Contracting as a career option for nurses: a nurse who feels trapped and powerless in a permanent nursing position will often leave nursing altogether, rather than seeking a more flexible way of working. Contracting can offer much greater freedom and autonomy.

Consider the following facts: nearly 20 percent of nurses not practising say if more flexible hours of work were available, they would consider returning to the clinical workforce. (1) Secondly, among reasons cited by nurses choosing not to work in clinical practice are that they have their own businesses or are self-employed. (1) These two facts can be used to form a hypothesis that if nurses see contracting as a viable career option, this may encourage them to remain in nursing. Contracting can offer the flexibility and career opportunities many nurses require.

Contracting, as defined in this article, refers to a nurse not employed permanently on a wage. It covers agency nursing, short and long fixed-term contracts and secondments.

In the early 20th century, contracting was the major employment field for professional nurses--they were commonly known as "private duty" nurses. (2) The private duty nurse was employed by a doctor, patient or family, to care for the patient, usually until the patient recovered, rather than by a hospital Nursing agencies today still supply nurses for private duties in facilities and private homes. However, cost is an issue because their wages are not publicly funded.

In Australia, private duty nursing was "the pinnacle of a nurse's career in 1900 [and] almost non-existent by the 1970s". (3) The reasons for the decline and the increased numbers of nurses employed by hospitals are identified as:

1) by the 1970s, increased opportunities for part-time work in hospitals;

2) the increasing level of technology associated with high dependency patients; and

3) improved wages and conditions for hospital-employed nurses. (3)

All nurses need to continue to develop professionally, a mandatory requirement under the Health Practitioners Competence Assurance (HPCA) Act. (5) But contractors have little, if any financial support to develop professionally, and time taken to do courses is not paid. Taking study leave within a contract may also not be an option.

Professional development starts with goat setting. One writer encourages nurses to attend careers events or job fairs, and to took at what options are available in order to set goals for career and professional development. (4) Back in 1999, then NZNO professional nurse adviser Di Gunn encouraged nurses to set short- and long-term goals for their careers when compiling their portfolios ready for competence-based annual practising certificates (APC). (6) This raises the issue of the difficulty of developing professionally when you might not be working in one particular area of nursing. With the arrival of the HPCA Act, (5) the nursing agencies addressed the issue of a potential decrease in available agency nurses in two ways: offering short courses; and advertising that they would place nurses where they wanted to work, enabling them to remain in an area of clinical specialty. As an agency nurse, this Act created a dilemma for me: I wanted to stay contracting because of the flexibility and I wanted my competence-based APC. Could I have both? The answer, I think, is to invest in education or training, and consider some longer contracts, longer than a day at a time. I took on several months-long contracts in order to address this. I had long before negotiated with the agency the clinical areas in which I wanted to work.

Benefits of performance appraisals

Another way of setting goals is through performance appraisals. Being self-employed means the freedom of no manager (or to be one's own manager), but it also means there's no one to tell you where you could improve your practice via the use of performance appraisal tools. After a film contract, I was once offered a short-term contract in a ward. I accepted it and found I enjoyed it. Then the manager offered me the clinical nurse educator position. This came as a complete surprise to me--I had no idea what my performance had been like because I hadn't had a performance appraisal for 17 years. Even though being offered the role was evidence my practice was good enough to be used as a role model for others, there is always room for practice development which a performance appraisal would have articulated and formalised. As a self-employed person, the absence of work is just about the only indicator that your practice needs improvement, and by that time, it is probably too late.

Recent research by the Health Workforce Advisory Committee found "unhealthy and sometimes dysfunctional work environments". It says in its report that a healthy workplace positive spiral incudes "participatory decision-making, teamwork and inclusiveness". (7) Australian nurse Fiona Armstrong also identified that nurses leave nursing because of "the lack of control over the organisation of their work". (8) Another researcher found nurses identified a sense of autonomy as important for job satisfaction. Having autonomy, therefore, is a key element to nurse retention. (9)

Being a contractor means a nurse does not have to engage in the politics or dysfunction of an organisation. This is one of the great advantages of this way of working. It's also a good way of choosing an employer--having had a "taste" of the environment, it may become easier to choose whether or not to return. I never have the same feeling of powerlessness as employed nurses struggling with rosters and management decisions that affect their daily work. I find they often use "the outsider" as a sounding board for their frustrations. The agency nurse can be an outlet for ward nurses wanting to express their anger.

One American writer encourages nurses to use the nursing process of assessment, planning, monitoring and evaluation to plan and develop a business, thus highlighting the transferability of skills from nursing into business. (10) Although being self-employed is risky, nurses are well-placed to assess risk, from clinical experience of patient assessment. Nurses with an entrepreneurial flair should seek out similar nurses. (10)

Building a reputation is vital and if you can't bring yourself to be out there "selling" yourself, business may be slower than anticipated. I have had to spend time "cold calling" on potential employers, and reminding them of what I do and what I do well A reputation isn't just built on being good at what you do--you have to tell people. Building a reputation with your agent is important too, because they are the ones who'll suggest you to the employer. At one stage, I had three agents in three different industries sourcing work for me (one for hospital-based nursing, one for film and television nursing/first aid, and one for my acting work). This is one situation when I think it is good to be a "yes" person: the more you say "yes" to work, the more work you will be offered. I was offered a short contract on a cruise ship, and, to cut a tong story short, I had to ring and apologise I wouldn't be able to take it. A couple of months later the recruiter rang back and said she remembered how polite I was and offered me another job. Mother was right--it pays to be polite! Another agent, who I worked for extensively and reliably over years, actually paid me sick leave when I had a work-related injury--they had no compulsion to do so because sick leave is built into the hourly rate. They simply chose to support a valued contractor. When you're self-employed, the harder you work, the more you earn. Compare this to the state of affairs in nursing, where the amount of risk and hard work isn't necessarily proportional to the pay packet.

As for the practicalities of being a contractor, they are simple: keep receipts and employ an accountant. For tax purposes, the square metres of office space in the home count towards a tax deduction, as do all expenses of running the office, eg paper, telephone costs and postage stamps. All equipment such as scissors and watches are claimable, as is car mileage and petrol in some circumstances. There's even a little book you can buy at the newsagents to record the necessary data. When I was working on film sets, I claimed the extra outdoor clothing I needed to protect myself against the elements in order to perform my duties. An amount of my mortgage interest is claimable, as well as costs of maintaining my house, because that is where my office is situated. All these claims decrease your taxable income. The investment of hundreds of dollars in consulting an accountant has paid off in thousands of dollars of tax rebates.

Managing the accounts

Being confident and knowledgeable about banking options is helpful. I originally thought it would be sensible to have a separate account in which to put aside money for my GST bill at the end of the financial year. However, I discovered it is advantageous to use my revolving credit account so that all my income goes into my overdraft. At the end of the financial year, I draw back on the available credit to pay the GST bill, thus having used my income to reduce my overdraft. The money I saved in mortgage interest was more than I would have earned in an incrementally increasing savings account. Being a disciplined saver and spender is necessary--when annual income is variable, annual spending and saving needs to be variable too, in order to avoid debt and the accompanying interest charges.

Banking and taxation aside, there is also the issue of employment taw when contracting. Recent employment court cases in New Zealand highlight the uncertainty between being an employee and being a contractor. (11,12) Despite the type of contract a person signs, it is the "real nature of the relationship [between employer and employee]" that decides whether the person is a contractor or employee. Contractors are responsible for paying their own tax and Accident Compensation Corporation (ACC) payments; they don't get paid leave; nor can they bring a personal grievance or claim unfair dismissal, whereas, the opposite is so for employees. However, some contractors, by the nature of the work they do, are employees and can take a case against an employer. Agency nurses are actually employed by the agency and this is evidenced by the fact the agency pays ACC levies for their nurse employees. The actions an employer takes, such as paying PAYE tax and ACC levies, indicate the worker is an employee, not a contractor.

Working independently means taking your business personally. Some years ago, white a fulltime university student with a small income, I had been telling my two young daughters about my experience of going to summer camp as a child and also of working in a summer camp in America in my first year of nursing practice. As a result of this conversation, I rang our local council and offered them my services as a nurse at their upcoming school holiday camp. They accepted, I was able to bring my daughters, and we enjoyed the experience of summer camp together.

For some years, I worked through a nursing agency Monday to Friday white my children were at school, as well as using a film crew agency to source other work. One year, my income as an agency nurse was about $30,000, but with a three-month contract on a television series shot locally, this increased by over $18,000. The hours were tong and I needed child care to cover the extended hours, but all meats were provided and I had no time to spend the extra money unlit after the contract ended, when the family enjoyed the windfall. Because I had calculated my mortgage payments on my agency nursing wages and we were living within that budget, it really was a windfall.

In my experience, contracts have usually been the most exciting and interesting work I've done as a nurse. Once, I took a short contract with P&O Cruises. Cruising among Pacific islands, with all meals provided and duty free goods available, was not only a pleasant experience but I also received a percentage of over-the-counter pharmacy sates. Film and television work is always a good way to get outdoors and work with interesting (and well) people.

Importance of setting goals

Agency nurses often complain about the way hospital staff treat them, that they are outsiders and their skills aren't always used appropriately. Some identify the key to survival as "a little tact and diplomacy". (13) While not disagreeing, I would add that having a sound philosophy and clear goals have helped me gain enjoyment through agency nursing and to sustain that type of employment for years, while taking up other contracts as well. My philosophy is about doing my best for the patient to achieve the best outcome. I set the same goal every day--to fully address all the patient's needs without handing anything over at the end of the day, and I set a long-term goal to be the nurse who is uppermost in people's minds when they need nursing services. This is about developing a good reputation, which is my way of getting long-term job satisfaction. This echoes research on autonomy and job satisfaction conducted by assistant professor of nursing at Jordan's Zarqua College of Nursing, Jajd Mrayyan's. (9) She noted the connection between participation in decision making and having a sense of autonomy, with job satisfaction and staff retention.

American business writers Sylvia Hewlett and Carolyn Luce, talking specifically about highly skilled women, say that reduced and flexible hours will encourage women to stay in the workforce. (14) This is also NZNO's belief, as evidenced by its support of the Flexible Working Hours Bill, due to have its third reading in Parliament next April. (15)

A survey by Hewlett and Luce showed that less than five percent of women were interested in rejoining the organisations they left, implying the vast majority of women felt unappreciated or "ill-used" by their employers. (14) Having certain skills as a nurse contractor can mean being more employable and this can be a leverage to negotiating payment.

Skilled nurses looking for interesting ways to develop their careers and to branch out in an entrepreneurial way should seriously consider taking up contract work. Future income cannot be guaranteed. However, with the shortage of nurses worldwide, there are opportunities to make money and to enjoy freedom in employment and flexibility of conditions. I hope my experiences as a contractor will encourage nurses to explore options within nursing, rather than feeling trapped in their current employment and then leaving the profession altogether.

This article was reviewed by Kai Tiaki Nursing New Zealand's practice article review committee in May 2006.

Reference

1) New Zealand Health Information Service. (2000) New Zealand Workforce Statistics. www.nzhis.govt.nz/stats/nursestats.html. Retrieved 14/7/05.

2) Peplau, H. (1966) A glance back in time. Nursing Forum; 5: 1, 60-75.

3) Madsen, W. (2004) Private duty nursing: the last days in central Queensland. Collegian; 11: 3, 34-8.

4) Davison, N. (2005) Making the most of a career's event. Nursing Times; 101: 1, 68-9.

5) Health Practitioners Competence Assurance Act. (2003) Wellington: New Zealand Government.

6) Gunn, D. (1999) Setting professional goals, Kai Tiaki Nursing New Zealand; 5: 2, 27.

7) Health Workforce Advisory Committee. (2003) The New Zealand Health Workforce: Future Directions--Recommendations to the Minister of Health 2003. Wellington: Author.

8) Armstrong, F. (2004) Can you hear us? There's a nursing shortage! Australian Nursing Journal; 12: 2, 21-24.

9) Mrayyan, M.T. (2004) Nurses' autonomy: influence of nurse managers' actions. Journal of Advanced Nursing; 45: 3, 326-336.

10) Zagury, C. (1997) Yes I can! Nurse entrepreneurs building the cycle of success. New Jersey Nurse; 27: 7, 11.

11) Churchman, P. (2004) Employees, contractors and the film industry. The New Zealand Law Journal; April 108-9.

12) Roberts, J. (2005) Contractor or employee? Employment Today; Dec-Jan, 48-9.

13) Mubika, T. (2000) An extra pair of hands. Nursing Times; 96: 30, 51.

14) Hewlett, S.A. & Buck Luce, C. (2005) Off-ramps and on-ramps. Keeping talented women on the road to success. Harvard Business Review; March, 43-54.

15) News and events. (2006/2007) Flexible working hours good for health care workers. Kai Tiaki Nursing New Zealand; 12: 11, 9.

Tess Dettagiacoma, RN, BA, MA (Appl), is currently working for Sydney's Ageing and Home Care's Department of Disability as a senior policy officer.