Fluid workforce management in the health sector: navigating the changing face of workforces and their management

Abstract

Purpose

This paper demystifies the fluid workforce phenomenon increasingly discussed in the circles of organizational innovators and explores the characteristic aspects of the fluid workforce in the healthcare sector.

Design/methodology/approach

We analyze the concept and provide a generic review of definitions of a fluid workforce in relation to other similar concepts established in the academic and practitioner literature, contextualize the fluid workforce phenomenon in healthcare and distinguish relevant drivers and categories of fluid workers in this sector. We also discuss the implications of a fluid workforce for healthcare organizations, drawing on the health labor market and human resource management (HRM) practices frameworks.

Findings

The fluid workforce in healthcare is not new. Today’s main novelties are related to the wide diversity of types of fluid workforce that have emerged, the expanding scale of diffusion of the fluid workforce and the emergence of digital technologies to support HRM decisions. While a fluid workforce may provide solutions to address mismatches in the supply and demand of health workers, it can also worsen working conditions, increase dual practice and have implications for existing HRM practices.

Originality/value

We disentangle a novel term for the public sector, healthcare and HRM literature. We discern similarities and distinctions, presenting a framework for managing and analyzing this workforce at organizational and labor market levels in the healthcare sector. Acknowledging the challenges in estimating the existing fluid workforce labor market size, we offer practical methodologies to empirically estimate its prevalence within the healthcare industry and build an agenda for future research.

Citation

Samaan, D. and Tursunbayeva, A. (2024), "Fluid workforce management in the health sector: navigating the changing face of workforces and their management", International Journal of Public Sector Management, Vol. 37 No. 4, pp. 593-609. https://doi.org/10.1108/IJPSM-10-2023-0311

Introduction

Governmental public health provision has a broad mandate encompassing health promotion, protection, and disease prevention. The way public health systems worldwide fulfill this mission varies widely, but they all depend on diverse and strong workforces. Comprehensive workforce planning and human resource management (HRM) strategies have to be defined that address the need for and leverage synergies between individual entities within the health ecosystem. To achieve this aim, health sector managers need to understand their workforce better (Dinkin et al., 2022), especially in light of the significant recent changes the sector has undergone.

The labor force of most economies has become more diverse over the last decades, and digitalization and other trends have been changing the world of work. Moreover, not all employment relations today occur within a bounded space, a structured time, or a task-based job description (Alfes et al., 2022; Minbaeva, 2021). All of these developments have triggered the proliferation of workforces consisting of freelancers, independent contractors, gig workers, paid-crowdsourced workers, moonlighters (Altman et al., 2021; Capgemini Research Institute, 2020), as well as workers borrowed from partners, volunteers, remote or even virtual workers (Altman et al., 2021).

These groups of workers have given rise to the umbrella term “fluid” workforce. Overall, there is no single, commonly accepted definition of the fluid workforce. It is generally acknowledged that many people today do essential work for organizations that cannot easily be subsumed under the classic employee-employer relationship. The line between who is an employee, and hence part of the traditional, regular workforce, and who is not has become blurred. However, it is clear that the fluid workforce is an integral part of the broader “workforce ecosystem,” which also includes regular employees; the whole workforce ecosystem is vital for creating value for organizations (Altman et al., 2021).

A fluid workforce offers organizations a certain degree of flexibility to react to market needs without maintaining an excessive regular workforce. Organizations make use of a fluid workforce when they want to obtain experts to enhance quality, accelerate processing speed, or compete in global markets (e.g. Alfes et al., 2022; Capgemini Research Institute, 2020). But a fluid workforce also poses challenges. Unlike the regular workforce, fluid workers are often not on the organization’s payroll; they have temporary, time-limited contracts; they enjoy either no or limited benefits including social security; and their work is not as well-regulated from a legal standpoint in many contexts (e.g. ILO, 2015). Therefore, some have raised questions about their quality of life and well-being (e.g. Caza et al., 2021) and attracted the attention of policymakers, HR specialists, and managers to the phenomenon of the fluid workforce (e.g. Alfes et al., 2022; Capgemini Research Institute, 2020). More knowledge is crucial as most of the discussions on fluid work are rather generic, positioning it as an emerging innovation, and overlook sector-specific circumstances (e.g. Altman et al., 2021; Capgemini Research Institute, 2020) and the synergies needed between HRM practices in a broader labor market system (Boon et al., 2019).

In this generic review paper, we aim to address this knowledge gap. Specifically, we aim to disentangle the fluid workforce phenomenon, which is considered more and more often in the circles of management innovators, and to review its potential implications for organizations and the broader labor market. In doing so, we focus specifically on the healthcare sector.

Healthcare is one of the largest sectors and largest employers in many countries (World Health Organization, 2021). It is challenged by the constantly growing consumption of healthcare services due to aging populations and rising chronic illnesses, leading to a continuous expansion in terms of employment and added value. The health labor market (HLM) follows, in principle, the same economic laws and legal regulations as the labor market in general. Nevertheless, certain distinctive features stand out.

Firstly, a significant proportion of employees within the health sector are public sector workers. According to a recent estimate by the World Bank, about 64% of all salaried workers globally are in the public sector, ranging roughly from 75% in Europe and Central Asia to 49% in Latin America and the Caribbean. This aspect highlights the relevance of our analysis for management considerations within the public sector (World Bank, 2023).

Secondly, certain characteristics determining the supply and demand of workers are more or also salient in the HLM. For example, the health sector is prone to demand and supply mismatches since the supply of skilled health workers needs to be planned over the long term and made feasible by education systems, while short-term demand shocks can be unpredictable (e.g. COVID-19). Hiring processes are also subject to long public institution procedures. This means that, at a given point in time and location, the supply of workers in healthcare professions cannot easily be increased when demand spikes.

The only way to meet short-term demand changes is through a more efficient matching of demand with the existing supply, or increasing the supply by attracting suitable people (potential matches) that are currently outside the standard health labor force (e.g. recently retired professionals). Due to the high skills or certification requirements, this latter group mainly consists of retirees or other people who choose not to work full-time. Attracting these workers into the local health labor market requires information symmetries between (potential) supply and demand, i.e. a very efficient matching mechanism. A fluid workforce in healthcare is usually hired to reduce such mismatches. For example, Cappelli and Keller (2012) mention that the health labor market for nurses in the United States is an example in which the fluid workforce has played a significant role.

The paper will thus contribute to the scholarly public management, health sector management, and HRM literature streams by demystifying the potential similarities and differences compared with existing workforce terminology used by both scholars and practitioners. In addition, we propose a framework of how the implications of fluid work could be analyzed at both organizational and labor market levels. The paper can also inform and guide future organizational HRM strategies aimed at managing the dual organizational workforce.

In this article, we first review and discuss generic fluid work definitions and categories. We contextualize them to the health sector by distinguishing applicable fluid workforce categories. We then draw on HRM practices and Health Labor Market (HLM) frameworks to discuss the potential implications of fluid work. Finally, we build an agenda for future research and practice with a fluid workforce in health.

Fluid workforce and its categories

The management literature (e.g. practitioners’ guides) often discusses fluid work and its implications in the context of opportunities for organizations (e.g. Altman et al., 2021; Capgemini Research Institute, 2020), which may present a one-sided, positive view on this matter. The scholarly literature has tried to balance such perspectives and to provide insights on individual attitudes and behavioral changes for specific categories of employees (e.g. Caza et al., 2021). Unfortunately, the situation is becoming more complex, as scholars and practitioners today use different terminology, emphasize slightly different characteristics of the workforce, or list different groups of workers under the fluid workforce (or an equivalent term).

We are not the first to note that there is no “accepted and shared vocabulary” for work forms or workers other than full-time regular employment (Cappelli and Keller, 2012). Olsen and Kalleberg (2004) refer to “non-standard work” or “non-regular forms of labour” and list other terms that have been used in the literature for similar working arrangements: For example, flexible staffing arrangements (Houseman, 2001), flexible work arrangements, market-mediated work arrangements (Abraham and Taylor, 1996), contingent work (Polivka and Nardone, 1989), and atypical employment (De Grip et al., 1997).

The ILO (2015) has recognized that the “standard working relationship,” understood as work that is full-time, indefinite, as well as part of a subordinate and bilateral employment relationship, has been declining in many countries over the last decades, but not universally. The ILO does not use the term “fluid workforce” or “hybrid workforce,” expressions that have recently emerged in the practitioners’ literature. Instead, it refers to “non-standard forms of employment” (NSE), an umbrella term that groups together distinct forms of work contracts that deviate from the standard working relationship. It distinguishes four types of NSE: (1) temporary employment; (2) part-time work; (3) temporary agency work and other forms of employment involving multiple parties; and (4) disguised employment relationships and dependent self-employment (see also Table 1). Gig work or work on digital labor platforms, which has gained importance over the last decade (ILO, 2021), is not explicitly mentioned in this categorization, but it is implicitly covered as it overlaps with several aspects of all four types, especially with casual work and ambiguous and disguised employment relationships. The ILO also points out that NSE can coincide with informality in developing and emerging economies. There is also evidence that NSE in the form of temporary work grew in many countries during the COVID-19 pandemic (see ILO, 2021).

The management and human resources literature typically employs a different terminology (not NSE) but refers to the same groups of workers with some variations on broader and narrower definitions. The term most closely related to NSE is “non-traditional employment relationships” or “new ways of working,” which has been discussed in the broader management (e.g. Ashford et al., 2007) and the specific HRM literature (e.g. Alfes et al., 2022; Oyetunde et al., 2022). Practitioners (Capgemini Research Institute, 2020) define the fluid workforce as (1) freelancers/independent workers (independent workers who supplement the organization’s core workforce); (2) gig workers (freelancers mediated through an app or platform); (3) paid crowd workers (workers completing microtasks); and (4) moonlighters (professionals with a primary permanent job but taking up fluid jobs on the side). Permanent employees are not considered part of the fluid workforce.

A distinguishing feature of the two groups, fluid workers and non-fluid workers, is the contract status, similar to our own classification. The fluid workforce is only temporarily tied to the organization, not on the payroll of the “employer,” typically excluded from any type of benefits including social security, not subject to employee-related employment laws, sometimes managed via online platforms, and their work is not yet well-regulated from a legal standpoint in many contexts. A quick look at the above categories of NSE, as specified by the ILO, reveals that the two definitions largely overlap. The NSE definition is a bit broader in some respects (e.g. temporary workers in the NSE definition can be on the respective organization’s payroll), and narrower in others (e.g. only “dependent self-employed” are considered NSE while true freelancers would not be considered as NSE, yet they are included in the definition of the fluid workforce). This latter definition also comprises an unconventional technology embraced, and data-driven approach to people management (e.g. gig work).

Another definition, based on a management survey in collaboration with Deloitte, starts with the idea that organizations need to redefine “their” workforce by asking who creates value for the organization (Altman et al., 2021). Traditionally, this used to be the permanent employees of an organization. However, confirming the insights of the previous studies, the authors found a broader workforce ecosystem of people who create value and should be considered. The workforce consists of (1) full-time and part-time employees; (2) contractors including gig workers and temporary workers; (3) service providers; (4) external contributors such as crowdsourcing innovators and lead user innovators; (5) technology for workforce augmentation such as artificial intelligence, robots, chatbots; and (6) developers and/or accessory providers (e.g. offering apps through an app store). Though there are some differences in perceptions of who belongs to the workforce of an organization and who does not (Altman et al., 2021), we clearly see that there is a large overlap and also some distinctions between the previous two definitions of NSE and the fluid workforce.

In summary, despite the differences in terminology used, all reviewed concepts have in common the acknowledgment that many people do essential work for organizations that cannot be easily subsumed under the classic employer-employee relationship. This observation coincides with Cappelli and Keller (2012), who emphasize that the functions, remuneration, contract types, and other workforce characteristics of the workers in such a category can vary significantly. The line between who is an employee, and hence part of the workforce, and who is not has become blurred.

This is making organizational boundaries and organizations themselves more fluid – as jobs are deconstructed and reinvented (Boudreau and Donner, 2021). The reasons for these developments, as well as the consequences, are manifold. For example, technology has been put forward, or the changing preferences of workers (e.g. Altman et al., 2021). Massive erosion of the employer-employee relationship in the workforce overall requires a reflection of the consequences not only on the organizational level but also on broader labor market levels (Boon et al., 2019). They are briefly discussed below, taking into account labor market and HRM practices frameworks.

Health sector and fluid workforce management

Temporary work in healthcare organizations in the form of travel and agency nurses, physical and occupational therapists, and locum tenens – doctors working in temporary rather than permanent positions (Ferguson et al., 2021) – is not new. When analyzing this work arrangement and applying the concept of a fluid workforce, however, it becomes evident that the terminology used within this sector to describe a fluid workforce appears to diverge from that employed by HRM scholars or practitioners. See our mapping of temporary workers in healthcare into the fluid workforce categories of the Capgemini Research Institute (2020) in Table 1.

It seems the healthcare literature neglects a broad spectrum of fluid workforce types that have emerged within the healthcare sector (Dinkin et al., 2022), particularly since the onset of the COVID-19 pandemic (e.g. see Alanezi and Alanzi, 2020 for discussion). This proliferation is attributed in part to the rise of staffing technologies, such as “Uber”-like platforms (Bhuyan et al., 2021).

This wider diffusion of the fluid workforce can have serious implications in the healthcare sector at both the organizational and broader system levels, thus both levels should be taken into consideration. Employees are simultaneously exposed to an interrelated set of organizational HRM practices (rather than single practices one at a time), and the implications of HRM practices are likely to be dependent on the broader labor market trends (e.g. Boon et al., 2019). At the organizational level, workforce management, including for the fluid workforce, is performed with the help of HRM practices, which mainly include job design, recruitment and selection, training and skills development, career planning and retention (George and Chattopadhyay, 2015), compensation and benefits, workforce planning and job design (Britnell, 2019). Meanwhile, labor market analysis is usually performed by analyzing supply and demand to identify the causes of labor market misalignments and to assess possible policy options (Garg et al., 2022). For example, understanding the forces that drive temporary worker shortages and surpluses, geographical imbalances, or suboptimal performance that are important to achieve functional labor markets, especially in sectors in which human labor is both essential and heavily regulated, like in the health sector (World Health Organization, 2021). Thus, the integration of these two frameworks can reveal the changes that a fluid workforce can bring to the functionality of labor markets and organizations’ efficiency in HRM (Boon et al., 2019). It also provides a balanced view of how they can be affected by a growing fluid workforce in the health sector. Such changes can be considered advantages or disadvantages, depending on the type of worker or enterprise and the preferences of the party involved (see Table 2).

Recruitment and selection

An important characteristic of the fluid workforce is that particular talents and competencies are sought externally when needed, and they are not retained when the immediate needs have been satisfied. This implies that the recruitment and selection decisions with such a workforce occur more frequently. Employing digital technologies (e.g. recruiting and selecting gig workers through online platforms, or hiring with the help of artificial intelligence (AI)) can solve the problem of asymmetry of information in the HLM, i.e. facilitating the matching between demand and supply of talent and skills (Di Lauro et al., 2022). It should also be noted that more frequent recruiting decisions to meet an organization’s current talent needs require a permanent and timely coordination of information between HRM and the operational divisions, as well as between HRM and national health workforce planning leaders. This could go as far as implementing information systems that predict demand fluctuations on the operational side that can signal recruitment needs to HRM, as well as systems that can estimate HLM demands.

Hence, although maintaining a fluid workforce provides an opportunity to find and recruit health workers more easily, it also poses challenges in the selection process. For example, it will often require a cultural shift in health organizations and up-skilling of HRM professionals to incorporate the new perspective, in which recruiting needs to happen fast and closely aligned with operational needs. This topic has mostly been neglected in research regarding the health sector (Potočnik et al., 2021). For the public sector, such adjustments in HRM are even more likely to pose challenges, as public organizations tend to be slower and less flexible than the private sector in adopting new technologies (e.g. AI tools, digital platforms) due to external budget constraints, regulatory requirements, security and privacy concerns, and established bureaucratic processes (Troshani et al., 2011).

Generic NSE has been associated with tasks that are not essential to the organizations (Shi, 2007). The previous assumption was that the recruitment and selection of workers for temporary positions do not require the same care and precision as when hiring employees for the regular workforce. However, this approach is not applicable if a fluid workforce becomes the “new normal” in a sector, and expands to scale, as we argue here. Digital technologies and non-rigid labor laws can make it feasible for an organization to rely on a fluid workforce, in which core tasks and highly skilled workers also become fluid. Thus, a fluid workforce can expand to all healthcare professional roles (e.g. doctors or nurses). Considering that today “all health professionals [are recommended to] be educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics” (Greiner and Knebel, 2003, p. 3), we recommend that all fluid workforce in healthcare must also be selected with the same care and precision as all other types of employees to protect the patients or peers from any potential harm (Edge Admin, 2020).

The COVID-19 pandemic has shown that countries use different mechanisms to address the immediate needs of the health sector, for example by recruiting health workers through temporary contracts, or the use of volunteers and health workers with foreign qualifications (Tursunbayeva and Di Lauro, 2022). Many of these short-term workforce adjustments in response to the COVID-19 pandemic were examples of the fluid workforce in the health sector. On the one hand, this illustrates the potential of the fluid workforce to increase the diversity of staff (e.g. race/ethnicity, gender, immigration, or disability status) (Naciti et al., 2022), a crucial but largely neglected topic in healthcare workforce management so far. On the other, it highlights the necessity of rapid training and the transfer of new skills to fluid health workers in order to provide health services, while addressing the challenge of evaluating the acquired competencies at the same time. The generic NSE literature suggests that “medical schools must select applicants who will not only excel academically but who also possess personality traits and values befitting a career in medicine such as compassion and inter-personal skills” (Patterson et al., 2017, p. 230). Meanwhile, the lack of a scholarly fluid workforce literature leaves unclear whether the skills shortages that organizations are addressing with a more fluid workforce are related to academic/cognitive or interpersonal skills. This could be an important avenue for future research.

Training and skills development

Fluid work arrangements shift the responsibility for professional training and development from employers to individual employees. The economic incentives for employers to invest in human capital that is fluid are lower since the returns on training and skills development are not exclusive to the employer who invests. The legal responsibilities towards training of the fluid workforce are also weaker. Thus, the greater the proportion of fluid workers in an organization, the greater the relevant decrease in the organizational investment in training of this workforce, similar to what has been observed by Davis-Blake et al. (2003) for NSE. This latter result has been connected in some contexts to a less skilled and less committed workforce with poor competency and efficiency. Contextualizing this phenomenon to healthcare presupposes a risk that poorer quality healthcare services will be provided by a fluid workforce (CU Thresia, 2016).

This likely decrease of investment in training is also contrary to the purpose of Continuing Professional Development (CPD) in healthcare that aims to warrant and improve the safety and quality of care provided for patients and the public. For example, in the UK, the NHS Constitution states that health organizations must invest in the skills and development of all their employees regardless of their employment approach (CPD News Team, 2021). The compliance of medical professionals with CPD requirements is also monitored by external professional associations such as medical councils (e.g. Royal College of Physicians of Ireland, 2021), which is not the case in many other sectors.

In some contexts, health organizations are also subject to organizational accreditation. To obtain this, such organizations need to demonstrate that their employees are appropriately skilled (Greiner and Knebel, 2003). All these healthcare sector-specific factors could be “stimulating” healthcare organizations to train a fluid workforce alongside regular employees, or in extreme cases to find alternative job design arrangements such as assigning a fluid workforce to simpler, monotonous jobs that do not need training/re-training but that people potentially feel less motivated to do (Jabagi et al., 2019). Hence, HRM faces a dilemma. On the one hand, the legal requirements in the health sector oblige organizations to only employ a workforce with sufficiently certified (upgraded) skills. On the other, the economic incentives to invest in skills enhancement of particular workers decline because the fluid workforce is less bound to a particular employer, and the newly trained skills can serve another organization.

From the perspective of another organization, this means that using a fluid workforce is a way to acquire needed skills externally instead of developing them in their existing employees, which again shows how the incentives to invest in skills are lowered for the sector as a whole. Currently, the healthcare sector in many advanced economies is facing dramatic staff shortages and difficulties in staff recruitment, relying heavily on medical professionals from abroad, including from low-to medium-income countries (e.g. NHS employs 26% of doctors from abroad) and expensive agency staff to plug clinical vacancies (Britnell, 2019).

On a positive note, fluid workers moving between different organizations could be a good source of knowledge transfer between them. To benefit from such expertise and to facilitate such transfers (George and Chattopadhyay, 2015), organizations would need to build relationships and knowledge-sharing opportunities for fluid workers with regular employees.

Career planning and retention

The existence of a career path and salary system in the health sector can also be affected by fluid work. Fluid work is shifting the responsibility for career planning previously shared between organizations and employees solely to employees. In such a work arrangement, employees move the skills that they developed and matured from organization to organization instead of building their careers in a single organization. Thus, the main goals of the fluid workers are likely to shift from being promoted within a specific organization towards increasing their employability and capacity to find future work engagements (Meier, 2022). This also means that for fluid workers, acquiring institutional knowledge is less valuable than acquiring technical skills. HRM is likely to face a workforce that has low staff engagement or commitment towards the organizations they work for.

A larger fluid workforce also impacts how organizations can retain regular employees. For example, previous research found that a rising proportion of a fluid workforce signals to regular employees that organizations are less and less interested in investing in their workforce, which could cause perceived job insecurity and reduced job value. Thus, (healthcare) organizations relying on a fluid workforce are recommended to carefully consider the social integration of these two groups of employees to retain their standard workers (George and Chattopadhyay, 2015).

Compensation and benefits

The main debate around the management of the fluid workforce relates to their compensation and benefits, which is relevant also to the health sector. Many organizations are shifting from paying for jobs to paying for skills (Meier, 2022). The compensation of a fluid workforce is affected by the duration of the tasks performed, the urgency of such tasks, and the availability of the skills needed on the market (Meier, 2022). Compensation options for a fluid workforce could include lump-sum payments (to reflect the preference of gig workers for a cash amount over other fringe benefits), per diem, per hour, or per patient approaches. This will increase the burden for payroll teams associated with more fragmented and irregular transactions, which could increase their reliance on HR payroll technologies and encourage automation of such tasks (Kulkarni, 2020). Payroll teams need to be considered when a fluid workforce is added to a pre-existing payroll system.

A fluid workforce is not subject to organizational (fringe) benefits, though some employers might still offer them to attract the skills needed (Miller, 2020). As such, organizations not providing fringe benefits would need to revisit their strategies for fluid employees’ motivation, engagement, or commitment without relying on this extrinsic motivation instrument that has been used to attract candidates and retain employees for many decades (Jabagi et al., 2019).

A recent US survey (Miller, 2020) demonstrated that, specifically in the healthcare sector, gig workers can out-earn traditional workers (e.g. average monthly income = $3.530 versus $4.590, respectively). This finding has been associated with their highly skilled and educated nature. Though, it is not clear whether this amount includes fringe benefits or not.

Job design

A growing fluid workforce in the health sector will lead to more flexible arrangements between employers and employees in terms of work assignments and the number of employers an employee can work for (Alfes et al., 2022). However, we know little about how the existing organizational processes and roles are being adapted for such work arrangements.

Job design plays a crucial role in employee motivation and retention, which can have a significant impact on healthcare service delivery. Health workers’ motivations affect the supply of workers willing to work under the conditions offered by the employer. Therefore, identifying the effect of fluid work on the motivation of both fluid and non-fluid health workers is key to bridging the supply and demand gap.

It is necessary to determine whether fluid work is suitable for the same type of jobs as those carried out by the regular workforce (in terms of complexity of tasks performed and skills requirements); whether these jobs would need to have higher horizontal (a greater division of jobs into tasks or specializations) or vertical (autonomy on the job) differentiation (Begoña Lloria, 2007); or whether these jobs are linked to seasonal demands for healthcare services (George and Chattopadhyay, 2015). For example, previous research has argued that it is better not to assign complex tasks that require interactions with others to NSE (consequently, potentially also to fluid workers) who would be with the organization for a shorter period (Sias et al., 1997).

It is also crucial to consider the potential impact of fluid work on health service delivery in terms of output and quality (Carayon et al., 2006), and on the various components of healthcare professionals’ job design including job autonomy and control; skill variety and use; job feedback; social and relational aspects; and job demands (Tursunbayeva and Renkema, 2022). Finally, we need to understand whether or how technology can be used for managing a fluid workforce in healthcare.

Workforce planning

The existing healthcare staffing model has been frequently accused of being inefficient, expensive for facilities, causing burnout of healthcare professionals, as well as putting patients at risk (Caulfield, 2020). For example, when a facility that relies only on its internal staff needs to fill a gap in its schedule, it results in a time-consuming game of phone calls between facilities. Thus, the healthcare sector has been tempted to try fluid workforce solutions offered by the gig economy including, for example, temporary nonmedical and medical staff such as doctors, nurses (Wrigley, 2018); or health workers that can be more easily found on online platforms to fill in for shifts (see Table 2 for some examples).

With the new method, the facilities, instead of calling multiple agencies to secure a nurse for a shift, can simply submit shifts to an online platform, which can broadcast the shift to a network of nearby nurses (Caulfield, 2020). For example, Nomad Health is an online platform that connects freelance doctors to hospitals directly, thereby eliminating the “middleman” that was once necessary. Through Nomad, physicians can search for available “gigs” (which can be short-, medium- or long-term gig contracts) (Naghieh, 2020), negotiate their own contracts, and be provided with malpractice insurance. In exchange for facilitating the connection, Nomad takes a cut that is significantly smaller than the commission a broker or agency would take in similar circumstances (Wrigley, 2018).

These kinds of staffing approaches are also envisioned at the broader national level. For example, Jeremy Hunt, Her Majesty’s Principal Secretary of State for Health, announced recently an intention to introduce an on-demand app for England’s National Health Service (NHS). The service is being billed as an “Uber-style” app that would allow those in charge of staffing at healthcare facilities to bring in nurses and other healthcare workers if they find themselves short-staffed or overly busy on a particular day. The mushrooming of such technological innovations (Schiavone and Leone, 2023), as well as overall fluid work in healthcare, has drawn the attention of practitioners and scholars who have reported a number of promised benefits for healthcare professionals, facilities, and patients (e.g. Wrigley, 2018), as well as a number of legal and ethical concerns that are attracting a broad media and public interest (Naghieh, 2020).

Discussion and conclusions

In this paper, we have aimed to enrich the knowledge on the generic fluid workforce phenomenon, conceptualizing it in a specific healthcare context. We also demystify the implications of the fluid workforce in healthcare on HLM in terms of supply and demand, and HRM in terms of job design, recruitment and selection, training and skills development, career planning and retention, compensation and benefits, and workforce planning. Indeed, we illustrate that fluid work can impact HLM and HRM through several channels. For example, by (1) introducing more flexible employment-employee arrangements, (2) impacting knowledge skills and training, (3) teamwork and management, (4) working conditions, and (5) influencing the motivation of the health workforce, as well as their job preferences. Direct consequences would be a changing demand for health workers, a re-organization of tasks, and a re-consideration of the skills and competencies needed. More employment flexibility may increase the risk of lowering working conditions while providing an option for addressing health workforce shortages in health facilities to cover shifts.

As the projected global health workforce crisis is approaching (Britnell, 2019), while the COVID-19 pandemic has redefined the “new normal,” the demand for specialist skills is growing, and exponential technologies are rapidly bringing the future of work, a fluid workforce promises to become increasingly relevant (Bhuyan et al., 2021) for organizations to meet the growing healthcare demands and maintain the quality of health services. The introduction of a fluid workforce in healthcare could generate more knowledge from angles not considered in other sectors/industries (e.g. their particular characteristics such as their highly educated and skilled nature, which differs from other sectors).

Conceptualizing and operationalizing the fluid workforce concept for the healthcare sector and identifying generic types of fluid workers has been challenging due to the different names of the concepts used and because existing categories overlap in the complex healthcare sector (e.g. gig workers and paid crowd workers).

We also note that while a fluid workforce is not new to the healthcare sector, it can definitely have disruptive consequences. For example, in higher-income countries, health organizations have been relying on agency work for decades, while in lower-income countries, much work had already been “fluid” or non-standard due to “softer” labor legislation or higher degrees of informality. What is new about this type of work specifically for the healthcare sector is the emergence of platform work (e.g. Uber-type work also in healthcare), work without specific time or space boundaries (e.g. working remotely) proliferating thanks to the exponential developments of technology (Alfes et al., 2022), preference shifts of workers and organizations towards such work, and last but not least policy measures implemented during the COVID-19 pandemic (e.g. social distancing norms).

We have noticed some re-branding of similar concepts by successive practitioner cohorts and consultants, as they sought to differentiate their knowledge and services; this has also been noted in the introduction of other HRM innovations. Specifically, for healthcare, we observe positioning of fluid work as a potential benefit for health professionals who can now engage in their own work design (i.e. how long or where to work from), which had not previously been the case for NSE. The impact of such a transformation should be studied carefully, considering for example its effect on the content of health professionals’ jobs; quality of patient care; and the power, motivation, and professional identity of health professionals (Naghieh, 2020).

Health organizations are already being criticized for being rather “traditional” and having their primary focus on legal compliance rather than employee-centered. For them to properly manage a fluid workforce would involve revisiting and rethinking their pre-existing HRM practices to avoid fragmented and parallel management processes and systems (Liu et al., 2006). Instead, a holistic workforce management approach must be created (Altman et al., 2021).

The main limitations of this paper involve, firstly, its high-level general review format aiming at defining and outlining the concept for the healthcare sector in general. Papers aiming to discuss innovations taking place in the circles of HR innovators are not uncommon in the scholarly literature, however (Minbaeva, 2021). Secondly, we do not differentiate between fluid workforce HRM practices in public versus private healthcare facilities, though there are differences between them which could affect how the health workforce is hired, available budget and flexibility, training, and how the regulations might influence hiring decisions (Burke et al., 2013).

To effectively manage a fluid workforce, health managers and leaders need to have a proper estimation of its size and development trends. As a part of our work on this paper, we attempted to estimate empirically the size of the fluid workforce in the healthcare sector. Given the heterogeneity of working arrangements and the lack of granularity and recentness of publicly available data, however, we were unable to provide estimates. We would like to share our insights from this exercise for future scholars [1]. To empirically investigate the fluid workforce trend in healthcare, two approaches could be potentially considered on a country-by-country basis: 1. Analyzing existing labor force surveys, with a focus on healthcare professions; and 2. Conducting specific surveys in the healthcare sector to provide detailed information on working conditions, such as contract status, weekly working hours, and platform usage. Due to the absence of systematic global data on fluid work in healthcare, the creation of a proxy indicator may also be useful. For example, many fluid workers do not work regular full-time hours, leading to a potential discrepancy between the number of physical persons (PP) and full-time equivalents (FTE). If this PP/FTE gap increases over time, it could indicate a growing fluid workforce in the healthcare sector.

Despite these limitations, we think our paper is of value to international communities of research, policy, and practice and can inform future research.

The pressure to deliver more efficient services to the public, as well as the emergence of new forms of work, demands that public sector organizations rethink their organizational processes, including those related to HRM, to continue creating public value (AlMunthiri et al., 2023). Our paper makes a significant contribution to the scholarly HRM literature in the public health sector, which is a significantly under-researched area compared to corporate HRM (Brunetto and Beattie, 2020). Specifically, the paper firstly disentangles a “new” concept that emerged in the circles of innovator practitioners in relation to the already more established concepts of NSE or temporary work. We identify potential similarities and differences and propose a framework of how the implications of fluid work can be analyzed at both organizational and labor market levels (Klein and Potosky, 2019).

Secondly, we define and apply this concept to the highly complex healthcare sector characterized by a highly educated and knowledgeable workforce, thus responding to the calls for more research in this direction (Naghieh, 2020). Thirdly, the paper discusses whether or how the (public) healthcare HRM practices are transforming due to emerging fluid work arrangements (often technology-enabled), as well as their consequences for the fluid workers themselves. Fourthly, the paper contributes to the discussions on the changing nature of public sector employment, which traditionally had been perceived as a job for life (Brunetto and Beattie, 2020). It also reveals HRM practices that can reduce/drive fluid employees’ well-being, engagement, and satisfaction (AlMunthiri et al., 2023) in the public sector, which need to be aligned to ensure their decent future in work. Fifthly, our paper establishes a need for more primary research to understand how the fluid work(force) can affect HRM practices and HLM (in healthcare). As more relevant research is published, we should consider employing the established review methodology for analyzing it. Future research should also comprise extended surveys, as well as interviews with key people in the health sector to investigate empirically the phenomenon of fluid work in the healthcare sector.

From a practitioner perspective, we discuss typologies of the fluid workforce in healthcare and the potential implications of a fluid workforce for the main HR practices in health organizations. Our study reveals the need to revise as well as develop and implement HRM strategies for managing the dual workforce. For public sector managers specifically, our paper can provide insights on how to understand better and strengthen the public sector workforce (Dinkin et al., 2022). Finally, we offer practical methodologies to empirically estimate the prevalence of the fluid workforce within the (public) healthcare industry at different levels.

From a policy perspective, our paper provides a discussion on the implications of fluid work in highly skilled and knowledge-intensive sectors such as healthcare, which could differ from those in lower-paid freelance occupations or sectors. Our paper calls on public sector leaders and managers to create coordination and monitoring mechanisms and tools to better grasp the evolution and diffusion of the fluid workforce in healthcare, as well as to ensure the quality of healthcare services to be delivered by the fluid workforce.

Table 1

Examples of the fluid workforce in healthcare*

	Freelancers/independent workers	Gig workers	Moonlighters
Capgemini Research Institute (2020) definition	Independent workers who supplement the organization’s core workforce	Freelancer mediated through an app or platform	Professionals with a primary permanent job but taking up fluid jobs on the side
Healthcare examples	Per diem professionals (Sharapova et al., 2019)	Nomadhealth.com is a platform that circumvents multiple specialized recruitment agencies to connect physicians directly with hospitals (Naghieh, 2020)	- Locum tenens (Sharapova et al., 2019) - Physicians working in secondary jobs (dual practice): it can become more common due to technology (“side gig”) (Bhuyan et al., 2021)
	Tele-health jobs	Health workforce providing virtual clinical consultations (e.g. Babylonhealth.com in the UK and “Doctor on Demand” in the US) (Naghieh, 2020)

*Source(s): Table created by authors

Table 2

Fluid workforce versus a non-fluid workforce*

HRM practice - HLM impact - Organizational HRM impact	Change	Challenge/Opportunity
Recruitment and selection - Affect the demand for workers - Cost resources and time, determine the talent pool of the organization	Talent acquisition from outside the organization More frequent hiring and dismissals	• Search and hiring costs increase for workers and organizations • More difficult to validate skills and potential • Fewer incentives for workers to develop organization-specific skills • Loss of organizational efficiency and teamwork • Need of new management skills • Organizations have access to a wider range of talents and recently developed workers’ skills • Digital tools (platforms) may support a better identification of missing talent
	Use of technology and digital platforms to coordinate work and manage work processes	• Biases in recruitment and selection of talent
Training and skills development - Reduces mismatches on the LM, increases employability - Improves operational effectiveness and flexibility	More frequent hiring and dismissals	• Costly training of workers may be necessary • Unclear who would invest in re-skilling (worker, employer, general public)
Career planning and retention - Affects supply of workers and social well-being of workers and their families - Determines organizations’ talent pool and institutional knowledge, operational effectiveness	Difficulties with retention	• Reduced identification of workers with hiring organizations and more difficulties with retention of workers
Compensation and benefits - Affect the supply of workers and social well-being of workers and their families, have broader macroeconomic implications on consumption patterns and social security - Cost resources, tools for motivation, reward and retention of talent, can improve productivity	More frequent hiring and dismissals	• Potentially fewer social security benefits and worse coverage of health and retirement risks for workers • Income insecurity for the worker • Weaker incentives to joining organizations and potentially lower bargaining power
Job design - Affects the supply of workers by influencing their motivation and interest in a certain role - Work processes depend on the interplay of job designs	More flexible employee-employer arrangements in terms of work assignments (i.e. which kind of work is to be performed over which period)	• Fluid workers may have multiple employers, which may or may not be the workers’ preference • The workspace (e.g. office, technology, and tools) needs to be adapted
	Lower or higher specializations (e.g. fewer, very specific tasks) Integration of fluid workers can change the job designs of non-fluid workers	• Exposure to a larger variety of work activities and work environments • Integration of fluid workers into work processes by having them concentrate on a very few, specific tasks • Potentially higher motivation, and more inter-organizational experience
	Use of technology and digital platforms to coordinate work and manage work processes	• Loss of control for workers • Focus on average and similar workers, loss of diversity • Algorithmic management methods could increase efficiency but also lead to worse working conditions (“Digital Taylorism”)
Workforce planning - Affects supply and demand of workers, reduces mismatches, and initiates necessary adjustments in education and training systems - Strategic planning tool to better anticipate future uncertainties	More frequent hiring and dismissals	• Firms can react more easily to demand change (i.e. expand or reduce product output or services) • Lower fixed costs for the organization/employer
	Use of technology and digital platforms to coordinate work and manage work processes	• Increase the number of jobs performed by foreign workers based abroad (“outsourcing”)

*Source(s): Table created by authors

Notes

1. The authors searched for and attempted to conduct such an estimate of the fluid workforce market in the (international) healthcare market by drawing on national data sources (e.g. OECD and National Health Workforce Accounts data, as well as data coming from (inter)national labor surveys). This attempt was defeated by the outdated and fragmented nature of publicly available data.