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Table 1 Documents retrieved, by key themes

From: Understanding nurses’ dual practice: a scoping review of what we know and what we still need to ask on nurses holding multiple jobs

Author and year



Specific settings/examples

Drivers and motivations

Consequences for provision of services

Consequences for nurses’ health

Policy options

Aiken (2007) [58]

Review of US nurse supply and demand, trends in nurse immigration

Does not specifically examine dual practice


Alameddin et al. (2009a) [59]

Examines impact of ‘just in time’ staffing policy in Ontario, Canada-and SARS outbreak; interviews with 13 nurse administrators.

Examines impact of ‘just in time’ staffing policy in Ontario, Canada- fewer full time staff, more part time and casual staff and agency staff.


Reports higher costs, reduced surge capacity

Fewer staff meant more overtime, stress related absenteeism increased.


Alameddin et al. (2009b) [48]

Tracking of 201,463 nurses registered with College of Ontario, 1993–2004

Focus is on all types of job, career move. Limited examination of casualisation


Batch and Windsor (2009) [60]

(a) Nursing has a higher rate of casualization than other professional and highly skilled workforces; (b) In Australia in 2011 in 2011, 47.5% of nurses were employed in non-standard work.

Casualisation of work

Australian hospitals

The casualisation movement aims at creating a more flexible and cheaper nurse workforce


Part-time and casual nurses are marginalised and excluded - called hole-pluggers; Marginalisation is accepted and normalised as a trade-off for the flexibility of this modality


Batch et al. (2015) [44]

In 2007 the percentage of part-time and casual nurses, that is those nurses working less than 35 h per week, is 49.8% or almost half the nursing population


Inflexible rosters and unreasonable and unreasonable workloads, unavailability of full-time work in the area of choice. Lack of opportunities for professional development.

Casual and part-time workers seen as peripheral workforce; Marginalisation of casual workers with consequences in career advancement; Implications in the quality of care due to lack of continuity of care and poor match of nurses’ skills to a workplace.


Baumann et al. (2006) [30]


‘Casualisation’ of the health workforce in Ontario following the SARS epidemic.

Canada (Ontario).


Employing an unbalanced proportion of full time and casual nurses reduces flexibility of a hospital management, as these latter would be less available to cover for unforeseen needs


Bhengu (2001) [19]

24 CC nurses, four focus groups, two hospitals in Durban, South Africa

Second jobs via agency working

Agency working in by public sector nurses in ICU, private sector hospitals

(a) Demand for CC nurses in the private hospitals; (b) Salaries failing to keep pace with inflation; (c) Testing the experience of working in private sector

Reported that ICU s in private sector hospitals totally dependent on agency moonlighters-so staffed by ‘strangers’

(a) Reported tiredness, more likely to go off work sick; (b) Risk of ‘habitual moonlighting’; (c) Psychosocial problems- different mix of ethnicity and language in private hospitals

Private sector hospitals should develop clinical guidelines to ensure safety in hands of ‘strangers’

Brown (1999) [47]

In 1996, female registered nurses (RNs) were moonlighting at the rate of about 12%; female advanced practice nurses (APNs) were moonlighting at the rate of about 24%.

Second jobs held concurrently to the primary one; But also, second job not held continuously, i.e. irregularly.


On average, both RNs and APNs earn more on their second job then they do in their primary jobs. - The reason for the high rates of second-job holding among nurses relative to females in the general workforce appears to be a function of the nursing profession itself.

Those with second jobs tend, on average, to work fewer hours per week on their primary jobs than those who only hold one job.


Creegan et al. (2003) [36]

51.7% of nurses in Australia worked part-time in 1997

Casualisation and non-standard (part-time) forms of nursing profession

Australia and references to the UK

(a) Women are more likely to work on a part-time basis in Australia. Nursing is a predominantly female profession; (b) Casualization is particularly common among Licenced Practical Nurses (16.5%) (c) Casualization is more common for rural States (20%)

(a) The hiring hospital has little control on quality and qualifications of agency nurses, used to top-up existing staff; (b) The savings associated with casualization of nursing are potentially large

Casual nurses do not enjoy the same protection and support systems as permanent ones, nor opportunities for professional development

(a) Need to understand better the shifting workforce patterns to improve management and planning of the nursing workforce; (b) To date, efforts have been directed towards recruiting more nurses in permanent positions. Better management of the casual workforce segment could represent an alternative policy.

Erasmus N. (2012) [53]

Broad focus on internship, unpaid overtime, moonlighting in SA. Mainly discusses doctors


Install electronic time recording in state hospitals, cessation of unpaid overtime, limits on medical intern shifts

Farzianpour et al. (2015) [61]

31% of nurses in private sector had a secondary job


Iran (Tehran private hospitals)


Feysia et al. (2012) [62]

Repeating findings from Serra et al. (2010)


Repeating findings from Serra et al. (2010)


Gillen (2013) [45]

1200 nursing magazine readers. 54% took up extra nursing work, and 10% another on outside nursing


UK, among Nursing Standard readers

To complement insufficient public sector salary 46% was thinking of leaving nursing profession


45.8% declared considering leaving nursing because poor salary


Gupta and Dal Poz (2009) [41]

(a) 11% Chad; (b) 7% Cote d’Ivoire; (c)26% Jamaica; (d) 1% Mozambique; (e) 0% Sri Lanka; (f) 7% Zimbabwe

Work at another location (health facility or other) in the previous month

In some cases it was reported that nurses did not have the right of private practice


Hipple (2010) [46]

(a) Report on data from US Labor stats; (b) 6.3% of nurses had multiple jobs- higher for male nurses (9.5%, but small sample)

Second jobs were in or out of health sector


Discusses possible impact of nurses working 12 h shifts- meaning they would have more free days for second jobs


Knauth (2007) [32]

64% of nurses on 12 h nightshift and 45% of those on dayshift had a secondary job

Extended periods of work across different professions (Moonlighting and secondary jobs)

Nurses in 12 h night and day shifts


Increased sleepiness, difficulty of communicating with managers, increased risk of accidents driving home, increased absenteeism, reduced alertness


Lane et al. (2009) [50]

A broad based global review of nursing labour market, health systems and macroeconomic policy

Has a brief section on dual practice as a ‘coping mechanism’

‘Dual practices range from legitimate private practice to moonlighting and informal charges for patients.’


Dual practice ‘often results in conflict of interest, idleness and absenteeism. However, not all dual practices can be considered as corrupt or leading to predatorial behaviour, but the impact of these practices can significantly undermine health services provision and public trust’.

‘Abusive multi-employment can result in negative consequences for health workers as well as patients’.


MacLeod et al. (2017) [35]

1.1% of all nurses were in a job-share arrangement

(a) 15.8% of all nurses were in casual jobs; (b) Casualization is particularly common among Licenced Practical Nurses (16.5%); (c) Casualization is more common for rural States (20%)

Canada, Registered and Licenced nurse population in rural areas and in the north of Canada


Casualisation of nursing in rural areas/communities is seen as a concern that should be addressed by Govt policies

McPake et al. (2014) [17]

Reports examples and prevalence of NDP for several countries from secondary sources

Unspecified multiple job-holding

Low- and middle-income countries


Depending on its prevalence and regulation, dual practice can hamper attainment of UHC


Different regulatory option depending on country GDP, regulatory capacity, and definition of boundaries between public and private sectors

Monteiro et al. (2012) [40]

26% (out of 570 nursing workers)

Second job in the same branch

(a) Public hospitals and health centers in Brazil; (b) Nurses, nursing assistants and nursing auxiliaries


Montour et al. (2009) [49]


Rural and community hospitals in the Hamilton Niagara area (Canada and US)

It was reported by nurses that part-time and casual nurses often seek employment in other hospitals and long-term care homes to supplement their income

Employment in multiple organisations contributes to scheduling issues because casual nurses are unavailable to fill vacant shifts


Paina et al. (2014) [63]

Five public sector ‘facility case studies’ in Kampala Uganda

‘Additional jobs’ (Focus was on all workers, not just nurses)


‘Distinct challenges’ for local management in trying to manage internal dual practice opportunities, linked to opportunities to be involved in externally funded research projects within the hospital.


Variation between national – formal policy and local- invormal policy on allowing workers to have second jobs.

Portela et al. (2004) [39]

41.5% of public hospital nurses were moonlighters

MJH was more common among nurses during 12 h night or day shifts

Public hospitals in Brazil


Long (12 h) night shifts found to have a less taxing effect on nurses health than day ones.


Ribeiro-Silva et al.(2006) [51]


Second job in another hospital or clinic

(a) Public hospitals Brazil; (b) Registered nurses and nursing assistants (N = 144)


Those who had two jobs devoted more time to sleep/rest on the job

(a) The less time devoted to leisure and personal needs among those who work more associated with quality of daily life; (b) Sleep on the job related to working on a second job. Those with two jobs had longer sleep episodes on the jobs (compared with those with a single job)


Rispel and Blaauw (2015) [21]

40.7% reported agency or moonlighting in previous year

Agency/ moonlighting

80 hospitals in 4 provinces in SA. All nurses surveyed


11.9% of moonlighters had taken vacation to do agency work or moonlight; 9.8% reported conflicting schedules between primary and secondary jobs


Strong nurse leadership, effective management and consultation with front line nurses to counteract potential negative impacts of agency- moonlighting

Rispel et al. (2011) [64]

(a) 28.0% IC95 [24.2; 32.1] moonlighting last 12 months; (b) 42.2% moonlighting ever; (c) 37.8% IC95 [32.4;43.6] agency nursing; (d) 69.2% IC95 [64.1;73.8] had done overtime, moonlighting or agency nursing in the preceding year; (e) 18.5% reported all activities

Additional paid work (nursing or not nursing nature) in private health facility, another government health facility, insurance company private health laboratory or same health care facility excluding overtime


(a) Taking care of patients, opportunity to learn new nursing skills, relationship with co-workers, agency’s weekly pay, choice of unit/ward, job variety, do it for the money, stimulating work, quality of supervision, modern equipment/infrastructure, selection of working hours, money owed to revenue service; (b) Predictors: - having children province, sector (higher among private sector) - professional nurse vs nursing assistant/ auxiliary nurse - working in adult critical care unit vs paediatric critical care unit. Working in general wards and other wards protects for moonlighting compared to working in paediatric critical care unit


Management of moonlighting was considered an important policy priority by the SA Government which is reflected in the 5-year HRH strategy

Rispel et al. (2014) [33]

28% moonlighting (965/3442)

Additional paid work (nursing or not nursing nature) in private health facility, another government health facility, insurance company private health laboratory or same health care facility excluding overtime; Last 12 months

(a) Intention to leave was higher among moonlighters compared to non-moonlighters; (b) Planning to go overseas was higher in moonlighters compared to non-moonlighters; (c) Moonlighting is a predictor or intention to leave primary health job

Salmon et al. (2016) [25]

(a) Report of a Bellagio meeting ‘focusing on the largely overlooked area of investment in nursing and midwifery enterprise as a means for both empowering women and strengthening health systems and services’

Second jobs only indirectly examined in the broader context of the objectives of the meeting.


Seleghim et al. (2012) [65]


Simultaneous other job (not specified) for 15% of nurses (just 5…)

Paraná State, Brazil


No specific health consequence, but sample too small for significance


Serra et al. (2010) [34]

(a) 5% of all the nurses followed had secondary jobs; (b) Average days per week in secondary job was 9 days. Average hours per day was 9 h (Vs 9.9 in primary)

87% of moonlighting nurses had a full-time job in public sector, and a secondary job in private/NGOs

Ethiopia, urban and rural areas

A greater proportion of nurses (50%) agreed in the second wave that you need to take up a secondary job to earn enough to support families


Stephenson (2017) [37]

Of 900 nurses completing an online survey in the UK, 47% declared engaging in bank and/or agency shifts

Ban on agency shifts is introduced for nurses with a substantial NHS contract as a cost-containment strategy for public sector

The UK

Agency and bank shifts as a way to balance the cap on increasing public sector salaries


Tailby (2005) [43]

(a) 80% (of 185,000) nurses registered with NHS nurse banks had another nursing job; (b) 60% worked occasionally or regularly additional shifts paid at bank rates or agency rates

(a) Need for additional income; (b) Need to refresh/update skills; (c) Attain a preferred pattern of working hours

Taylor et al. (2004) [52]


Casualisation of work

Mental health nurses in New South Wales, Australia


Casualisation of work was reported to be a major source of career fatigue and burnout


Wynton and A. Kleebauer (2016) [38]


Agency nursing, other country (England, Scotland)


Economic- higher rate for single day fees than in home country of N Ireland