JONA Volume 44, Number 7/8, pp 411-416 Copyright B 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

THE JOURNAL OF NURSING ADMINISTRATION

Flexible Working Arrangements in Healthcare A Comparison Between Managers of Shift Workers and 9-to-5 Employees Danielle Mercer, MBA Elizabeth Russell, MSc Kara A. Arnold, PhD OBJECTIVE: This study examined healthcare managers’ perceptions of flexible working arrangements and implementation barriers. BACKGROUND: Work-life conflict can lead to negative health implications, but flexible working arrangements can help manage this conflict. Little research has examined its implementation in 24/7/365 healthcare organizations or within groups of employees working 9 AM to 5 PM (9-5) versus shift-work hours. METHODS: Questionnaires regarding perceptions to, benefits of, and barriers against flexible working arrangements were administered to managers of 9-5 workers and shift workers in an Atlantic Canadian healthcare organization. RESULTS: Few differences in perceptions and benefits of flexible working arrangements were found between management groups. However, results indicate that the interaction with patients and/or the immediacy of tasks being performed are barriers for shift-work managers. CONCLUSIONS: The nature of healthcare presents barriers for managers implementing flexible working Author Affiliations: PhD Candidate (Ms Mercer), Department of Management, Saint Mary’s University, Halifax, Nova Scotia; and PhD Candidate, Department of Psychology (Ms Russell), and Associate Professor, Faculty of Business Administration (Dr Arnold), Memorial University of Newfoundland, St John’s, Canada. Mss Mercer and Russell are listed alphabetically and equally contributed to this study. The authors declare no conflicts of interest. Correspondence: Dr Arnold, Memorial University of Newfoundland, 300 Prince Phillip Dr, St John’s, NL, Canada A1B 3B6 ([email protected]). DOI:10.1097/NNA.0000000000000091

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arrangements, which differ only based on whether the job is physical (shift work) versus desk related (9-5 work). In recent years, ‘‘flexibility’’ has become a workplace buzzword,1 as organizations are increasingly responding to the need for employee-centered flexibility and control regarding the organization of work. This need for flexibility can be attributed to changes within the work-family interface, which demonstrates the conflicts employees face between their work and personal lives.2 ‘‘Sweeping changes in the composition of families and the workforce, such as more dual-career couples and working mothers with young children, have increased the likelihood that both male and female employees have substantial household responsibilities in addition to work responsibilities.’’3(p414) In addition, ‘‘generation Ys’’ seek different and more flexible work arrangements from those of previous generations.4 To respond to the changing needs of diverse employees, organizations are increasingly adopting flexibility measures that seek to maintain work-life balance5 and enhance employees’ well-being. Flexible working arrangements are valued by workers across the lifespan, including new graduates, individuals caring for young children or aging parents, and those transitioning into retirement.6 Given these demographic changes in the workforce, organizations are increasingly offering a range of flexible work options.7 These arrangements are broadly defined as ‘‘employer provided benefits that permit employees some level of control over when and where they work outside the standard workday’’8(p49) and include a range of working patterns such as reduced

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hours, nonstandard hours, remote working, and compressed hours.9 Growing interest in this area has been the catalyst for an increasing number of studies examining flexible work arrangements and has contributed to our understanding of outcomes for both employees and the organization (eg, see Kelliher and Anderson7). A considerable body of research indicates the many benefits of flexible working arrangements, yet few studies address implementation issues in nontraditional scheduling. In healthcare organizations specifically, the inclusion of flexible working arrangements can be more challenging because of the 24/7/365 work environment and the prevalence of shift-work arrangements, in which organizations must always be ‘‘open for business’’ and constantly responsive to patient needs. Nontraditional Hours in Healthcare Settings Developing and sustaining a healthcare workforce that satisfies the demands of the organization are a challenging task.10 Nonstandard workVmainly shift workVis common in healthcare settings.11 The potential for negative implications of shift work on worklife balance are well documented.12 Being required to work around the clock not only challenges regular biological functioning,13 but is also socially incompatible.14 For instance, 92% of nurses reported work-family conflicts, with half reporting weekly occurrences.15 Others16 portray healthcare operations as ‘‘greedy institutions’’ that place excessive demands on workers’ time, energy, and commitment.14(p215) However, not all jobs in healthcare require nonstandard working hours, instead relying on standard 9 AM to 5 PM working hours. This difference in work hours between departments can make implementing flexible working arrangements challenging, as a ‘‘one size fits all’’ approach is not guaranteed to be effective. Flexible working arrangements occur when ‘‘employees are able to diverge from traditional working hours.’’17(p1) At a quick glance, this seems possible for these healthcare employees working standard hours but is potentially more difficult for those working non-standard hours or shift work. Successes and Failures of Flexible Working Arrangements Case study research has been conducted regarding the successes and failures of flexible and alternative work arrangements in healthcare organizations across Canada and the United States. For example, an open-rota system in which nurses self-scheduled their work and rest periods had significant benefits for job satisfaction, work-life balance and team cohesion.18 Conversely, the Hamilton Health Sciences found only modest success when they implemented self-scheduling among nurses,

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which has since been discontinued.19 These mixed findings suggest that not all healthcare organizations successfully introduce flexible scheduling, and that there are obstacles to overcome before potentially facilitating long-term positive outcomes. Current research suggests that it is essential for not only employees but also for managers to have a vested interest in flexible scheduling and to see a real need for some degree of change.20-22 Unfortunately, managing the scheduling of work to best support employee work-life balance and to meet the requirements of 24/7/365 care is stressful and challenging.14 Although the role of managers in enabling worklife balance has been studied, there is a gap in research examining barriers faced by healthcare managers in accommodating flexible working arrangement requests by employees working nonstandard hours versus those working standard hours. The current study seeks to address this gap by examining and comparing healthcare managers’ perceptions of flexible working arrangements and the barriers they face when implementing these in a 24/7/365 work environment.

Methods Participants The current study was a component of a larger project conducted in an Atlantic Canadian healthcare organization. All managers in the organization were invited to participate (n = 700) through internal e-mail, including managers from 51 departments. Of the 700 managers contacted to participate, 238 (34%) participated in the larger project. However, the current study was interested only in managers who reported having responsibility for managing shift-work employees (n = 42) or 9-5 employees (n = 88), with a total sample size of 130 managers (ie, not all managers in the organization had employees reporting directly to them). Managers of 5 types of flexible working arrangements were included: mobile work, flexible time, self-scheduling, compressed workweek, and job sharing. Procedure A questionnaire with 62 open- and close-ended questions was the instrument used in the larger study; however, the focus of the current research is on 3 items that addressed managers’ perceptions of flexible working arrangements including (a) perceived outcomes, (b) advantages, and (c) barriers to flexible working arrangements in a 24/7/365 organization. Measures Perceived Outcomes Perceived outcomes were measured by asking, ‘‘Thinking about the employees reporting to you, does a

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flexible working arrangement pattern generally impact (1) the quality of work they deliver, (2) the quantity of work they deliver, and (3) their ability to work in a team?’’ Closed-ended responses for each included ‘‘positive effect,’’ ‘‘no effect,’’ or ‘‘negative effect.’’

However, these complications were mostly interpreted as minor issues, which could be worked around and which were outweighed by the benefits of flexible working arrangements. Scheduling meetings for everyone to attend can sometimes be challenging because of everyone’s varying schedules, but I think that is the nature of the work. Prescheduled meetings planned well in advance work well, though, because everyone has control over their own schedule except for unanticipated issues that arise on occasion.

Advantages of Flexible Working Arrangements The advantages of flexible working arrangements were measured by asking, ‘‘Research suggests the following advantages may result when employees have access to opportunities to use flexible workplace practices. Please check all that you think apply.’’ Participant choices included higher ‘‘quality work,’’ ‘‘higher volume work,’’ ‘‘more effective teamwork,’’ ‘‘improved work-life balance,’’ ‘‘decreased stress levels,’’ and ‘‘increased job satisfaction.’’

9-5 managers consistently noted the increased morale, confidence, trust, and mutual respect experienced when employees felt recognized and appreciated and that their unique and specific needs were being considered.

Barriers Managers were asked, ‘‘In your experience, are there any barriers to implementing flexible workplace practices?’’ Participants could choose yes or no but also could expand on any barriers they have experienced.

Since working with flexible work arrangements, I have reduced sick time and client contact times. My staff report feeling supported and able to achieve a positive work-life balance. The flex arrangement enhances their feelings of professional and personal accountability, and I feel that no one takes advantage or produces a lower quality/quantity of work. It is a major plus in the management of my teamVgreat for engagement and healthy workplace.

Results Perceived Outcomes of Flexible Work Arrangements Positive effects were reported by the majority of both 9-5 and shift-work managers to an item asking whether a flexible working arrangement impacted the quality of work, the quantity of work, and teamwork. Descriptive statistics are presented in Table 1, which demonstrates that 66% of 9-5 managers report positive effects on the quantity of their employees’ work, the quality of their work, and their ability to work as a team. A somewhat higher percentage of shift-work managers reported these positive effects. Few from either group reported negative outcomes. Qualitative responses to this item mirrored these descriptive statistics. One participant noted that, ‘‘Flexible hours ensure that there are times when teams cannot meet as a cohesive unit.’’

Qualitative results of those managers supervising shift workers were similar. Challenges were related to working in teams or groups and during execution of physical work requirements. Usually if the staff member needs to leave early, this is already impacting the person they are working with, so with flexible arrangements, they both work together as a team to ensure all the work is done.

However, consistent with responses related to meeting coordination issues among the 9-5 managers, proactive and effective teamwork was reported to help overcome any problems with those employees working in groups.

Table 1. Perceived Outcomes of Flexible Working Arrangements Managers: 9-5 Workers Positive Effect na Thinking about employees reporting to you, do Quantity of work employees deliver? 88 Quality of work employees deliver? 83 Ability to work in a team? 86

n

%

No Effect n

flexible working 58 66 28 56 67 27 54 63 25

%

Managers: Shift Workers

Negative Effect n

%

Positive Effect na

n

%

arrangements generally impact 32 2 2.2 41 31 76 33 0 0.0 40 27 68 29 7 8.1 41 30 73

No Effect

Negative Effect

n

%

n

%

7 11 8

17 28 20

3 2 3

7 5 7

Abbreviation: n, total number of participants in agreement. a The total number of participants responding to this statement.

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One participant reflected on the importance of teamwork to the success of flexible working arrangements: ‘‘For the outpatient team, the ability to be flexible contributes to teamwork.’’ Benefits reported by shift-work managers related more to directly tangible working benefits rather than more intangible positive outcomes but were consistently positive. Managers noted that flexible working patterns were beneficial in particular to cooperation and productivity. There is a lot that we cannot control in healthcare. Taking control of what we can, like scheduling practices, to improve quality of work life, demonstrates in a concrete manner that we value employees and what they do.

Advantages of Flexible Working Arrangements Both managers supervising 9-5 and shift-work arrangements reported multiple advantages to implementing flexible working arrangements. Although responses for the 2 groups of managers differed somewhat, the advantages most likely to be supported by both groups were less related to organizational productivity, and more to employee satisfaction. In particular, improved work-life balance and job satisfaction were cited by both groups of managers as the most important advantages of flexible working arrangements. Organizational impacts such as volume of work and teamwork were less frequently cited as advantages of flexible working arrangements by both 9-5 and shift-work managers, supported by approximately half of each group. Descriptive statistics are presented in Table 2. Barriers Toward Flexible Working Arrangements Responses from management groups differed when asked whether they experienced barriers toward flexible working arrangements. More than 75% of managers with shift workers experienced barriers to implementing this sort of scheduling, whereas only half of the managers with 9-5 workers perceived any barriers at

all to flexible scheduling (Table 3). Managers were asked to explain qualitatively any barriers they may have experienced when implementing flexible workplace practices. 9-5 managers reported barriers based more on operational requirements of their healthcare organization, whereas managers of shift workers felt that a lack of physical presence was more of a barrier to flexible workplace practices. Managers of 9-5 employees cited operational barriers, including staffing, lack of client support both routinely and during crises, and reduced efficiency. One participant reported that ‘‘Insufficient staff to compensate for support requirements contributes to staff becoming unavailable when urgent or emergent services are required.’’ Concern about employees taking advantage of the situation was raised by managers of 9-5 employees: ‘‘IThe later hours may be nonproductive and just filling in time to ‘make up’ hours.’’ Furthermore, management-level support was not easy to provide when the organization itself was not supportive: The barriers to flexible work practices in the past have been the overall philosophy of the organization. It is hard to encourage a flexible environment if not supported by the organization or the person to whom I report.

For managers of shift workers, union and organizational barriers to implementing flexible scheduling practices did not qualitatively differ. However, unitlevel barriers were more related to physical presence in the workplace rather than the operational challenges noted above for 9-5 managers. Given that a physical presence was required for nearly all shift-work positions, many jobs were simply not conducive to working flexible schedules. Ithe nature of the departmentI food services is very task drivenI with strict timelines that must be met not all positions (eg, cook) can be granted

Table 2. Advantages of Flexible Working Arrangements Managers: 9-5 Workers na

No. of Participants in Agreement

Managers: Shift Workers %

na

No. of Participants in Agreement

%

Research suggests the following advantages may result when employees have access to opportunities to use flexible workplace practices: Higher-quality work 88 64 73 42 32 76 Higher-volume work 88 52 59 42 19 45 More effective teamwork 88 50 57 42 23 55 Improves work-life balance 88 83 94 42 39 93 Decreases stress levels 88 73 83 42 30 71 Increases job satisfaction 88 77 88 42 37 88 a

The total number of respondents answering this question.

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Table 3. Barriers Toward Flexible Working Arrangements Managers: 9-5 Workers na

No. of Participants in Agreement

Managers: Shift Workers %

na

In your experience, are there any barriers to implementing flexible working arrangements? Yes 85 46 54 39 No 85 39 46 39

No. of Participants in Agreement

%

30 9

77 23

a

The total number of respondents answering this question.

flexibility (that is without strict parameters)I other positions can/and are granted more flexibility (eg, food operations supervisor).

Another manager noted: ‘‘I do not see geography as a problem, more so the nature of the work.’’ Although barriers for 9-5 and shift-work managers differed based on operational and practical requirements on the job, the positive impact on important workplace variables including morale boosting, productivity, did not differ.

Discussion In this exploratory study, we investigated perceptions toward flexible working arrangements from the perspective of managers in a healthcare organizationVa 24/7/365 environment. More specifically, we examined the similarities and differences between perceptions of managers who supervise employees who work 9-5 versus those working shifts. Previous studies examined topics related to flexible working arrangements and perceptions of organizations,3 of managers,23 and of employees14 more generally, but to our knowledge little research has been conducted in relation to managers’ perceptions of and barriers to flexible working arrangements in the context of a 24/7/365 healthcare setting. Results suggest that managers, regardless of the working hours of their employees, perceive positive outcomes and advantages of implementing flexible working arrangements, consistent with previous research.8,12,24 Whereas 9-5 employees tended to work primarily from desks and with clients during regular office hours, the shift workers were doing more hands-on work for which physical presence was essential; for example, dealing directly with patients, cleaning, cooking, and working at loading docks. Differences in barriers to flexible working patterns between the 2 groups were reflected primarily in the differences between the more physically based work of the shift workers, when compared with the 9-5 workers whose work was less physical and could in many cases be conducted offsite. We believe our results indicate that

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the type of work hours (standard versus shift work) is not necessarily the challenge, but the interaction with patients and/or the immediacy of the tasks being performed (eg, the washroom needs to be cleaned). Our findings suggest that there is no resistance toward flexible working arrangements on behalf of managersVthe key difference lies in the fact that these arrangements create operational or physical barriers, both of which can be adjusted depending on individual departments. Therefore, a singular flexible working arrangement policy for an entire organization would be impractical; policies instead should be written at an organizational level (macro) focused on general acceptable principles and on top-down organizational support. Departmental level (micro) rules and implementation procedures will vary across departments and groups but should be checked for consistency with organization-wide principles. This is consistent with previous recommendations that top-down support from management and the organization is crucial to successful implementation of flexible scheduling in nursing.23 This study is limited by the fact that participants were all managers from 1 healthcare organization in Atlantic Canada. Therefore, generalizability may be limited. However, we have no evidence to suggest that that employees from this organization differ from other healthcare organizations throughout Canada or internationally. Similarly, our study was conducted with managers in several departments with different work hours, which brings forward a diverse range of participants. Department-specific issues might have emerged if we had been able to conduct an in-depth study at the department level. Future studies could narrow the scope and investigate the perceptions of and barriers experienced by healthcare managers operating in each department that have implemented flexible workplace practices. We must also acknowledge the fact that there was no demographic information provided related to sex, age, or marital status of managers, which if used in the future could test for any meaningful relationships or unique trends. For instance, work-life balance accommodations are perceived as applying primarily to working women with family obligations.25,26

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Therefore, testing differences between male and female healthcare managers may support or reject this idea (ie, female managers may be more likely to accommodate flexible working arrangements). However, in this regard, the majority of employees in healthcare settings including the one in this study are female, and there may not be enough male participants to make a valid comparison.

Conclusion The 24/7/365 nature of the healthcare environment presents certain issues and barriers in the opinions of managers toward implementing flexible working arrangements. What becomes clear from this study, however,

is that managers’ perceptions are not a concern but that the actual requirements of the work (ie, teamwork, physical presence) that differ between 9-5 employees and shift-work employees present implementation challenges. As our findings highlight, both groups of managers see benefits and advantages to flexible working arrangements and would like their employees to be able to avail of the opportunity. However, the differences in reported barriers suggest that organizational support must be present and unanimous and must be enabledVnot dictatedVthrough a topdown approach. Simply put, there is no ‘‘one size fits all’’ solution for the development of flexible working arrangements in a 24/7/365 healthcare setting.

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