The effects of HR flexibility practices in healthcare organizations

Master’s thesis Tilburg University

Faculty of Social and Behavioural Sciences Human Resource Studies

January 2012- August 2012

Author

Name: Floor Janssen

ANR: S 872028

Supervisors

First supervisor Charissa Freese

Second supervisor Susanne Beijer

Supervisor Ayton Hans Slurink

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Abstract

This exploratory research investigated the current use of labor flexibility practices by healthcare

organizations and the effectiveness of the various flexibility practices. The main goal that organizations

are pursuing with implementing flexibility practices is to fit the personnel planning as closely as possible

to the current demand of care by clients. It was found that organizations currently mainly focus on

internal flexibility practices. HR managers indicated that the effects of the use of internal flexibility

practices are lower absenteeism, increased employee satisfaction, and increased financial turnover. HR

managers did not clearly indicated uniform effects of external flexibility practices. Many of the flexibility

practices also showed to be effective, in a sense that the flexibility practice cooperates to the set goal by

organizations to link the demand of clients as closely as possible to the deployment of personnel. Some

flexibility practices were indicated to be ineffective, but show potential to be effective to organizations in

the future. This because they currently either do not pursue the goal of linking the personnel planning as

closely as possible to the demand of care, or causes negative consequences to the degree that the HR

manager characterises the practice as ineffective.

Keywords: flexibility, labor, healthcare, effectiveness, HRM, internal flexibility, external flexibility,

flexicurity, exploratory

1. Introduction

A shortage of nearly 450.000 employees in Dutch healthcare is to be expected in 2025

(Zorginnovatieplatform, 2009). Currently, several trends contribute to this future perspective, but the

major driving forces are twofold. First, the overall working-age population is declining (Fujisawa &

Colombo, 2009). The average age of healthcare employees is increasing for years in the Netherlands, with

an average increase of one year of age per year, and was already 40,5 in 2003 (Zinsmeister, 2005). This

has led to the situation in which middle-aged nurses from the baby boom generation now dominate

hospitals´ workforces in many countries, with the insecurity whether the new generation will be able to

replace the current workforce. (World Health Organization, 2006). Second, the healthcare branch

specifically is not only affected by demographic changes in labor supply. The demand for healthcare is

also strongly influenced by the same demographic developments; meaning that the aging of the

population will lead to a higher demand of care (Fujisawa & Colombo, 2009; RVZ, 2010). According to CBS

(2010, in Woittiez & Eggink, 2011) the peak of the population’s aging will be between 2030 and 2045. To

cope with the aging population, 25% of the Dutch workforce needs to be employed in the healthcare

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sector in 2025; whereas in 2009 only 14% of the Dutch workforce was employed in the healthcare sector

(Intermediair, as cited in Coppens, 2010). So there is a simultaneous trend of a growing demand for

healthcare, and a declining supply of healthcare employees. The combination of these two factors is likely

to lead to labor shortages in the future of healthcare.

Because there are solutions to cope with the rising demand of care and the growing labor

shortage of healthcare employees, a number of organizations are already in an incipient stage to respond

to these future changes. A possible strategy to respond to future labor shortages which will be the aim of

this research, is to optimize capability planning among organizations’ workforce, using internal and

external flexibility. There are great opportunities to be explored in this area as the healthcare sector is

high labor-intensive (Fujisawa & Colombo, 2009). Labor is the most important production factor in the

healthcare branch, as the care is almost exclusively delivered by people (Kabene, Orchard, Howard,

Soriano & Leduc, 2006). Because human capital is very important in healthcare, it is worthwhile to have

solid Human Resource (HR) policies (Walburg, 1997). However, what makes the healthcare sector unique

is that when policies are developed, the rational economical mentality cannot overrule the relational

aspect in healthcare (Beex, 2009). The fact that quality of care always prevails should be the starting point

of strategic workforce planning. Moreover, with implementing flexibility practices, the interest of clients

should be directive.

By creating flexibility in labor, employers attempt to stay agile in both busy and quiet times (Qin &

Nembhard, 2010). Agility is the ability to respond to unpredictable change (Wadhwa & Rao, 2003). In

contrast to agility, flexibility is aimed at daily operational issues in response to known changes in the

environment like the future shortage of healthcare employees (Qin & Nembhard, 2010; Wadhwa & Rao,

2003). Being able to respond quickly to change by having HR flexibility practices can be seen as a right

step in ensuring the agility of an organization, by making it easier to respond quickly to unpredictable

changes.

Most developments to improve both internal and external flexibility in the healthcare sector

seem to come from a new employment relationship perspective. The new employment relationship is

characterized by flexibility from both the employer and the employee, and is based on trust and open

communication (Roeling, Cavanaugh, Moynihan & Boswell, 2000). Internal flexibility mostly aims at

flexible arrangements within the organization. It mainly focuses on the internal flexible shell by varying

working hours of internal employees. External flexibility on the other hand mainly focuses on the external

environment by hiring and firing, and forming alliances with other organizations in the branch (Keller &

Seifert, 2005). Relatively new forms of employments relationship based on either internal or external

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flexibility contribute to create a large degree to the current overall labor market flexibility. The concept

flexible employment is shown to have already partly reduced unemployment during the last economic

crisis (2008-2011) by using the flexible shell to dissolve fluctuations in the demand of services (Cörvers,

Euwals, & de Grip, 2011). The flexible shell of the workforce thus also has an important role in coping with

fluctuations in the demand of labor to prevent forced quits (Dekker & Achterberg, 2008). Summarizing,

fluctuations in the demand for healthcare in combination with a continuous shortage of labor supply

make strategic personnel planning essential in the healthcare sector.

Therefore, the aim of this study is to find motivations why organizations make use of flexibility

practices in healthcare to deal with the expected upcoming labor shortage. Moreover, the short- and

long-term effects of various flexibility practices used by healthcare organizations will be studied in order

to gain insight in their practical usefulness. Therefore the research question is:

What are short-term and long-term effects of flexibility practices in healthcare, and which factors

influence the use and effectiveness of flexibility practices from an HR managerial perspective?

This study aims to add to the scientific discussion of future labor shortages in healthcare, and

therefore adds to the current lively debate on the future of healthcare. It also aims to give healthcare

organizations knowledge on the current state of healthcare in the area of flexibility, and the benefits and

disadvantages of various flexibility practices. Organizations could use outcomes to draw conclusions for

their own particular context concerning flexible personnel practices. Moreover, managers often formulate

objective goals, but rather base change on intuition (Isenberg, 1984). This study provides HR manager

some objective guidance in their decision on the use of flexibility practices.

2. Theory

2.1 Flexibility

Labor flexibility is a way to adapt effectively to the fluctuations in the demand of care that are

prevalent in the healthcare sector (Cörvers et. al., 2011). Key elements in definitions on labor flexibility

are to effectively, and timely adapt the volume or costs of labor to deal with uncertainties in the future

(Cörvers et. al., 2011; De Haan, Kwakkel, Walker, Spirco & Thissen, 2011; Kelliher, 1989; Milliman, Von

Glinow & Nathan, 1991). This research will use the definition on labor flexibility of Milliman et. al. (1991,

p. 325). They define it as “the capacity of HRM to facilitate the organization’s ability to adapt effectively

and in a timely manner to changing or diverse demand from either its environment or from within the

firm itself”. This definition covers the aspect of adapting effectively and in a timely manner. But more

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importantly, it emphasizes that changes in the demand of labor can come either from the external

environment, or from within the organization itself. However for this research, another aspect is added to

this definition. Guest, Oakly, Clintion and Budjanovcanin (2006) mention labor flexibility as a means to

make full and efficient use of human resources. As the focus of this research is on the human resources of

organizations, and the challenge to deal with future labor shortages in healthcare, it is important to

emphasize the role of human resources in creating labor flexibility. The full definition of labor flexibility

used in this research will therefore be: “the capacity of HRM to make full and efficient use of human

resources, and to facilitate the organization’s ability to adapt effectively and in a timely manner to

changing or diverse demand from either its environment or from within the organization itself”.

The specific focus of this study will be on the HR flexibility practices that attempt to achieve labor

flexibility. HR flexibility practices can be defined as: “atypical forms of employment that do not match the

standard concept of normal employment” (Keller & Seifert, 2005 p.3). Key aspects that are considered as

normal employment are a permanent employment contract, fulltime work, stable wage, and compulsory

social insurance contributions (Keller & Seifert, 2005). This definition of HR flexibility practices is

deliberately relatively broad. Therefore, no HR practices will be excluded from this study that initially do

not seem to add to organizations’ overall labor flexibility.

2.1.1 Flexible shell

The overall Dutch workforce has a so called flexible shell. This flexible shell consists of both

internal and external flexible forms of working. There are all kinds of flexible arrangements that form this

flexible shell. For example, workers with a temporary or small hour contract, on-call employees,

temporary agency workers, independent contractors, and freelancers (Cörvers et. al., 2011; UWV, 2010).

According to UWV (2010) this flexible shell contains 34% of the total Dutch workforce. However, more

sources state a flexible shell of 20% is most optimal percentage to deal with (CBS, 2010). The purpose of

this flexible shell is to create a functional degree of labour market flexibility which enables organizations

to timely adjust the volume of labor to the current demand, and to employ only the required amount of

labor at any point of time in the organization’s existence (Cörvers et. al.,2011; Kelliher, 1989).

Both sides of the employment relationship have a desire for flexibility. From an organizational

perspective there is increasing competition between healthcare organizations, and they are facing labor

market shortages. Organizations will inevitably require greater flexibility. On the other hand, employees

increasingly desire flexibility in addressing work and non-work related needs (Roehling et. al., 2000). This

increasing desire for flexibility fits in the ‘new employment relationship’ which is characterized by open,

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two-way communication (Roehling et. al., 2000). This means that organizations are clear in their

expectations of flex workers, and what workers can expect in return. On the other hand, flexible workers

have different motives to do flex work. Some see flexible labor as a bridge to better career prospects,

while others choose a flexible job to cope with the demands of family life (Dekker & Achterberg, 2008; Zijl

& Leeuwen, 2004).

This increasing focus on labor flexibility has both advantages and disadvantages. A disadvantage

of increasing labor flexibility is that it reduces the unity within an organization. Also, organization’s

structures become more complex by a larger variety of contracts between workers and the employer

(http://www.arbeidsrechter.nl /flexibiliteit -coordinatie-personeel-werknemers retrieved on January 18th

2012). Furthermore, as organizations require greater flexibility of workers, this leads to less job security

for employees (Roehling et. al., 2000). However, Roehling et. al. (2000) mention that job security is not

necessarily part of the new employment relationship, as the traditional loyalty of employees is also no

longer expected.

2.1.2 Labor flexibility in healthcare

Looking specifically at the healthcare sector, some major changes have occurred in the way

healthcare and corresponding subsidiaries are provided to clients in the Netherlands since January 1th

2012. These changes have directly influenced the dynamics in the demand of healthcare. Organization’s

capability planning is often directly coupled to the client’s healthcare indication and their accompanying

subsidiary. Previously, healthcare concerning short and long term healthcare was funded by centralized

governmental subsidiaries under the ‘Act Exceptional Medical Expenses’ (Algemene Wet Bijzondere

Ziektekosten, AWBZ) by providing a personal budget (persoonsgebonden budget, PGB) to clients.

Currently, access to the personal budget subsidiary is limited, and terms were tightened. This tightened

subsidiary also led organizations to tighten their personnel costs per client. A closer fit between the

clients demand for care became prevalent. Flexibility practices seem to fit this view by linking deployment

of personnel to the current demand for care by clients. Also, clients in the need of a subsidiary from the

ABWZ without residence are recently covered by the ‘Act Social support’ (Wet maatschappelijke

ondersteuning, WMO). This has led to a decentralization of healthcare in which municipalities are

responsible for the implementation of the subsidiaries which are covered by the WMO

(http://www.rijksoverheid.nl).

Some practical implications of the changes in AWBZ and WMO are that clients can no longer

subtract their own financial contributions to their healthcare costs concerning non-residential care from

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taxes. Instead, these clients will receive a 33% discount on their own financial contributions. Another

consequence is that clients with a relatively high income, will pay a higher financial contribution. Further,

a direct negative consequence of a decentralized way of providing healthcare is that there can be

considerable differences in the supply of healthcare facilities per municipality. Deployment of personnel

will be required to adjust to the changed method of subsidiaries as labor costs are one of the largest

expenses of healthcare organizations. Flexibility in the workforce is desirable in order for organizations to

be able to cope with adjusted amounts of funding per client, which is directly linked to the amount of

deployment of personnel to a client.

Another major institutionalized change is the introduction of the concept of

Zorgzwaartepakketten (ZZP’s) in the Netherlands, which is implemented in 2007. The height of the ZZP

indication determines the amount of subsidized care the client is to receive, and is also directly linked to

the funding a healthcare organization receives for its client (Platform GGZ). As the demand for care is

parallel to the funding, there is an opportunity to align personnel planning directly to the care with the

ZZP system.

Cörvers et. al. (2011) state that organizations use flexible labor as a mean to quickly adapt to

changes due to economic fluctuations, and other fluctuations in the external and internal environment of

the organization. The changes described above are examples of recent changes in the healthcare branch

that led organizations to focus more on the opportunities flexibility practices provide to their

organization. In order to answer the research question, the degree to which healthcare organizations are

currently using internal and external flexibility will be studied first. This way the current situation in the

healthcare branch will be outlined. Therefore the following sub question will be answered:

Sub question 1: Which human resource flexibility practices are used in healthcare?

The next section will elaborate more on internal and external flexibility.

2.1.1 Internal flexibility

This study will focus on both the internal and external flexibility of the organizations’ workforce.

Internal flexibility involves the adaptability and employability of workers within an organization. It is key

for flex workers to constantly acquire and renew skills to make moving from job to job as easy as possible.

In doing so they also facilitate an organizations’ ability to adapt effectively to changing demands from

either the external environment or from within the organization itself (European Commision, 2004;

Milliman et. al., 1991).

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The conceptualization of internal flexibility that will be used in this research consists of four

distinctive categories (Keller & Seifert, 2005). First, there is internal numerical flexibility. This is about the

possibility of organizations to vary the total number of hours worked to handle fluctuations in the

demand of labor. Next, there is internal functional flexibility. Here organizations rely on the employability

of their workers, and handle fluctuations in utilisation by relying on a multi-skilled workforce. Third is

internal temporal flexibility. Within this concept, organizations use part-time work to vary the number of

worked hours for a limited period of time; for example during busy periods per day, week or year. Last,

there is internal wage flexibility. In this category, pay is used to overhear changes in the demand of labor

by for example performance-related pay (PRP), or by diverging from collective labor agreements (Keller &

Seifert, 2005). An overview of these definitions can be found in table 1.

These four concepts can be used as tools for organizations to manage their internal flexibility. For

example internal temporal flexibility can be of particular use in the Dutch context as a relatively large

percentage of the Dutch workforce has a part-time job (46.8%). According to Eurostat (2009) this is the

highest percentage of part-time work in Europe. These internal flexibility practices prevent either

overcapacity in quiet times or paying overtime premiums in more busy times (Keller & Seifert, 2005).

Besides, internal flexibility offers a great advantage to organizations as employees do not have to be laid

off due to a flexible buffer. Concluding, even though there are fluctuations in the demand of care, when

using internal labor flexibility there is no loss of human capital, and also no loss in team productivity

(Keller & Seifert, 2005).

2.1.2 External flexibility

Often, managers require their subordinates to work a bit harder when the workload is temporary

too high for the fixed number of employees to handle. When a point is reached where work cannot be

done anymore by the current, fixed workforce, external resources provide a solution (Läubli, 2010).

External flexibility can be defined as flexibility in the number of employees according to the needs of the

organization (Keller & Seifert, 2005). External flexibility thus means that external people are being

deployed in departments on a temporary basis when the demand of labor requires it. It refers to workers

who are not directly employed by the organization itself. These temporary workers can be, for example,

workers from a temporary working agency, stand-by employees from an external flex pool or

independent contractors.

External flexibility can be divided into three categories (Keller & Seifert, 2005). First, there is

external numerical flexibility. This implies that fluctuations in the demand of labor can be overcome by

varying the number of employees by hiring and firing, and using temporary workers. Second is external

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functional flexibility. This concept is about improving the ability of the workforce to adapt to changes in

the external labor market. Last, there is external wage flexibility. Here labor costs can vary using wage

costs subsidies. Table 1 gives an overview of the concepts internal and external flexibility.

Elements of flexible ways of working as described in table 1 are viewed as building blocks of

different flexibility practices. Therefore, flexibility practices can contain more than one element as

mentioned in table 1.

Table 1 Internal and external flexibility

Internal External

Numerical Working time accounts, working time

adjustments, introduced to secure jobs

Hiring and firing, temporary

agency workers, fixed term

employment

Functional Further training, work organization Providing jobs skills suited to the

external labor market

Temporal Petty employment / mini jobs, part-time jobs

Wage Clauses allowing divergence from collective

agreements, alliances for jobs, petty

employment/ mini jobs, performance-related

pay

Wage cost subsidies

Source: Keller & Seifert (2005, p. 308).

However, it can be argued that external flexibility is not necessary at all when internal flexibility is

organized well. The aim of flexibility is to employ the required number of staff in the required capacities

at any point of the organizations’ life (Kelliher, 1989). If the internal flexibility is able to deal with all

fluctuations in the demand of care, and all temporary fluctuations in the workforce like maternity leave

and illness, there would be no demand for external flexibility.

But, as the most innovative solutions for labor market shortage stem from external flexibility, it

would be a missed opportunity to ignore external flexibility in this study. An example of external flexibility

is access to an external labor pool. This pool exists of workers with a wide assortment of tasks and skills.

This way firms are able to quickly adapt to changes in the demands of their clients. This way of dealing

with labor shortages may prove to be cost effective on the longer term, were external contract work or

alliances often bring about longer term obligations and benefits (Lepak, Takeuchi & Snell, 2003).

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2.2.1 Possible effects of flexibility practices

Psychological contract

As mentioned before, the new employment relationship is characterized by flexibility from both

the employer and the employee, and is based on trust and open communication (Roehling et. al., 2000).

This is a part of the psychological contract between employees and employers which refers to the

reciprocal obligations both parties perceive to have towards each other (Rousseau, 1990). With the rise of

the new employment relationship in the mid-90s, job security is not necessarily a part of the employment

relationship anymore (Roehling et. al., 2000). On the other hand, employee loyalty to the organization is

also no longer expected in return (Rousseau, 1990). Flexibility employment thus might have an effect on

the perceived obligations towards each other of both the employee and the employer. Not all employees

will be content with this new employment relationship. Some employees will prefer to stay with the

traditional employment relationship; characterized by a long term employment relationship, security,

stability, and predictability (Hiltrop, 1995). They may feel that the psychological contract between

themselves and their employer is broken, as they are confronted with more job insecurity, fewer benefits,

and increased workloads (Hiltrop, 1995). Especially older workers may perceive the new employment

relationship as betrayal as they have always showed loyalty, but do not get job security in exchange

anymore (Hiltrop, 1995).

Also, the quality of care could be influenced by flexibility practices in healthcare. Firstly, client

satisfaction may be influenced by flexible labor practices as patients develop expectations about the

relationship with healthcare staff (Ancarani, Di Mauro & Giammanco, 2009). Flexible employment means

that clients will receive care from a larger number of different staff members. Clients may perceive this as

bothersome as cohesion and constancy are highly valued by clients (Ancarani et. al., 2009). Second, it is

questionable whether the quality of employees’ performance is affected by flexible employment. One

could state that flexible employment leads employees to perform non-routine, non-expertise tasks, which

will lead employees to spend more time on tasks (Bhattacharya, Gibson & Doty, 2005). However, the

performed tasks of employees are the same regardless of the type of employment contract; therefore the

quality of the care delivered by the organization’s staff should stay leveled. Moreover, in this study it is

interesting to consider whether organizations perceive that flexible labor practices affect the quality of

healthcare, and in what way.

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Employee commitment

Another aspect that could derive from a perceived ‘broken’ psychological contract is lowered

employee commitment. Porter (1974) mentions the desire to stay with the organizations as a main

indicator of employee commitment. However, this desire to stay, or loyalty to the company, is no longer

self-evident as the employee also no longer receives job security in return (Hiltrop, 1995). This would

mean that there would be less employee commitment in flexible employment relationship; this while

commitment is especially important in a tight labor market as commitment creates predictable employee

behavior on the short-term (Boxall, Hwee Ang & Bartram, 2011). However, the opposite can also be

stated by arguing that employees’ commitment increases considerable with flexible work arrangements

because many contemporary workers prefer flexible work (Van Delft, 2011). However, it also important to

keep in mind that also a lot of employees to not prefer flexible work. So employee commitment can either

positively or negatively be influences by flexible work arrangements.

Organizational outcomes

The effects of flexibility practices described above are affecting employees. However, flexible

labor practices could also affects organizational outcomes such as employee turnover, financial turnover,

and absenteeism. Research has shown that more use of flexibility practices leads to lower employee

turnover rates, because flexible labor practices cope with fluctuations in the demand of care by for

example reducing the number of working hours. Forced layoffs are therefore prevented. Though, flexible

workers themselves are often victims of unemployment (Cörvers et. al., 2011; Di Tella & MacCulloch,

2005). Other than that, financial turnover could also be affected by labor flexibility practices. It can be

argued that it has a positive effect on financial turnover as fluctuations in the demand of care can be

handled, and therefore overcapacity is prevented. On the other hand, one could state that flexibility

practices have a negative effect of financial turnover as flexibility causes less routine, which will harm the

overall efficiency, and will actually increase costs (Bhattachary et. al., 2005). Also, labor flexibility practices

may reduce absenteeism. On the short term because combining work and non-work related activities is

easier, and on the long term it could decrease absenteeism by improving employees’ health through

reduced stress and increased job satisfaction (Possenriede, 2011).

There are considerable differences between different areas within healthcare. For example, there

are large differences in the speed of adaptation of labor-saving innovations in different areas of

healthcare. Examples of labor-saving innovations in healthcare are the use of domotics, and remote care

(Läubli, 2010). There is a striking slow adaptation of innovations in the nursing homes and in the home

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care sector. Hospitals on the other hand are relatively quick in adopting labor-saving innovations,

especially in combination with product innovations. Läubli (2010) mentions some possible causes that

could affect the speed of the adaptation of innovations. Concepts that enhance the speed of adaptation

of innovation are the financial necessity to change in order to survive, and the support of directors and

the executive staff in healthcare. A general factor that inhibits healthcare providers to adapt technological

labor-saving innovations is the unfamiliarity with information technology (IT) (Läubli, 2010).

2.2.2 Short-term and long-term effects

In this study, a distinction is made between short-term and long-term effects of human resource

flexibility practices . This distinction is made to be able to judge the effectiveness of different flexibility

practices. For example, it may be the case that organizations adopt a certain flexibility practice to cut

labor costs on the short-term. Other motives could be to anticipate on future labor shortages on the long-

term, or possibly to be an attractive employer on both the short- and long-term. When there are different

motives to adopt a flexibility practices, the perception of effectiveness can also deviate. Therefore, a

distinction between short-term and long-term effects is made. A short-term effect can be defined as

within 0-6 months. Long term effects are aimed at 6+ months.

Possible short-term effects of flexibility practices are greater job insecurity of employees (Dekker

& Achterberg, 2008; Cörvers et. al., 2011), and better work-life balance of employees (Roehling et. al,

2000). Possible long-term effects of labor flexibility practices are improved labor productivity, and greater

cost-efficiency (Bhattacharya et. al., 2005).

2.2.3 Effectiveness

The meaning of the term effectiveness is framed in this sector to make judgements on the

effectiveness of different flexibility practices in healthcare. However, the concept effectiveness is quite

complex. Especially rationalizing effectiveness within healthcare is of often subject to sensitive ethical

debates (Bruyx, Friedrich & Schone-Seifert, 2011). There are numerous definitions on effectiveness. Some

elements frequently used to grasp the concept effectiveness state that practices are effective once the

expected effects are large enough (Buyx et. al., 2011), it positively affects health related quality of life

(Aday, Begley, Lairson & Slater, 1999; Buyx et. al., 2011; Mandal, 2007), and it affects employees attitudes

positively (Gregory, Harris, Armenakis & Shook, 2009). However, these definitions also raise a lot of

questions. When are effects large enough, and how do you measure the quality of life? Another definition

on quality and cost-effectiveness within healthcare is: “the degree to which entire services or their

component part (e.g. diagnostic tests, treatments, caring procedures) fulfil stated goals” (St Leger,

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Rowsell, Standing & Haycox , 1992 as cited in Mandal, 2007, p. 415). This definition will be used as the

starting point in measuring effectiveness in this research: effective flexibility practices fulfil the intended

organizational goals.

Acknowledging the multidimensionality of effectiveness, this study focuses on the following

specific aspects of effectiveness. First of all, the organization itself must perceive the labor flexibility

practice as effective to the organization. Moreover, when organizations implement a certain flexibility

practice, this is done to achieve a certain goal. When this goal is reached, this is an indicator that the

flexibility practice was successful to the organization. Effectiveness is thus context specific. A particular

flexibility practice could be effective in healthcare organization A, while it is detrimental for healthcare

organization B. Second, there should be no large negative consequences due to the particular flexibility

practice. Something can be classified as a large negative consequence when the organization experiences

considerable negative consequences caused by implementing a certain flexibility practice, and the

researcher indicates that these negative consequences influence the flexibility practice in such a manner

that it is not effective to the organization. Specific details on measurement of the concept effectiveness in

this research will be outlined in the methodology section. All in all, flexibility practices have different

effects on organizational outcomes, or are in some way affecting stakeholders.

Conceptual model

Figure 1 visualizes a mental model on how this research is judging the effectiveness of labor

flexibility practices. First, a clear view on the flexibility practices currently used by healthcare

organizations is created, based on the definition of internal and external flexibility practices as

summarized in table 1. One could expect healthcare organizations to make use of relatively similar labor

flexibility practices, with the exception of some progressive, innovative initiatives. Relative conventional

labor flexibility practices like employment contracts with variable hours and part-time contracts are

expected to be implemented in many organizations, while labor flexibility practices like performance

related pay and flex pools are expected to be less prevalent. Though, there may be considerable

differences between different sectors within healthcare. As mentioned earlier, nursing homes & in-home

medical care facilities are in general slower in adapting innovative practices than for instance hospitals

which are generally more progressive (Läubli, 2010). Further, these flexibility practices have certain

effects, which will influence the overall effectiveness of the practice in use. Some anticipated effects are

listed in figure 1. Further, possible contextual factors are incorporated in figure 1. This initiates room for

possible (unexpected) variables that are indicated to affect either the flexibility practices themselves, the

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effects of flexibility practices, or the relationship between flexibility practices and effects. Possible

contextual factors could be organizations’ size, or the institutional context. For example, the size of

organizations could influence the use of a flexible practices, for example an internal flex pool because this

could only be cost-efficient when applied in a large organization.

Figure 1 Model on the effects of labor flexibility practices

When sub question 1 is addressed, there will be a clear picture of the current use of flexibility

practices in healthcare. Then, it is interesting to take a closer look at the effects that different flexibility

practices have on organizations, and why some innovative flexible initiatives are perceived as successful

and other practices as less successful. Sub questions 2a and 2b aim to provide more insight in the various

short-term and long-term effects of flexibility practices. Sub question 3 will aim to indicate what flexibility

practices can be labeled as effective to healthcare organizations.

Sub question 2a: What are the short-term effects of internal and external flexibility practices on

healthcare organizations?

Sub question 2b: What are the long-term effects of internal and external flexibility practices on healthcare

organizations?

Sub question 3: Which HR flexibility practices in healthcare are effective?

Flexibility practice A Short- & long-term effects on:

- Psychological contract

- Quality of care

- Employee commitment

- Employee turnover

- Financial turnover

- Absenteeism

Possible contextual factors

Flexibility practice B

Flexibility practice C

Flexibility practice

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3. Methodology

3.1 Design

This study has an exploratory nature. The sub questions serve as a guideline in answering the

main research question. To achieve this, qualitative research is conducted. Qualitative research studies

subjects in their natural settings in an attempt to make sense of phenomena, and to interpret them by

bringing meaning to them (Denzin & Lincoln, 1994). Due to the explorative nature of this research, actors

were interviewed in depth using semi-structured interviews to develop an image of the current situation,

and thereafter to find explanations for what has been found (Schutt, 1996). Interviewing, as opposed to

sending questionnaires also provides the advantage to learn more about why organizations or individuals

take certain decisions. This why question is what this exploratory research addresses and was the main

aim of this study as it attempted to discover why certain flexibility practices are effective or ineffective in

healthcare. As the analysis is done on HR managerial level, interviews are held with HR managers or

specialists on capability planning who can generally provide a broad look on the theme within their

particular organization. Alongside effects of flexibility practices on the organization; effects on employees

and clients were also addressed from the perspective of HRM. A disadvantage of studying the effects and

effectiveness of various flexibility practices solely from an HR managerial level is that conclusions could be

based on assumptions from an HR perspective on flexibility practices rather than true objective effects

and effectiveness.

3.2 Sample

The geographic area from which data is collected are the provinces of Noord-Brabant and

Limburg in the Netherlands. The research aims at the healthcare sector. The following sub areas within

healthcare were a part of this study: hospitals, nursing homes & in-home medical care, disabled care,

home care, mental health care. The two provinces, and the five different sectors within healthcare were

represented equally in the sample. Random sampling was used in this research. First a list of all relevant

healthcare organizations with a minimum of 500 employees was made. Next, respondents within each

area of healthcare above were randomly chosen, and asked to participate. Respondents were requested

to participate in this study by telephone. A total of 16 candidates were approached from 15 different

healthcare organizations. 15 of those candidates agreed to participate in the research. Data was gathered

until a point of saturation was reached. Saturation is reached when fewer and fewer new insights occur

during data gathering (Crabtree & Miller, 1999).

In table 2 an overview is given of the participating organizations. Quite large variations in

16

absenteeism percentage can be noted. Also, the part-time percentage varies extensively between

organizations, and sectors within the healthcare branch.

Table 2 Organizational information on the respondents in the sample

Organization Employees FTE’s* Part-

time

rate**

Volun-

teers

Clients Absen

teeism

Employee

turnover

Financial

turnover

1.1 Hospital 2.271 1.411 62% 200 494*** 4,6% 8,3% 123.888.677

1.2 Hospital 1.781 1.134 64% 200 384*** 5,61% 1,76% 112.165.000

2.1 Nursing

homes & in-

home medical

care

3.133 1.821 58% 1.085 2.909 6,72% 10% 122.344.819

2.2 Nursing

homes & in-

home medical

care

8.906 3.844 - 17.627 6,1% 11,1% 244.880.882

2.3 Nursing

homes & in-

home medical

care

8.728 4.785

43% 2700 9000 8,13% 8,8% 267.869.510

3.1 Home care 1.819 629

35% 0 5.903 7,5% 10% 25.123.646

3.2 Home care 618 393,8

63% 0 2.200 10,1% - 20.370.210

4.1 Mental

care

2.250 1.530,

74

68% 250 16.384 5% 6,9% 127.831.969

4.2 Mental

care

2.312 1.844

80% 150 10.460 5,38% 13,34% 145.948.000

5.1 Disabled

care

1.284 812,17 63% 680 979 4,66% 6,18% 53.651.217

5.2 Disabled

care

5.487 2.726

49% 1500 3141 5,54% 16,5% 211.731.299

5.3 Disabled

care

2.500 1.651

66% 988 2.563 4,7% 12,2% 118.800.000

6.1 Aditional - - - - - - -

7.1 Aditional - - - - - - - * Fulltime equivalents

**FTE / employees *100

*** The number of clients in hospitals is measured by the number of recognized beds

17

3.4 Procedure

To gain information, appointments with HR managers or specialists on capability planning in the

different sub areas within the healthcare sector were planned. The interviews’ length varied between 60-

90 minutes. The interviewer first created a confidential relationship with the participant by guaranteeing

respondents’ anonymity. In an interview of approximately one hour, the interviewer addressed the

general topics on flexibility. In addition to the general topics the interviewer tried to gain knowledge on

organization-specific information, and information on innovative flexibility initiatives that were relevant

for this research. The interviews were recorded, and transformed into a digital script. The data was

processed using data-driven coding using Atlas.ti, which means that codes were created based on the

collected data. Next, content analysis was applied to summarize comments into meaningful categories.

This was done by gaining familiarity with the responses, generating themes by recurring comments, and

placing comments into the corresponding themes (Cummings & Worley, 2009). After categorising,

conclusions could be made from the data.

The specific procedure of judging whether a certain HR flexibility practice is effective or not, is as

follows. Judging the effectiveness was done by the researcher, based on the answers to sub question 2a,

2b, and 3. The definition that serves as a starting point for measuring effectiveness was “the degree to

which entire services or their component part (e.g. diagnostic tests, treatments, caring procedures) fulfil

stated goals” (St Leger, Rowsell, Standing & Haycox , 1992 as cited in Mandal, 2007, p. 415). The main

indicator of effectiveness used in this research therefore was whether the goal set by the organization to

the specific flexibility practice is met or not.

Four main criteria were applied in judging whether a flexibility practice is effective or not. First,

organizations were asked what the goal of implementing the specific flexibility practices that they apply

was. Second, organizations were asked whether this goal was reached or not. Third, the respondent was

asked whether (s)he perceives large negative consequences due to the flexibility practice. Last, the

respondent was asked to indicate whether these negative consequences are large enough to the degree

to which you could label the implementation of this flexibility practices as ineffective. When the

researcher perceived that the a clear goal of a flexibility practice was reached, or the flexibility practice

actively contributes to achieving this goal, and there are no considerable negative consequences due to

implementing a flexibility practice, the flexibility practice was judged as being effective.

However, the fact that only one respondent is questioned within a particular organization could

lead to a biased view on the total organization’s perspective on the effectiveness of flexibility practices.

Therefore, the researcher will use its own expertise on the subject of flexible labor practices, and insights

18

from other healthcare organizations, to critically assess the respondent’s judgement on effectiveness of

labor flexibility practices in use.

3.3 Instrument

Prior to the interview, some numerical information on the organization was gathered through a

desk research in order to determine possible moderating effects. This mainly numerical information is

referring to numbers from December 31th 2010, and was available via annual reports. This data was

collected in advance of the interview, and respondents were asked to verify this data during the

interview. The following data was collected: the number of employees, number of Full Time Equivalents

(FTE’s), number of volunteers, number of clients, percentage absenteeism, percentage employee

turnover, and number of financial turnover.

Next, in the actual interview, questions were addressed in order to gain data for answering the

research and sub questions. There were multiple questions that address the separate sub questions, and

all respondents were asked the same questions in order to guarantee reliable and valid data.

The sub questions cohesively answer the overall research question. Sub question 2a and 2b

addresses the short term and on the long term effects of flexibility practices. Last, through sub question 3

this study is attempting to make some statements about the overall effectiveness of different flexibility

practices. Table 3 outlines the interview questions that were addressed in order to find answers on the

sub questions.

Table 3 Interview questions

Sub question 1: Which human resource flexibility practices are used in healthcare?

* What does the workforce planning of your organization look like at this moment?

* How do you make use of flexibility with the permanent workforce?

- Hoe does your organization cope with labor shortages due to unexpected illness or absence?

- Why do labor shortages occur?

-- Are there shortages in certain types of jobs?

* Does your organization make use of the following flexibility practices, and why:

- Contracts with variable hours

- Education/training/courses

- Part-time contracts

- Short-term contracts

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- Pay for performance (PRP)

- Deviate from collective labour agreements

- Internal flex pool

- Cooperation and exchange of personnel within the organization

- Hiring and firing

- Temporary agency workers? How many in numbers or FTE?

- Encouraging employees to adapt to the external labour market

- Varying salary based on subsidiaries

- Alliances with other organizations

- External flex pool

* Are there any other flexibility practices which your organization makes use of which I did not mention?

Sub question 2a: What are the short-term effects of internal and external flexibility practices on

healthcare organizations?

* Which effects does flexible work has on employees on the short term?

If the respondent does not mention the themes below, these themes are specifically addressed by the

interviewer.

- Can you substantiate this with objective data?

- Do you think flexible work influences employee turnover?

- Do you think flexible work influences employee absenteeism?

- Do you think flexible work influences employee commitment?

- Do you think flexible work influences the quality of work that employees deliver?

* What effects do you think flexible work has on the organization on the short term?

- Do you think flexible wok influences the financial turnover of the organization?

* Is the client satisfaction influenced by the flexibility of staff? If so, how? If not, how is this prevented?

- To what extent is client satisfaction affected by frequent changes in staff, services and

different employment contracts?

- To what extent does your organization take the wishes of the client in terms of staff into

account?

Sub question 2b: What are the long-term effects of internal and external flexibility practices on

healthcare organizations?

* Which effects does flexible work has on employees on the long term?

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If the respondent does not mention the themes below, these themes are specifically addressed by the

interviewer.

- Can you substantiate this with objective data?

- Do you think flexible work influences employee turnover?

- Do you think flexible work influences employee absenteeism?

- Do you think flexible work influences employee commitment?

- Do you think flexible work influences the quality of work that employees deliver?

* Which effects do you think flexible work has on the organization on the long term?

- Do you think flexible work influences the financial turnover of the organization?

Sub question 3: Which HR flexibility practices in healthcare are effective, and why?

* When do you think workforce planning is effective?

- What was the goal of the specific flexibility practices implemented within the organization?

- Is this goal reached?

- Were there any negative consequences due to implementing flexibility practices?

- Were these negative consequences large enough, to the degree that you could judge the

flexibility practice as being ineffective?

* What are your expectations of future labor shortages in healthcare?

- Which problems occur in workforce planning?

- What is going very well in workforce planning?

4. Results The results will be outlined in the following section. These will be illustrated with direct

quotations of respondents. Respondents are linked to their corresponding organization, and are

numbered and categorized by the various healthcare sectors; e.g. hospitals, nursing homes & in-home

medical care, disabled care, home care, mental health care. For example home care is coded as 3, and the

specific home care respondent is coded as 2. Then the respondent is referred to as home care 3.2.

Respondents which are not directly employed in one of the healthcare sectors are referred to as

additional. A complete list of the organizations and quotations can be found in the appendix.

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4.1 HR flexibility practices

This section addresses sub question 1, Which human resource flexibility practices are used in

healthcare? Various flexibility practices belonging to internal or external flexible as defined in table 1 will

be outlined. Table 3 presents human resource flexibility practices the use of flexibility practices

investigated in this research by the 14 participating organizations.

Table 3 Use of human resource flexibility practices

Internal flexibility practices In use by

number of

respondents

External flexibility practices In use by

number of

respondents

Numerical

Contracts with variable hours

12

Numerical

Hiring and firing

Temporary agency workers

2

12

Functional

Education

12

Functional

Encourage adaption to

external labor market

8

Temporal

Part-time jobs

Short term contracts

14

14

Wage

Performance-related pay

Deviate from CLA*

1

0

Wage

Vary wage due to subsidiaries

0

Additional

Flex pool

Exchange of staff

10

9

Additional

Flex pool

External cooperation

1

9

* Collective labor agreement

4.1.1 Internal flexibility practices

Contracts with variable hours

Opinions on the use of contracts with variable hours vary substantively. They vary from it being

essential for creating a flexible shell, to having no use at all. Respondents illustrate advantages and

disadvantages of contracts with variable hours. Nursing homes & in-home medical care 2.2 illustrates:

”First, teams must always try to solve fluctuations themselves. We want to work with a fixed formation

from around 80% to 85%. The flexible shell around this fixed number of hours should contain team

members having contracts with variable hours. This is desirable.” However Mental health care 4.1 states:

“Contracts with variable hours have advantages, but also disadvantages. Especially when you agree on a

minimum amount of hours and eventually work a maximum number of hours. At some point employees

could pose a claim.”

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A main reason that organizations mention to avoid contracts with variable hours, is that according

to Dutch law, employees can claim a certain number of working hours after performing this amount of

hours weakly for three months, or more than 20 hours a month (Article 7:610b BW). A downside of

contracts with variable hours that employees could experience is that, when they are contracted via a so

called min-max contract, they are obliged to work more hours than is minimally decided if their employer

requires this, until the maximum of hours that is contracted. Therefore, employees find it undesirable to

commit for a large flexible part.

Other organizations emphasize the advantage of contracts with variable hours, regarding creating

an initial buffer in case of short-term labor shortages due to sickness or holiday leave, and seasonal busy

periods. Hans Slurink, a sales manager at a personnel planning organization indicates that “there is always

approximately 8% holiday leave and 5% sickness leave among employees”. Respondent additional 7.1

proposes a relative small range of 4 variable hours for every employee, which is minimally 11% of a

fulltime employment relationship. In this way he wants to create a large flexible shell using contracts with

variable hours. Though, as this variable range of 4 hours would also be given to part-timers, the

percentage of the flexible shell would be larger than 11%. When the whole workforce of the organization

would have a small flexible range like the proposed 4 hours, this would eliminate another disadvantage of

contracts with flexible hours, which is that when an employee with a contract with variable hours gets

sick or goes on holiday leave, the flexible shell of a department is often also considerably lowered. When

each employee has a small flexible range, this would not be an issue any longer.

Although 12 of the 14 participating organizations make use of flexible contracts, some

respondents experience this as “a heritage from the past. No new contracts with variable hours are given

to employees” (Hospital 1.2). The reason why hospital 1.2 does not use contracts with variable hours

anymore is because they experience it as something which employees prefer in the employment

relationship, but which is not desirable for the organization. Before, the labor market was tight and the

concession was made to offer contract with variable hours. Though, currently they experience that new

employees are readily available and this concession does not have to be made . Overall, the risk

organizations run on receiving a claim on a number of working hours is seen as the major disadvantage of

contracts with variable hours.

Training and education

Education is part of internal functional flexibility. In the participating organizations education is

abundantly present in almost all organizations, and is both aimed at vertical and horizontal growth.

23

Though the use of education within healthcare organizations is mostly aimed at ensuring a sufficient

influx of new employees due to expected labor shortages and quality improvement of the current

workforce, while the definition of internal functional flexibility is mostly aimed at using education as a

tool to broaden skills of employees to ensure employability. Nursing homes & in-home medical care 2.1

illustrates this view on education: ”I firmly believe that we must sturdily invest in education. You can

either keep on looking in the current labor market for future employees, but those ponds are nearly

exhausted. I strongly believe that we should invest in education for potential candidates so that they have

the opportunity to obtain the right qualifications. Healthcare is a profession where qualifications are

obliged. We want focus on potential candidates that do not yet own the right degrees and qualifications

for employment in healthcare”.

Part-time jobs

Part-time employment is universally used by the participating organizations.

Mental health care 4.1: “Part-time contracts are inextricably linked to healthcare. In general many women

work in healthcare, who only want to work part-time”.

Nursing homes & in-home medical care 2.3: “The problem is that you cannot attract young employees

with part-time contracts. Young people just want a fulltime job. However, that is difficult to realize in the

planning as you do not need a fixed amount of people throughout the day. In healthcare you have to deal

with peak moments in which labor is necessary”.

It is often cited that part-time contracts are both advantageous for the organization and the employee.

The female employee prefers working part time to combine the professional life with other activities in

their private lives, while the healthcare organization benefits from part-time contract because “peak

moments in care are concentrated in the morning” (home care 3.2). Also, the use of part-time jobs

provides another advantage to the organization as there is an opportunity to temporarily raise the

number of working hours to cover a higher workload for a limited period of time, a week, month or year.

A difficulty experienced by healthcare organizations is that young employees prefer a fulltime

contract which healthcare organization often cannot offer. This is directly linked to the peak moments in

healthcare. More personnel is needed during certain times a day, while the rest of the day is more quiet.

This makes it difficult for organizations to realize a fulltime working day, and often there will be split shifts

throughout the day which is not ideal for the employee.

24

Short term contracts

Another element of internal temporary flexibility, short term contracts, is also universally used by

the healthcare organizations in this research.

Disabled care 5.1: “To know what kind of employee you actually hired. You do not know the employees’

exact qualifications yet after only one month of probation. So it is also a bit of control that you can use”.

Disabled care 5.3: “It is a possibility to offer all new employees a temporary contract. If anything happens

you can easily dismiss them. However this is bad for my image. Once everybody knows that you get three

temporary contracts at our organization and then you are out, how should I find new employees? You will

get such a negative reputation, so that is no solution”.

So, on the one hand short term contracts are often used to find out whether the employment relationship

works out for all parties involved. If not, the employment relationship can easily be terminated. On the

other hand, short term contracts are used for certain specific occasions like substitution during summer

vacation or temporary replacement for maternity leave.

Though, contracts for a short period also appears to have a number of disadvantages. Disabled

care 5.3 states that employee turnover in their organization is the largest among employees with contract

for a short period and contracts with variable hours. Therefore, the investment of recruitment, selection

and any education or training of this group of employees would also be lost relatively quickly.

Performance-related pay

Further, opinions on the use of performance-related pay (PRP) vary greatly. A small majority of

respondents indicate that PRP is not desirable. The argumentation often is that PRP is not undesirable in

general, but specifically for the healthcare sector. nursing homes & in-home medical care 2.2 illustrates:

“Not in healthcare. Then you will get internal competition which does not seem right to me. You are

working with people, not products. You want to sells your products at any costs. In healthcare this does

not work this way. You cannot say after showering this many people you get an reward, no. That will be at

the expense of the quality of healthcare”. Proponents of PRP indicate that it could be beneficial, provided

that there is a sturdy assessment system. Hospital 1.1 indicates: “It is just ridiculous. Whether you

perform lousy or extraordinary, you will still get rewarded equally on a periodic basis according to the

collective labor agreement. People who perform better should be rewarded. And people who do not

perform well should also not receive this periodic reward. I do not think you should reward everyone

equally”.

25

Deviate from collective labor agreement

The participating organizations do deviate from the collective labor agreement where there is

room to do so. Mental care 4.2 illustrates: “Rather not. But yes, there are some exceptions. Regarding

salary we sometimes grant a premium. Also, sometimes 40 hour contracts are made with employees

[instead of the 36 hour working week standard]“.

However, within the definition of Keller and Seifert (2005) of internal wage flexibility,

organizations do not deviate from the collective labor agreement in terms of pay. A single organization

deviates in a positive way from the function appreciation systematics (in Dutch: ‘functiewaarderings

gebouw’, FWG) for a certain function. Nursing homes & in-home medical care 2.3 illustrates why

organizations do not often use this flexibility practice: “You make a collective labor agreement because

you do not want to compete within your branch in terms of employment. When you are free to pay

higher salaries, you would still be competing in terms of employment, and that is not allowed. The CLA is

collectively binding. However, the CLA also contains areas in which you can deviate. They are called

decentralized provisions. For example to make deviating travel compensation policy. However, it is stated

in the CLA in which areas you are allowed to deviate”.

Internal exchange of staff

A majority of the participating organizations indicates to exchange staff between departments or

locations. However, a widespread comment is that it happens only on a small scale, and often informally.

Disabled care 5.3: “Cooperation and exchange of personnel between departments or locations is currently

not the way we want it to be. Employees are often rigidly focused on their own department. We are going

to improve this though. Employees need to realize that it is about the whole organization, and you have

to be a bit more flexible then only your own team”.

Internal flex pool

A majority of the organizations have an actively operating internal flex pool. An internal flex pool

offers various advantages and disadvantages. These will be illustrated using quotations.

Home care 3.2: “In a team you help and support each other. You miss the familial element of a team in

the flex pool” .

Hospital 1.1: “The problem is that certain departments like child care or intensive care only contain

specialized personnel. Once they would also deposit a part of their personnel budget to the flex pool they

would never get something in return”.

nursing homes & in-home medical care 2.2: “Once a department has a vacancy they can also choose to

26

employ a worker from the flex pool. Often this flex worker has already had a long probation period so this

gives security for the department. But also the other way around, a flex worker has had the chance to

take a look at different departments, and can make a well based decisions for a certain department”.

nursing homes & in-home medical care 2.2: “The largest cost-effective aspect of the flex pool is that once

it runs well there will be little use of external temporary agency workers which are costly”.

Overall, flex pools are mainly used to fill in short-term, ad hoc labor shortages due to sickness,

holiday leave or fluctuations in the demand of care. Some organizations also use the flex pool to fill in

relatively long-term periods like replacement during maternity leave. Forecasting is often mentioned in

combination with the flex pool. Hospital 1.2 illustrates: “At the start of the year I visit team managers and

discuss disturbances in personnel planning en the amount of hours they expect to detract from the flex

pool. Once I have a clear image of the expected demand of the flex pool I make sure I have the right

people in the flex pool“.

4.1.2 External flexibility practices

Hiring and firing

Respondents experience hiring and firing of employees to adapt to the demand of labor as

something which is quiet uncommon in their organization. Though, actually a majority of the respondents

does make use of this in practice. Especially mental health care organizations use this flexibility practice,

as they currently face strong financial cuts imposed by the government. Therefore they face large number

of layoffs. Paradoxically, they also expect growth in the future in which they might face a need for extra

employees. For this reason mental health institutions actively accompany employees into a new job.

Mental health care 4.2 illustrates: “It is a paradox. We have to decline the number of employees while we

also know that we need that same labor potential in the future. Therefore we want to deal with these

layoffs well to make sure that people do not get the feeling that they never want to have anything to do

with this organization anymore. We want to make sure that we accompany people well from their current

job to another job”. Also nursing homes & in-home medical care organizations currently make extensive

use of the hiring and firing practice. In contrast with the mental health care organizations they recently

received additional funding from the government to realize ‘more direct hands to the bed’. nursing homes

& in-home medical care 2.3 illustrates: “We need many extra employees. However, we now have the

good fortune that mental health care organizations need to downsize extensively. Many nurses are laid

off there, and we would love to employ more nurses”. Other comments on this practice indicate that the

hiring and firing of employees can be prevented by forecasting, and the use of zero hour contracts.

27

Temporary agency workers

Responses to the use of temporary agency workers are unambiguous and unanimous; preferably

as little as possible. Home care 3.1 illustrates why: “What we see is that the margin of temporary agency

workers is low. In proportion they are very expensive. We need to pay an extra 19% taxes for temporary

agency workers”. Though, as can be seen in table 2, a large majority of the respondents do use this

flexibility practice. A much cited motive why organizations use temporary agency workers while they

actually prefer to avoid them is that it provides a solution to fill in the very last labor shortage that cannot

be solved internally. Furthermore, temporary agency workers are often used to fulfill highly specialized

functions. There is also a movement to cope with all fluctuations internally, in which the internal flex pool

functions as an agency for temporary employment. Home care 3.1 illustrates: “By broadening the flex

pool we did not need temporary agency workers anymore”.

Encourage adaption to external labor market

The majority of the respondents prefers not to encourage employees to extensively to adapt to

the external labor market. The following quotation clearly indicates why, nursing homes & in-home

medical care 2.2: “Clearly we want to retain employees in healthcare as we face labor shortages”. Many

respondents mention the fear of losing qualified staff as a restrain to encourage employees to be

attractive in the external labor market. Respondents indicate that they only orient to the external labor

market with specific employees who are in a second track due to prolonged illness or when the

employment relationship is damaged. A single respondent mentions the advantages of adaption to the

external labor market. nursing homes & in-home medical care 2.1: “We think it is important that

employees keep educating themselves to get the right certificates, which also makes them more

attractive on the external labor market. You could argue that it is not in our advantage to do so. They

could all leave with their qualifications secured. However, we hope that we can at least retain employees

in the healthcare branch”.

Vary wage due to subsidiaries

None of the responding organization uses this flexibility practice. The following quotations

explains why; nursing homes & in-home medical care 2.3: “You may not differ from the collective labor

agreement in a positive way. The healthcare branch has secured certain things in a collective labor

agreement because they do not want to compete on employment terms, also salary”.

External flex pool

Table 2 shows that only one respondent uses an operational external flex pool. The majority of

28

organizations indicate to focus on the functioning of the internal flex pool in the first place, which they

perceive to be not satisfactory yet. Only then would they consider an external flex pool. However, it is not

excluded that an external flex pool could be beneficial in the future. Mental health care 4.2 illustrates:

“The use of network organizations is increasing. Often these include organizations from multiple branches

who exchange vacancies. If one organization experiences overcapacity and another under capacity there

is a possibility for exchange”.

External cooperation

Respondents indicate to cooperate extensively with other organizations in the healthcare branch.

Though, this cooperation is mostly aimed at providing products or services to clients. What was also

mentioned is that the government wants to promote integrated care (in Dutch: ketenzorg), which is

aimed at smoothening the transition from one health care organization to another. An example of such a

sequence is when a client has had surgery at a hospital, is transferred as quickly as possible to an in-home

medical care institution for revalidation, and continues with home care after. Though, with regards to

personnel there is little cooperation or exchange. This is also caused by the fact that the government

wants to stimulate competition to create a free economic market. Therefore, forming a cartel is

prohibited. Though, organization are allowed to cooperate, within boundaries of a maximum of €5.5

million turnover in goods, or €1.1 million turnover in services

(http://www.nma.nl/wet__en_regelgeving/mededingingswet/default.aspx). The Dutch Competition

Authority (Nederlandse Mededingingsautoriteit, NMa) is responsible to ensure that this rule is respected.

nursing homes & in-home medical care 2.3 illustrates: “Once healthcare organizations try to exchange

data on salaries or anything involving a cost price and something would be documented on paper or e-

mail, then you run the risk to receive a personal fine [..] I know an example from another nursing home

organization in Noord/Brabant. People from the NMa came in and closed all offices for two days.

Employees that had a laptop at home were escorted home by two people to retrieve the laptop. All the e-

mail and all cabinets were checked. They received ridiculously high fines of the NMa”.

4.2 Contextual factors

Operational versus strategic management

Overviewing all results from the responding organizations a recurring phenomenon occurred. A

separation in the group of respondents could be made in those who pursue the goal of doing things right,

while others focus on doing the right thing; meaning that some focus mainly on operational execution

29

regarding the trend of using HR flexibility practices, while others actively participate in the change

process. It is difficult to label this observation with a fitting term. However, respondents could be

categorized into the groups that stress the different HR roles of Ulrich (1997). The more operational HR

managers will be referred to as the administrative expert, and the more strategic HR managers as the

strategic partner.

This classification is based on a number of observations. Administrative expert organizations are

searching for the right direction to head in, concerning flexibility practices. Examples are when

organizations are taking initial steps in universalizing personnel planning methods in the organization.

Strategic partners on the other hand, often already have a sturdy personnel planning method and a

corresponding strategic view on the topic. They are more focused on fine-tuning the practices to optimize

desired outcomes of their strategic personnel management. Also, the strategic partners are often not

afraid to implement new, ambiguous practices, while administrative experts are more focused on

operating between a fixed framework. Thus, a differentiation between a strategic approach or an

operational approach could be distinguished.

Overall, the HR managers of large organizations, and hospitals in general were the strategic

partners. Also, HR managers with characteristics of a strategic partner have a clear vision on HRM, and

the implementation of flexibility practices.

4.3 Effects of HR flexibility practices

The previous paragraphs described HR flexibility practices in use by healthcare organizations. This

section will describe the effects of various HR flexibility practices in order to answer sub question 2a,

What are the short-term effects of internal and external flexibility practices on healthcare organizations?

and sub question 2b, What are the long-term effects of internal and external flexibility practices on

healthcare organizations?

In these sub questions, a distinction was made between short term and long term effects of HR

flexibility practices. However, overall, the use of HR flexibility practices is mostly aimed at achieving long

term effects. Mental care 4.1 illustrates: “We have a long-term policy which we translate in practices we

need to achieve those long-term goals”.

4.3.1. Direct effects of HR flexibility practices

Effects on the organization

The main desired effects of implementing flexibility practices from the perspective of the

organization is increased profitability. The cost-efficient advantages are mainly due to less binding

30

obligations towards flexible employees and the possibility to fluctuate in the number of working hours

according to respondents. Disabled care 5.3 illustrates: “I think from a prudential point of view, flexibility

practices are beneficial. You are less tied to flexible employees than to regular employees. You need to

buy out or remediate regular employees”. Nursing homes & in-home medical care 2.2: “You will have

lower personnel costs. You have the choice to lower the number of working hours when necessary. If

employees work less hours, you also have to pay them in proportion”.

Also, the use of flexibility practices adds to the optimization of the current personnel planning to

the vision that the planning should fit as closely as possible with the demand of care.

Effects on employees

Firstly, respondents indicate that the effects of flexibility practices on employees differs,

depending on the individuals’ viewpoint. Nursing homes & in-home medical care 2.1 illustrates: “

Individual employees will have different positive or negative views on them [flexibility practices]”.

Respondents indicate that when additional flexibility is required from employees, at first this will

lead to resistance from employees. Causes that are mentioned to certify this resistance are: “can be

perceived as threatening (Hospital 1.2), “people naturally prefer stability” (nursing homes & in-home

medical care 2.1), “at first it takes a lot of effort to get employees into the new mindset. Though, after a

year it is already the natural state of mind” (Hospital 1.1). However, on the long run organizations

experience that employees are very pleased with the changes of flexibility. Nursing homes & in-home

medical care 2.1 illustrates: “We have a large group of employees who are used to stability and often

think that is the only thing which is possible. We notice that once employees for any reason whatsoever

undergo some change, that it makes them very happy”. However, this link between flexibility practices

and employee satisfaction cannot yet be found from numerical information on for example absenteeism

or turnover from the researched organizations.

Furthermore, respondents also experience flexibility practices to affect absenteeism; though

opinions vary on whether there is a positive or negative effect. “Flexible work can have an adverse effect

of absenteeism when the demand of flexibility of employees is out of balance” (home care 3.2). Though, a

small majority emphasizes the advantages of flexibility practices on absenteeism. They reason: “once

employees are satisfied with the way of planning, this will result in lowered absenteeism” (Hospital 1.2).

Respondents especially emphasize the effect of flexibility practices whereby employees or teams get

more responsibilities which accordingly led to more ownership of the job. Hospital 1.1 illustrates: “a

higher sense of responsibility due to flexibility practices will lead to lower absenteeism”.

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Other than absenteeism, respondents also mention employee turnover as an effect of HR

flexibility practices. Overall, they mention that turnover is always higher among employees working with

HR flexibility practices, then it is among the fixed employees with fixed hours. In particular short term

contracts and contracts with flexible hours are designated as practices that cause employees to resign

more quickly. Disabled care 5.1 illustrates: “flex workers also long for a certain stability and an secured

income”. However, respondents also indicate that employee turnover is not necessarily a negative

phenomenon. Hospital 1.1 adds: “I think you should always keep a certain amount of employee

turnover”.

Another effect of HR flexibility practices on employees is the degree of employee involvement. In

general organizations indicate that the level of perceived involvement of employees with flexible

contracts is lower than their colleagues with fixed employment relationships. The following quotes

illustrates causes of this lower involvement. Mental health care 4.2 argues: “Employee involvement of flex

workers is lower than that of fixed employees within a team. Employees with relatively small part-time

contracts mostly do the operational activities, hands on. These employees are involved less in work

meetings or other activities other than the actual providing of care, which could make people feel that

they are being left out”. Disabled care 5.1 makes some suggestions how to ensure employee involvement

of those employees working with HR flexibility practices. “You could involve them by linking them to a

fixed location or fixed pool of flex workers. Also you could clearly communicate what the organizations’

vision is on flex workers and their relevance for the organization”.

Another effect that is produced by HR flexibility practices is the quality of care delivered by

healthcare employees. Opinions diverse on the impact of flexible HR practices on the perceived quality of

care. The general view is that, theoretically, the quality should be equal as all healthcare workers should

have equal medical qualifications. However some respondents experience a lower perceived quality of

care delivered by flex workers, mainly due to discontinuity for clients. Home care 3.2 illustrates: “flex

workers are not familiar with the specific situation. And quality is also in the perception of the client.

When something is less familiar, the quality is lower in the perception of the client”. However, other

respondents argue that “flex workers provide care with a greater degree of quality as they constantly

operate under different circumstances” (Disabled care 5.1).

The last effect of HR flexibility practices on employees is its effect on workers’ work-life balance.

This topic was not raised by the researcher but was frequently mentioned by respondents. Though,

perspectives on this topics also vary. Overall, flexibility practices are perceived as having both positive and

negative effects on employees’ work-life balance. Those with positive views state that “when flexibility

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practices allow a working schedule that enables employees to also pursue private activities this is very

positive. There should be balance between work and private life. Once there is misbalance, problems will

arise; either on the working site or in the private situation” (Mental health care 4.2). Those that

emphasize negative consequences on flexibility practices on work-life balance state that by a lack of

stability and routine in the working schedule, employees cannot plan their private life in advance as

flexibility is required in the working situation. Especially in combination with the care of children this

could be experienced as difficult by employees.

Overall, the effects of HR flexibility practices on employees are perceived as reasonably positive

to organizations. It decreases absenteeism, and seems to increase employee satisfaction. However it also

increases employee turnover en decreases employee involvement. All the effects mentioned in this

paragraph had no clear short term effects, the effects are mainly long term based.

Though, this study takes an organizational view. It should also be noted that from an employee

point of view, flexibility practices can also bring negative consequences. Increased job insecurity and

negative effects on the work-life balance were mentioned by organizations as negative consequences of

flexibility practices on employees.

Effects on clients

The main topic of discussion regarding effects of HR flexibility practices on clients, is the number

of different employees that deliver care to a client and the influence of this phenomenon on client

satisfaction. A number of respondents mentions that clients perceive it as harmful when many different

and changing staff members provide the healthcare that clients require. Though a number of respondents

also contradict this view. Nursing homes & in-home medical care 2.3 states: “The idea is that clients find it

harmful to see different faces all the time. The reality is different. What I hear from practice is that older

people often like to tell their story. When three different people visit you in a week to provide care, then

you can tell your story three times a week. However, there are also people who do not like it. But in

general people do not experience this as a problem”.

Although opinions on the effect of many different employees on the satisfaction of client differ,

there is some common ground; namely that some specific groups of clients benefit from continuity.

Groups that were appointed as being more sensitive in this phenomenon were clients with behavioral

problems and autistics. Disabled care 5.3 illustrates: “For some of our clients with a disability, continuity

and stability is very important. For those clients we choose to use a limited number of temporary

employees because these clients find it difficult to adjust to a new staff member”.

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4.3 Effectiveness of flexibility HR practices

To frame the concept effectiveness respondents were asked to indicate when they would label HR

flexibility practices as being effective. First of all, respondents made no distinction between different

goals of different flexibility practices. Respondents were almost unanimous in their viewpoint on the

anticipated goal of using flexibility practices by organization. They indicate that the overall personnel

planning is effective when the planning is tailored to the demand of healthcare, and flexibility practice

contribute in achieving this goal. Disabled care 5.2 illustrates: “You must ensure that you can fluctuate in

size and volume of your workforce, also qualitative. So, being able to fluctuate in volume, both

quantitative and qualitative”. However, the majority of respondents feels that this goal is not yet

achieved. Many organizations are currently figuring out what flexible HR practices could mean to their

specific organization, what choices to make and how to implement them. Disabled care 5.3 adds: “Every

organization should always be occupied with improving the effectiveness of their personnel planning”.

The goal of all flexibility practices is to tailor personnel planning as closely as possible to the current

demand of healthcare at any point in time.

When this goal is met, or the flexibility practice is actively contributing in achieving this goal, a

flexibility practice can be labeled as effective. Also, there should be no large negative consequences as

described in paragraph 3.4. Two main negative consequences of flexibility practices that were mentioned

by respondents are: high costs for the organization, lower employee involvement.

Internal flexibility practices

A number of internal HR flexibility practices can be distinguished that are being perceived as

effective by respondents. First, contracts with variable hours are perceived as being useful for both the

employee and the organization. Though opinions vary on the effectiveness of this flexibility practice,

overall they prove to be useful for organizations trying to pursue a planning is tailored to the current

demand of healthcare. Employees, as another party of benefit, also have an overall positive view on

contracts with variable hours. Mental health care 4.1 illustrate: “having control of your own working

hours is the greatest satisfier for our employees”. Second, overall short term contracts are also seen to

be beneficial to healthcare organizations. It offers organizations security to be able to lay off employees

when necessary due to governmental cutbacks. Also, it provides organizations the possibility to review

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the qualifications of employees without directly having a binding employment relation. Third, despite

some disadvantages, the use of an internal flex pool also seems to be particularly effective. Using an

internal flex pool is both cost-efficient for the organization in contrast to the use of external flexibility

practices, and also provides the opportunity to offer continuity to clients. Last, there is the use of part-

time jobs. This practice appears to fulfill needs of both the employer and the employee. On the one hand,

the use this practice is inevitable as a majority of the female employees requires this of their employer.

Moreover, part-time contracts are widely used by healthcare organizations as they have to deal with daily

peaks in the demand of care. A downside is that it is hard to schedule employees in contiguous shifts on a

full time basis, which makes it difficult to attract especially younger employees who overall prefer to work

full time. No major negative consequences were mentioned in relation to the four flexibility practices

described above.

Last there are a number of internal HR flexibility practices that are relatively ineffective. First,

there is the use of education and training. Though education is widely available to employees throughout

the responding organizations, it was not aimed at creating employability like the definition of functional

flexibility describes. Also, this practice does not contribute in achieving the goal of tailoring personnel

planning as closely as possible to the demand of care of clients. Further, respondents did not have a clear

vision on using education for employability as it was no priority topic on the organizations’ agenda.

Second, performance-related pay is often perceived as being undesirable specifically in the healthcare

sector as the overall culture is that everybody should be treated equally. A main goal of healthcare

organizations is to provide humane services to their clients. Performance-related pay is generally seen as

having negative effects on the humanness of the delivered services. Though, some organizations foresee a

potential usefulness of performance-related pay when a valid assessment system is implemented.

However, at this moment none of the respondents have such a system. All and all in all, PRP also does not

clearly achieves the described goal of a flexibility practice to fulfill the current demand of care by client.

Also, respondents suggest that this practice has large negative consequences on the clients well-being.

Another flexibility practice that could be labeled as ineffective is deviating from the collective labor

agreement (CLA). However, the CLAs used in the responding healthcare organizations leave little room for

deviation. The small adjustments that can be made appear not to majorly impact employees’ decisions to

give preference to certain employers. Thus, although this practice does not have significant negative

effects, it does not pursue the goal of tailoring the supply of labor to the current demand of care. The last

flexibility practice that can generally be labeled as ineffective is internal exchange of staff. Although, this

practice has the potential to be effective, and has no significant negative consequences, this practice is

35

currently not used by respondents to fulfill the goal of an effective flexibility practice.

Concluding, there are numerous internal flexibility practices that are being perceived as useful,

and which pursue and achieve the goal of an effective flexibility practice. Also, internal practices in

general are being perceived as more effective than external practices. External flexibility practices are

viewed upon as an indispensable solution, when internal flexibility practices are no longer sufficient.

Home care 3.1 illustrates: “the first step is to look at solutions internally. After that, the step to external

labor needs to be made quickly”. Nursing homes & in-home medical care 2.1 adds: “with the flexible shell

you work from the core outwards. First you will look at the team. If no solution can be found there, you

continue to the department, location, and the organization as a whole”. Also, some practices can be

labeled as being ineffective. Another category are practices which are ineffective according to the used

definition of effectiveness, but who could potentially be effective if implemented in another manner.

These latter group will be outlined in more detail later on.

External flexibility practices

Though organizations have an overall preference for internal flexibility practices, there is also an

external flexibility practices that seem to be effective to organizations; which is the use of hiring and

firing. As the healthcare branch inevitably has to deal with governmental changes, in particular with

regard to funding, the use of hiring and firing provides organizations the option to quickly react to these

kinds of changes by adapting the volume of the workforce.

There are also a number of external flexibility practices that are generally perceived as ineffective

by organizations. A clear example is the use of temporary agency workers. Although this provides a

solution when almost all other internal and external flexibility practices are no longer sufficient,

organizations prefer to avoid the use of this practice due to its high costs. Another flexibility practice

which is mainly ineffective is encouraging employees to adapt to the external labor market. Due to

current and expected labor shortages in healthcare, respondents prefer not to use this practice too often

in fear of losing qualified potential. A third external practice is to vary wage due to subsidiaries. This is

currently not applicable in the healthcare branch, and also not perceived as desirable by respondents.

Lastly, both external cooperation and an external flex pool seem ineffective to the responding

organizations. Organizations encounter some difficulties when they would want to implement this

practice. The Dutch government wants to stimulate competition within the healthcare branch, which

discourages employers to cooperate, also on the area of personnel. Though, the latter two practices could

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potentially be effective in the future when implemented to achieve the goal of aligning the supply of labor

as closely as possible to the demand of labor.

Table 4 combines all the previously described advantages and disadvantages of the various

flexibility practices. The practices are categorized as either effective or ineffective. This is based on the

measurement of effectiveness as described in the methodology section.

Table 4 Advantages and disadvantages of flexibility practices

Effective

flexibility

practices

Advantages Disadvantages

Contracts with

variable hours

- creates a buffer for ad hoc

absenteeism

- contribute in forming a flexible shell

- when every employees has a small

amount of variable hours this creates

a large flexible shell

- to the organization: employees can claim

a larger amount of working hours

according to article 7:610a BW

- to the employee: are forced to work the

maximum contracted hours when the

employer requires this.

Short term

contracts

- provides the opportunity to

organizations to get familiar with the

qualification level of employees

without directly committing to a long-

term employment relation

- employees could easily be laid off

when necessary

- causes high employee turnover

- therefore investments in recruitment,

selection, and education could easily be

lost

- has negative effects on the image of the

organization as an attractive employer

Part-time

contracts

- are attractive to female employees

- are easily to schedule for peak

moments a day in healthcare

- in case of temporary increased

workload, this contracts provide room

to increase the amount of worked

hours

- due to peak moments of the demand of

care it is hard to offer fulltime contracts

- this makes it difficult for organizations to

attract new young employees who

generally prefer fulltime contracts

Internal flex

pool

- has the potential to make temporary

agency workers redundant which is

cost-efficient

- employees in the flex pool have a

relatively long probation period, and

could be hired later

- employees have the opportunity find

the activities, colleagues, and

- negatively affects employee involvement

- employees miss the familial element of

working in a team

- demand for specialized functions is

difficult to realize with an internal flex pool

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department of their preference

-can be used to fill in short and long

term demands for labor

Hiring and

firing

- advantageous to organization when

rapid cuts or growth of the workforce

is necessary

- causes discontinuity to employees and

clients

- negatively affects employee involvement

Ineffective

flexibility

practices

Advantages Disadvantages

Deviate from

minimal CLA*

Temporary

agency

workers

Adapt to

external labor

market

Vary wage

due to

subsidiaries

External flex

pool

External

cooperation

- employees could benefit from

additional facilities

- offers a solution in case of a demand

for a specialized function

- offers a possibility to find personnel

when almost all other flexibility

practices do not provide a solution

any more

- provides the opportunity to part

from employees who no longer fit

with the organization

- it perceived to be potentially

beneficial by organizations

- over- and under capacity can be

leveled between organizations by

exchanging vacancies

- is aimed at providing products or

services to clients

- there is little room within the CLA* for

extensive deviation

- offers no clear advantage to the flexibility

labor

- negatively affects the financial turnover

of an organization

- is therefore perceived as undesirable to

organizations

- due to expected labor shortages in

healthcare, organizations do not

unnecessarily want to lose qualified staff

- varying wage is unattractive as it causes

competition between organizations in the

branch. This competition is prevented by

using the pre-determined wages according

the CLA*

- organizations currently prefer to focus on

optimizing the functioning of the internal

flex pool

- use of this practice is complicated by the

Market regulation- and Market

competition law and the control bodies

- organizations avoid this practice out of

fear of receiving extensive fines

- use of this practice is complicated by the

Market regulation- and Market

competition law and the control bodies

- organizations avoid this practice out of

fear of receiving extensive fines

38

Education and

training

Performance-

related pay

Internal

exchange of

staff

- ensures vertical and horizontal

growth of employees

- could increase the functional

flexibility of employees

- would therefore create an increased

flexible workforce

- that is able to internally level over-

or under capacity between

departments

- would provide an more fair

distribution of wage according to the

quality of performance

- contributes to increased functional

flexibility of employees

- provides the possibility to internally

level over-and under capacity and

could therefore save costs.

- the practical use of this practice is

currently not aimed at creating an multi-

skilled workforce

- achieving increased employability is

currently no goal of this practice

- is perceived to lead to negative

consequences on the quality of care

- currently there is no proper assessment

system

- demands a change in the mindset of

employees

- this practices is currently underutilized

by organizations

* Collective labor agreement

4.2.3 Other results

Due to the open character of semi-structured interviews, some additional topics related to

flexible labor were discussed. These will be outlined next.

Changes in society

A widespread comment that was made on the use of flexible HR practices, was that the overall

mindset of society is changing to a more flexible state. Causes mentioned for this movement were

increased individualization and commercialization. This manifests itself, inter alia, through larger amounts

of funding to areas that political leaders indicate as more important, which currently is the nursing homes

& in home medical care sector. Also a movement to more extramural and informal care derives from

increased individualization and commercialization. Disabled care 5.2 illustrates: “the mindset of society is

changing. Flexible employment will increasingly be used in healthcare I think. Eventually, this will certainly

benefit clients. The client will increasingly be able to be the director its own healthcare process”.

Additional 6.2 adds: “with flexible ways of working you can easily react on the demand of care in a high

39

qualitative manner”.

Several possible causes of this changing mindset on healthcare and HR flexibility practices were

mentioned by respondents. General societal motives for more flexible ways of working that were

mentioned are individualization and commercialization. Motives that specifically apply to the healthcare

branch were that people in general live longer, and stay at home longer which requires different kinds of

care. Also, the way healthcare is financed was recently changed by the Dutch government. This led to the

possibility to tie a direct link between a clients’ available finances due to subsidiaries for healthcare and

the personnel costs that are made for a specific client. A majority of the respondents mention financial

necessity as a main motive to implement flexibility practices, and thereby cut costs. Disabled care 5.3

illustrates: “It [changing mindset on healthcare] is related to finances. With the new way of financing

healthcare we can better regulate the demand of care and the supply of labor which should be attached

to that”.

Another element of this changing mindset is that the position of the client in the process of

healthcare is not experienced as satisfactory at the moment. Though virtually all formal organization

vision and mission describe that the client is the focal point, organization experience that planning of

personnel does not reflect this vision. The planning is in most organizations still mainly focuses on

preferences and wishes of employees. Hospital 1.1 illustrates: “Meeting expectations of the customer,

that is what it is all about. We are still organized around the professional. The planning is based on the

availability of our employees. I think we should base the planning on whether customers have a demand

for care”. This changing mindset on how healthcare should function is also likely to affect the

employment relationship according to respondents. Disabled care 5.2 illustrates: “I think we ought to

consider whether the types of current employees still fit with the kind of healthcare we want to provide.

This discussion could also lead to a conclusion whereby certain employees to not fit the organization

anymore, with a possibility of a dismissal”.

Forecasting

Another notable results is that the organizations that can be labeled as strategic partner

emphasize the use of forecasting. In the context of flexible use of labor, forecasting is used to predict the

demand of healthcare and the supply of labor which fits this demand. In this way organizations are

partially able to anticipate on fluctuations. Forecasting is mainly long term oriented, as it takes

considerable time to achieve effective HR flexibility practices based on forecasted trends. Hospital 1.1

illustrates: “We want to know what the trends are. Some other organizations choose to apply a flexible

40

percentage, for example 90% fixed employees and 10% flexible employees. We have some doubts on that

method. For some departments within our hospital this could work. However, other departments like

geriatrics are always full. There a 10% flexible shell would not be useful”.

Some examples of forecasting personnel planning is that hospital 1.2 is aware of the fact that

there is an average of 10 pregnant employees a year, who will go on maternity leave. Also hospital 1.1

found out that nine months after summer holiday, there is an increased amount of births, which also

leads to an increased amount of babies in the children’s department of the hospital. These are examples

of fluctuations which are known in advance, and could be taken into account in the yearly personnel

planning.

Geographical area

The geographic area from which data was collected are the provinces of Noord-Brabant and

Limburg in the Netherlands. However, respondents implicate that there are large demographic

differences within this area. Mental care 4.2 illustrates: “demographic developments are largest In

Limburg. The aging of the population is the fastest in this region”, in particular the south of Limburg.

These demographic differences could have different implications on the outcomes of this

research. For example, in the south of Limburg there is a large shortage of labor in healthcare. Therefore,

employees have a relatively powerful position in contrast to the employer. As flexibility practices

implicate increased job insecurity, this would not be attractive to new employees. So, it could have a

negative effect on the amount of flexibility practices that are used in the south of Limburg. This cannot

necessarily be concluded from the relatively small dataset in this research. Overall, there seems to be a

relatively high absenteeism in the province Limburg as compared to Noord-Brabant. A possible

explanation for this phenomenon could be that older people often suffer more medical ailments.

Self-scheduling and decentralism

Another unforeseen result that was mentioned by a number of employees, is an increased

emphasize on self-scheduling and decentralism. Two participating organizations have already

implemented this approach to personnel planning. Home care 3.1 illustrates: “Employees indicate: give us

complete control over the clients and our team. Then we will regulate the process much more efficiently”.

Next to increased efficiency, the rationale behind implementing a structure of small, independently

functioning teams, suggests that this would lead to an increased sense of responsibility of employees.

Home care 3.1 states: “in a large team, nobody takes responsibility”. Nursing homes & in-home medical

41

care 2.2 and home care 3.1 illustrate: “Individuals functioning in a small team experience an increased

amount of responsibility. When they are feeling a little ill, they are less like to call in sick because they will

have the feeling to let down their team, and to create a planning problem for another team member”.

This quotation suggests that absenteeism will decrease due to self-scheduling and the implementation of

working in small scale teams.

However, control is not handed over completely to the operational staff. “The team manager sets

a framework in which the team is free to act” (Nursing homes & in-home medical care 2.2). However,

home care 3.1 does warn for a disadvantage of implementing small scale teams and self-scheduling.

Namely, that employees might feel over responsible and get overloaded by the amount of responsibility.

For this matter, support should be offered.

Overall, implementing self-scheduling in seen to lead to increased efficiency in the amount time

that can be spend directly on clients. “Also the organizations want to achieve that teams will become

more flexible” (Nursing homes & in-home medical care 2.2).

To conclude, in figure 2 a visual model of the described HR flexibility practices and their main

effects is presented. This model does not suggest causal effects between the different variables. It reflects

relationships between different flexibility practices and their effects, as emerged from the interviews with

healthcare organizations as described in the results chapter.

42

Internal flexibility practices

External flexibility practices

Figure 2 Model on the effects of HR flexibility practices

Contracts with variable hours

long-term effects

Contextual factors

Education & training

Part-time jobs

Short term contracts

Performance-related pay

Deviate from CLA

Internal flex pool

Exchange of staff

Employee satisfaction

Absenteeism

Employee turnover

Employee involvement

Quality of delivered care

Hiring and firing

Temporary agency workers

Adapt to external labor market

Vary wage due to subsidiaries

External flex pool

External cooperation

long-term effects

Employee satisfaction

Employee turnover

Absenteeism

Employee involvement

Quality of care

Work-life balance

Financial turnover

Client satisfaction

Work-life balance

Financial turnover

Client satisfaction

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5. Conclusion and discussion

In this chapter we reflect on the research question: What are short-term and long-term effects of

flexibility practices in healthcare, and which factors influence the use and effectiveness of flexibility

practices from an HR managerial perspective?

The largest motivator to explain the increased use of flexibility practices, is the financial necessity

that healthcare organizations currently experience to cut costs or operate more efficiently (Boxall et. al,

2011). Flexibility labor practices contribute to both those aims. However, the various flexibility practices

have different effects to different stakeholders. It can be concluded that overall, the use of flexible HR

practices is aimed at achieving long term effects. One exception is the use of the practice hiring and firing.

This is often done to adapt to the current labor demand on the short term. For example when

organizations are confronted with a lowered government funding which makes downsizing necessary, as

in currently the situation in mental healthcare.

5.1 Short- and long-term effects

From an organizational perspective, flexibility practices are perceived as having a positive effect

on the financial turnover on the long term. However, due to the exploratory nature of this research, no

causal link between implementing flexibility practices and increased profitability can be made. Also,

results show a positive effect of flexibility practices on employee satisfaction, and absenteeism is said to

decrease on the long term (Dalton & Mesch, 1990). Further, employee turnover is said to be higher

among employees working with flexibility practices. This is not necessarily a bad thing as an average

amount of employee turnover is perceived to be beneficial for the organization. However, this contradicts

with implications from literature which state that employee turnover would decline due to flexibility

practices, as forced quits are prevented by being able to fluctuate in the total number of working hours

(Di Tella & MacCulloch, 2005). Increased employee turnover could be explained by an increased job

insecurity of employees, that leads them to relatively quickly change to a more stable form of

employment.

A downside of flexibility practices is a decrease of employee involvement with the organization. A

decrease in employee involvement was not indicated to result from an incompatible psychological

contract of the employee and the employer as mentioned in the introduction, in which the employee

feels the psychological contract is broken. It was mainly caused due to the lack of a feeling of binding with

a fixed team and fixed clients. Last, quality of the delivered care and work-life balance are mentioned as

effects of flexibility practices. Based on the data, no uniform conclusion on these two effects could be

44

made, on whether they positively or negatively affect employees working with flexibility practices.

However, Thomas and Ganster (1995) found that employees with access to flexible scheduling

experienced less work-family conflict.

Further, scientific literature confirms the view that increased job insecurity is one of the largest

negative effects of flexibility practices on employees (Cörvers et. al., 2011; Dekker & Achterberg, 2008;

Roehling et. al., 2000). Job insecurity is also associated to the investigated effects in this research. Batt

and Valcou (2003) found that job insecurity is positively related to turnover intentions, and negatively

related to work-life balance. This statement would mean that implementation of flexibility practices in

general would lead to increased employee turnover and work-life conflicts. Moreover, effects on turnover

and work-life balance could also vary between different practices. Further research is necessary to

indicate the effect of different flexibility practices on employee turnover.

Lastly, organizations perceive that the use of flexibility practices affects client satisfaction, either

positively or negatively. However, viewpoints on this matter are highly differentiated. Though, it can be

concluded that organizations perceive the position of the client in the organization unsatisfactory at the

moment as compared to the position of the employee. The planning is often based on the availability of

the professional, not on the demand of care of the client. A consequence of a personnel planning that

puts the employees’ wishes first, is that there is almost inevitably over- or under capacity of personnel.

Déhora Consultancy Group (2012) recently researched the consequences of over- and under capacity, and

showed that 35% of respondents indicated to make extra costs as a result of hiring extra personnel, and

42% indicated that overtime was made in case of under capacity (http://www.penoactueel.nl/

nieuws/werktijdenvoorkeur-grootste-uitdaging-personeelsplanning-8420.html). These extra costs could

be lowered when a closer link between clients demand and the deployment of workers would be made.

5.1.1 Best practice or best fit

To achieve a closer fit between the clients demand and personnel planning, there is not optimal

percentage of a flexible shell. In the introduction, optimal percentages ranged from 20% to 34%.

However, results show that there is no best practice in applying a flexible shell. A best fit approach seems

to be most suitable in achieving an ideal percentage of flexible employment. Several vulnerable groups of

client, especially in the disabled care sector, are indicated to benefit most from continuity, also in staff.

Here a small flexible shell would be desirable. Also with regard to the various flexibility practices no best

practice can be appointed. The choice for a particular flexibility practice depends on the intended goals or

effects that the organization is attempting to reach. An example of two effects that often conflict with

45

each other are employee satisfaction and cost-efficiency. Also, no clear distinction between the five

subsectors in healthcare could be made.

Organizations have indicated that the leading goal of all flexibility practices is to fit the demand

for care of client as closely as possible to the deployment of personnel. Besides this main goal,

organization often have certain sub goals like improving client satisfaction or lowered the absenteeism

rate. Though, these sub goals seemed to be inferior to the main goal. As the main goal can be achieved via

various flexibility practices, for example internal exchange of staff or an internal flex pool, the sub goals

could cause organizations to choose for different flexibility practices that fit closest to their sub goals.

Overall, most important results from scientific literature indicate that it is not the individual HR

practices that are effective, but the coherent set of practices (Batt & Valcou, 2003, Boxall et. al, 2011).

Also, the effects investigated in this study are connected. Mudor and Tooksoon (2011) indicate that job

satisfaction significantly affects employee turnover. Also, an unbalance in the work-life situation is shown

to cause increased turnover (Batt & Valcou, 2003).This implies that the various effects of flexibility

practices are also interconnected.

5.2 Effectiveness of flexibility practices

No best practices can be appointed on which flexibility practices are universally effective and

which are ineffective. Though, based on the leading goal of flexibility practices to achieve a close fit

between demand of care en deployment of personnel, some practices could generally be appointed as

effective or ineffective from an HR managerial perspective. Therefore, some practices that were clearly

perceived as effective or have the potential to become effective in the future will be explained in more

detail.

5.2.1 Effective flexibility practice

The flexibility practice that could be indicated as most effective at the moment, is the use of an

internal flex pool. Notwithstanding that this flexibility practice is relatively new to the responding

organizations. In a quiet short period of time, this flexibility practice was implemented by the majority of

the organizations in this research. Respondents indicate that this practice is particularly aimed at the goal

of an effective personnel planning. It was also indicated that the functioning of the internal flex pool could

still be optimized on areas as structure, types of contracts, and optimal size. This means that the size of

the internal flex pool in most cases could be extended to cope with all labor fluctuation internally, instead

of being forced to utilize external flexibility practices which organizations do not prefer. In order to realize

46

this, the scope of functions should also be broad enough to cope with labor fluctuation in different

functional areas. However, employee involvement was shown to be lower among employees within the

internal flex pool. This could be addressed by for example ensuring that the internal flex pool has its own

manager, work meetings, team trip etc.

5.2.2 Potentially effective flexibility practices

Also, there are a number of flexibility practices that are currently classified as ineffective, but

have the potential to be effective. A flexibility practice that can be considered as such, is the use of

performance-related pay. Though none of the participating organizations in this research uses this

practice, over half of the respondents does not exclude that PRP could potentially be beneficial to their

organization, provided that there is a sturdy assessment method. This because PRP could stimulate

employees to extra effort (Delfgaauw, 2005). Scientific literature indeed indicates that performance-

related pay lead to higher employee productivity (Gielen, Kerkhofs & Van Ours, 2006). Though, Gielen et.

al. (2006) indicate that only 10% of healthcare organizations used PRP in 2001, while in the construction

sector this was 56%. A possible reason mentioned for this difference is that whereas performance and

output is relatively easy to measure in construction, this is not the case in healthcare. Also, respondents

question the effectiveness of this practice as it is topic to an ethical debate. This debate is mainly about

the discussion whether PRP would undermine the humanity of healthcare; it would encourage employees

to focus on quantity rather than quality (Cowling, 2000). Moreover, it has the potential to become topic

of political debate, and media attention. This could be a reason for organization to exercise restraint in

implementing this flexibility practice.

Overall, PRP could prove to be effective in healthcare in the future. Delfgaauw (2005) also

indicates that performance-related pay would be desirable in healthcare, especially due to the predicted

labor shortages. This is likely to cause an increase in employees’ wages due to their reinforced market

position. Therefore, linking pay to performance could positively affect the efficiency of work.

Education and training

Another flexibility practice that is currently ineffective, but has the potential to become effective

in healthcare organization is the use of education and training. Currently this practice is only used to

assure vertical and horizontal growth of employees. Groot and Maassen-van den Brink (2000) indicate

that though this increased employees’ qualifications, it does not significantly increase employability.

Groot & Maassen-van den Brink (2000) indicate that especially in more simple jobs functional flexibility

47

increases the possibility for employees to be employed elsewhere in the organization. Specifically for

healthcare, this would implicate that organizations benefit most from investing in job functions like nurse

level 3 (in Dutch: verzorgende) and nurse level 2 (in Dutch: helpende). However, a possible issue in the

use of this practice is the willingness of employees to participate in an educational process. Immink (1994)

showed that the longer employees did not attend education, the lower their willingness to participate in

education and training was.

Overall, by increasing employees’ functional flexibility through education and training, employees

could be retained within the organization even though the content of the job is changed (Delsen, 1998). A

reason why this is desirable, is that is provides a possible solution to the fact that organizations in

healthcare often cannot provide a fulltime contract as they have to deal with peak moments a day. Due to

this phenomenon, they experience difficulties to attract and retain young employees, who often prefer to

work a relatively large amount of hours. An example of such a problem, is present in nursing homes and

in-home medical care. In the morning a relative large amount of employees is necessary to assist clients

with getting out of bed etcetera. However, in the afternoon a much smaller amount of staff is required.

When employees do want to work fulltime, this is not always possible. Another possibility could be to

work for example in child daycare in the afternoons, as this sectors experiences a peak in the afternoons

after school time. However, this would require closer cooperation between organizations.

However, cooperation between organizations is a flexibility practices that is also labeled as

ineffective in this research. Currently, organizations are reluctant in external cooperation relating to

employment out of fear to receive extensive fines of the implementing agencies of Dutch labor law. The

current focus of organizations is on the restrictions of external cooperation, not on opportunities.

However, the question is also whether an increased focus on external cooperation would be desirable.

According to respondents of this research, external cooperation will become increasingly important in

healthcare. Advantages that external cooperation could bring to organizations is increased access to

information, use of economies of scale in for example providing training to employees, and to level out

over- and under capacity in personnel. A success factor that is mentioned in scientific literature is when

healthcare organizations make standard agreements between on topics involved in the cooperation

(Boon & Bastiaanse, 1995). However, currently no objective statements can be made on the financial

benefits from external cooperation (Boon & Bastiaanse, 1995). More research in needed to make

statements on the effectiveness of external cooperation among healthcare organizations.

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Internal exchange of staff

A last, and major undervalued practice is the use of internal exchange of staff. Organizations

indicated to only occasionally use this flexibility practice, and on a small scale. The current major flaw of

this practice seems to be a lack of knowledge, on which departments experience overcapacity, and which

experience under capacity. When this is known, the organizations could save personnel costs by

exchanging internal staff between departments of locations. Also, forecasting could prove to be useful in

predicting over- and under capacity.

An option to enhance employability of the workforce is to create the opportunity of job rotation.

In this way organizations would be better able to handle over- and under capacity between departments.

This increased mobility throughout the organization is said to benefit the organization as it would increase

employees’ motivation (Ortega, 2001). Simultaneously, internal exchange of staff is connected to

education and training, as job rotation is said to increase firm learning (Ortega, 2001). Also, it is a way to

retain employees within the healthcare branch. Moreover, job rotation also provides advantages to

employees by providing them the opportunity to develop their professional qualities (Ortega, 2001). The

use of the flexibility practice internal exchange of staff could for example be enhanced by distributing

information on other proceedings of other departments throughout the organization.

Employees’ preferences

An important note in the effectiveness of flexibility practices, is that employees’ preferences

highly affect the effects and effectiveness of flexibility practices. So, whether (s)he is satisfied with a

certain flexibility practice or not. Nishii, Lepak & Schneider (2008) support this statement by indicating

that “employees’ perceptions on HR practices are likely to precede the employee attitudes and behavior”

(p. 4). Therefore, employees’ perceptions should be taken into account when translating HR practices into

desired organizational outcomes. The main disadvantage of flexibility practices to employees is increased

job insecurity (Cörvers et. al., 2011; Dekker & Achterberg, 2008). Also, the growing emphasize on

employability demands a certain amount of extra mobility of employees, which lead to increased job

insecurity (Heikant, 1996). However, others indicate that employability enhances job security instead of

decreasing it. In highly uncertain times employees with higher functional flexibility would be more likely

to be retained within the organization (Ortega, 2001).

Overall, though respondents indicate that the demand of the client should be the starting point

of personnel planning, and flexibility can be created by using various types of flexibility practices, a certain

degree of balance should be preserved between the three main stakeholder in order for the relationship

49

to be effective. These are, the client, employee, and organization.

7. Limitations

One of the greatest strengths of qualitative research is that is provides rich and detailed

information in an interactive manner. However, some limitations could also be noted. These will be

outlined next.

Mingers (2001) notes that all research is biased in some manner. The main limiting factor to this

research is the size of the sample. Due to the comprehensive nature of the healthcare branch and the

time-consuming nature of semi-structured interviews relatively few respondents represent the different

sub areas in the healthcare branch. This limits the reliability and validity of this research. Also, due to the

exploratory nature of this research and the relatively unexplored topic, it is not possible to claim the

causality and generalizability of findings to healthcare in general. Though, the objective of qualitative

research in general is not to predict but to describe, and occasionally explain events (Willig, 2001). Hence,

respondents were encouraged to provide personal retrospectives and insights on the topic.

Another limitation of the interviews is interviewer bias. This can manifest itself in reflexivity in

which the interviewers personal values and social identify may have affected the interviews and the

conclusions that are drawn (Willig, 2001). Therefore, the research could be guided by assumptions and

paradigms. Besides interviewer bias, respondents’ viewpoints could also be biased. As solely one

respondents was interviewed per responding organization, this could cause a distorted image of the

organizations’ overall point of view.

Moreover, interviewee bias could also distort results. This study has relied on the responses of HR

managers and specialists on the various flexibility practices, their effects, and the associated

effectiveness. However, this does not necessarily mean that conclusions on the effectiveness of flexibility

practices can be made. Rather, conclusions are made on how HR managers view flexibility practices

(Boxall et. al, 2011). Guest (1999) notes that research from an employee perspective often deviates from

results from an HR perspective. Thus, the actual HRM practices could deviate from perceived HRM

practices (Wright & Nishii, 2007). To validate outcomes, multiple interviews should be held in a single

organization with HR or expert managers, and additionally flexibility practices should be assessed through

the eyes of other major stakeholders like employees and clients (Boxall et. al., 2011).

50

8. Recommendations

Recommendations for future research

Some recommendation for future research can be made based on this research. First of all,

conclusions from this research should be interpreted with caution, due to the fact that this research

initially started studying effects of different flexibility practices in healthcare. More research on the

effects and effectiveness of flexibility practices is needed to ensure reliability. Preferably this should be

focused at individual flexibility practices and their effects in order to be able to make detailed conclusions.

Also, this exploratory research has surfaced a number of other potential topics for future research. These

will be outlined.

A topic of interest is that respondents have indicated that increased focus on forecasting of the

demand of labor would be beneficial for the overall efficiency of the personnel planning, and for the care

provided to clients. Future research could review whether forecasting indeed positively affects the cost-

efficiency of personnel planning, and bring benefits to clients, and possibly employees. Especially,

research on the financial consequences of forecasting labor demand would be desirable.

Further, this research has indicated a number of flexibility practices which, in their current use,

are labeled as ineffective, but have the potential to be effective. This means that according to this

research definition of effectiveness, these practices can be seen as ineffective. They do not directly add to

the goal of flexibility practices to achieve a fit between the demand of care of client and the deployment

of personnel. Though, it was also indicated that they do not have large negative consequences. However,

respondents have emphasized the possible effectiveness of these practices when they would be

implemented. Although they are currently not used effectively by their organizations, they could be in the

future they indicated. These are the internal flexibility practices: education & training, and internal

exchange of staff, and the external flexibility practices: external cooperation, and external flex pool. These

four practices are also all related to the subject employability or functional flexibility. Further research

could indicate whether these practices indeed have the potential to be effective, and how these practices

could be implemented to achieve increased employability of the workforce. This could be done by

focusing in depth on the individual four flexibility practices mentioned, in relation to their effects, and

overall effectiveness. Also, besides external cooperation in healthcare as a topic in relation to

employability, also little is known on the effects that external cooperation has on organizations and

employees.

A final recommendation for future research is aimed at the effect of flexibility practices

specifically on clients. Results of this research showed paradoxical views on this topic. While some

51

respondents indicate that clients suffer under the fact that they receive care of a large number of

different staff members with which they are not familiar, others indicate that clients with mental or

physical ailments often lack social contact and benefit from social contact with a larger amount of

different people. This topic is also connected to the vision of healthcare organizations. Are organizations

aiming for continuity to clients, or cost-efficiency. Also, as organization’s indicate to want more emphasize

on clients and less on the professional, it would be useful to research the impact of flexible ways of work

perceived by clients. Therefore, to get more insight in this topic, the effects and effectiveness of various

flexibility practices could be researched from the perspective of clients. How do they experience the

flexible labor practices from the healthcare organizations, and how does this affect their perception of

quality of care.

Practical recommendations

An obstacle in the current use of flexibility practices by organizations, is the resistance that this

topic generates among employees. However, the effectiveness of organizations’ policies depends on the

willingness of employees to support these (Fust & Cable, 2008). Though, flexibility practices are also

aimed to make effective use of labor, and therefore to reduce the amount of labor costs, another

ultimate goal is to realize the right amount, and the right quality of staff with the current demand of care

at any point in time. Therefore, organizations should take the responsibility to persuade employees

towards achieving organizational goals. Possible tactics to achieve this goal are: allowing employees to

help design the change, and explain why change is needed (Fust & Cable, 2008).

Other than resistance of employees, respondents also experienced difficulties with getting line

managers to join to their full capacity in the process of implementing flexibility practices. McGovern,

Gratton, Hope-Hailey, Stiles and Truss (1997) add that the cooperation of line management could distort

the impact of HR practices. Also, it should be prevented that line managers mold HR policies to make

them more ‘workable’ in their specific context (Boxall et. al., 2011). McCarthy, Darcy & Grady, 2010

showed that managers are more likely to adopt and implement practices to which they have a positive

attitude. Therefore, to successfully implement flexibility practices in an organization, adequate attention

should be paid to the role of line management in the process of policy-making and implementation. Line

managers could for example be informed on the possibilities and relevance of flexibility practices. Even

better would be to involve line management in policy-making on flexible use of labor within the

organization, and how the policy could be realized.

Concerning the future direction healthcare is heading, some phenomena should be taken

52

into account that either directly or indirectly influence the use of flexible labor practices. First, Dutch

politics aim for increased emphasize on extramural and informal care. This will require a functional

flexibility of employees that focuses more on extramural care. Flexibility practices like education &

training, external flex pool, external cooperation, and encouraging employees to adapt to the external

labor market could contribute this increased emphasize on extramural care. Another future implication is

that labor law will possibly be adjusted in the future. A number of respondents cited that legislation is not

yet adjusted to an increasingly flexible mindset in the professional environment. The contextually based

human resource theory of Paauwe (2004) suggests that institutional mechanisms like the ones described

above affect the strategic choice of organizations, which in turn affects the choice of HR strategies. Thus,

as organizations are dependent on institutional forces, it would be wise to be alert on current invents and

their possible impact on the organization. An organizations’ flexibility enables it to adjust to contextual

forces like institutional developments. Labor flexibility adds to the overall flexibility of the organization to

respond adequately to contextual developments.

Lastly, respondents indicated the growth of self-employment in the healthcare branch. Self-

employment can be defined as a persons who perform paid work, and are not employees (Bosch & Van

Vuuren, 2010). This form of employment also fits with the increasing individualization and

commercialization. Home care and mental care are mentioned as the two main sectors within healthcare

where employees consider to switch to self-employment (De Veer & Francke, 2009). This could be

explained by the highly independent nature of proceedings in home care. Also treatments of

psychological disorders in mental care require independent functioning of employees. However, this

flexibility practice was not included in this research. Future research could provide more insight in the

effectiveness of self-employment. For example does it positively affect financial turnover, or employee

satisfaction. What are effects on the quality of care experienced by the organization and the employee,

and what is the perception on the quality of care of clients.

53

Reference list

Aday, L. A., Begley, C. E., Lairson, D. R., & Slater, C. H. (1999). Evaluating the healthcare

system: Effectiveness, efficiency, and equity. Journal of Policy Analysis and Management,

18(4), 693–723.

Ancarani, A., Di Mauro, C., & Giammanco, M. D. (2009). How are organisational climate models and

patient satisfaction related? A competing value framework approach. Social Science & Medicine

69, 1813–1818. doi:10.1016/j.socscimed.2009.09.033

Batt, R., & Valcou, P. M. (2003). Human resource practices as predictors of work-family outcomes and

employee turnover, Industrial relations. a Jounal of Economy and Society, 42(2), 189-220.

DOI: 10.1111/1468-232X.00287

Beex, J. (2009). Van zakelijk kwaliteitsdenken naar kwalitatief zorgetisch hulpverlenen: Een bestudering

van de rol van kwaliteitsmedewerkers in de ouderenzorg (Master’s thesis, Tilburg University, the

Netherlands). Retrieved from http://arno.uvt.nl/show.cgi?fid=95819

Bhattacharya, M., Gibson, D. E., & Doty, H. (2005). The effects of flexibility in employee skills,

employee behaviors, and human resource practices on firm performance. Journal of

Management, 31 (4), 1-19. doi: 10.1177/0149206304272347

Bosch, N. M., & Van Vuuren, D. J. (2010). De heterogeniteit van zzp’ers, Economische Statistische

Berichten, 95(4597), 682-684.

Boxall, P., Hwee Ang, S., & Bartram, T. (2011). Analysing the ‘black box’ of HRM: Uncovering HR goals,

mediators, and outcomes in a standardized service environment. Journal of Management

Studies, 48 (7), 1504-1532. doi: 10.1111/j.1467 6486.2010.00973.x

Buyx, A., Friedrich, D., & Schone-Seifert, B. (2011). Rationing healthcare by effectiveness. British Medical

Journal, 342(7792), 531-534. Coppens, M. (2010). HRM and the HR function in Dutch healthcare organizations (Master’s thesis,

Tilburg University, the Netherlands). Retrieved from http://arno.uvt.nl/show.cgi?fid=106223

Cörvers, F, Euwals, R., & de Grip, A. (2011). Labour market flexibility in the Netherlands: The role of

contract and self-employment. Den Haag: CPB.

Cowling, M. (2000). Performance related pay in Belgium and The Netherlands. Applied economics

letters, 7(10), 653-658. doi:10.1080/135048500415969

Crabtree, B. F., & Miller, W. L. (1999). Doing qualitative research. Thousand Oaks CA: Sage.

Cummings, T. G., & Worley, C. G. (2009). Organizational development & change, South-Western

Cengage Learning: Mason, OH.

Dalton, D. R., & Mesch, D. J. (1990). The impact of flexible scheduling on employee attendance and

turnover. Administrative Science Quarterly, 35, 370-87.

54

De Haan, J., Kwakkel, J. H., Walker, W.E., Spirco, J., & Thissen, W. A. H. (2011). flexibility and related

concepts have been proposed as ways to deal with the uncertainties that the future. Elsevier,

43, 923-933. doi:10.1016/j.futures.2011.06.002

Dehóra Consultancy Group (2012). Retrieved from http://www.penoactueel.nl/nieuws/

werktijdenvoorkeur-grootste-uitdaging-personeelsplanning-8420.html on June 5th 2012.

De Veer, A., & Francke, A. L. (2009). Werken als zelfstandige, of toch maar niet? Tijdschrift voor

Verpleegkundigen, 7/8, 34-35.

Dekker, F., & Achterberg, P. (2008). Flexibel werken tijdens laagconjunctuur: De arbeidsmarktpositie van

flexwerkers. Tijdschrift voor Arbeidsvraagstukken, 24 (2), 114-124.

Delfgaauw, J. (2005). Marktwerking in de zorg en de kosten van arbeid. Economische Statistische

Berichten, 4458, 180-181.

Delsen, L. (1998). Zijn externe flexibiliteit en employability strijdig. Tijdschrift voor HRM,

2, 27-46

Denzin, N. K., & Lincoln, Y. S. (1994). Introduction. Entering the field of qualitative research. In: Denzin,

N. K., & Lincoln, Y. S. (eds.). Handbook of qualitative research. Thousand Oaks: Sage.

Di Tella, R., & MacCulloch, R. (2005). The consequences of labor market flexibility: Panel evidence based

on survey data. European Economic Review, 49, 1225 – 1259.

doi:10.1016/j.euroecorev.2003.11.002

European Commission. (2004). Facing the challenge; The Lisbon strategy for growth and

employment. Luxembourg: Office for Official Publications of the European Communities.

Eurostat (2009). Labour market latest trends. Retrieved January 23th, 2012 from http://epp.eurostat.ec

.europa.eu/cache/ITY_OFFPUB/KS-QA-09-035/EN/KS-QA-09-035-EN.PDF.

Fujisawa, R. & Colombo, F. (2009). The long-term care workforce: Overview and strategies to adapt

supply to a growing demand. OECD Health Working Papers, 44. http://dx.doi.org /10.1787/

225350638472

Fust, S. A., & Cable, D. M. (2008). Employee resistance to organizational change: Managerial influence

tactics and leader–member exchange. Journal of Applied Psychology, 93(2), 453–462.

Gielen, A., Kerkhofs, M., & Van Ours, J. (2006). Prestatiebeloning en productiviteit. Economische

Statistische Berichten, 91(4491), 373-375.

Gregory, B. T., Harris, S. G., Armenakis, A. A., &, Shook, C.L. (2009). Organization culture and

effectiveness: A study of values, attitudes, and organizational outcomes. Journal of Business

Research, 62, 673-679. doi:10.1016/j.jbusres.2008.05.021

Groot, W., Maassen - van de Brink, H. (2000). Education, training and employability. Applied Economics,

32(5), 573-581. doi:10.1080/000368400322471

55

Guest, D. E., Oakley, P., Clinton, M., & Budjanovcanin, A. (2006). Free or precarious? A comparison of the

attitudes of workers in flexible and traditional employment contracts. Human Resource

Management Review 16, 107–124. doi:10.1016/j.hrmr.2006.03.005

Heikant, E . (1996) . Employability bij de ABN AMRO Bank: onderzoek naar de inzetbaarheid

van administratieve medewerkers in commerciële functies in het district midden Brabant,

Afstudeerscriptie.

Hiltrop, J. M. (1995). The changing psychological contract: The human resource challenge of

the 1990s. European Management Journal, 13(3), 286-294.

Immink, B. (1994). Preventief leeftijdsbewust personeelsbeleid, Afstudeerscriptie

Kabene, S. M., Orchard, C., Howard, J. M., Soriano, M., & Leduc, R. (2006). The importance of human

resources management in Health care: A global context. Human Resources for Health, 4(20),

doi:10.1186/1478-4491-4-20

Keller, B., & Seifert, H. (2005). Atypical employment and flexicurity. Management Revue, 16(3), 304

- 323.

Kelliher, C. (1989). Flexibility in employment: Developments in the hospitality industry. International

Journal Hospitality Management, 8(2), 157-166.

Läubli, M. (2010). De flexpool. Sigma, 5, 38-42.

Lepak, D.P., Takeuchi, R., & Snell, S. A. (2003). Employment flexibility and firm performance: Examining

the interaction effects of employment mode, environmental dynamism, and technological

Intensity. Journal of Management, 29(5), 681–703. doi:10.1016/S0149-2063(03)00031-X

Mandal, A. (2007). Quality and cost-effectiveness – effects in burn care. Elsevier, 33, 414-417.

doi:10.1016/j.burns.2006.08.035

McCarthy, A., Darcy, C., & Grady, G. (2010). Work-life balance policy and practice: Understanding line

manager attitutes and behaviors. Human Resource Management Review, 20(2), 158-167.

http://dx.doi.org/10.1016/j.hrmr.2009.12.001

McGovern, P., Gratton, L., Hope-Hailey, V., Stiles, P., & Truss, C. (1997). Human resource management

on the line? Human Resource Management Journal, 7(4), 12-29.

Milliman, J., Von Glinow, M.A., Nathan, M. (1991). Organizational life cycles and strategic international

human resource management in multinational companies: Implications for congruence theory.

The Academy of Management Review, 16, 318-339.

Mingers, J. (2001). Combining IS research methods: Towards a pluralist methodology. Information

Systems Research,12(3), 240-259.

Mudor, H., & Tooksoon, P. (2011). Conceptual framework on the relationship between human resource

management practices, job satisfaction, and turnover. Journal of Economics and Behavioral

56

Studies, 2(2), 41-49.

Nishii, L. H., Lepak, D. P., & Schneider, B. (2008). Employee attributions of the “why” of HR practices:

Their effects on employee attitudes and behaviors, and customer satisfaction. Personnel

Psychology, 61, 503-545.

Ortega, J. (2001). Job rotation as a learning machine. Management Science, 47(10), 1361-1370.

Paauwe, J. J. (2004). HRM and performance : Achieving long-term viability. Oxford University Press.

Platform GGZ (2007). Zorgzwaartepakketten GGZ.

Porter, L. W., Steers, R. M., Mowday, R. T., & Boulian, P. V. (1974). Organizational commitment, job

satisfaction, and turnover among psychiatric technicians. Journal of Applied Psychology, 59,

603-609.

Possenriede, D. (2011). The effects of flexible working time arrangements on absenteeism –

the Dutch case (Working paper). Retrieved from http://doku.iab.de/veranstaltungen/2011/

ws_flex2011_possenriede.pdf on February 27th

2012.

Qin, R., & Nembhard, D. A. (2010). Workforce agility for stochastically diffused conditions: A real options

perspective. International Journal of Production Economics, 125, 324–334.

doi:10.1016/j.ijpe.2010.01.006

Roehling, M. V., Cavanaugh, M. A., Moynihan, L. M., & Boswell, W. R. (2000). The nature of the

employment relationship. Human Resource Management, 39, 305-320.

Rousseau, D. M. (1990). New hire perceptions of their own and their employer’s obligations: A study of

psychological contract. Journal of Organizational Behavior, 11(5), 389-400.

Raad voor Volksgezondheid & Zorg (2010). Ruimte voor arbeidsbesparende innovaties in de zorg: Door

slimmer werken meer kwaliteit met minder mensen. Retrieved from http://www.rvz.net on

June 1th 2012.

Schutt, R. K. (1996). Investigating the social world: The process and practice of research, 1th ed.

Thousand Oaks, CA: SAGE Publications.

Thomas, L. T., & Ganster, D. C. (1995). Impact of family-supportive work variables on work-family

conflict and strain: A control perspective. Journal of Applied Psychology, 80(1), 6-15.

Ulrich, D. (1997). Human Resource Champions. Boston, MA: Harvard Business School Press.

UWV (2010). Kennismemo 10 02. Groei van de flexibele arbeid en de gevolgen voor het beroep op WW.

Amsterdam: Kenniscentrum UWV.

Van Delft, J. A. (2011). Zorgt flexibel werken voor behoud van werknemers? (Bachelor thesis,

Universiteit van Utrecht, the Netherlands). Retrieved from http://igitur-

archive.library.uu.nl/student-theses/2011-1111-200544/AfstudeerscriptieJudithvanDelft.pdf on

February 27th

.

57

Wadhwa, S., & Rao, K. S. (2003). Enterprise modeling of supply chains involving multiple entities flows:

Role of flexibility in enhancing lead time performance, SIC Journal, 12(1), 5-20.

Walburg, J. A. (1997). Integrale kwaliteit in de gezondheidszorg. Deventer: Kluwer.

Willig, C. (2001.) Introducing qualitative research in psychology: Adventures in theory and method.

Philadelphia: Open University Press.

Woittiez, I., & Eggink, E. (2011). Vergrijzing en gebruik van verpleging en verzorging. Economische

Statistische Berichten, 96(4601), 20-22.

World Health Organization (2006). Working together for health: The World Health Report 2006. Geneva,

Switzerland: World Health Organization.

Wright, P. M., & Nishii, L. H. (2007). Strategic HRM and organizational behavior: Integrating multiple

levels of analysis (CAHRS Working Paper #07-03). Retrieved from

http://digitalcommons.ilr.cornell.edu/cahrswp/468

Zijl, M., & van Leeuwen, M. J. (2004). Tijdelijk werk: tussenstap of springplank. Amsterdam: SEO.

Zinsmeister, J. (2005). Leeftijdsbewust personeelsbeleid is noodzaak in zorginstellingen. Gids voor

personeelsmanagement, 84, 1-6.

Zorginnovatieplatform (2009). Zorg voor mensen, mensen voor zorg: Arbeidsmarktbeleid voor de

zorgsector richting 2025.