RESEARCH ARTICLES

Sickness absenteeism of nursing team in a health insurance company

Alessandro Formenton^I; Vivian Aline Mininel^II; Ana Maria Laus^III
IR.N., Specialist in Occupational Health Nursing. Master’s degree student at the Graduate Program in Basic Nursing, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, São Paulo, Brazil. E-mail: alessandroformenton@usp.br.
^IIR.N., Ph.D. in Sciences. Researcher at the Center for Studies and Research on Hospitals and Nursing, University of São Paulo at Ribeirão Preto College of Nursing. Ribeirão Preto, São Paulo, Brazil. E-mail: vivian.aline@usp.br.
^IIIR.N., Professor at the Graduate Program in Basic Nursing, University of São Paulo at Ribeirão Preto College of Nursing. Coordinator of the Center for Studies and Research on Hospitals and Nursing. Ribeirão Preto, São Paulo, Brazil. E-mail: analaus@eerp.usp.br.

ABSTRACT: Although sickness absenteeism compromises healthcare quality and efficiency of services, there are few studies in nursing about it. This is a quantitative descriptive and retrospective study that analyzed sickness absenteeism in the nursing team of a health insurance company located in the backlands of the São Paulo State, Brazil. Secondary data collected from medical statements as of 2007 were analyzed according to the following categories: gender, work unit, professional category, sick leaves and their respective causes according the International Classification of Diseases. Most of 98 workers on a leave were females, from the hospital unit, and generated 172 sick leaves on an average of 1.76 due to respiratory system diseases. Absenteeism average was 5.39, being higher among nursing technicians from the emergency care unit. Absenteeism affects organization dynamics, work environment, and healthcare assistance, and requires identification of causes for enabling setting up priority intervention strategies.

Keywords: Absenteeism; personnel management in hospitals; nursing; health insurance company. 

INTRODUCTION

The performance of nursing actions in different work contexts is directly influenced by the quantity of human resources available. The adequate provision of nursing staff is an important strategy for the quality and improvement of health care services and, consequently, for health care results¹.

In hospitals, the nursing staff represents the majority of human resources, and it is considered the professional category that most suffers from poor working conditions, due to the unhealthiness of the environment and cost containment measures that encourage absenteeism².

The changes in nursing work during the last decades have driven workers to intense labor rhythms, with double shifts in precarious conditions. As a consequence of this context, high rates of absenteeism have been identified among the nursing staff, associated with illness and loss of quality of life of the worker^3-5.

In order to understand the importance of this issue for Brazilian nursing workers and health care institutions as managers of human resources, and because of the lack of national studies on absenteeism among the nursing staff in the supplementary health care sector, the aim of this study was to analyze sickness absenteeism among the nursing staff of a health insurance company in the interior of São Paulo, which integrates the network of the supplementary health care sector in this region.

LITERATURE REVIEW

Absenteeism refers to absences at times when the employee should normally be working⁶. It is a crucial issue for organizations because it is linked to several factors, making it extremely complex and difficult to manage.

Sickness absenteeism refers to the absence of a worker due to health problems, and in hospital environments, its occurrence is the leading cause of unforeseen absences⁷. In addition to the impact on the lives of workers, this issue has emerged as an important factor that compromises performance and quality of care services provided⁸.

In the national context, studies indicate musculoskeletal and respiratory diseases, and mental and behavioral disorders, as the disease groups with the greatest impact on the number of days absent from work in nursing^3,4,9-11. Such studies emphasize the relationship of such conditions with the work environment, and reflect the precarious labor conditions and organization of the nursing work dynamics.

An integrative review on absenteeism in nursing pointed out that exposure to poor working conditions favors the development of diseases that predispose absenteeism; therefore, sensitizing institutions and employers regarding personnel sizing and working conditions is essential to mitigating absenteesim¹⁰.

Due to the importance of absenteeism in the hospital environment, many institutions have adopted the rate of nursing absenteeism as an indicator of personnel administration, and as a way to evaluate nursing performance^4,11.

Nevertheless, despite being an increasingly studied subject in the context of health care and nursing, there are still few studies on absenteeism¹². Furthermore, few studies are found on absenteeism in the Brazilian supplemental health care sector, which currently cares for approximately 47 million beneficiaries with medical plans with and without dental care¹³.

The National Supplemental Health Care Agency, created by the Federal Government and subordinated to the Ministry of Health, emerged with the aim of regulating the institutions that sell health care plans, called health insurance companies¹⁴. To meet such demand, through health insurance companies, the supplemental health care sector employs health care professionals in various branches of service, such as hospitals, clinics, laboratories and companies, and nursing is a category with large representation in this industry.

METHODOLOGY

This is a descriptive, exploratory, retrospective study with quantitative analysis, conducted at two medical units pertaining to a health insurance company in the interior of São Paulo state, Brazil. The emergency unit has its own building, with 18 observation beds and 31 beds for clinical and surgical inpatient care, and 75 nursing professionals (12 nurses, 24 nursing technicians and 39 nursing assistants). The hospital unit has 84 beds for clinical and surgical inpatient care, integrating the structure and sharing some common services with the municipal charity hospital, and 127 nursing professionals (16 nurses, 42 nursing technicians and 69 nursing assistants). Both units provide uninterrupted services to insured members with the presence of nursing staff at all times.

The study population consisted of nursing professionals (nurses, nursing technicians and nursing assistants) assigned to the units under study, all of which had a formal job contract with the company during the period between January 1 and December 31 of 2007, totaling 202 professionals. The nursing staff of the two units operates in 12-hour shifts per 36 hours off, and the hiring scheme adheres to the rules of the Brazilian Consolidation of Labor Laws (CLL).

Manual data collection was conducted in the Human Resources department of the institution investigated, to which all health certificates of the professionals are sent. Information of interest was entered into an Excel spreadsheet, namely: sex, work unit, professional category, absences and their causes.

Absenteeism was analyzed according to the variables described above, as well as work days missed and related diseases, according to the International Classification of Diseases (ICD-10)⁹. Statistical analysis was performed by calculating attendance rates (AR), mean absences and work days missed³. The formulas used are described as it follows:

The research proposal was approved by the Research Ethics Committee of a Public Higher Education Institution, under protocol No. 921/2008, and received approval for data collection from the Administrative Board and Human Resources Management of the company.

RESULTS

Of the data collected, stratified by occupational category, sex and work unit, it is noteworthy that 98 (48.28%) of the professionals experienced some type of absence from work due to illness in the period analyzed, predominantly among the women 78 (79.6%). Regarding the distribution of all workers in relation to the work location, values ​​slightly above those recorded in the emergency unit were found in the hospital unit, as shown in Table 1. As for sick leaves, it is observed that the subjects reported one or more events in the period, producing 172 absences, ranging from 1.67 to 1.78 absences per professional category. Interestingly, the mean absence per technical-level professional was higher in the hospital, whereas the nurses had higher means in the emergency unit, as shown by the data in Table 2.

The calculation of the time missed from work caused by absenteeism due to health problem showed that the 98 absent professionals generated 528 days missed, with a mean of 5.39 days missed from work per nursing professional absent in the period analyzed, in both care units. The highest mean values ​​were found in the emergency unit, especially among nursing technicians, whereas nursing assistants stood out in the hospital unit, as shown in Table 3.

Among the causes of absenteeism found, 23 (13.4%) were due to respiratory disease; 21 (12.2%) to diseases of the musculoskeletal system and connective tissue; 19 (11%) to infectious and parasitic diseases; 19 (11%) to unclassified signs, symptoms and abnormal findings; 16 (9.3%) to genitourinary system illnesses; 14 (8.1%) to pregnancy, childbirth and postpartum period; 10 (5.8%) to diseases of the eye and its surrounding structures; and 9 (5.2%) to external causes.  Eleven absences (6.4%) showed no corresponding ICD and 30 (17.5%) had various causes.

DISCUSSION

Sickness absenteeism among nursing professionals is a major multifactorial and complex problem, which therefore needs to be analyzed from the perspective of the labor process, the organizational culture and aspects directly related to the health of the nursing staff. This approach is essential to reduce economic costs, increase job satisfaction and improve the quality of nursing care^15,16.

Absenteeism, despite not being the only issue that interferes with the quality of nursing care, has been touted as one of the variables that unquestionably needs to be analyzed when assessing the standard of care required by a health care institution17. Based on the results above, of the total nursing staff of the institution, the majority is found in the hospital unit (63%), in regard to distribution by work location. There is a balance in the percentage of nursing technicians and nursing assistants in both units investigated, although the representation of nursing assistants in both stands out. Nurses are found in greater number in the emergency unit, which can be understood as necessary in light of the characteristics of the immediate care provided in this unit, which requires specific professional skills.

A comparative analysis of absences between units investigated showed that the emergency unit recorded the highest percentages, among all of the workers, in relation to the hospital unit. Individually, the absences of nursing assistants, which had higher values, stood out in the emergency unit, whereas the nursing technicians, followed by nurses, stood out in the hospital unit.

Studies on first aid and emergency care units point out that adverse working conditions and other variables in these specific units are more likely to trigger changes in the physical and psychological wellbeing of workers, with emphasis on illnesses such as stress, depression and anxiety, which therefore should reflect the number of absences due to illness¹⁸.

Classification of the professionals absent according to sex showed a predominance of women, similar to the Brazilian reality of nursing4. A study conducted to examine the factors associated with sickness absenteeism among nursing workers showed that marital status, especially when the worker has children and greater domestic responsibilities, was a factor of great influence on levels of absenteeism observed among female nurses, and additional studies that better explore the interference of the weight of domestic work on absences and illness of nursing professionals were recommended¹⁹.

Of the 98 nursing professionals who were absent from work in the period of one year, nursing technicians, followed by nursing assistants, were the most absent. High levels of absenteeism among nursing technicians and assistants have been reported in several studies that attribute these findings to the reduced number of nurses, which could determine greater obligation to stay at work. Furthermore, nurses tend to assume leadership roles in the nursing team, which require greater attendance, besides the lower exposure to risks of contamination and disease due to exercising more administrative tasks in the hospital context¹⁵.

The occurrence of a higher number of absences from work among the mid-level professionals has been reported by several authors, and some relate this finding to the hierarchical position occupied (job responsibility requires more constant presence) and the nature of the work performed (tasks that require more physical effort, performing repetitive and monotonous activities)^4,20,21.

Some authors also warn that absences that occur among workers in higher-ranking positions are more easily solved with internal arrangements, which may lead to lower rates of sickness absenteeism among nurses in comparison to other nursing professionals, which does not correspond to the reality³.

The relevance of the categories of mid-level nursing staff was and still is the subject of specific studies on working conditions, health and quality of life^22-24.

It is also necessary to consider that studies with the aim to identify illness absenteeism among nursing professionals should consider their situation of functional readjustment/readaptation, which is a reality in health care institutions, and may influence the results. The limitation of the employee from work due to medical condition or health problem influences the number of human resources available for existing activities.

In public organizations, due to job security, workers have aged in the institutions, presenting physical and psychological distress with a decline in functional capacity, and increasing the possibility of absence due to health problems. A study developed in a public university hospital found that 6% of the chief nursing staff were in the situation of functional adaptation, and of the population studied, 40% were nursing assistants²⁵.

Table 2 shows that despite variations in the number of staff, the mean absence was the same for the various categories, being 1.76 absences per ​​professional in the period analyzed. In the hospital unit, there was a higher mean absence per professional (1.92) relative to the emergency unit (1.56), where greater values were obtained ​​for nurses (2.5). In the hospital unit, nursing technicians and assistants stood out, with 2 and 1.94 absences, respectively. Yet attention should be given to the category of nursing technicians in general, for the two units analyzed. These findings show lower values than those ​​found in another study in a secondary-level public hospital, which evaluated the causes of absenteeism among the nursing staff, and obtained an overall mean of 2.7 per absent employee⁹.

Divergence of results in relation to the professional category was also observed when compared to other studies conducted for the same purpose, in which the nursing assistants had greater representation in absenteeism compared to other members of the team^3,9,19,26.

Table 3 presents an interesting result regarding the work days missed: although the hospital unit had a higher mean absence per professional (1.92), the emergency unit had the greatest amount of working days missed - 7.2 days missed per absent professional, compared to 3.85 days missed in the other unit. This demonstrates that absences from the hospital unit were shorter, a fact that should be viewed with caution since long absences may signal health problems of greater severity or chronicity.

Absences for health reasons were the main causes of days missed in the emergency room of one university hospital, which found the missed time of the nursing employees to be 2.3 times higher than that observed in these categories of professionals specialized in emergency care, which suggests the importance of monitoring the causes in units with these characteristics^8,27.

These findings corroborate a study that identified sickness absenteeism among nursing professionals in a university hospital where the emergency care sector was the work location with the greatest number of days missed²⁸.

In this study, analysis of the two units shows that nursing technicians were the most absent from work during the study, with a mean of six days missed per absent professional.

The mean number of days missed from work (5.39) was below the means found in another study, which showed 20.1 days for nurses and 31.8 days for nursing assistants, who also worked in a hospital unit⁹.

The comparison of the days missed from work in relation to absences reveals a mean of 7.2 days missed per absence in the emergency care unit, and 3.85 days missed per absence in the hospital unit. Despite being brief, they are recurrent, and when added together they total 528 days of work missed.

Regarding the causes of absenteeism, according to ICD assigned, respiratory system diseases were the most common cause, followed by musculoskeletal disorders and infectious and parasitic diseases.

One analysis of scientific literature on absenteeism in nursing identified that the reported diagnoses that produced the highest number of absences were diseases of the respiratory and musculoskeletal systems, infectious and parasitic diseases, diseases of the nervous and integumentary systems, mental disorders and ill-defined symptoms and signs, which corroborate the findings of this study. In the period between 2003 and 2008, the authors report that the greatest group of studies deals with mental illness among workers. They further conclude that these causes may be related to poor working conditions and risk factors in the profession day-to-day^10,12.

Respiratory diseases such as upper respiratory tract infection, asthma, oropharyngitis and pneumonia also represented the major cause of illness among the nursing staff, according to a study conducted in a teaching hospital. Such diseases were attributed to frequent exposures to biological and chemical agents, but constitute pathologies that usually require few days of absence¹⁴.

Nevertheless, another research has pointed to musculoskeletal and connective tissue diseases as the leading cause of sickness absence among nursing professionals^3,4,29.

In relation to musculoskeletal diseases, data from the World Health Organization points to the growing number of osteoarticular diseases and injuries that affect the general population, estimated to be the cause of increased spending on health care, and one of the most common reasons for work absenteeism and permanent disability³⁰.

Although in this study mental disorders and behaviors have emerged as the thirteenth cause of absenteeism, some researchers have warned of the growth of this type of health problem in the general population, and even among health care and nursing workers^5,31.

Studies with nursing professionals revealed that situations within the workplace may provoke anxiety, such as instability or worsening of the health status of patients, lack of materials, equipment and personnel, as well as highly-complex procedures. The literature also shows that the associated triggering factors may be related to the internal environment and work process, such as the sectors of professional activity, shift, interpersonal relationships, work overload, problems with the work scale, and external factors to work such as sex, age, domestic workload, family support and income, overall health condition of the employee and the individual characteristics of professionals⁵.

The level of pressure exerted by the work organization, demand for greater productivity associated with the continuous reduction of the workforce, pressure of time and the increasing complexity of tasks, in addition to unrealizable expectations and tense and precarious labor relations, can generate tension, fatigue and burnout, thus becoming factors responsible for work-related situations of stress, and consequently generating the potential for mental disorders⁵.

Although the identification of the age of the professionals and the presence of diseases were not objectives of this study, these should be considered in studies of this nature, in light of studies that have shown a positive relationship between age and the number of absences from work, explained by the authors as a variable related to the higher risk of chronic diseases, and therefore greater possibility for sick leave^15,31.

It is important to note that some absences were not related to disease, representing lost data for the study.

CONCLUSION

The results of this study showed that absenteeism in recurring, short periods is a real problem for the nursing staff, a fact that affects organizational dynamics, the work environment and the provision of care. These cumulative events generate financial loss for the institution, work overload for the staff, and compromised quality of care to patients.

Knowledge of absenteeism and illness in the hospital organization is important, even for sizing of the nursing staff, influencing the level of technical safety to be established for the health care institution, so as to minimize the negative effects of absences on workers as much as possible.

Thus, it is necessary to recognize the causes behind absenteeism among nursing professionals, in order to prioritize intervention strategies in the workplace, since such causes may be associated with the activity itself.

One limitation of this study was the difficulty in accessing information due to the precariousness of available data, pointing to the importance for institutions to invest in creating databases with consistent information on employees, in order to enable monitoring of occurrences in a more systematic manner.

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