Sick Leave Determinants in the Healthcare Sector (Part I): A Review of Contextual Factors

This is Part I of a series describing sick leave determinants in the healthcare sector. Parts II and III will be published in April and July.

Background

Absenteeism is any failure to report for or remain at work as scheduled, regardless of the reason.¹ Absenteeism generates substantial costs for social welfare and health care systems and, in the 2010s, expenditures on sickness benefits amounted on average to 0.8% of GDP in Organization for Economic Cooperation and Development “OECD” countries.² In that context, it is not surprising that a large body of empirical literature has been devoted to analysis of work absenteeism.³ Some of those studies are essentially descriptive in nature, while others attempt to identify the main factors associated with absenteeism, using either individual-level data or organizational-level studies.^4–18

Although absence definitions varied, a typological framework could be established using the following classifications of absence: voluntary or involuntary, planned, or unplanned albeit that some authors differentiate involuntary absenteeism (e.g., certified sickness) and voluntary absenteeism (e.g., annual leave or vacation, uncertified sickness). It has been further suggested that unplanned absence is often short-term and sometimes voluntary.¹⁹

A greater volume of studies exists regarding commercial/industrial settings and that literature has guided this review on the basis that certain elements and influencers of human behavior can be pertinent regardless of setting. Where healthcare studies relating to absenteeism are available, it is difficult to generalize their findings as the research base is fragmented and often rooted in small-scale case studies.²⁰ The studies on absenteeism are generally conceptual rather than studies of impact and, therefore, limited with regard to availability of qualitative or quantitative data. Also, the majority of studies on absenteeism that do relate to healthcare originate in developed countries and mostly concentrate on nursing staff.^21–24

The most common type is sick leave.²⁵ However, absenteeism is a complex multi-factorial issue involving influences other than simply health. It has been suggested that factors such as lower job satisfaction, current sick pay arrangements and less demanding performance standards may be contributors.²⁶ The link between absenteeism and staff turnover has been reported.²⁷ High absenteeism in health care workers is a particular challenge, noting that the average health care worker between 25 and 54 years of age missed nearly 12 days of work per year as a result of illness or disability, in comparison to seven days in other sectors.²⁸ Therefore, this review aims to comprehensively discuss factors impacting absenteeism in the healthcare setting and consequences of this occurrence. This review is the most comprehensive and current regarding absenteeism in the healthcare setting. The scale of the topic is considerable and, therefore, the review is structured as three Parts dealing, in sequence, with Contextual factors, Organizational-level factors, and factors at the level of the individual.

Methodology

The approach adopted in this semi-structured narrative review was to examine contextual, published studies and to explore the impact of determinants on absence behavior, concentrating on the number of available studies within healthcare settings. While research identified included all staff categories within the healthcare setting, there is particular focus placed on the Nurses and Midwifery staff category due to its large cohort size, multiple grades, and diverse skills, which contribute to relevance across all healthcare facilities.

To ensure a comprehensive and accurate review of peer-reviewed articles and other relevant publications on absenteeism and related factors such as presenteeism, a systematic search was conducted initially to identify relevant source material. Databases accessed were Google Scholar, Econ Lit, PubMed, ResearchGate, ScienceDirect, Emerald Insight, Medline, PsychInfo, Web of Science and Scopus. Search terms included “absenteeism”, “absence rates”, “health”, “healthcare”, “hospital” and “nursing”, and these were used in multiple combinations. Articles were read and assessed for relevance. The inclusion criteria were (i) peer-reviewed academic journals published in English in the period January 2004-April 2022; (ii) research that focused on causal factors of absenteeism; (iii) articles with accessible abstracts and full text; (iv) annual surveys. Exclusion criteria were (i) editorials, commentaries, reviews, and duplicates; (v) conference abstracts. Annual company surveys were included namely to provide commercial data on absenteeism in the workplace. We included annual surveys from the Chartered Institute of Personnel Development with data submitted from companies. After screening the articles, associated reference lists were reviewed to identify additional citations that were not found directly by the search terms. Notably, while studies included were published as late as April 2022, their data collection pre-dated COVID and, therefore, factors specific to COVID were not considered.

Definition of absenteeism

Absenteeism is a temporary absence from work (temporary withdrawal from an organization) for reasons such as illness, bereavement, or other personal issues.²⁹ Absenteeism leads to substantial human, social, and economic costs and, therefore, understanding the role of physical, psychological, work-related factors and psychosocial work factors is key to preventing this outcome.³⁰ Absences can be either short-term or long-term in duration. Davy et al., found in their study of 71 papers, the most common measure of absenteeism reported was ‘absence frequency’ defined as the number of days absent (incidents) over a given period.¹⁷ Other measures used were total days, duration, and percentage. Absenteeism causes are often categorized with reference to the duration of absence, defined as the total length of time (e.g., number of days) an employee has been absent from work over a certain period regardless of the number of absence episodes. Absence duration is considered an indicator of ‘involuntary absenteeism’ resulting from the inability rather than unwillingness to work, for instance because of involuntary factors such as illness due to a reaction to job stress.³¹ Contrary to absence duration, absence frequency is considered an indicator of ‘voluntary absenteeism’ with the implication that there is some form of personal decision whether to attend work or not.³²

Causes of absenteeism

Absenteeism causes can be complex and multi-faceted and, as set out, are often understood in terms of duration which infers voluntary or involuntary absence from work.³³ The causes can be categorized broadly in terms of physical and mental illness. The literature outlines several factors that have associations to absenteeism. Absence may be a genuine illness; occupational causes such as work-related injury or illness or attitude to work; social ailments such as family and carer responsibilities, bereavements or miscellaneous such as undiagnosed psychological or psychosocial problems. Minor illness remains the most common cause of short-term absence, followed by stress. Indeed, stress, acute medical conditions and mental ill health are the most common causes of long-term absence.³⁴ Studies from several countries have identified a variety of factors that are related to sickness-absence from work, including sociodemographic factors and psychosocial working conditions.^35,36 However, there is a commonality of the causes of absence internationally.

Reports originating from healthcare settings also reported many of the same causes of absenteeism experienced in other sectors, but further identified specific challenges. Trinkoff, Storr and Lipscomb, in their US study, found that nurses in jobs where they worked with their head or arms in awkward postures were significantly more likely to be absent than those without such demands.³⁷ Musculoskeletal system ailments were the most common complaints among nursing professionals.^38,39 The 2005 Canadian Institute for Health Information Report stated that nurses with absenteeism totaling more than 20 days commonly reported high job strain, low supervisor support and high physical demands on the job, low control over practice, lack of respect from supervisors, or high role overload as factors responsible for absenteeism.⁴⁰ A Swedish study by Josephson et al., found that nurses dissatisfied with the quality of care provided to patients had higher probability of being on long-term sickness absence.⁴¹ Work schedules and terms of contract have been identified as factors that could influence health workers’ presence or absence at work.¹⁸ In essence, there is consensus that, in the healthcare setting, the physical nature of work and job stress has a significant impact on absenteeism.

Contextual factors

The negative effects on health of inadequate working conditions have long been recognized, but frequently these are only consciously perceived by workers and society at large through their most obvious consequences: occupational injuries and occupational illness.⁴² However, less specific ailments, such as musculoskeletal disorders, accounting for a great number of sick leave episodes, are related to working conditions including psychosocial factors.⁴³ Psychosocial work factors including high psychological demands and low job control have been associated with increases in work related absenteeism.⁴⁴

Nature of work

In their study of healthcare settings, Ticharwa et al., found that incidences of absenteeism are linked to hours of work.⁶ The findings indicated that those who do double shifts or overtime were predisposed to incidences of absenteeism because of strain resulting from excessive work. Night rostering was also considered to be a contributory factor to absenteeism, as night workers were more prone to fatigue and chronic conditions; hence they tend to be absent more often. These findings are particularly relevant in the healthcare setting where overtime and night duty are commonplace.

Ticharwa et al., analyzed the total hours lost per department and showed that absenteeism was more pronounced on inpatient wards, with all wards having more absenteeism hours compared to specialist departments.⁶ The study found that wards with older patients’ subject to frailty, dementia and multiple long-term conditions had significantly higher average absenteeism per nurse than general medical wards. Similarly, a ward with a mixture of cognitively challenging patients and manual handling was associated a high absenteeism rate. Specialty departments had absence averages below the mean average.⁶ Similarly, hospice nurses can experience distressing events daily and thus may turn to support from co-workers or family members as a resource for coping.⁴⁵ Sickness leaves were commonly unplanned and of short duration (less than a week) and were more frequently taken by nurses working in Intensive Care Units compared to general wards.¹²

Furthermore, Tripathi’s study reported that nurses working in the ward areas took the highest number of unplanned sickness leave (7.36 days per absence), while planned sickness leaves were highest (64.8 days) among those in operating theatres.¹² Unplanned sickness was dominated by diseases of the respiratory tract, digestive system, infections, and injury. Planned sickness leaves mainly constituted pregnancy-related illness leave and was highest among younger nurses in operating theatres and intensive care units. Another influence on absenteeism is the changing of rostering patterns; moving nurses to cover shortages in other wards caused psychological unrest and contributed to absenteeism.⁴⁹ This may provide an explanation for the high absenteeism rates in nursing pools as this cohort is generally rotated across departments on a regular basis, sometimes daily. There are other contributory factors such as leadership skills and organization capabilities that may reduce stress. Also, there does seem to be evidence that more physically demanding roles do have a direct association with higher absenteeism levels.

Cultural expectations

Nyathi and Jooste proposed that absence “culture” can influence the absence patterns of health workers.⁵⁰ Contagion effects may also occur as workers respond in a similar fashion to co-workers being absent or alternatively being present when they might legitimately be absent (presenteeism). There are several studies of the contagion of moods being shared by employees, readily apparent and discussed among themselves.^51,57 Attendance (i.e., previous attendance and perceived absence norm) was the best predictor of absenteeism, with greater than 50% significant results. If perceived absence norms, prior individual absence, or poor attendance records, have been high then current absenteeism may increase, as absence cultures may develop. When the culture supports poor attendance, future individual attendance will align itself with cultural norms and expectations.⁵⁹ Isah et al., in their study among the entire staff of a hospital in Nigeria identified common causes of absence including: attendance at examinations, social events like marriage and burial, adverse weather conditions, and travel and transportation problems.¹¹ Overall, the literature demonstrates that it is important for administrators to screen prior absence behavior of potential employees, and monitor attendance behavior of current employees, for patterns in absenteeism as it appears to be a strong predictor of future absence levels.

Economic conditions

People are less likely to be absent from work because of sickness when they are faced with the potential threat of unemployment.⁵⁶ Empirical observations confirm that absenteeism is procyclical; that is, workers are on average less absent in times of bad economic conditions and high unemployment.^54,55,60 For instance, if firms use individual work absence as a selection criterion in lay-off decisions and, as a result, lay-off workers with high absenteeism then average absenteeism is lower during high unemployment.⁴ Economic conditions, incentives, work ethics and work group norms are said to create pressure to attend.⁵² Notably, studies of the impact on absence levels during the recent economic recession seem to indicate a downward trend.¹³ Also of note is that Shoss’ study reflects a behavior called “job preservation” aimed at avoiding the loss of one’s job.⁴⁶ Employees who are fearful of losing their jobs or promotional opportunities may be concerned about the consequences of being absent, and will curtail voluntary absences as a result or even attend when unwell (presenteeism). Irrespective, taken collectively, these international studies confirm that economic conditions are negatively associated with absenteeism, mainly as a result of job security fears.

Seasonality

Seasonality has been documented in the literature as an influence on health status and behaviors.⁵³ Absenteeism rates tend to have seasonal variations, with absenteeism more pronounced during winter and school holidays. There are a number of studies regarding impact of seasonality on absenteeism in the healthcare setting specifically. Ticharwa et al., performed a study in a 300-bed tertiary teaching hospital in Perth, Western Australia, and found that winter was associated with sickness-related absenteeism, as nurses take leave to care for family members.⁶ Such illness affected nursing staff and the people they care for, such as children and elderly parents, meaning nurses would take unplanned leave to recover at home or to look after family members. Similarly, school holidays resulted in planned absenteeism as staff took leave to care for children during these times. That study also observed leave was more pronounced on certain days of the week.⁶ Shi and Skutergard described how summer absenteeism impacts on increased absence, where employees may call in sick to have a sunny day off often during the school-holiday period.⁴⁸ Absenteeism rates on the weekend were lowest, possibly due to the financial incentive associated with working weekends as well as the availability of family members to care for children.⁶¹ In the Irish public and private health sectors specifically, indicators suggest that one-day absences are most frequent, on Mondays and Fridays.⁴⁷ Gianino et al., completed a study in an Italian teaching hospital over three years from 2010-2013 with an average of 5,401 healthcare workers each year.⁵ They found that the mean level of absenteeism increased for all job categories increasing from 5.17 days to 8.57 days during annual flu epidemic periods. Similarly, Yassi et al., completed a study in Canadian hospitals finding that an approximately 35% higher absenteeism rate was observed during the influenza season.⁵⁸ In summary, the international literature conducted in the healthcare setting, with the nursing cohort, suggests that short-term unplanned absence occurs during the winter and summer seasons. Frequent absences in the winter months may be as a result of family responsibilities for children or elderly members. It is also likely that there is more sickness during flu season. During the summer months, increases in short-term absence may be influenced by school holidays and child-minding responsibilities.

Limitations

It is important to highlight potential limitations to this paper. In general, the theoretical development and the amount of knowledge available about the causes of absenteeism in a healthcare setting are quite modest.^14–16 In that challenging context, and cognizant of a paucity of relevant literature, this study focused on the specific factors influencing absenteeism in the healthcare setting. The observed scarcity of material is unsurprising, in the context of organizations’ reticence to provide access to their data due to potential vulnerabilities, such as commercial sensitivities or critique by oversight bodies in addition to political pressures. Inability to access data of this type is reflected across many countries, albeit that that some provide summary information (e.g., Ireland and the United Kingdom).¹⁷ However, even then, varied definitions of absenteeism are utilized that are related to national contexts, which affects the nature of data gathered and analyzed.¹⁸ For example, in the United States, the terms “short-term disability” and “long-term disability” are often used in place of absenteeism. It is possible that the search terms used may not have captured some material pertinent to this review.

Conclusion

This review describes a reasonably consistent picture of contextual factors associated with absenteeism in healthcare. While many factors predicted to be associated with absenteeism, such as nightshift working, seasonality or physically demanding roles correlated clearly with increased absenteeism, the literature demonstrated that previous attendance was the best predictor of absenteeism. Unsurprisingly, people were found to be less likely to be absent from work during times of bad economic conditions. Interventions such as monitoring current absence patterns of existing employees may negate the development of cultural norms in the workplace.

DISCLOSURES/CONFLICTS OF INTEREST

The authors have no conflicts of interest to disclose.

AUTHOR CONTRIBUTION

All Authors have reviewed the final manuscript prior to submission. All the authors have contributed significantly to the manuscript, per the ICJME criteria of authorship.

• Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work; AND

• Drafting the work or revising it critically for important intellectual content; AND

• Final approval of the version to be published; AND

• Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Corresponding author

Professor Colum Dunne,
School of Medicine,
University of Limerick,
Limerick,
Ireland.
Tel: +353-(0)86-0430739
Email: colum.dunne@ul.ie
ORCID: 0000-0002-5010-3185