.41–2.15)				(0.42–1.19)
	ICU		1.08	2.76**				1.32
			(0.56–2.06)	(1.32–5.78)				(0.88–1.98)
	Theatre		1.47	1.52				1.69**
			(0.76–2.82)	(0.72–3.20)				(1.23–2.32)
	Other		0.59	1.75				1.15
			(0.30–1.16)	(0.88–3.51)				(0.81–1.62)
Years working at	Less than 1 year	–		–	–			–
primary job	1–4 years	1.67		0.88	0.72			1.16
		(0.87–3.21)		(0.48–1.59)	(0.25–2.11)			(0.71–1.88)
	5–9 years	1.40		1.04	0.44			1.38
		(0.92–2.11)		(0.49–2.24)	(0.10–1.86)			(0.88–2.17)
	10–14 years	1.75*		1.17	0.67			1.42
		(1.01–3.02)		(0.51–2.71)	(0.12–3.70)			(0.85–2.38)
	15–19 years	1.86*		1.03				1.41
		(1.07–3.24)		(0.45–2.34)				(0.78–2.56)
	20 or more years	1.35		1.05	0.11			1.23
		(0.79–2.29)		(0.56–1.97)	(0.01–1.06)			(0.75–2.03)
Constant		0.28***	0.19***	0.07**	0.08***	0.01***	0.05***	0.42
		(0.15–0.52)	(0.08–0.48)	(0.01–0.49)	(0.03–0.20)	(0.01–0.02)	(0.03–0.07)	(0.12–1.45)
Observations		1208	1299	1195	1135	1280	1280	1205
Model p value		<0.001	<0.001	<0.001		0.030	0.005	<0.001

Type 2 indicators in moonlighting nurses. ***p<0.001, **p<0.01, *p<0.05.