Absenteeism of nursing staff : decisions and actions of nurse managers *

Objective: Measure absenteeism among nurses and nursing technicians/aides in three hospitals and explore possible management decisions by nursing managers to deal with it. Method: Quantitative, qualitative study. In the qualitative stage, monthly rates, annual average and overall rates of absenteeism were measured among nurses and nursing technicians/aides from 12 service units in the hospitals, over 12 months, according to the equation proposed by the Support Center for Hospital Management (NAGEH – Núcleo de Apoio à Gestão Hospitalar). In the qualitative stage, 12 nursing managers from 12 units were interviewed. Results: The quantitative stage revealed important differences in each institution and between institutions, with various monthly rates exceeding the monthly rate of 6.7% recommended by the Federal Council of Nursing (COFEN – Conselho Federal de Enfermagem). The qualitative stage examined positive impact decisions taken by these institutions, where relationships with managers, dialogue, and meeting the physical and emotional demands of professionals were considered important factors. Conclusion: Absenteeism was a reality in day-to-day nursing staff management. It varied according to the month of the year and in different service units, and it was possible to classify these units according to the degree of the problem. In addition, the results showed that employee illness, dissatisfaction with institutional conditions, and inadequate interpersonal relationships were key factors, enabling management decisions based on each hospital’s particular reality. DeScriPtOrS Absenteeism; Nursing Human Resources in Hospitals; Human Resource Management in Hospitals; Nursing Supervision; Management Indicators. correspondence addressed to: Paulina Kurcgant Av. Dr. Enéas de Carvalho Aguiar, 419 Cerqueira Cesar CEP 05403-000 São Paulo, SP, Brazil pkurcg@usp.br USP


intrODUctiOn
Institutional assessment of performance in the production and service sectors uses indicators as a measuring tool.However, since health care is a sector that provides services, the essential elements required for the use of indicators to assess health care quality are conceptual consensus and covenantal understanding in the decision-making, strategic and operating realms of health institutions.
Indicators are generally represented by numeric variables, and may be absolute numbers or ratios between two events, establishing a numerator and denominator.The numerator refers to the event to be measured.It must have a clear, objective and scientifically-based definition and be easily applicable and relevant to the phenomenon that will be evaluated.The denominator is the population at risk, or being assessed for risk, for the same phenomenon considered in the numerator (1)(2) .
Reliable information needs to be obtained; since these are quantitative data indicators, there is a risk of employing reason to assess institutional performance, by preferring some indicators that are more measurable than others.Thus, indicators should be chosen that focus on the work processes being evaluated and, also, according to the perceptions of the actors engaged in the work process (3) .
In the care context and with a focus on health human resources management, it is important to select indicators that can be analyzed and compared with standards from within and outside the institution (4) .
The Support Center for Hospital Management (NAGEH), as a subgroup of the Commitment to Hospital Quality Program, develops activities aimed at improving hospital management as well as indicators applicable to nursing services (5) .
In this regard, the nursing staff absenteeism indicator, which is included in the NAGEH proposal as a quality indicator of the nursing staff management process, assesses the quality of human resources management.
To provide input that would support the assertion that absenteeism is an indicator of the quality of human resources management, the objective of this study was to measure absenteeism among nursing professionals in three hospitals and explore possible decisions with a positive impact for dealing with it.

MetHOD
This is a descriptive exploratory study, quantitative and qualitative in nature, which was conducted from August 2013 to July 2014 in two general public teaching hospitals and a university hospital, located in the city of São Paulo, referred to in this study as hospitals H1, H2 and H3.
The data was collected in 12 medical-surgical inpatient units (IU) recommended by the nursing directors of the three hospitals: 4 in Hospital H1, 2 in Hospital H2 and 6 in Hospital H3.In quantitative terms, the variable analyzed was the nursing staff absenteeism rates (nurses and nursing technicians/aides) calculated in these units during the peri-od studied; the units are designated U1 to U12.In qualitative terms, the population consisted of the 12 nursing managers of these units, referred to in this study as E1 to E12.Data on absenteeism rates was collected by consulting institution documents and the results were recorded on spreadsheets.The qualitative data was obtained from the nursing managers in individual semi-structured interviews, based on the following questions: "How do you view absenteeism among the nursing staff ?" and "What decisions or actions have you taken in this regard?" To analyze the quantitative data, the equation proposed by NAGEH and the absenteeism monthly average rate of 6.7% recommended by Federal Council of Nursing (COFEN) Resolution No. 293/04, were adopted (6) .
Calculating the absenteeism rates of nursing professionals absenteeism rate = No.man -hours missed No. of man -hours worked ×100 The number of man-hours worked is the total number of hours worked by nursing professionals during the period under consideration.
The number of man-hours missed is the monthly number of working hours missed by nursing professionals, regardless of the work regime adopted in the health institution, divided by the number of hours worked.
The number of man-hours missed includes all absences, including justified, all sick leaves, blood donations, voter and military enrollment, judicial summons and suspensions arising from the application of disciplinary measures.It does not include vacation and legal leaves of over 15 consecutive days.
To analyze the qualitative data collected in the interviews, the meaning units contained in the dialogues of the nursing managers were obtained, which when grouped by similarity of meaning, constituting the empirical categories of the study (7) .
As far as ethical and legal aspects, the project to which this study belongs was approved by the Research Ethics Committee of the School of Nursing of USP, Process Reference No. 1110/2011/CEP-EEUSP-SISNEP-CAAE:0132,0,196.198-11.

MeasureMent of absenteeisM aMong nursing professionals
Table 1 and Figure 1 present nursing staff absenteeism rates, month-to-month and total for the year studied and in the different service units of each hospital.
Table 1 and Figure 1 show that nurse absenteeism rates in Hospital H1 in Surgical U1 (8.2%) and U2 (8.25%) and Internal Medicine U3 (7.5%) and U4 (12.8%) exceeded the average monthly rate of 6.7% recommended by COFEN, with the rate from U4 being the highest in Hospital H1.In the nursing technician and/or aide category, although the higher rates of U1 (6.5%) and U2 (6.5%) complied with the recommended rate, in U3 (9.7%) and U4 (7.4%) the rates exceeded the recommendation.
In the two units from Hospital H2, the maximum monthly rates in the nurse category, in Internal Medicine U5 (8.2%) and Surgical U6 (12.2%), were considerably higher than the suggested average.The results for nursing technicians/aides in U5 (6.8%) are only slighter higher than the recommended rate, but in U6 the rate (8.8%) exceeds the appropriate level.
In Hospital H3, for the nurse category, in the Internal Medicine units, the maximum monthly rate of U7 is 12.2%, U8 is 8% and U9 is 8.5%, all above the recommended limit.The Internal Medicine units had high maximum rates, varying from 19% in U10, 15.8%It can also be noted in Table 1 and Figure 1 that the lowest annual nurse absenteeism rate, in Hospital H1, was 1.5% in U2 and the highest was in U3 (3.6%); for nursing technicians/aides, the lowest annual rate was 2.8% in U1 and U2, and the highest was in U3 (6.5%).In Hospital H2, the lowest annual rate for nurses was 2% in U5 and the highest was 4.4% in U6; for nursing technicians/aides, the annual rate was 3.6% in U5 and 3.9% in U6.In Hospital H3, for the nurse category, the lowest annual absenteeism rate was 2.4% in U8, and the highest was in U10 (7.4%); for nursing technicians/ aides, the annual rate ranged from 4.6% in U9 to 16.3% in U11.Therefore, the highest annual rates of nursing staff absenteeism (4.5% and 8.1%) occurred in Hospital H3.Table 2 presents the overall absenteeism rates for nurses and nursing technicians/aides, by units (Internal Medicine and Surgical) and hospitals.
The nurses in Hospital H1 had a minimum overall absenteeism rate of 0.3% and a maximum of 5.9%; in Hospital H2 the lowest overall absenteeism rate was 0.2% and the highest was 8%; and in Hospital H3 the lowest overall rate was 2.2% and the highest was 9.4%.Nursing technicians/aides in Hospital H1 had a minimum overall absenteeism rate of 2.9% Source: printed records of shifts and/or electronic system for each unit of the hospitals.As far as the annual average of overall absenteeism rates, nurses from Hospital H1 had the lowest absenteeism rate (2.5%) when compared to the rates of Hospitals H2 (3.2%) and H3, which had the highest rate (4.5%).
In terms of nursing technicians/aides, the lowest rate was 3.8% in Hospital H2 and the highest was 8.1% in Hospital H3.Hospital H3 had the highest annual average rates of nursing technician/aides staff absenteeism, when compared to the annual rates in Hospital H1 and H2.

perceptions, decisions and Managerial actions on the part of nurses
In the qualitative aspect, the content analysis of the nursing managers' responses in relation to absenteeism enabled formulation of empirical categories: "institutional factors," "professional factors," and "decisions/actions in relation to absenteeism."The "institutional factors" category consisted of the meaning units: "perception of absenteeism" and "consequences of absenteeism." In terms of the meaning unit "perception of absenteeism," the nursing managers noted: "What I see is that the person wants to change sectors ... wants the manager to notice they aren't happy ..

. wants to change schedules (E3)." "Absenteeism may reflect lack of motivation in relation to the work they perform (E7)."
The meaning unit "consequences of absenteeism" is illustrated in the following excerpts:

"Absences ultimately take a toll on care and the whole team (E5). "Absenteeism demonstrates quality of work and mainly how the staff member is perceived (E4)." "Absenteeism has an impact on nursing activities (E12)." "Absenteeism is negative for nursing (E9)."
The "professional factors" category includes the mining units: "causes of absenteeism" and "interpersonal relationships."With regard to the meaning unit "causes of absenteeism," interviewees explain: "Absenteeism is related to the employee' s health..

.it is unexpected (E6)." "Medical leaves indicate health problems as the cause (of absenteeism) (E8)." "It is often noted that absenteeism is not due to a health problem, but it is a factor that predisposes you to a health problem (E2)."
In relation to the meaning unit "interpersonal relationships," the interviewees revealed as causes of absenteeism:

"The staff member is not valued as a person and professional (E1)." "lack of communication between leaders and employees (E6)." "multi-professional relationship difficulties (E10).
With respect to the category "decisions/actions in relation to absenteeism," it is composed of the meaning units "decisions of nursing managers" and "actions with a positive impact." In the meaning unit "decisions of nursing managers," the interviewees commented:

"I look at the number of patients and the number of staff members (E7)." "I reorganize the team to cover the needs of the shift (E10)."I ask another coordinator for help to cover the shift (E6)." "I reassess the staff ' s activities on that day (when someone is absent) (E4)."
In terms of the meaning unit "actions with a positive impact," the nursing managers shared the following:

"I examine the medical certificates of the employees from my unit (E5)." "I switch people' s free days when they ask in advance, to switch a free day (E1)." "There is an internal system for redistribution to other units (E11)."
Also in terms of actions with a positive impact, the nursing managers noted:

DiScUSSiOn
In U1, U2 and U4 of Hospital H1, the lowest nurse absenteeism rate was in December, at 0%; for nursing technicians/aides, it was in August, with rates of 0.3% and 0.9% in U2 and U4, respectively.The highest nurse absenteeism rates in this institution occurred from September to November in U3 and U4, with 7.5% and 12.8%, respectively; and for nursing technicians/aides, the highest rates occurred in March in U1 and U2, with a rate of 6.5% in both units.In this in- stitution, in Internal Medicine U3 with 7.5% and Surgical U4 with 12.8%, the absenteeism rates exceeded the 6/7% monthly level recommended by CONEF.In Hospital H2, the lowest nurse absenteeism rates were in February, at 0% and 0.4%, and for nursing technicians/aides it was in May and June with rates of 1% and 1.3% in U5 and U6 respectively.The highest nurse absenteeism rates in this institution occurred in the months of January and September (8.5% and 12.2%) and for nursing technicians and aides it was in December, with rates of 6.5% in U5 and 8.8% in U6.Therefore, the rates of Internal Medicine U5 and Surgical U6 exceeded the maximum level recommended by Resolution 293/2004.
In Hospital H3, the lowest nurse absenteeism rates were in June, in U7 and U10, with rates of 0% and 0.5% respectively; and for nursing technicians/or aides it was in March, in U7, U10 and U12, with rates of 0.8%, 4.1% and 3.3% respectively.The highest nurse absenteeism rates in this institution occurred in November in U9 and U10, with rates of 8.5% and 19% respectively.For nursing technicians/aides, it was in month of December in U9 and U11, with rates of 16.9% and 36.9%respectively.In this institution, the rates in three Internal Medicine units were above the level set by Resolution 293/2004.
A study conducted in inpatient units of a public health institution mentioned that out of 414 nursing employees, 310 (74.9%) had some kind of unforeseen absence (8) .Another study found that Surgical Units registered the highest rates of absenteeism, followed by Internal Medicine Units (14.7%), among others.This same study also showed that the highest absenteeism rates occurred among nursing technicians/aides in Internal Medicine units (9) .
In another study conducted in a teaching hospital for education and research purposes, absenteeism rates in the nursing category ranged from 0% to 46.3%.For nursing technicians/aides, they varied from 0.5% to 11.6% (10) .It should be noted that maternity leaves, occupational accidents and sick leaves provided by the National Social Security Institute were considered as absences.In addition, the study was performed using a different methodology from this study, for calculating nursing staff absenteeism percentages.
In terms of average annual rates of absenteeism among nurses, in Hospital H1, the lowest was 1.5% in U2 and the highest was 3.6% in U3; and for nursing technicians/aides, the lowest was 2.8% in U1 and U2, and the highest was 6.5% in U3.In Hospital H2, the lowest annual rate for nurses was 2% in U5 and the highest was 4.4% in U6; for nursing technicians/aides, the annual rate was 3.6% in U5 and 3.9% in U6.In Hospital H3, for the nurse category, the lowest annual absenteeism rate was 2.4% in U8, and the highest was 7.4% in U10; for nursing technicians/aides, the annual rate ranged from a low of 4.6% in U9 to 16.3% in U11.
In the distribution of absenteeism rates according to the care units where the nursing professionals worked, nine units had rates that met the COFEN standard.In three units, all belonging to the hospital, the absenteeism rate exceeded the desired standard for nurses (two units), as well as for nursing technicians/aides (three units).Two of these were Internal Medicine units (U10 and U11) and one was a Surgical Unit (U7).Supporting this finding, another study found an absenteeism rate that exceeded the standard among nursing technicians/aides in a Surgical Unit (9) .
In the qualitative aspect, the responses of the nursing managers took into account institutional factors, professional factors and managerial decisions/actions as essential elements in relation to absenteeism.These three categories revealed a not-always-harmonious relationship of the interests and intentions of the operative group in their formal and informal relationships with the health organizations.
The nursing managers identified as predisposing conditions for absenteeism those related to the institution, in terms of physical environment, human resources and material resources.In this regard, the institutional factors that caused staff members to miss work were perceived by the nursing managers as factors that generated job dissatisfaction.
Work-related problems, combined with personal ones, produced a feeling of impotence and dissatisfaction (4) .
Other studies have shown that the conditions provided for carrying out work, such as the physical and social environment, are elements that cause dissatisfaction and are predictors of absenteeism (9,11) .
On the other hand, the consequences of absenteeism are lower institutional performance and loss of quality and financial resources, which also undermines the care provided.
As far as the causes of absenteeism, the nursing managers considered employee illness, as well as predisposing factors for illness, as essential causes.
The literature regarding occupational health has shown that medical leaves were the cause of unforeseen absenteeism (12) .Of these, musculoskeletal system diseases were the most common among nursing professionals (8,13) .
Also, with respect to predisposing factors for health problems, one study asserted that employees came to work mentally and physically willing, but left mentally and physically unwell (14) .
Another factor deemed by nursing managers as contributing to absenteeism involved personal relationships.
According to a study on the theme, two important elements are communication between managers and employees to clarify the reasons for absences and informal conversations that result in better personal and professional relationships (15) .
As for decisions/actions in relation to absenteeism, nursing managers considered that quantitatively and qualitatively adjusting human resources to meet the needs of patients was an action with a positive impact.
Other such positive actions used by nursing managers involved personal and professional relationships, with meetings focusing on professional appreciation; listening and helping to solve personal problems; and open channels of communication.
Another study that examined managerial actions of nurses to deal with nursing staff absenteeism corroborates the decisions listed by the nursing managers in this study (13) .

cOnclUSiOn
The quantitative and qualitative results of this study attest to the fact that absenteeism is a reality in day-to-day nursing staff management and requires, in addition to constant internal and external quantitative monitoring, the adoption of immediate and mediate managerial actions.
Although the quantitative results differed in the three institutions, they were manifested specifically and regularly in all of them.Thus, the internal monitoring of absenteeism in each institution during the study period revealed variations by month and in different service units, resulting in an average annual rate that made each situation distinct and provided input for management decisions tailored to each institution's reality.
In turn, external monitoring, when the absenteeism rates in the three institutions were compared, yielded different percentages, which enabled the institutions to be ranked and classified according to the degree of problems faced in this regard and involved specific managerial decisions for dealing with absenteeism in the different institutional contexts.
The qualitative results in the three institutions studied showed that the main causes of absenteeism were employee illness, dissatisfaction with institutional conditions and inadequate interpersonal relationships.As for the actions and decisions taken by nursing managers in relation to absenteeism, these could be considered immediate, when they occurred when nursing managers discovered the employee was absent, and mediate, when they happened in the midst of work.
Mediate decisions, in this study, were found to be similar among the nursing managers from the three institutions, and focused on better institutional conditions and enhanced personal and professional relationships, as being more assertive decisions to reduce absenteeism.