Received: 13 September 2021 Revised: 2 April 2022 Accepted: 11 April 2022 DOI: 10.1111/jonm.13632 ORIGINAL ARTICLE High hiring rate of nurses in Catalonia and the rest of Spain hides precarious employment from 2010 to 2019: A quantitative study Paola Galbany-Estragués RN, PhD1,2 | Pere Millán-Martínez PhD student, MArch, Data Analyst1,3 | 1 Joan-Carles Casas-Baroy RN, PhD | Mireia Subirana-Casacuberta RN, MSN, PhD1,4 | Anna Ramon-Aribau BS, PhD1 1 Research Group on Methodology, Methods, Models and Outcomes of Health and Social Abstract Sciences (M3O), Faculty of Health Science and Aim: This study aims to describe the hiring of nurses in Catalonia and the rest of Welfare, Centre for Health and Social Care Research (CESS), University of Vic-Central Spain over 10 years. University of Catalonia (UVIC-UCC), Vic, Spain Background: Precarious employment (PE) has negative consequences for nurses’ 2 AFIN Research Group and Outreach Centre, Autonomous University of Barcelona, quality of life and work performance. Cerdanyola del Vallès, Spain Methods: Quantitative study using a retrospective, longitudinal, descriptive design. 3 , Servei Català de Trànsit Carrer Diputacio We analysed publicly available employment data from Catalonia and the rest of Barcelona, Spain 4 Spain. Nursing Department, Parc Taulí Hospital  i Innovacio Universitari, Institut d’Investigacio  Results: Nurses are among the health professionals with the lowest proportion of Parc Taulí I3PT. Consorci Sanitari Parc Taulí, open-term (permanent) contracts, 25% during the first 4 years of employment. Dur- Universitat Autònoma de Barcelona, Sabadell, Spain ing the study period, each nurse hired had an average of 3.44 contracts per year. The proportion of nurses with a fixed-term (non-permanent) contract shrank from 25.3% Correspondence Joan-Carles Casas-Baroy, Research Group on in 2006 to 20.5% in 2012 and grew rapidly to 38.7% in 2018. We estimate that Methodology, Methods, Models and 14,800 nurses signed fixed-term contracts in 2018 without ever having registered as Outcomes of Health and Social Sciences (M3O), Faculty of Health Science and Welfare, unemployed in nursing. Centre for Health and Social Care Research Conclusion: High rates of fixed-term hiring and the high number of contracts per (CESS), University of Vic-Central University of Catalonia (UVIC-UCC), C. Sagrada Família nurse are evidence of a high level of PE for nurses in Catalonia. 7, 08500 Vic, Spain. Implications for Nursing Management: When policymakers and workforce planners Email: joancarles.casas@uvic.cat design recruitment and retention programmes for nurses, they should consider Funding information improving working conditions by extending more open-term contracts to combat PE Consell de Col.legis d’Infermeres i Infermers de Catalunya and, indirectly, the shortage of nurses. KEYWORDS contracts, nurses, precarious employment, Spain Paola Galbany-Estragués and Pere Millán-Martínez should be considered joint first author. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. © 2022 The Authors. Journal of Nursing Management published by John Wiley & Sons Ltd. J Nurs Manag. 2022;30:1337–1344. wileyonlinelibrary.com/journal/jonm 1337 1338  ET AL. GALBANY-ESTRAGUES 1 | I N T RO DU CT I O N allows fixed-term contracts to systematically meet structural needs (EUR-Lex, 2016). Nurses throughout Spain have opposed the austerity Precarious employment (PE) is multidimensional, and researchers measures implemented by the Spanish government, as they perceive across the disciplines have tried to define it from the point of view of that their workloads have increased and their working conditions and economic, labour and social systems (Kreshpaj et al., 2020). New tech- the quality of health services have deteriorated (Gea-Sánchez nologies, globalization and economic recessions have changed the et al., 2021). In Catalonia in particular, nurses have also noted the nature of labour agreements (Padrosa et al., 2021). There is no single deterioration of their working conditions, among which are the loss of definition of PE, which is associated with terms such as flexible, tem- economic remuneration, rotation to different departments, an porary, casual, atypical, non-standard, contingent, underemployment increase in patient complexity and increased demand for health ser- and poor (Benach et al., 2014). Kreshpaj et al. (2020) classify PE into vices, as well as an increase in the number of patients per nurse three dimensions: insecure employment, income inadequacy and lack (Granero-Lázaro et al., 2017). The deterioration of working conditions of rights and protection. In this sense, PE describes a situation of is accentuated when nurses work in nursing homes (Fité-Serra unfavourable ‘quality of employment’, encompassing employment et al., 2019) where labour agreements are even less favourable. conditions (e.g., working hours, organisation and pay) and the formal While researchers have analysed the characteristics of PE and and informal relations between workers and employers (Julià how it affects nurses and other workers, to our knowledge, no et al., 2017). At the same time, PE has enabled economic growth research has quantified the relationship between PE and hiring rates (Kreshpaj et al., 2020), and flexible contracts may enhance some peo- in any country. This study describes the hiring of nurses in Catalonia ple’s work–life balance. and the rest of Spain from 2010 to 2019 and its link to PE. Because PE is more prevalent in young people, women, immigrants, people of PE is a problem in many countries, our findings have implications for lower social class and less training and those who perform manual work health policy beyond Catalonia and Spain. (Baines & Kgaphola, 2019; Julià et al., 2017). PE affects the health of indi- viduals, families and the community (Benach et al., 2014; Julià et al., 2017). Precarious workers are at risk of stigmatization and social 2 | METHODS isolation (Julià et al., 2017). PE affects all professions but is especially prominent in those dedicated to care, such as nurses, who represent 59% 2.1 | Design of health professionals worldwide (Baines & Kgaphola, 2019; World Health Organization, 2020). In Turkey, PE has increased nurses’ conflicts We analysed the hiring rate to give us a greater understanding of at home, as they are unable to meet their families’ expectations PE. To do so, we conducted a quantitative study with a retrospective, (Sarıtaş, 2020). In Brazil, nurses’ working conditions have worsened, lead- longitudinal, descriptive design (Grove & Gray, 2019) using open- ing them to experience physical and psychological deterioration and access data from 2010 to 2019. We analysed the data published by compromising the societal value of nursing (Dias et al., 2019). In Mexico, the Ministry of Universities of the Government of Spain (Ministry of the liberalization of the market following the North American Free Trade Universities of Spain, 2021), the Observatory of Occupations of the Agreement has led the Mexican health system to adopt private sector State Public Employment Service (SEPE)1 (Ministry of Labour and models that have worsened PE for nurses (Nigenda et al., 2020). In Social Economy of Spain, 2021), the Central Balance Sheet Data Poland, PE leads to a shortage of nursing students, because the profes- Office of Catalonia (CatSalut, 2021) and the National Institute of sion is unattractive to young people (Marc et al., 2019). Statistics (INE, 2021). The characteristics of the working environment and the qualifica- tions of nursing staff affect the well-being and satisfaction of patients (RN4CAST, 2017). In the last 10 years, European nurses have 2.2 | Samples and settings improved the quality of care. They are now better trained, more com- petent and more empowered, allowing them to make complex deci- The study population is the generalist nurses from Catalonia and the sions and provide comprehensive care (Cabrera & Zabalegui, 2021). rest of Spain (excluding Catalonia) represented in the data summa- However, power, class and gender relations lead nursing to be a pre- rized by the SEPE. We use the SEPE’s terms ‘unemployed nurses’ carious profession with little social recognition (Dias et al., 2019; (those without work and registered as seeking employment in nursing World Health Organization, 2020). the last day of the period under consideration) and ‘non-specialized In Spain, the economic crisis that began in 2008 led to the imple- nurses’. We use the Central Balance term ‘full-time equivalent mentation of austerity policies that affected the health sector and, in employees’ (CatSalut, 2021), defined as the hours worked by part- turn, the health of the population (Sánchez-Recio et al., 2020; time personnel divided by the average annual hours worked in full- Spijker, 2020). The crisis also affected health professionals and espe- time jobs (Organisation for Economic Co-operation and Development cially nurses, as the most vulnerable part of the health workforce. In [OECD], 2001). From the INE, we use the term ‘nurses licensed to 2013 alone, Spain lost 5200 active nurses (Galbany-Estragués & practice’ (enfermeras colegiadas) (INE, 2021), which is defined by Span- Nelson, 2016). The European Court of Justice has noted that Spanish ish law as nurses who are certified members of a regional professional legislation conflicts with the rule of law in the European Union, as it nursing association.  ET AL. GALBANY-ESTRAGUES 1339 2.3 | Data collection following their graduation, by profession. Grey lines show overall trends across all university graduates in Spain. From the SEPE, we obtained the monthly series of employment statis- This figure shows that, in the case of graduates in medicine, the tics between 2010 and 2019 (covering the period from the beginning percentage of workers with open-term contracts is zero between the of the series to the beginning of the COVID-19 pandemic), from the second and fourth years. This is explained by the fact that graduates Central Balance Sheet (Catsalut, 2021), the annual series of statistics in medicine continue their studies to prepare for specialist exams and of the ratio of workers according to type of contract from 2008 to then as residents. Between 30% and 40% of graduates in occupational 2017 (which comprise all publicly available data), and from the INE, therapy, human nutrition and dietetics and physiotherapy have an the annual series of active licensed nurses from 2010 to 2019 (INE, open-term contract the first year after graduating, which increases to 2021). We chose this period to coincide with the SEPE data. From the approximately 50% by the fourth year. Graduates in pharmacy have Ministry of Universities, we used indicators of participation in the the highest proportion of open-term contracts: above 50% in the first social security system among university graduates in 2014, which is year after graduation and 65% by the third year. Employed nursing the most recent publicly available employment data about new graduates, on the other hand, have among the lowest proportions of graduates. open-term contracts in the first year (just over 25%), and this figure does not improve during the following 3 years. The SEPE publishes monthly and yearly statistics for job seekers, 2.4 | Ethical considerations unemployed people and the number of contracts issued in each occu- pation, including nursing (non-specialist nurse, specialist nurse and Because we used public data, no ethical approval was required. We nurse-midwife). These data are the source for Figures 2–5. have a commitment to use the data ethically and transparently, in Figure 2 shows trends in the number of unemployed nurses in accordance with the approach of Catalonia’s Office for Open Data Catalonia and the rest of Spain. The two series have different orders (Vidal-Juanola, 2021). of magnitude, which is logical considering the difference in population size: Catalonia’s population grew from 7,462,044 inhabitants in 2010 to 7,722,203 inhabitants in 2020, while Spain’s population grew from 2.5 | Data analysis 46,486,621 inhabitants to 47,332,614 inhabitants. In Catalonia, the number of unemployed nurses grew exponentially between 2010 and We performed a descriptive analysis of the different time series and 2012, when it reached its maximum of 1500. Beginning in 2012, the used the data visualization packages brinton and ggplot2 of the R sta- number gradually decreased until 2018, when it returned to the 2010 tistical computing environment (Millán-Martínez & Oller, 2021). value of around 500 unemployed nurses. In the rest of Spain, the curve is bell shaped, with a rapid increase in unemployment between 2010 and 2013 and a slower recovery between 2013 and 2020. In 3 | RESULTS the rest of Spain, the number of unemployed nurses also presents high seasonality with marked valleys during August and September We first examined the indicators of participation in the social security and less pronounced ones in December, coinciding with holiday system of university graduates published by the Ministry of Universi- periods. We also observe that as unemployment increases, so does ties of Spain (2021). In Figure 1, coloured lines represent trends in the the amplitude of the wave derived from seasonality. percentage of 2014 health graduates having an open-term (perma- Figure 3 shows that, despite the difference in population between nent) or fixed-term (non-permanent) contract over the 4 years Catalonia and the rest of Spain, the monthly count of nursing F I G U R E 1 Percentage of open-term or fixed-term contracts of health graduates over the 4 years following graduation. Source: Ministry of Universities of the Government of Spain 1340  ET AL. GALBANY-ESTRAGUES F I G U R E 2 Monthly number of unemployed nurses in Catalonia and the rest of Spain. Source: Observatory of Occupations of the State Public Employment Service (SEPE) of the Ministry of Labour and Social Economy of Spain F I G U R E 3 Monthly number of contracts held by nurses in Catalonia and the rest of Spain. Source: Observatory of Occupations of the State Public Employment Service (SEPE) of the Ministry of Labour and Social Economy of Spain contracts is very similar. The two trend lines share a cycle, although in Spain, the average number of contracts per nurse ranges between one Catalonia, we find the minimum in 2011, and in the rest of Spain, this and four, with large peaks in July and smaller peaks in December. minimum is delayed until 2013. Between 2012 and 2017, the growth Because there were 12 times more contracts in a month than of both lines corresponds to the decrease in unemployment in nursing unemployed nurses in the same month, we can deduce that contracts in Spain in this period. As of 2017, however, the number of contracts especially benefited nurses who were not registered as unemployed. both in Catalonia and in the rest of Spain trends downwards, while Figure 5 shows the monthly number of nursing contracts and the unemployment continues to fall. We also observe that the number of monthly number of nurses who have benefited from these contracts contracts in the rest of Spain presents seasonal cycles that peak in Spain. We observe that these two statistics are positively correlated in June. (r = .89) and that the two trend lines share a cycle. The evolution of Given that the data represented in Figure 2 contrast with those in the number of contracts and nurses hired peaks in July, and as the Figure 3 and in order to explore the different behaviour of the two number of contracts increases, the separation between the two trends territories analysed, we offer Figure 4, which represents the evolution also increases, with the average value of the ratio of contracts per of the monthly ratio of contracts held by nurses with respect to the nurse hired between 1.6 and 1.8, and the extremes of this ratio monthly number of unemployed nurses in Catalonia and the rest of around 1.4 and 2.2 (see Figure S1). Notably, between 2010 and 2020, Spain. We observe that the ratio of both territories falls suddenly each nurse hired each month, had on average, between 1.6 and 1.7 between 2010 and 2012 and, from this moment on, grows steadily contracts in that month, indicating PE. If we look at the aggregated until 2019. The two ratios differ in the regularity of the intra-annual data by year, we can see that, for example, in 2019 in Spain, 195,214 cycles and in the order of magnitude of the average annual value, with contracts were issued to a total of 56,684 nurses; that is, each nurse both being much more stable in the rest of Spain. The order of magni- hired had on average 3.44 contracts that year. tude of the average value in the case of Catalonia is from four con- The disaggregated number of single nurses hired for Catalonia is tracts per month per unemployed nurse in 2011 to around 12 in not available, which prevents us from including this data in Figure 5. 2019, meaning that in 2019, there was a monthly ratio of 12 contracts However, we know that in Catalonia in 2019, a total of 76,851 con- per unemployed nurse. (This does not mean that on average each tracts were issued, and we estimate that they benefited a total of nurse in Catalonia had 12 different contracts, because not all con- 22,315 nurses. We obtain this number by applying the Spanish ratio tracts go to nurses who are registered as unemployed.) In the rest of of 3.44 contracts per nurse and considering that contracts in  ET AL. GALBANY-ESTRAGUES 1341 F I G U R E 4 Monthly ratio of contracts held by nurses and the monthly number of unemployed nurses in Catalonia and the rest of Spain. Source: Observatory of Occupations of the State Public Employment Service (SEPE) of the Ministry of Labour and Social Economy of Spain F I G U R E 5 Monthly number of contracts held by nurses and the monthly number of nurses hired in Spain. Source: Observatory of Occupations of the State Public Employment Service (SEPE) of the Ministry of Labour and Social Economy of Spain Catalonia represent almost 40% of contracts in Spain overall, while fewer single nurses, given that a nurse can be registered as unem- Catalonia has only 17% of the population of non-retired licensed ployed for more than 1 month over a given year). If we take the num- nurses (47,714 registered in Catalonia in 2019 compared with ber of nurses without an open-term contract (approximately 18,108) 267,861 registered in Spain). and subtract the sum of the monthly count of unemployed nurses Finally, the only data relating to the proportion of nurses with (approximately 6,597), it follows that there are at least 11,511 nurses open-term contracts with respect to the total number of employed without an open-term contract who have not been registered as nurses that is not protected by the Catalan Data Protection Authority unemployed in nursing (this means that they are not unemployed, that is that published annually in the Central Balance Sheet (CatSalut, they have not registered as job seekers and/or that they have regis- 2021). Figure 6 shows the proportion of graduates with a 3- or 4-year tered as job seekers but not in nursing). We therefore deduce that the university health degree (mainly nurses) with an open-term contract number of people who worked regularly as nurses by stringing or fixed-term contract (interim, casual or substitution), by year. Interim together fixed-term contracts without registering as unemployed in contracts are, in theory, used to cover a vacant permanent position nursing was between 11,511 and 18,108 in 2018. Taking the midpoint until an open-term contract can be signed; in practice, they can last between these two values, we estimate 14,809 nurses (31%) fit this for years because the administration often fails to fill vacancies. description, out of a total of 46,793 registered active nurses. Casual contracts are used to cover sporadic needs, such as peaks in workload. Substitution contracts are used to cover short-term absences due to circumstances such as illness and maternity leave. 4 | DI SCU SSION The proportion of those with a fixed-term contract decreased from 25.3% in 2006 to 20.5% in 2012 and then increased dramatically to Among health graduates, nurses are the workers with among the low- 38.7% in 2018. If we extrapolate the result of this sample to the group est proportion of open-term (permanent) contracts in the first 4 years of active licensed nurses in Catalonia in 2018 (46,793), we can after their graduation. There are many more unemployed nurses in approximate the number of nurses with fixed-term contracts at the rest of Spain than in Catalonia, but the number of contracts is sim- 18,108 nurses in 2018. ilar (SEPE, Ministry of Labour and Social Economy of Spain, 2021). Another consideration is that the sum of the monthly count of Therefore, there is a great difference between the ratio of contracts unemployed nurses in Catalonia in 2018 is 6597 (which correspond to per unemployed nurse. While in Catalonia, the ratio is between four 1342  ET AL. GALBANY-ESTRAGUES F I G U R E 6 Proportion of graduates with a three- or four-year university health degree (mainly nurses) with open-term or fixed-term (interim, casual, or substitution) contracts in a sample of between 100 and 109 (depending on the year) Catalan health facilities. Source: Central Balance Sheet Data Office of Catalonia and 12 contracts per unemployed nurse, in the rest of Spain, the ratio PE is one of the factors that leads Spanish nurses to emigrate or is between one and four. This high ratio of contract per unemployed leave the profession in search of better living conditions (Galbany- nurse indicates that the Catalan health system much more frequently Estragués et al., 2019; Galbany-Estragués & Nelson, 2016; Rodríguez- requires nurses to string together multiple fixed-term (non-perma- Arrastia et al., 2021). These data coincide with nurses’ perceptions of nent) contracts each year, causing high rates of PE. poor working conditions, including fixed-term contracts (Fité-Serra The number of nursing contracts per year would appear to be a et al., 2019; Granero-Lázaro et al., 2017). Junior nurses with fixed- favourable indicator, but in fact, it indicates PE and a lack of adher- term contracts show high levels of emotional fatigue, depersonaliza- ence to European Union law. According to European Union law, fixed- tion and lack of personal fulfilment, which leads them to suffer psy- term contracts cannot systematically meet ongoing structural needs  pez chological problems such as stress and anxiety (Acea-Lo (EUR-Lex, 2016). These contracts have been used especially in Catalo- et al., 2021). PE is so recurrent in the nursing profession that even nia, a region in which, for example, in 2019, a number of contracts new Spanish graduates consider the possibility of emigrating due to between 10 and 15 times greater than the number of unemployed lack of work and job insecurity (Gea-Caballero et al., 2019). people in nursing were issued every month. Despite the difficulties in We must emphasize that the period of analysis is prior to the collecting data about the type of contracts that health professionals COVID-19 pandemic. Nursing understaffing in Catalonia and the rest hold (because they are protected by the Catalan public administra- of Spain made it particularly difficult to meet care needs during this tion), we estimate that in 2018, approximately 14,800 nurses strung health emergency. The 2020 hiring figures show fewer contracts than together several fixed-term contracts without registering as unem- the prior year, given emergency hiring programmes designed to create ployed in nursing, as shown in Section 3. staffing stability during the COVID-19 crisis. The number of nursing Nurses ensure the safety and quality of care (Aiken et al., 2017). contracts in Catalonia shrank 21% between 2019 and 2020 In Spain, citizens living in regions with a higher nurse–patient ratio (in contrast to 14% in the rest of Spain, SEPE). This dramatic decrease are more satisfied with their health system (Ministry of in the number of contracts during the greatest health crisis in a cen- Health, 2019). The region of Spain with the highest ratio of nurses tury points to Spain’s and especially Catalonia’s tendency to overuse per population is Navarra (8.6 nurses per thousand inhabitants), fixed-term contracts. Catalonia’s health system, and likely many while Catalonia has a ratio of 6.2 nurses per thousand inhabitants. If others around the world, now faces the opportunity to address PE by Catalonia wanted to place itself on par with Navarra, it would have permanently incorporating the nurses hired to face the COVID-19 cri- to incorporate 17,325 nurses into its health system, about 35% more sis. Health policies should be updated, and the working conditions of than the nurses it currently has. If Catalonia wanted to approach the nurses improved to avoid compromising the response of health sys- median of the European Union, which is around 9.5 nurses per thou- tems (see Lasater et al., 2021). The World Health Organization has sand inhabitants, the figure would be even higher: 24,197 nurses committed to a global strategy on human resources for health, Work- would need to be hired (50% more). In making such comparisons, we force 2030, which calls for the defence of personal, labour and profes- must take into account that different European countries have dif- sional rights of all health personnel (World Health ferent health models. However, taking Spanish data as a reference Organization, 2020). If these actions are not taken, the shortage of point, it is evident that Catalonia needs to hire and retain more nurses is likely to continue in many countries, and their citizens are nurses by offering them open-term contracts instead of a string of likely destined for decreased quality of life and increased mortality, fixed-term ones. morbidity and dissatisfaction (Aiken et al., 2017; RN4CAST, 2017).  ET AL. GALBANY-ESTRAGUES 1343 5 | L I M I T A T I O NS interpretation of the data. PGE, PMM, JCCB and ARA have been involved in drafting the manuscript, and PGE, PMM, JCCB, MSC and To analyse the seasonality of nursing hiring, we requested statistical ARA revised it critically for important intellectual content. PGE, PMM, data from Statistics from Hospitalisation Health Facilities (EESRI) from JCCB, MSC and ARA have given final approval of the version to be the Agency for Health Quality and Assessment of Catalonia (AQUAS). published. Each author should have participated sufficiently in the We were denied access to the data because it is protected by the Cat- work to take public responsibility for appropriate portions of the con- alan Data Protection Authority, and this research was not sponsored tent. PGE, PMM, JCCB, MSC and ARA agreed to be accountable for by a university belonging to the Catalan Association of Public Univer- all aspects of the work in ensuring that questions related to the accu- sities (ACUP). To overcome this limitation, we analysed open data racy or integrity of any part of the work are appropriately investigated sources that made it possible to assess PE in nursing in Catalonia and, and resolved. more specifically, to reveal Catalonia’s heavy reliance on fixed-term contracts in nursing. ET HICAL APPROVAL No ethical approval was required because we used public databases. 6 | C O N CL U S I O N S DATA AVAILABILITY STAT EMEN T Authors do not wish to share the data. The high hiring rate of nurses in Catalonia conceals a problem of PE. In 2018, between a minimum of 11,511 nurses and a maximum of ORCID 18,108 held fixed-term (non-permanent) contracts without appearing Paola Galbany-Estragués https://orcid.org/0000-0003-3775-1695 in unemployment statistics. Their failure to enrol in the unemploy- Pere Millán-Martínez https://orcid.org/0000-0003-0879-9358 ment registry likely reflects the fact that they become accustomed to Joan-Carles Casas-Baroy https://orcid.org/0000-0002-2021-8459 the pattern of consecutive short fixed-term contracts. These data Mireia Subirana-Casacuberta https://orcid.org/0000-0003-1577- indicates the ongoing structural need for nurses in the Catalan health 4159 system. PE influences the decision of Catalan nurses and Spanish Anna Ramon-Aribau https://orcid.org/0000-0003-3303-9932 nurses more broadly to emigrate and to leave the profession, which accentuates the shortage of nurses. This shortage endangers the abil- ENDNOTE 1 ity of the health system to provide high-quality care to citizens. Our Standard abbreviation in Spain. analysis points to the importance of examining statistical data closely; seemingly positive data for the hiring of nurses can in fact hide dismal RE FE RE NCE S levels of PE. The finding that ‘good’ hiring numbers can hide PE may Acea-Lo  pez, L., Pastor-Bravo, M. M., Rubinat-Arnaldo, E., Bellon, F., be helpful to quantitative health researchers in other countries. Blanco-Blanco, J., Gea-Sanchez, M., & Briones-Vozmediano, E. (2021). Burnout and job satisfaction among nurses of three Spanish regions. Journal of Nursing Management, 29(7), 2208–2215. https:// doi.org/10.1111/jonm.13376 7 | I M P L I C A T I O N S F O R NU R S I N G Aiken, L. H., Sloane, D., Griffiths, P., Rafferty, A. M., Bruyneel, L., MANAGEMENT McHugh, M., Maier, C. B., Moreno-Casbas, T., Ball, J. E., Ausserhofer, D., Sermeus, W., & For the RN4CAST Consortium When policymakers and workforce planners, nationally and internation- RN4CAST Consortium. (2017). Nursing skill mix in European hospi- tals: Cross-sectional study of the association with mortality, patient ally, design recruitment and retention programmes for nurses, they should ratings, and quality of care. BMJ Quality & Safety, 26(7), 559–568. consider addressing PE by extending more open-term (permanent) con- https://doi.org/10.1136/bmjqs-2016-005567 tracts to combat shortages and attract new generations of nurses. Baines, D., & Kgaphola, I. (2019). Precarious care: International comparisons of nonprofit social service work. Women’s Studies International Forum, 74, 210–217. https://doi.org/10.1016/j.wsif. ACKNOWLEDGEMEN TS 2019.05.001 We thank the Consell de Col.legis d’Infermeres i Infermeres de Catalu- Benach, J., Vives, A., Amable, M., Vanroelen, C., Tarafa, G., & Muntaner, C. nya for making this study possible. We also thank Dr Susan Frekko for (2014). Precarious employment: Understanding an emerging social her feedback and for translating the manuscript into English from the determinant of health. Annual Review of Public Health, 35, 229–253. https://doi.org/10.1146/annurev-publhealth-032013-182500 original Spanish. Cabrera, E., & Zabalegui, A. (2021). Bologna process in European nursing education. Ten years later, lights and shadows. Journal of Advanced CONF LICT OF IN TE RE ST Nursing, 77, 1102–1104. https://doi.org/10.1111/jan.14727 We have no conflict of interest. CatSalut. Servei Català de la Salut. (2021). Informes economicofinancers de la Central de Balanços. Central de Balanços de Catalunya. https:// catsalut.gencat.cat/ca/coneix-catsalut/informacio-economica/central- AUTHOR CONTRIBUTIONS balancos/ PGE, PMM, JCCB, MSC and ARA made substantial contributions to Dias, M. O., Souza, N. V. D. O., Penna, L. H. G., & Gallasch, C. H. (2019). the conception and design, acquisition of the data and analysis and Perception of nursing leadership on the fight against the 1344  ET AL. GALBANY-ESTRAGUES precariousness of working conditions. Revista da Escola de Millán-Martínez, P., & Oller, R. (2021). A Graphical EDA Tool with ggplot2: Enfermagem da USP, 53, e03492. https://doi.org/10.1590/S1980- Brinton. The R Journal, 12(2), 631. https://doi.org/10.32614/RJ-2021-018 220X2018025503492 Ministry of Health. (2019). Opinion of the citizens. Health barometer. EUR-Lex. (2016). Sentencia del tribunal de justicia (Sala Décima). de 14 de https://www.sanidad.gob.es/estadEstudios/estadisticas/ septiembre de 2016. http://eur-lex.europa.eu/legal-content/ES/ BarometroSanitario/home_BS.htm TXT/?uri=CELEX:62015CJ0016 Ministry of Labour and Social Economy of Spain. (2021). Public Service for Fité-Serra, A. M., Gea-Sánchez, M., Alconada-Romero, A.,  Tomás State Employment. Monthly Labour Market Information by Occupation. Mateos, J., Blanco-Blanco, J., Barallat-Gimeno, E., Roca-Llobet, J., & SEPE. https://www.sepe.es/HomeSepe Muntaner, C. (2019). Occupational precariousness of nursing staff in Ministry of Universities of Spain (2021). Indicators of affiliation to Social Catalonias public and private nursing homes. International Journal of Security of university graduates. https://www.universidades.gob.es/ Environmental Research and Public Health, 16(24), 4921. https://doi. portal/site/universidades/menuitem. org/10.3390/ijerph16244921 78fe777017742d34e0acc310026041a0/?vgnextoid= Galbany-Estragués, P., Millán-Martínez, P., del Mar Pastor-Bravo, M., & b747122d36680710VgnVCM1000001d04140aRCRD Nelson, S. (2019). Emigration and job security: An analysis of work- Nigenda, G., Serván-Mori, E., Aristizabal, P., & Zárate-Grajales, R. A. force trends for Spanish-trained nurses (2010–2015). Journal of Nurs- (2020). The correlates of precarious working conditions in the Mexi- ing Management, 27(6), 1224–1232. https://doi.org/10.1111/jonm. can nursing labour market from 2005 to 2018: A repeated cross- 12803 sectional study. Journal of Nursing Management, 28(5), 1010–1020. Galbany-Estragués, P., & Nelson, S. (2016). Migration of Spanish nurses https://doi.org/10.1111/jonm.13034 2009–2014. Underemployment and surplus production of Spanish Organisation for Economic Co-operation and Development. (2001). Glossary nurses and mobility among Spanish registered nurses: A case study. of statistical terms. https://stats.oecd.org/glossary/detail.asp?ID=1068 International Journal of Nursing Studies, 63, 112–123. https://doi.org/ Padrosa, E., Belvis, F., Benach, J., & Julià, M. (2021). Measuring precarious 10.1016/j.ijnurstu.2016.08.013 employment in the European Working Conditions Survey: Psycho- Gea-Caballero, V., Castro-Sánchez, E., Díaz-Herrera, M. A.,  Sarabia- metric properties and construct validity in Spain. Quality and Quan- Cobo, C., Juárez-Vela, R., & Zabaleta-Del Olmo, E. (2019). Motiva- tity, 55, 543–562. https://doi.org/10.1007/s11135-020-01017-2 tions, beliefs, and expectations of Spanish nurses planning migration RN4CAST. (2017). Final Report Summary—RN4CAST (Nurse Forecasting: for economic reasons: A cross-sectional, web-based survey. Journal Human Resources Planning in Nursing). https://cordis.europa.eu/ of Nursing Scholarship, 51(2), 178–186. project/id/223468/reporting Gea-Sánchez, M., Briones-Vozmediano, E., Legido-Quigley, H., Rodríguez-Arrastia, M., Ropero-Padilla, C., Fernández-Sola, C., & Muntaner, C., Rocaspana, M., & Blanco-Blanco, J. (2021). The resis- Portillo, M. C. (2021). Nursing emigration in the United Kingdom: A tance of nurses to austerity measures in the health sector during the qualitative exploration of the Spanish nursing community. Nursing financial crisis in Spain. Gaceta Sanitaria, 35, 42–47. https://doi.org/ Open, 8, 675–687. https://doi.org/10.1002/nop2.672 10.1016/j.gaceta.2019.08.009 Sánchez-Recio, R., Alonso, J. P., & Aguilar-Palacio, I. (2020). The use of Granero-Lázaro, A., Blanch-Ribas, J. M., Roldan-Merino, J. F., Torralba- health care services in the Great Recession: Evaluating inequalities in Ortega, J., & Escayola-Maranges, A. M. (2017). Crisis en el sector the Spanish context. Gaceta Sanitaria, 34(3), 245–252. https://doi. sanitario: impacto percibido en las condiciones de trabajo de las org/10.1016/j.gaceta.2019.10.009 enfermeras. Enfermería Clínica, 27(3), 163–171. https://doi.org/10. Sarıtaş , C. T. (2020). Precarious contours of work–family conflict: The case 1016/j.enfcli.2017.03.005 of nurses in Turkey. The Economic and Labour Relations Review, 31(1),  n en enfermería. In Desarrollo Grove, S. K., & Gray, J. R. (2019). Investigacio 59–75. https://doi.org/10.1177/1035304619879327 de la práctica enfermera basada en la evidencia (7th ed. (en español)). Spijker, J. (2020). Los efectos de la Gran Recesio  n y las políticas de Elsevier. austeridad en la salud de la poblacio n española. Gaceta Sanitaria, Instituto Nacional de Estadística (2021). Profesionales sanitarios colegiados. 34(3), 220–222. https://doi.org/10.1016/j.gaceta.2019.12.006 https://www.ine.es/dyngs/INEbase/es/operacion.htm?c=Estadistica_ Vidal-Juanola, A. (2021). Ètica i dades obertes https://formaciooberta.eapc. C&cid=1254736176781&menu=ultiDatos&idp=1254735573175 gencat.cat/espaistematics/gestio-dades/etica-i-dades-obertes.html Julià, M., Vanroelen, C., Bosmans, K., Van Aerden, K., & Benach, J. (2017). World Health Organization. (2020). State of the Worlds Nursing. Investing Precarious employment and quality of employment in relation to in education, jobs, and leadership. https://www.who.int/publications- health and well-being in Europe. International Journal of Health detail-redirect/9789240003279 Services, 47(3), 389–409. https://doi.org/10.1177/0020731417 707491 SUPPORTING INF ORMATION Kreshpaj, B., Orellana, C., Burström, B., Davis, L., Hemmingsson, T., Additional supporting information may be found in the online version Johansson, G., Kjellberg, K., Jonsson, J., Wegman, D. H., & Bodin, T. of the article at the publisher’s website. (2020). What is precarious employment? A systematic review of defi- nitions and operationalizations from quantitative and qualitative studies. Scandinavian Journal of Work, Environment & Health, 46(3), How to cite this article: Galbany-Estragués, P., 235–247. https://doi.org/10.5271/sjweh.3875 Lasater, K. B., Aiken, L. H., Sloane, M. D., French, R., Martin, B., Reneau, K., Millán-Martínez, P., Casas-Baroy, J.-C., Subirana-Casacuberta, Alexander, M., & McHugh, M. D. (2021). Chronic hospital nurse M., & Ramon-Aribau, A. (2022). High hiring rate of nurses in understaffingmeets COVID-19: An observational study. BMJ Quality & Catalonia and the rest of Spain hides precarious employment Safety, 30(8), 639–647. https://doi.org/10.1136/bmjqs-2020-011512 from 2010 to 2019: A quantitative study. Journal of Nursing Marc, M., Bartosiewicz, A., Burzynska, J., Chmiel, Z., & Januszewicz, P. (2019). A nursing shortage—A prospect of global and local policies. International Management, 30(5), 1337–1344. https://doi.org/10.1111/ Nursing Review, 66(1), 9–16. https://doi.org/10.1111/inr.12473 jonm.13632