Multiple jobholding and part-time work among nurses in long-term care homes compared to other healthcare sectors: Evidence from Ontario

Abstract

About two-thirds of Canadian COVID-19 related deaths occurred in long-term care homes (LTCHs). Multiple jobholding and excessive part-time work among staff have been discussed as vectors of transmission. Using an administrative census of registered nurses (RNs) and registered practical nurses (RPNs) in the Canadian province of Ontario, this paper contrasts the prevalence of multiple jobholding, part-time/casual work, and other job and worker characteristics across health sectors in 2019 and 2020 to establish whether the LTCH sector deviates from the norms in Ontario healthcare. Prior to COVID-19, about 19% of RNs and 21% of RPNs in LTCHs held multiple jobs. For RPNs, this was almost identical to the RPN provincial average, while for RNs this was 2.5 percentage points above the RN provincial average. In 2020, multiple jobholding fell significantly in LTCHs after the province passed a single site order to reduce COVD-19 transmission. Although there are many similarities across sectors, nurses, especially RNs, in LTCHs differ on some dimensions. They are more likely to be internationally educated and, together with nurses in hospitals, those who work part- time/casual are more likely to prefer full-time hours (involuntary part-time/casual).

Overall, while multiple jobholding and part-time work among nurses are problematic for infection prevention and control, these employment practices in LTCHs did not substantially deviate from the norms in the rest of healthcare in Ontario.

1. Introduction

Long-term care homes (LTCHs), also known as nursing homes, have been a key battleground in the fight against COVID-19 in Canada (e.g., [1]). As of August 23, 2021, about 6% of reported Canadian COVID-19 cases, and 57% of total deaths, had been linked to LTCHs [2], while 3,793 COVID-19 deaths were reported among Ontario LTCH residents [3]. Demographic and epidemiologic factors partly explain the deaths in Canada's LTCHs, however attention has also focused on long-standing deficiencies in this sector as contributors to COVID-19’s spread within homes [[4], [5], [6]]. For example, three and four person rooms and other design issues associated with older facilities are key drivers of cross-infection and rapid spread of infectious diseases [[7], [8], [9], [10]].

International comparisons of Canada's LTCH sector's performance during COVID- 19 are ongoing, with preliminary results sometimes making non-standard comparisons due to data limitations. For example, a report by the Canadian Institute for Health Information [11] showed that during the first wave of the pandemic (February 2020 to August 2020), Canada reported the highest proportion of all COVID-19 deaths in LTCHs among 16 other Organisation for Economic Co-operation and Development (OECD) countries. However, the report did not consider, among other issues, the varying shares of individuals living in LTCHs across these nations. In more detailed work, Comas-Herrera et al. [12] show that, as of late 2020, Canada's COVID-19 deaths per LTCH resident were roughly in line with those in other developed countries given the prevalence of COVID-19 in the non-LTCH population, and the share of the population living in LTCHs. These authors found that while in Canada 59% of COVID-19 attributed deaths occurred in LTCHs, this represented 2.6% of the LTCH population, whereas in the United Kingdom these figures were 34% and 7.2% respectively.

Taking both the relative size of the LTCH population and community spread into account are key insights of Comas-Herrera et al. [12] The importance of community spread is also observed in research comparing across regions (typically health regions) in Canada. Deaths per capita in LTCHs are highly correlated with (some would say driven by) the prevalence of COVID-19 in the surrounding community (e.g., [10,13]). Keeping COVID from entering a residence is crucial since the results of such a breach can be devastating given the frailty and proximity of residents. CIHI [14] reports that for Ontario in wave 1, 26 homes, or 5% of the total, accounted for 54% of COVID-19 deaths. Ontario's Long-Term Care COVID-19 Commission discusses many relevant issues in depth (e.g., outdated infrastructure, pandemic unpreparedness, and staffing instability) [15].

Provincial governments have been urgently seeking to stop the introduction of the disease into LTCHs and its spread [16,17]. Lockdowns dramatically reducing the number of visitors were a key response. Other key factors discussed as vectors for the spread of COVID-19 are multiple jobholding [18], and excessive part-time work that increases the number of persons entering each home. Some provincial governments in Canada, including Ontario, introduced regulations to stop multiple jobholding in LTCHs [17]. Past studies have shown multiple jobholding and part-time work to be a common phenomenon in healthcare [[19], [20], [21], [22]]. Part-time and casual work may be more common in healthcare due to budget constraints and demands to provide around the clock care where service intensity has time-of-day peaks and troughs [[23], [24], [25]]. On the supply side, nurses have diverse preferences. Part-time/casual working arrangements are desirable for many [24], while at the same time involuntary part-time work is also common and monitored by the Ontario government.

Recent studies in the United States (U.S.) have looked at the extent of multiple jobholding in LTCHs. Van Houtven's [26] study of 30 nursing homes in the northeastern U.S. find LTCH workers commonly hold second jobs, with one in six workers reporting a second job of 20 hours or more. Baughman et al. [27] using the Current Population Survey in the U.S. find approximately 6% of licensed practical nurses and registered nurses hold second jobs. Furthermore, using device-level geolocation data in the U.S., Chen et al. [28] show that 5.1% of individuals present in one nursing home travelled to at least one other nursing home shortly thereafter. The study suggests eliminating these linkages could reduce infections in nursing homes by up to 44%. A similar Ontario study show that human transitions between LTCHs, approximated by cell phone location data, fell sharply – from 42.7% to 12.7% – after a provincial emergency order restricting multiple jobholding in LTCHs [29].

Apart from COVID-19 related issues, this paper presents a useful description of multiple jobholding, and part-time work among nurses across healthcare sectors. This is relevant both to COVID-19 and infection transmission in general. Studying these issues contributes to a long-standing literature in nursing human resources (review articles include: [21,[30], [31], [32], [33]]).

We use an administrative census of registered nurses (RNs) and registered practical nurses (RPNs) in Ontario (called licensed practical nurses or LPNs in the rest of Canada) to ascertain the prevalence of multiple jobholding and part-time/casual work in LTCHs relative to other healthcare sectors. In addition, we examine demographic and work characteristics.

2. Methods and materials

Administrative data used with provincial permission (Hamilton Integrated Research Ethics Board project 10947) from Ontario's Health Professions Database (HPDB) are employed in the study. This database derives from regulatory college registration records (which nurses are obligated to provide under the Regulated Health Professions Act, 1991) collected at the end of each calendar year, and provides information on employment, education, and demographic characteristics of regulated healthcare professionals in Ontario [34]. We focus on RNs and RPNs in 2019 and 2020, the most recent years for which data are available. Variables in the study include characteristics of each job (the healthcare sector, full-time/part-time/casual status, and geographic location); this information is collected for up to three jobs per nurse, and individual-level variables (agency employment, age, sex, year of first registration in Ontario, preference for full-time/part- time/casual work, education level, year and location of first practice, location of first education in the profession, and languages spoken). Full-time is defined within the HPDB as working 30 or more hours per week, part-time as working less than 30 hours per week, and casual implies working on an as-needed basis.

We compare across healthcare sectors: LTCHs, hospitals, primary care, home care, supportive housing/retirement homes and “other”, where the last aggregates all other practice settings (e.g., rehabilitation facilities). Nurses are assigned to the sector of their first reported job. We provide the distribution of multiple jobholders in each healthcare sector. Next, we compare nurses’ actual employment status and their preferred employment status. Further, for multiple jobholders, we provide a cross- tabulation of the sectors of their first and second job to determine the degree to which multiple jobholders work in a single sector, and whether there are employment-linkages between sectors. Lastly, we employ logistic regression analyses to identify individual characteristics of nurses that may be associated with multiple jobholding, part- time/casual employment, and involuntary part-time/casual employment.

We only include nurses actively working at least one job in Ontario and remove all jobs located outside the province. The data were self-reported, thus, imputations are made for a small number of respondents with incomplete responses to relevant questions. For example, among those who answered “none of the above” for their education level, we take their education as equivalent to a diploma. Furthermore, for those answering “unknown” for their country of first practice, we assume this was the same as the location of their earliest professional education. For those with a missing year of first practice in the profession, we impute this to equal the year of first practice in Ontario if their first place of professional practice was Ontario. Lastly, we assume the healthcare sector is “other” for those that answered “unknown” for their practice setting. For any other relevant questions where the respondent did not provide an answer, we remove the observation; this amounts to the removal of fewer than 20 each of RNs and RPNs (across both years) leaving a dataset for analysis of approximately 98,350 RNs and 49,110 RPNs in 2019, and 99,250 RNs and 49,820 RPNs in 2020.

3. Results

3.1. Multiple jobholding

The upper panel of Table 1 displays the distribution of multiple jobholding for RNs and RPNs in 2019 by sector. Approximately 19% of RNs and 21% of RPNs reporting a first job in LTCHs are multiple jobholders. Among LTCH RNs multiple jobholding is statistically significantly lower in all sectors with the exception of supportive housing where it is almost identical. However, the gaps across sectors, except for home care, are modest and not obviously significant in terms of policy. Tests of statistical significance are provided in Table 4, panel A. In contrast, for RPNs who list LTCHs as their first place of practice, multiple jobholding is essentially identical to that in hospitals, primary care, and “other”.

Table 1.

Multiple Jobholding and Employment Status of RNs and RPNs by Healthcare Sector of First Job 2019 (% of sector total)

	RNs							RPNs
	Long-term Care	Hospitals	Primary Care	Home Care	Supp. Housing	Other	Total	Long-term Care	Hospitals	Primary Care	Home Care	Supp. Housing	Other	Total
% of Workforce	7.3	61.3	4.0	4.5	0.8	22.1	100.0	26.7	32.3	6.3	2.6	8.1	23.9	100.0
Number of Jobs Held
1 Job	81.2	84.0	83.3	87.1	80.9	83.3	83.7	79.2	79.7	80.1	76.4	77.6	80.4	79.5
2 Jobs	15.9	14.0	14.5	11.6	16.2	14.1	14.1	18.0	17.7	17.0	20.7	19.2	17.1	17.8
3 Jobs	2.5	1.7	1.7	1.2	2.8	2.2	1.8	2.5	2.3	2.7	2.6	2.6	2.3	2.4
4+ jobs	0.4	0.3	0.5	0.2	0.0	0.5	0.3	0.3	0.3	0.2	0.0	0.5	0.3	0.3
N (All jobs)	7190	60320	3890	4380	790	21770	98350	13110	15890	3080	1290	3980	11750	49110
Agency Nurses	1.5	0.7	1.3	5.3	2.7	8.5	2.8	2.5	1.3	2.5	26.9	3.5	20.1	7.1
Single Jobholders	25.0	15.7	46.0	72.3	33.3	79.7	65.3	25.2	8.1	34.6	73.5	25.4	74.3	62.7
Multiple Jobholders	75.0	84.3	54.0	27.7	66.7	20.3	34.7	74.8	91.9	65.4	26.5	74.6	25.7	37.3
Employment Status: Single Jobholders
FT	68.5	68.5	56.7	81.4	60.0	71.7	69.2	57.6	54.4	70.1	64.0	59.4	61.9	58.5
PT	23.6	25.8	32.7	12.0	23.6	18.8	23.9	32.0	39.0	24.2	25.7	28.8	28.2	32.7
Casual	7.9	5.7	10.6	6.6	16.4	9.4	6.9	10.4	6.6	5.7	10.3	11.8	10.0	8.8
N (Single Jobholders)	5810	50600	3220	3650	630	16660	80570	10300	12650	2440	730	3060	7690	36870
Employment Status: First job for those with 2 or more jobs
FT	50.7	57.5	44.1	78.9	47.8	58.8	57.3	39.6	41.7	49.6	55.9	43.2	48.9	43.5
PT	38.9	35.9	43.7	15.3	34.6	31.4	34.8	47.0	50.6	42.6	33.3	43.6	38.9	45.7
Casual	10.4	6.6	12.2	5.8	17.6	9.8	7.9	13.4	7.7	7.8	10.8	13.2	12.2	10.7
Employment Status: Second job for those with 2 or more jobs
FT	5.4	3.6	4.3	4.4	4.0	4.1	3.9	6.0	3.6	5.7	7.5	6.2	6.6	5.3
PT	31.3	27.6	30.7	21.7	35.0	29.4	28.3	37.9	36.2	35.3	35.7	33.7	34.0	36.0
Casual	63.3	68.8	65.0	74.0	61.0	66.5	67.8	56.1	60.2	59.0	56.8	60.1	59.3	58.7
Two FT Jobs	3.1	2.7	3.2	4.0	N/A	3.2	2.9	4.0	2.5	5.3	7.0	3.7	4.9	3.8
N (Multiple Jobholders)	1270	9280	620	500	140	3260	15070	2490	3020	560	210	790	1700	8770
Employment Status: Agency Nurses with 1 job
FT	22.2	28.6	47.8	52.7	71.4	66.0	62.4	18.1	N/A	55.6	49.0	37.1	61.3	57.5
PT	22.2	27.1	26.1	26.9	N/A	19.4	20.6	28.9	47.1	N/A	31.4	20.0	23.7	25.0
Casual	55.6	44.3	26.1	20.4	N/A	14.6	17.0	53.0	N/A	N/A	19.6	42.9	14.9	17.4
Employment Status: First job for Agency Nurses with 2 or more jobs
FT	61.7	61.3	59.3	60.9	N/A	59.3	60.0	41.3	42.8	60.8	51.1	35.9	47.0	45.2
PT	22.2	30.0	N/A	21.9	N/A	27.4	27.3	40.1	50.5	N/A	33.7	47.6	34.3	38.9
Casual	16.0	8.8	N/A	17.2	35.7	13.3	12.8	18.6	6.7	N/A	15.2	16.5	18.8	15.9
Employment Status: Second job for Agency Nurses with 2 or more jobs
FT	N/A	3.2	N/A	N/A	N/A	7.2	4.9	5.7	N/A	N/A	8.7	N/A	6.3	5.3
PT	N/A	19.1	N/A	N/A	N/A	27.4	22.8	30.0	N/A	N/A	34.8	N/A	34.8	31.6
Casual	71.6	77.7	88.9	71.9	85.7	65.4	72.3	64.4	74.2	74.5	56.5	64.1	59.0	63.1
Two FT Jobs	N/A	1.6	0.0	N/A	0.0	6.4	3.7	3.2	N/A	N/A	6.5	0.0	4.0	3.4
Involuntary PT/Casual
All RNs/RPNs	13.7	10.2	7.1	3.0	9.8	7.2	9.4	25.5	21.6	15.3	19.8	24.4	18.8	21.7
PT/Casual Nurses	39.1	30.7	15.6	14.9	23.1	23.5	28.5	54.9	44.8	45.1	48.1	54.7	45.9	48.8
Single Jobholders	33.7	28.6	12.7	12.1	20.2	20.7	25.9	51.8	41.1	40.0	42.5	51.4	43.4	45.3
Multiple Jobholders	54.4	39.1	27.0	31.3	32.1	33.3	38.5	63.5	55.9	57.6	64.0	63.0	53.6	58.5
N (PT/Casual)	2510	20080	1760	890	330	6700	32280	6080	7650	1050	530	1780	4800	21890
N (Single jobholders)	1850	15990	1410	760	250	5210	25470	4440	5780	740	390	1260	3610	16220
N (Multiple jobholders)	660	4090	360	130	80	1490	6810	1650	1870	300	140	510	1190	5670

Notes: N/A implies suppressed for confidentiality. Observations have been rounded to the nearest ten for confidentiality and the totals may therefore be affected by rounding. Agency employment is captured on an individual basis, and not on a per-job basis. The first three panels on employment status exclude agency nurses. N(RN) = 98,350; N(RPN) = 49,110.

Source: Ontario Ministry of Health's 2019 Health Professions Database

Table 4.

Logistic Regressions - Differences Across Healthcare Sectors of First Reported Job 2019.

	Uncontrolled Results				Controlled Results
	RNs		RPNs		RNs		RPNs
	OR	ME	OR	ME	OR	ME	OR	ME
	(1)	(2)	(3)	(4)	(5)	(6)	(7)	(8)
Panel A - Dependent Variable: Multiple Jobholding; Sample: All RNs/RPNs
Hospital	0.823***	-0.028***	0.965	-0.006	0.825***	-0.026***	0.965	-0.006
	(0.026)	(0.005)	(0.028)	(0.005)	(0.028)	(0.005)	(0.029)	(0.005)
Primary Care	0.864**	-0.021**	0.947	-0.009	1.052	0.007	1.000	0.000
	(0.045)	(0.008)	(0.047)	(0.008)	(0.057)	(0.008)	(0.051)	(0.008)
Home Care	0.642***	-0.059***	1.176*	0.028*	0.746***	-0.039***	1.073	0.012
	(0.035)	(0.007)	(0.081)	(0.012)	(0.042)	(0.007)	(0.075)	(0.012)
Supp. Housing	1.020	0.003	1.095*	0.015*	1.188	0.026	1.028	0.005
	(0.098)	(0.015)	(0.048)	(0.007)	(0.116)	(0.015)	(0.046)	(0.007)
Other	0.865***	-0.021***	0.929*	-0.012*	0.958	-0.006	0.962	-0.006
	(0.030)	(0.005)	(0.029)	(0.005)	(0.035)	(0.005)	(0.031)	(0.005)
Panel B - Dependent Variable: Part-time/Casual Employment Sample: Single Jobholders
Hospital	1.002	0.000	1.126***	0.029***	1.038	0.008	1.069*	0.015*
	(0.030)	(0.006)	(0.030)	(0.007)	(0.033)	(0.006)	(0.030)	(0.006)
Primary Care	1.598***	0.108***	0.572***	-0.128***	1.467***	0.082***	0.512***	-0.141***
	(0.073)	(0.011)	(0.028)	(0.010)	(0.070)	(0.010)	(0.026)	(0.010)
Home Care	0.546***	-0.113***	0.880	-0.031	0.582***	-0.097***	0.699***	-0.078***
	(0.027)	(0.009)	(0.060)	(0.016)	(0.030)	(0.009)	(0.050)	(0.015)
Supp. Housing	1.414***	0.078***	0.922	-0.020	1.243*	0.045*	0.784***	-0.053***
	(0.122)	(0.020)	(0.038)	(0.010)	(0.112)	(0.019)	(0.034)	(0.010)
Other	0.861***	-0.031***	0.827***	-0.046***	0.880***	-0.025***	0.810***	-0.047***
	(0.028)	(0.007)	(0.024)	(0.007)	(0.031)	(0.007)	(0.025)	(0.007)
Panel C - Dependent Variable: Part-time/Casual Employment in all jobs; Sample: Multiple Jobholders
Hospital	0.807***	-0.053***	0.968	-0.008	0.781***	-0.058***	0.978	-0.005
	(0.047)	(0.014)	(0.051)	(0.013)	(0.048)	(0.015)	(0.054)	(0.012)
Primary Care	1.367**	0.078**	0.686***	-0.094***	1.220*	0.047*	0.640***	-0.102***
	(0.131)	(0.024)	(0.061)	(0.022)	(0.122)	(0.024)	(0.060)	(0.021)
Home Care	0.334***	-0.240***	0.553***	-0.147***	0.327***	-0.236***	0.478***	-0.168***
	(0.038)	(0.022)	(0.067)	(0.030)	(0.039)	(0.022)	(0.061)	(0.028)
Supp. Housing	1.310	0.067	0.900	-0.026	1.178	0.039	0.743***	-0.067***
	(0.226)	(0.043)	(0.070)	(0.019)	(0.210)	(0.042)	(0.061)	(0.019)
Other	0.760***	-0.067***	0.718***	-0.082***	0.740***	-0.070***	0.735***	-0.070***
	(0.049)	(0.016)	(0.041)	(0.014)	(0.051)	(0.016)	(0.044)	(0.014)
Panel D - Dependent Variable: Involuntary Part-time/Casual Employment; Sample: Single Jobholders
Hospital	0.828***	-0.017***	0.814***	-0.033***	0.710***	-0.027***	0.752***	-0.041***
	(0.037)	(0.004)	(0.027)	(0.005)	(0.035)	(0.004)	(0.026)	(0.005)
Primary Care	0.488***	-0.052***	0.482***	-0.101***	0.584***	-0.039***	0.465***	-0.099***
	(0.043)	(0.006)	(0.032)	(0.008)	(0.053)	(0.006)	(0.032)	(0.008)
Home Care	0.206***	-0.083***	0.718***	-0.052***	0.277***	-0.073***	0.539***	-0.083***
	(0.023)	(0.005)	(0.063)	(0.013)	(0.032)	(0.005)	(0.050)	(0.011)
Supp. Housing	0.730*	-0.027*	0.936	-0.011	0.830	-0.015	0.777***	-0.037***
	(0.111)	(0.012)	(0.047)	(0.008)	(0.132)	(0.012)	(0.041)	(0.008)
Other	0.529***	-0.047***	0.701***	-0.055***	0.627***	-0.035***	0.702***	-0.051***
	(0.028)	(0.004)	(0.025)	(0.006)	(0.036)	(0.005)	(0.027)	(0.005)
Panel E - Dependent Variable: Involuntary Part-time/Casual Employment in first job; Sample: Multiple Jobholders
Hospital	0.551***	-0.099***	0.781***	-0.056***	0.568***	-0.084***	0.795***	-0.049***
	(0.037)	(0.013)	(0.043)	(0.012)	(0.041)	(0.012)	(0.045)	(0.012)
Primary Care	0.488***	-0.115***	0.643***	-0.098***	0.623***	-0.072***	0.658***	-0.086***
	(0.062)	(0.018)	(0.063)	(0.020)	(0.082)	(0.019)	(0.067)	(0.020)
Home Care	0.216***	-0.192***	0.666**	-0.090**	0.255***	-0.162***	0.587***	-0.108***
	(0.038)	(0.016)	(0.088)	(0.028)	(0.045)	(0.016)	(0.080)	(0.026)
Supp. Housing	0.582*	-0.091**	0.921	-0.019	0.694	-0.057	0.789**	-0.050**
	(0.131)	(0.033)	(0.074)	(0.019)	(0.162)	(0.034)	(0.066)	(0.017)
Other	0.441***	-0.128***	0.617***	-0.106***	0.555***	-0.087***	0.640***	-0.092***
	(0.035)	(0.013)	(0.038)	(0.013)	(0.047)	(0.013)	(0.041)	(0.013)
N (All)	98350	98350	49110	49110	98350	98350	49110	49110
N (Single Jobholders)	82340	82340	39040	39040	82340	82340	39040	39040
M (Multiple Jobholders)	16010	16010	10070	10070	16010	16010	10070	10070

Notes: Standard errors in parentheses. *p<0.05, **p<0.01, ***p<0.001. Observations rounded to the nearest ten for confidentiality. Long-term Care is the omitted (base) in category in all regressions. OR=Odds Ratio. ME=Marginal Effect. Average marginal effects are used. Control variables listed in Appendix Tables 6A, and 9A to 12A.

Source: Ontario Ministry of Health's 2019 Health Professions Database

The 2020 data were collected in late December 2020, after a single site order was passed by the province in April 2020 restricting LTCH and retirement home staff from working at multiple homes [35,36]. Compared to 2019, in 2020 (Appendix Table 1), multiple jobholding among RNs and RPNs remained similar in all sectors except LTCHs and supportive housing, the only two sectors affected by the restriction. Multiple jobholding decreased significantly in these sectors for both sets of nurses. Multiple jobholding also fell among home care RPNs.

3.2. Agency nurses

The second panel of Table 1 displays the percentage of nurses employed in at least one agency job across sectors in 2019. In the HPDB, information on agency employment is not collected for each job, thus among multiple jobholders it is not possible to determine how many and which job(s) are with an agency. For multiple jobholders that identify as agency nurses, we assume agency employment is in the sector of the first reported job. Due to this data limitation, we cannot compare each sector's reliance on agency nurses. Overall, a small percentage of RNs, 2.8%, and a slightly larger share of RPNs, 7.1%, report working for an agency in 2019.

Across most sectors, the majority of agency nurses are multiple jobholders, except in home care and “other” for both RNs and RPNs. In 2020 (Appendix Table 1), the percent of agency nurses decreased modestly across most sectors.

3.3. Employment status by sector

Following the section on agency nurses, Table 1 displays the employment status of single jobholders, and the first and second jobs of multiple jobholders (excluding agency nurses) in 2019. About 69% of RNs in LTCHs with one job are full-time, compared to 58% of RPNs. The percentage of full-time employment among LTCH RNs is identical to hospitals, higher than in primary care and supportive housing, but lower than in home care and “other.” The percentage of full-time work among LTCH RPNs is similar to most sectors with the exception of primary care. For multiple jobholders, the probability of a full-time first job is lower in LTCHs than most sectors: approximately 51% for RNs, and about 40% for RPNs compared to 57% and 44% overall. For both RNs and RPNs, home care is most likely to have a full-time first job, while primary care (LTCHs) is least likely to have a full-time first job for RNs (RPNs). A much smaller share of second jobs is full-time. Some workers’ second job is full-time because their first job is (unusually) part time. Among multiple jobholders, approximately 3% of LTCH RNs and 4% of LTCH RPNs have two full-time jobs.

The Ontario Long-term Care Commission noted some homes provided more full- time hours to adjust for reduced staffing from the single site order [15]. In 2020, Appendix Table 1 shows the percentage of full-time jobs among single jobholders remained fairly similar in LTCHs and most sectors, except in supportive housing, where full-time employment increased for both RNs and RPNs. However, among multiple jobholders in LTCHs and supportive housing, full-time employment in the first job increased for both sets of nurses. Our findings suggest the single site order reduced multiple jobholding, and there is some evidence of an associated increase in full-time hours (especially among multiple jobholders), in both LTCHs and supportive housing.

In the next three panels of Table 1, we report the employment status for nurses with at least one agency job. For single jobholders, LTCH RNs and RPNs are least likely to have full-time employment. For RNs with multiple jobs, the differences in full- time employment in the first job are modest across sectors, while for RPNs there are greater sectoral differences. Refer to Appendix Table 1 for the 2020 results.

3.4. Involuntary part-time/casual employment

The last panel of Table 1 displays the percentage of RNs and RPNs who, preferring full-time, are involuntary part-time or casual in 2019. We interpret this mismatch as a measure of dissatisfaction. The first row of the panel contains the results of involuntary part-time/casual employment among all nurses within each sector, while the second row is restricted to part-time or casual nurses in their first job. These results are striking; 39% of part-time or casual RNs, and 55% of RPNs, in LTCHs are dissatisfied with part-time or casual work. This is much higher than in other sectors with the cross-sector differences being more pronounced for RNs. However, among RPNs, the prevalence of involuntary part-time/casual work is quite similar in LTCHs and supportive housing. We additionally subdivide those in part-time or casual positions into single and multiple jobholders. Multiple jobholding part-time/casual nurses are significantly less satisfied with their employment status across all sectors than single jobholders, with those in LTCHs continuing to be the least satisfied especially among RNs.

The 2020 results appear in Appendix Table 1. Despite an increase in full-time employment among multiple jobholders in LTCHs, the large sectoral gaps persist in 2020, with LTCH nurses being least satisfied with their employment status.

3.5. RN and RPN characteristics

Appendix Table 5A provides descriptive statistics for RNs and RPNs by sector in 2019. While a sizeable minority of nurses want part-time employment, approximately 72-79% of RNs and RPNs prefer full-time work, which, as seen in Table 1, is appreciably lower than the share working full time. This important mismatch is explored in Table 2 .

Table 2.

Actual Employment Status vs. Preferred Employment Status for RNs and RPNs by Healthcare Sector of First Job 2019 (%).

	RNs				RPNs
	Preferences				Preferences
Actual Work Status of First Jobs	Full-time	Part-time	Casual	N	Full-time	Part-time	Casual	N
Long-term Care
Full-time	96.0	3.3	0.7	4680	97.5	2.1	0.4	7030
Part-time	41.1	57.6	1.4	1890	57.4	41.8	0.8	4590
Casual	33.1	17.6	49.4	620	47.5	22.8	29.8	1490
Hospitals
Full-time	96.1	3.3	0.6	40240	96.4	3.0	0.5	8230
Part-time	34.4	64.0	1.5	16530	47.1	52.2	0.8	6570
Casual	13.4	13.0	73.6	3550	30.7	23.9	45.4	1080
Primary Care
Full-time	91.8	7.1	1.1	2130	95.5	3.6	0.9	2040
Part-time	15.5	81.7	2.8	1330	45.3	53.0	1.6	860
Casual	16.0	16.5	67.5	430	44.2	22.1	33.7	190
Home Care
Full-time	95.3	4.4	0.3	3490	97.8	N/A	N/A	760
Part-time	15.1	81.6	3.3	580	48.6	50.0	1.4	370
Casual	14.6	13.0	72.4	320	46.9	19.8	33.3	160
Supp. Housing
Full-time	93.6	N/A	N/A	450	97.7	2.0	0.2	2200
Part-time	N/A	69.8	N/A	200	58.2	40.5	1.3	1280
Casual	14.4	15.2	70.5	130	45.9	23.5	30.6	500
Other
Full-time	93.5	5.4	1.1	15070	95.7	3.1	1.1	6950
Part-time	26.7	69.5	3.7	4550	49.1	49.1	1.8	3450
Casual	16.8	15.0	68.2	2150	37.8	22.3	39.8	1350
Total
Full-time	95.3	4.0	0.7	66050	96.6	2.7	0.7	27210
Part-time	32.0	65.9	2.0	25080	51.0	47.9	1.1	17110
Casual	16.3	14.2	69.4	7200	40.6	22.8	36.5	4770

Notes: N/A implies suppressed for confidentiality. Observations have been rounded to the nearest ten for confidentiality and the totals may therefore be affected by rounding. Some percentages have been rounded to the nearest whole number for confidentiality, and total percentages may therefore be affected by rounding.

Source: Ontario Ministry of Health's 2019 Health Professions Database

Some notable differences exist across sectors and occupations. RNs in LTCHs are much more likely to have been educated and first practiced outside of Canada and the U.S. This pattern is not as obvious for RPNs, although RPNs in LTCHs are slightly above the provincial averages for these characteristics. Similar patterns can be observed in language(s) of practice, with RNs in LTCHs being more likely to speak English and another language other than French. RNs in LTCHs are about three years older than the profession average though their years of practice are more similar; this pattern is similar, though not as pronounced, for RPNs. On average, nurses in LTCHs have spent more years out of nursing than those in other sectors as might be expected given the interruption associated with the migration implicit in the aforementioned place of first nursing education/practice.

Finally, like their peers in primary care, nurses in LTCHs are much more likely to practice in a rural area than the profession average. RNs in LTCHs are also more likely to have a diploma. For the same set of statistics in 2020, refer to Appendix Table 5B.

3.6. Actual versus preferred employment status

Table 2 presents a cross-tabulation of RNs’ and RPNs’ actual employment status (in the first job for multiple jobholders) versus their preferred employment status. About 41% of RNs, and 57% of RPNs, who work part-time in LTCHs prefer to work full-time. This reflects a higher rate of mismatch than any other sector, except supportive housing RPNs. The pattern across sectors is similar, though not as large, for casual workers. If we take this mismatch as a proxy of job dissatisfaction, we conclude that the LTCH sector workforce, alongside supportive housing RPNs are the most dissatisfied. For the profession as a whole, while a subset of the workforce prefers part-time, a large share, 32% and 51% of RNs and RPNs, are involuntary part-time. The cross-tabulation for 2020 can be found in Appendix Table 2.

3.7. Multiple jobholders across sectors

In Table 3 we provide a cross-tabulation of the healthcare sector in which nurses work for their first and second jobs in 2019. Around 61% of RNs who work in LTCHs in their first job also work in LTCHs in their second job. This is the highest level of sector congruence. For example, in the hospital sector, the degree of congruence is 46%. A similar pattern of results is observed for RPNs.

Table 3.

Sector of First Job vs. Second Job for Multiple Jobholders 2019 (%).

RNs	Sector (2nd Job)
Sector (1st Job)	Long-termCare	Hospitals	PrimaryCare	Home Care	Supp.Housing	Other	Total
Long-term Care	60.9	12.8	2.3	1.6	2.7	19.7	1350
Hospitals	10.1	46.1	5.3	1.4	1.4	35.6	9660
Primary Care	8.0	30.8	30.0	1.1	1.4	28.7	650
Home Care	8.3	41.1	2.3	12.9	2.1	33.3	570
Supp. Housing	10.7	19.3	4.0	4.0	27.3	34.7	150
Other	8.7	32.6	3.6	1.2	1.1	52.8	3630
Total	2230	6280	890	290	280	6050	16010

RPNs	Sector (2nd Job)
Sector (1st Job)	Long-term Care	Hospitals	Primary Care	Home Care	Supp. Housing	Other	Total
Long-term Care	56.9	6.3	3.4	2.4	11.1	19.9	2730
Hospitals	21.9	32.2	6.7	2.9	7.5	28.8	3220
Primary Care	20.7	15.4	25.0	3.9	8.9	26.0	620
Home Care	23.0	9.8	3.6	28.9	11.8	23.0	310
Supp. Housing	29.7	7.2	4.6	4.2	34.6	19.8	890
Other	21.3	13.8	5.2	3.1	8.8	47.9	2310
Total	3210	1720	630	380	1150	2980	10070

Notes: Observations have been rounded to the nearest ten for confidentiality and the totals may therefore be affected by rounding.

Source: Ontario Ministry of Health's 2019 Health Professions Database

The 2020 results in Appendix Table 3 show a reduction in multiple jobholding in LTCHs and supportive housing. However, despite the single site order restricting within- sector multi-jobholding, some nurses were employed in two LTCHs or two supportive housing jobs. The single site restriction did not affect agency nurses, and never completely prohibited working in two LTCHs where the benefit outweighed the risk.

3.8. Determinants of multiple jobholding, part-time/casual employment, and involuntary part-time/casual employment

3.8.1. Likelihood of multiple jobholding

Table 4, panel A, displays logistic regression results for multiple jobholding, a binary dependent variable equal to one if the individual has two or more jobs, and zero otherwise. For each regression, we display odds ratios and average marginal effects (i.e., the average change in the dependent variable – the probability that respondents hold multiple jobs – given a one-unit change in the independent variable). Odds ratios are more common in the literature, but we provide both since quantifying the magnitude of any change in probabilities is useful to our policy question.

Without controlling for covariates, the results in columns 1–4 show RNs whose first practice location is in LTCHs are slightly more likely to be multiple jobholders compared to other sectors, except supportive housing. However, the statistical significance is partly attributable to the large number of observations rather than there being a large difference across sectors. The marginal effects indicate that while multiple jobholding in LTCHs does differ from that in the majority of sectors, the differences are not large in magnitude. Even more similarity is observed for RPNs in columns 3 and 4; there are no highly statistically significant differences across sectors.

In columns 5–8 of Table 4, panel A, we control for individual characteristics although we only display the odds ratios and marginal effects for the sectors. Appendix Table 6A displays the coefficients on the control variables. In the controlled analyses, we exclude variables representing languages spoken and location of the earliest professional education since they are highly collinear with place of first practice, and similarly years of practice and age since they are highly collinear with years of practice in Ontario [37]; but, see Appendix Table 7A for results with all these regressors. Furthermore, we include a squared term on years of practice variables, despite both coefficients being statistically insignificant and equal to one, meaning there is no evidence of diminishing returns to years of experience in and outside of Ontario. We do so for consistency with our regression analysis for part-time/casual employment, and involuntary part-time/casual employment (Appendix Tables 9A, 10A, and 11A), where these coefficients are statistically significant and slightly greater than one, and since there is little harm in including them. However, regression models that do not include these terms are in Appendix Table 8A.

The controls affect the sectoral gaps in multiple jobholding, but the changes are modest. For example, one of the larger changes follows from primary care RNs, without controls, being 2.1 percentage points less likely to hold multiple jobs; introducing controls “explains” that gap effectively reducing it to zero. With controls, none of the sectoral coefficients are large in magnitude/statistically significant for RPNs.

As seen in Appendix Table 6A, most control variables’ coefficients are statistically insignificant and/or small in magnitude, although there are some exceptions. RNs who began practicing outside of Canada/the U.S. are 4.4 percentage points more likely to be multiple jobholders compared to those who began practicing in Ontario.

Appendix Table 4, Panel A, displays the logistic regression results for multiple jobholding in 2020. LTCH and supportive housing RNs and RPNs are now less likely to be multiple jobholders compared to most sectors, with larger sectoral gaps compared to 2019. For the 2020 regressions with controls, regressions with additional variables, and regressions with linear specifications, refer to Appendix Table 6B, Appendix Table 7B, and Appendix Table 8B respectively.

3.8.2. The probability of having only part-time/casual employment

Table 4, panels B and C, are similar to Table 4, panel A, but the dependent binary variable is equal to one if an individual is only employed in part-time or casual positions (i.e., no full-time employment). In Table 4, panels D and E, the dependent variable is equal to one if the nurse is involuntary part-time/casual; it thus considers employment preferences. We perform separate analyses on single jobholders (panels B and D) and multiple jobholders (panels C and E), as there may be inherent differences between these groups. For example, single jobholders may prefer part-time/casual work and self-select into these positions, while multiple jobholders may prefer full-time employment but work multiple part-time/casual jobs in the absence of full-time work.

LTCH RNs that have one job (Table 4, panel B) are similarly likely as the hospital sector, but about 11 percentage points less (more) likely than primary care (home care) RNs to be part-time/casual. RPNs have a broadly similar pattern, except in primary care and supportive housing where the opposite results are found. Compared to the uncontrolled results, when covariates are added (columns 5-8), the sectoral coefficients decrease slightly in magnitude for RNs. However, among RPNs, the sectoral gaps are now larger in primary care, home care, and supportive housing. Lastly, RNs with a university degree, male RNs/RPNs, and RNs/RPNs that began their first practice outside of Canada/the U.S. are less likely to be part-time or casual (Appendix Table 9A).

The results for multiple jobholders, Table 4, panel C, are fairly similar to those for single jobholders. However, what changes there are may suggest heterogeneity in part- time/casual status among single and multiple jobholders. For example, among RNs, the likelihood of part-time/casual work is lower for hospital multiple jobholders compared to those in LTCHs, which is not the case for single jobholders. For results in 2020 refer to Appendix Table 4, Panels B and C, and Appendix Table 9B.

3.8.3. Likelihood of involuntary part-time/casual employment

Table 4, panels D and E, display the logistic regression results for both single and multiple jobholders with involuntary part-time/casual employment as the dependent variable. Involuntary part-time/casual employment is a binary variable equal to one if an individual prefers full-time work but is employed part-time or casually, and zero otherwise. We also perform the same analyses for nurses overall, and part-time and casual nurses only in Appendix Table 11A.

For both single and multiple jobholders, RNs and RPNs working in LTCHs are more likely to be involuntary part-time/casual compared to all sectors. The coefficients on all sectors are statistically significant, and significant in magnitude. However, as with the results for part-time/casual employment, hospital RNs and RPNs with one job are more similar to their counterparts in LTCHs than are those in other sectors. For example, hospital RNs with more than one job are 9.9 percentage points less likely than LTCH RNs to be involuntary part-time/casual. The corresponding figure for single jobholders is only 1.7 percentage points. As with our results for multiple jobholding, few control variables are statistically significant, or significant in size (refer to Appendix Table 10A). The results for 2020 are found in Appendix Table 4, panels D and E, Appendix Table 10B, and Appendix Table 11B.

4. Discussion

The COVID-19 pandemic brought attention to multiple jobholding and part-time employment in healthcare, especially LTCHs, as an important element of infection prevention and control as well as influencing other aspects of quality of care. This paper documents employment status and other worker and job characteristics among RNs and RPNs by sector, and compares LTCHs to the rest of healthcare in Ontario.

Overall, while there are some statistically significant differences across sectors, we do not find that LTCHs differed substantially from the rest of healthcare in terms of the prevalence of multiple jobholding and part-time work in 2019. LTCHs most resemble hospitals in these aspects of their human resource practice, and supportive housing has a similar share of multiple jobholders. However, 2020 shows a significant decrease in multiple jobholding in LTCHs and supportive housing, likely a result of the provincial single site restriction (not prohibition) passed in April 2020 to reduce the spread of COVID-19 within homes. Despite this decline in multiple jobholding, a number of nurses continued to work in two LTCHs or two supportive housing homes.

We find that certain characteristics are unique to the LTCH workforce compared to other sectors. Both RNs and RPNs in LTCHs are more likely to be able to practice in more than one language, and to have received their first level of professional education outside of Canada/the U.S. We also find that beginning one's practice in a country outside of Canada/the U.S. is associated with a modestly higher likelihood of multiple jobholding among RNs. Covell et al. [38] found that Internationally Educated Nurses (IENs) experience difficulty securing their first Canadian nursing job, leading to a higher likelihood of multiple jobholding. An Australian study by Chu et al. [39] reported IENs may face covert and overt prejudices during the hiring process for full-time employment. However, our results for part-time/casual employment only (Appendix Table 5A and B) indicate RNs who began their practice outside of Canada/the U.S. are, perhaps surprisingly, less likely to be employed in part-time/casual positions only. Furthermore, we do not find a strong association between the location of first practice and involuntary part-time/casual employment, which is higher among LTCH RNs and RPNs.

Due to data limitations, our study focuses on RNs and RPNs, and does not capture the prevalence of multiple jobholding among the entire LTCH workforce. Personal support workers (PSWs) also play a critical role in the care of LTCH residents and accounted for 59% of the average proportion of staff employed in LTCHs in 2018, while RNs and RPNs accounted for 8% and 17% respectively [40]. Another 2015 study, using a sample of eleven for-profit LTCHs in Ontario, found nursing assistants provided the majority of care (76.5%) [8].

Although we classify the first job listed as an individuals’ primary job, this may not be the case. Among multiple jobholders, 5.1% list a second job that is full-time, however the percentage of multiple jobholders with two full-time jobs is slightly lower at 3.1%. Thus, it is reasonable to assume most RNs and RPNs list their primary job first, and our results would not significantly change. We also remove jobs outside of Ontario; thus, it is possible a small percentage of single jobholders are multiple jobholders with employment outside Ontario.

Our findings have implications for health systems, specifically for the delivery of quality and safe patient care, and nurses/providers’ welfare. Though we find multiple jobholding in LTCHs does not significantly differ from the norms in healthcare, the rate of multiple jobholding in healthcare overall may be high. Research on the role multiple jobholding has on patient care is limited. However, multiple jobholding may be associated with other factors that contribute to quality of patient care. For example, Lombardi et al. [41] found multiple jobholding increases LTCH workers’ risk of work and non-work injury, sick leave, absenteeism, burnout, and physical and mental stress. Turnover, closely related to absenteeism and burnout, has been shown to reduce quality of patient care [42,43]. Policies aimed at reducing multiple jobholding and part-time work in LTCHs may be useful given that LTCH nurses were more likely to be dissatisfied with part-time work.

5. Conclusion

Overall, our study of Ontario RNs and RPNs in 2019 and 2020, finds that in 2019 18.8% of RNs, and 20.8% of RPNs, in LTCHs held multiple jobs (two or more jobs).

While this number may seem high, the rates for all of healthcare in Ontario are 16.3% and 20.5% for RNs and RPNs respectively; LTCHs are not much different. Furthermore, the prevalence of part-time and casual work is similar between the hospital and LTCH sectors. However, we observe that RNs and RPNs in LTCHs are more likely to be dissatisfied with part-time/casual employment than nurses in other sectors.

Declaration of Competing Interests

None.