Absenteeism – illness of the nursing staff of a university hospital

Objective: to analyze absenteeism illness of the nursing staff. Method: this was a retrospective study of a university hospital in the city of Goiânia, Goiás, Brazil, using a quantitative approach. Data were collected from functional records of the staff during the period from 2008 to 2012. Results: of 602 workers, 435 had 1574 medical certifi cates. Diseases of the musculoskeletal system and connective tissue, followed by mental and behavioral disorders were the major diseases for sick leave. The occupation with the highest number of medical certifi cates was the nursing technician. Females and the age group between 41-50 years prevailed in the sample. Ambulatory was the area with most frequent events, followed by the medical clinic and emergency room. Conclusion: absenteeism-illness affects the functioning of the service, the nursing staff and users, promoting work overload, and interfering in the quality of nursing care.


INTRODUCTION
In light of the impacts of changing values in the modern, globalized world, the restructuring process that began in the 1990s, the profile of the work and the workers changed to adapt to technological innovations, with new management models of established quality.Along with that an intensification of work occurred, resulting from the increased pace, responsibilities and complexity of tasks, bringing higher unemployment, informal work, changing forms of work, and the determinants of the health-disease process (1) .Some activities can trigger anxiety, dissatisfaction, stress, and tension, generating unexcused absences or those justified by medical leave, also known as absenteeism (2) .
According to the International Labor Organization (ILO), absenteeism is the practice of an employee who does not show up for work for a period of one or more days (or shifts,) when he has been assigned for a day of work (3) .
Absenteeism is considered a problem in all areas of activity because the absence of a worker has negative impacts on the dynamic labor production, causing a shortage of personnel, and consequently quantitatively and qualitatively reducing the production (3)(4) .In addition, absenteeism produces financial impacts, causing costs associated with the person himself (benefits, salary); costs associated with managing the problems caused by absenteeism; costs of replacing employees with overtime, hiring substitutes; costs of reduction in the quantity or quality of the work (4) .
Nursing professionals deserve mention, as they constitute the largest number of workers in the health area in the hospital setting.Nursing is considered a stressful and tense profession, resulting from contact with suffering and death, working in shifts, acceleration of working rhythms, professional versatility, and musculoskeletal effort required to perform the care, etc (5) .
It is important to further discussion about absenteeism -illness in the nursing service, understanding its impact on the institutional routine due to the absence of employees by absences justified by medical certificates.Thus, the following questions emerged: how does the phenomenon of absenteeism-illness present in the context of nursing?What are its attributes and characteristics?
The aim of the study was to analyze the absenteeism-illness of nursing team professionals in a university hospital.

METHOD
This was a retrospective study with a quantitative approach, conducted between November of 2008 and October of 2012, in a university hospital in the city of Goiânia, Goiás, Brazil.The institution had 310 beds to attend to users of the Unified Health System (SUS) at low, medium and high complexity of attention levels.
During the study period, the staff consisted of 2,493 workers in different kinds of employment contracts and positions, of whom 989 were permanent staff.Of these, 602 were nursing staff.The data were collected from the files of the nursing team, as follows: 127 nurses, 381 nursing technicians, and 94 nursing assistants.
The sample selected for the study consisted of 435 functional dossiers of employees from the nursing team, pertaining to permanent staff of the institution, who had at least one absence from work, justified by a medical excuse during the period of 01/11/2008 to 31 / 10/2012.
The functional dossiers of employees who presented a medical excuse were excluded when the cause of absence was: maternity leave, adoption, dental leave, short-term leave to care for sick relatives, or death of family members, and those employees from the nursing team who resigned to work in another institution during the study period.
The data collection was performed in the Human Resource Management (HRM) and in the Medical Service (MS) during the period from January to June of 2013.
Data were recorded on a form containing the following variables: name, gender, age, area of work, International Classification of Diseases (ICD), position and days of absence.The medical diagnoses were decoded and grouped.Sick leaves were organized based on the International Statistical Classification of Diseases and Related Health Problems, 10th revision -ICD-10.
The HRM record book provided information on the name, position, area of work, employer and period of absence.In the functional dossiers, the exchange of areas, data from the medical excuse and other medical service documents were investigated.
The duration of absenteeism was calculated in days, from the beginning to end date, according to the medical excuse.The data were presented in absolute and relative frequencies.The Statistical Package for the Social Sciences(SPSS) version 18.0 for Windows, was used for analysis.To ensure workers' anonymity, each analyzed dossier received a numerical coding.
The study was approved by the Research Ethics Committee of the Clinics Hospital, Federal University of Goiás, and Protocol No 01749412.7.0000.5078.The study was approved by the Office of Personnel Management, Nursing Board and Board of Medical Service of the institution.

RESULTS
Of the 602 staff of the nursing team, 443 (73.6%) had a medical excuse to justify their absence from work; of these, eight functional dossiers were not found, and 435 were analyzed.
Of the 435 workers from the nursing team who had a medical excuse, 92.9% were female, 7.1% male; the age group with the highest number of employees was 41 to 50 years, representing 35.9% of the total.Nursing technician was the category with the highest number of medical excuses (Table 1).
The pathologies with the highest incidence were the diseases of the musculoskeletal system and connective tissue, with 310 (19.70%) occurrences, and mental and behavioral disorders with 284 (18.04%) (Table 2).
Table 3 presents the major categories of disease that excelled in medical excuses, with evidence of back pain, repetitive strain injury (RSI), depression, bipolar disorder and stress.
Table 4 presents the workplace in which the nursing staff personnel were working when they were absent due to illness.
The age group of employees of the departments with the highest number of medical excuses was those with ages between 51 -60 years, from the ambulatory area, professionals of the medical clinic at 41 years old and from emergency room at 50 years.

DISCUSSION
This study shows the predominance of absenteeism in women, with 92.9% of cases, justified by the fact that the nursing worker profile is formed predominantly by women.During the four years studied, 73.6% of the professionals absent from work presented medical excuses related to illness reasons.
The absenteeism in females is also influenced by the fact that most of women in the labor market are responsible for domestic activities and caring for children.They usually arrive tired to work because of the tasks performed at home, are sick more frequently, and miss more days of work (7) .Recent studies report that women seek health services 1.9 times more than men (8) .
The data demonstrate that regardless of sex, the greater frequency of sick-leave was in the age group from 41 to 50 years (35.9%),followed by those between 31-40 years (30.3%).Approximately 59.5% of workers who presented medical excuses were over 40 years old.
A study was performed with municipal workers in Goiânia, from 2005 to 2010, with a professional staff of 28,230 employees, of which 47.5% had at least one medical leave in the period:, 40,578 sick leaves were registered for health treatment provided to 13,408 workers, who were absent for 944,722 days.The profile of the absent workers related to the first sick leave was characterized by a predominance of women (52.0%), older than 40 years (55.9%) (9).
Nursing technicians and assistants were the professionals who had more medical excuses, accounting for 81% of all workers from the nursing team.This finding is alarming because these professionals represent the largest contingent of the nursing team workforce.Their absences compromise the care given, and consequently disrupt the team by generating overload activities for other workers.
The higher rate of absenteeism among nursing technicians and assistants may be related to the lower remuneration, less demand for scientific and technical education, and the greater need for physical effort in the execution of patient care (10) .
The main diseases responsible for absence from work of the nursing staff were diseases of the musculoskeletal system and connective tissue, with 310 medical excuses (19.70%), followed by mental and behavioral disorders with 284 (4.18%).
The World Health Organization (WHO) designated the decade of 2000 to 2010 as the decade of bone and joint, due to the increasing number of musculoskeletal diseases and injuries that affect the world's population.It is estimated that by the year 2015, these would be the causes of increased spending within healthcare, and one of the most frequent reasons for labor absenteeism and permanent disability (11) .
A study performed with nurses of Ibadan, in the southwest of Nigeria, showed that 84.4% had work-related musculoskeletal disorders (WMSDs) one or more times in their professional lives.Nurses with more than 20 years of clinical experience were about four times more likely to develop WMSDs than those with 11 to 20 years of experience (12) .
Due to the characteristics of the work performed by the nursing staff, and the great risk of developing musculoskeletal disorders, it is necessary to improve the working environment in order to alleviate risks to the health of these workers.
The second type of disease presented in this study as responsible for the absence of the workers was mental and behavioral disorders (MBD, with 284 (18.4%) cases.The depressive episodes, bipolar disorders and stress were the most common.
As for mental illness, mood disorders accounted for most of the absences.These results confirm other studies that show depressive problems as a major cause of absenteeism (9,13) .The majority of the studied population engaged in the provision of direct care within public health.This activity is characterized by high psychological demands, with low social support and control over the work, associated with an increased risk of sick-leave due to psychiatric disorders.
The MBD are among the main factors related to absenteeism in the European Union, especially cases of depression and anxiety associated with stress disorders.In a cohort study with 9904 workers in Denmark, an increased risk of absenteeism recurring in the group of employees with previous episodes of absenteeism due to MBD was observed (13) .
The nursing professional coexists constantly with pain, suffering and death.These conditions can lead them to develop psychiatric disorders.The relationship between stress and work demonstrates that the human being is faced with a professional world that often requires more than her capacity in contemporary society.This fact generates a constant state of stress among workers; this is occupational stress.Diseases emerge when the individual's capacity to respond to work in a healthy way runs out.Stress is recognized as one of the most serious risks to an individual's psychosocial well-being (14) .
In mapping the areas in which absenteeism -illness occurred, the ambulatory area appeared as the place with the highest number of absences, with 201 (12.8%) cases.Although the ambulatory area is considered to be one in which less physical effort is required from the worker, this result can be explained by the fact that this is the hospital area to which the workers with restrictions on activities at work are relocated.During the survey period, workers located at the outpatient clinic, who had sick leave, were mostly older than 51 years of age.They previously performed unhealthy activities, such as manipulation of substances, specialized tests and other procedures.
The second and third places with a significant percentage of sick-leave were the medical clinic, with 177 (11.2%), and the emergency room, with 143 (9.1%) cases.These areas require great physical effort from the worker, such as a large number of activities, presence of dependent patients, and daily contact with death, causing physical and emotional distress (7) .
One study (7) reported that the areas that showed the highest medical leave rates were: medical clinic and ICU.These differences can be explained by job characteristics of these units.The environment is tense, with the management of intense and painful situations that may contribute to physical, chemical and psychological disorders.This increases the risk of health problems and sick leave.
According to a study performed in the ICU (15), the work in hospitals is characterized by exposure to physical and emotional exhaustion, due to daily contact with the anguish and the suffering of clients and family members.This was realized as a contributing factor to the absenteeism of nursing staff.
It is essential that health professionals, especially nurses, as they are professionals who lead the teams, seek measures focused on the prevention of absenteeism.Knowing the work environment may contribute to the implementation of preventive actions for the health of workers, reducing the physical, psychological and social suffering and costs (16) .
The promotion of activities in educational work must be conducted under nursing leadership, focusing on prevention and aimed at increasing the awareness of professionals.Encouragement in new life habits should be given, through preventive lectures, and labor planning exercises in the workplace, with the help of a professional physical educator.Some rest may be imposed on activities, and interventions implemented in the workplace for possible risks.The team's physical and emotional well-being in the workplace is an assignment of the leader (16) .
Another strategy referred to in the literature is the use of alternative practices and measures to relieve stress.Acupuncture and auriculotherapy are some of these techniques indicated by their practitioners as producing a good effect with a positive therapeutic outcome.Among the benefits of these techniques is the reduction of anxiety, stress and a significant improvement in generalized anxiety disorders (17) .
This study is an important instrument for planning the actions of the teams of the Integrated Subsystem of Attention to the Health of the Federal Public Servers (SIASS).Its objectives are to organize actions and health promotion programs, prevention of diseases, and monitoring the health of federal employees, aimed at health care (18) .The actions of the SIASS units are already highlighted in the literature (19) .

CONCLUSION
This study found that the health of the nursing staff is compromised, as 73.6% of them presented medical excuses for illness.The professionals with more than 40 years of age were predominant, with a prevalence of musculoskeletal system diseases, mental and behavioral disorders.The more frequent categories of diseases were dorsalgia, depression episodes, recurrent depressive disorder, and bipolar affective disorder.Because of the specificity of local management, the ambulatory presented the highest absenteeism rates.The results enable recommendation of strategies of care for the workers of the institution, which may be applicable to other institutions and providers of health services.
Some important measures for overcoming the analyzed scenario are: identifying the risks inherent in the workplace environment and establishing preventive interventions; creating a labor workplace gymnasium/wellness center; providing therapeutic support to the professionals; performing periodic meetings with psychology professionals in order to discuss, reflect and better understand the process of distress and death experienced in the workplace; performing an ergonomic study of the workplace, focusing on planning and implementation of preventive measures.
The results show indicators of weaknesses in the working world that will allow managers to establish actions to combat diseases involving absenteeism, and therefore positively impact its reduction.Moreover, it can contribute to the discussion of ethical and professional implications of the daily practices of the nursing team, and strategies for confronting the challenges imposed by the work process.
The hospital institutions usually focus their priority on patient care, often forgetting the health professionals who perform the work.It is important to adopt health policies and actions aimed toward the worker, ensuring the promotion of health and prevention of occupational diseases, in order to guarantee the quality of care provided to patients.

Table 2 -
Groups of diseases presented in the medical excuses of nursing staff (N = 435) according to the International Classification of Diseases (ICD 10), Goiânia, Goiás, Brazil, 2014

Table 4 -
Distribution of medical excuses (N = 1574) by professional category and services, Goiânia, Goiás, Brazil, 2014 Note: * In this category the departments with fewer than 20 medical excuses during the study period were grouped, encompassing the following sectors: Reception.Hospital Infection Control Service.Reference Center for Ophthalmology.Center for Neuroscience.Shopping.Staff coordination.Sewing service.Executive Board.Digestive Endoscopy.Physical Therapy.Speech therapy.Hemodynamics.Sanitation.Clinical Laboratory.Internal regulation nucleus.Chemotherapy.Human Reproduction.Radiology.Social service and Pediatric Emergency.

Table 3 -
Major categories of diseases presented in the medical excuses of nursing staff (N = 435), according to the International Classification of Diseases (ICD 10), Goiânia, Goiás, Brazil, 2014