Fatores Relacionados Ao Absenteísmo Por Doença Em Profissionais De Enfermagem Factors Related to Sickness Absenteeism among Nursing Personnel

Objective To analyze short-term leaves among the healthcare staff of a university hospital. Methods Study population included 965 nursing professionals active on 1 January 2000. Leaves up to 30 days in one year were analyzed. Sickness leaves (one-year aggregate), Descritores Absenteísmo. Enfermagem, recursos humanos. Análise de regressão. Hospitais universitários. Risco relativo (saúde pública). Distribuição de erro binomial negativa.


INTRODUCTION
Nursing professionals have a number of unique characteristics.These include gender distribution, hierarchy, and a high load of both physical and emotional stress. 3,6,14,21,22,24,25Studies investigating the characteristics related to sickness among these professionals are rare in Brazil.There is not enough adequate research in this field, the profile of morbidities associated with work absenteeism among nursing professionals being hardly known.At the same time, there is a growing concern about this category, which includes roughly 780 thousand professionals countrywide. 10number of studies indicate that short-term leaves may provide information concerning the health status of any given group of workers.19 There is no consensus as to how to define short-term sickness leaves.Such definition depends on each country's labor legislation, as well as on norms specific to each institution.
The aim of the present study is to analyze short -term leaves among the nursing personnel of a university hospital.Subjects included patients seen at the Serviço de Atenção à Saúde dos Trabalhadores (Worker Healthcare Service -WHS).In this Service, medical appointments are mandatory in order to control and investigate all sickness leaves and optional for the treatment of clinical occurrences that do not necessarily require absence from work.All sickness leaves at the studied hospital have as an attachment a medical diagnosis, recorded from the very first day of absence.The availability of such information distinguishes the present study from the majority of previously published studies on this subject.

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Reis RJ dos et al Simultaneously to the study of leaves of absence, the frequency and reason for which the professionals sought medical care were analyzed.This information, in addition to explaining the reasons, more or less frequent, that lead t o worker absenteeism, reflects the actual morbidity perceived by these professionals.
The present study represents an initial descriptive analysis of case records correspondent to one year of study among nursing professionals.It will serve as a rehearsal for a cohort study of the entire healthcare staff of a public university.
From the methodological point of view, the present study employs approach methods designed for clearly interdependent recurrent events, among which leaves of absence generated by a single worker may be included.Event recurrence implies situations in which some subjects have a greater probability of repeating the studied event than others, in such cases, the event cannot be characterized as an independent one.Population-wide comparison of recurrent events poses a challenge, 13 since the traditional approaches, such as Poisson regression, which treat events as independent, are not valid.If treated inadequately, analysis may lead to mistaken conclusions, in both statistics interpretation and interval estimation. 1,18With this in mind, a number of authors have considered negative binomial distribution as more adequate for the analysis of recurrent events, since it allows, at least partially, for variance estimation, which Poisson regression is unable to do. 18

Methodology
Study population included all 965 nursing professionals active on 1 January 2000 at the university hospital.WHS's assistance demand database was used as a source of information.This database includes the records of all medical appointments taken place at the Service, and is precisely structured, either by appointment or by medical procedure.Data on nursing professionals that did not seek medical assistance during the present study were obtained directly from the hospital's Human Resource department files.Observation period in the present study was the entire year 2000.Variables investigated included "seeking for medical assistance" (classified as "yes" or "no"), "number of appointments", and "number of short -term leaves".
In accordance to the normative and legal context of the present study, short-term leaves were defined as those which, accounted for a maximum of 30 missed days, alone or combined, in one fiscal year.If this number is exceeded, the professional must be submitted to special medical investigation in order to determine the need for leave prorogation or for further leaves. 7eave duration" in days and "associated diagnoses", registered according to the Chapters of International Statistical Classification of Diseases and Related Health Problems -ICD1O, were analyzed as secondary variables.The final group of variables, classified as "administrative causes", included appointments carried out solely for work ineptitude assessment purposes.In this case, the diagnosis of the disease which originated the sickness leave was not classified; instead, it was considered as an "administrative procedure".Variables considered as potentially associated with sickness leaves were also evaluated; these included gender, age, and occupation (nurse, nursing technician, or nursing assistant).Work regime was also considered, professionals being classified as "public servants" or "private employees" (hired according to Brazilian private sector labor regulations).
Statistical analysis calculated bivariate associations between factors, number of appointments, and diagnosis descriptions.Associations between studied factors and the number of leaves of absence were established by means of relative risk determination, obtained through a negative binomial distribution model.SPSS 10 and S-PLUS 4.5.software were used for statistical analysis.

RESULTS
Six hundred twenty-three professionals (65.5% of the sample) sought medical assistance at least once, mean rate being 5 per 100 workers/month.Of the total population, 139 were nurses, 590 were nursing technicians, and 236 were nursing assistants.As to gender, 837 subjects were female.Mean age was 39 years (SD=8.46);minimum age was 20, and maximum, 69.7 years.Concerning work regime, 71.4% of the population were "statutory" workers.Table1 presents the characteristics (occupation, gender, and work regime) of workers who sought WHS, in comparison to those who did not.A total of 1,364 sickness leaves were granted, a mean 2.15 (SD=1.8)and maximum 12 per worker who sought WHS assistance.The figure shows sickness leave frequency according to recurrence.Thirty-six percent of workers were granted more than one sickness leave.These leaves accounted for 5,279 missed workdays, a mean 8.3 (SD=9.2) days, and a maximum 30 days per worker.The mean number of leaves population-wide was 1.4 (SD=1.8)per worker; mean leave duration was 5.5 (SD=8.4)days, median 1.0 day, and third quartile 7 days.Of the 633 workers who sought WHS assistance, 556 (87.8%) were granted at least one sickness leave, representing 57.6% of total study population.Of these 556 workers, 37.6% were granted one leave, 26.3%, two leaves, 14.7% three leaves, 10.4% four leaves, and the remainder (11%) were granted five or more leaves.Concerning leave duration, 16% of subjects were granted one day, 12.9% two days, 8.3%, three days, 8.1%, four days, and 54,7% were granted five or more days sickness leave; 68.6% of appointments resulted in sickness leaves, and mean leave duration was 2.7 (SD=4.5) days, with a maximum 30 days, per appointment.In 46.6% of the appointments that yielded leaves of absence a single day was granted, in 13.5%, two days, and in the remaining 39.9%, three or more days.Significant differences were detected in the proportion of sickness leaves between men and women -the latter being 1.59 times more likely to be granted sickness leaves than the former (95%CI: 1.09-2.31).The odds of a "statutory" worker being granted a leave of absence were 1.67 times greater than those of a private employee (95%CI: 1.26-2.22).There was a significant difference in mean leave duration between work regimes (t=3.4,p=0.001); mean duration was greater among statutory workers.The difference in leave duration between men and women is borderline significant (t=1.85,p=0.065).No differences in age were found between workers that were granted leaves of absence during the year and those who were not.There was a significant difference in mean age between statutory workers who received leaves (41.9 years, SD=7.8), and private employees who received leaves (35.3 years, SD=7.4), the former being older (t=8.5, p=0.000).

Morbidities
Diagnoses that generated the greatest number of sickness leaves included group X (Diseases of the respiratory system), with 18.2% of total leaves, followed by group XIII (Diseases of the musculoskeletal system and connective tissue), with 13.4%, and group I (Certain infectious and parasitic diseases) with 8.7% NA: Number of appointments.
%C: Percentage of all appointments.
%ASL: Percentage of appointments leading to sickness leaves per diagnosis group.
%LA: Percentage of sickness leaves over the total number of leaves of absence.
ICD -International Classification of Diseases, 10 th revision.
It is also evident that the distribution of sickness leaves according to diagnostic group was similar to the number of appointments.Leaves were granted in 84.2% and 81.4% of appointments related to groups XI (Diseases of the digestive system) and VII (Diseases of the eye and adnexa) respectively.For groups I (Certain infectious and parasitic diseases), XIX (Injury, poisoning and certain other consequences of external causes), VI (Diseases of the nervous system), XIV (Diseases of the genitourinary system), XVIII (Symptoms, signs and abnormal clinical & laboratory findings), and X (Diseases of the respiratory system), 70%-80% of appointments produced sickness leaves.

Factors associated with sickness leaves
In order to determine factors associated with sickness leaves, two negative binomial regression models were adjusted, one for each gender.Variables included in the model were occupation, work regime, and age (the respective median values were used as cutoff points).Table 4 presents the results of this analysis.Work regime was significant among women.Female statutory workers were 1.42 times more likely to be granted leaves than female private employees (95%CI: 1.14-1.76).Male statutory workers had a 1.42 times greater chance of being granted leaves than male private employees (95%CI: 1.23-3.91).
The chance of a man older than 36 years being granted a leave was about 0.36 (36%) that of a younger man, which means that younger men have greater levels of absenteeism.Occupation, for both men and women, had no influence on absenteeism after adjustment for work regime and age.

DISCUSSION
The unequal distribution between genders shows that nursing is still predominantly a female occupation.In spite of the entire population coming from the same hospital, the present study allows us to evaluate strata and compare behavior in view of certain conditions, such as job stability -which is granted to "statutory" workers but not to private employees -and their participation in the granting of leaves.There is an expressive difference between these two categories, perhaps due to statutory workers feeling more secure when on leave, their positions being secured by job stability.Other studies 26 suggest that labor disability rates decrease due to fear of dismissal.The great age gap between both work regimes may be explained by the fact that there have been no public statutory nurse selection processes since 1994.Thus mean age is much higher among statutory workers than among private employees, who can be hired as needed.This may also have an effect upon the increase of appointment and sickness-leave rates among statutory workers, since this rate is expected to increase with age.The WHS appointment rate, considered as high, reflects conditions proper of the present study population: easy access, mandatory disability evaluation, population c omposition (healthcare professionals, which can contribute towards the greater valorization of certain symptoms and signs that, for the general population, might not have justified consulting a physician).Physical disability per se is often not the direct reason for taking leave; instead, sickness leaves impose themselves as a preventive measure.This is the case with herpes simplex and mild respiratory infections, or with professionals with skin lesions, which may lead to infection by germs present in the hospital environment.
The different appointment rates for the different occupations may be explained, initially, by the smaller number of nurses, which could discourage these professionals from taking leave.Likewise, hierarchically, the nurse may feel g reater responsibility towards the team, which would also encourage them to continue work, even under adverse circumstances.As their activity is more an administrative one, the potential for patient contamination is not as large.On the other hand, internal arrangements among hierarchically superior occupations are more frequent, which could contribute towards a smaller demand for medical attention.For some authors, predominantly administrative occupations -as is the case with nurses if compared to nursing assistants and technicians -have smaller morbidity and mortality rates, and therefore a smaller amount of sickness leaves. 11,15,17,19 has been widely demonstrated that young men are more prone to sickness leaves than older men. 2,8,9,23Likewise, several authors have demonstrated that, generally speaking, women are more likely to be granted sickness leaves than men. 2,8,9,11Other authors, 14 however, have shown that shortterm sickness leaves -up to seven days, in this case -were more common among me n, whereas long-term leaves -longer than seven days -were more frequent among women.There is a relation between leaves of absence and work regime.It would be interesting, however, to study the role of other variables, such as time working for the company, shift, and number of children, so that the influence of other factors may also be determined.
The present study investigates a recurrent event -work absenteeism, which involves the same subject repeatedly -through relative risk determination.With this in mind, a negative binomial regression model was employed -an alternative for dealing with non-independent events -aiming at obtaining a precise estimate.Among the professionals who sought WHS assistance, a mean 2.15 leaves per worker was obtained for the year 2000, the maximum being 12 leaves for a single worker.Data demonstrated that the event "sickness leave" repeated itself for a same subject, and that the probability of having other appointments was not equal to that of having only the first one, therefore not characterizing an independent event.

% 2 :
Percentage of the total population who were granted sickness leaves.M/W: Mean number of sickness leaves per worker over the entire population.Mean (Standard Deviation): Mean number of days missed per worker on leave.*p<0.05.

Figure -
Figure -Number of sickness leaves distribution according to percentage of workers.

Table 1 -
Characteristics of workers who sought medical assistance.

Table 2
presents sickness leave distribution and comparison according to occupation, gender, and work regime.

Table 2 -
Distribution of sickness leaves according studied variables.Percentage of workers that sought WHS assistance who were granted sickness leaves.

Table 3 -
Distribution of appointments and leaves of absence according to the great disease groups.

Table 4 -
Negative Binomial Regression model estimates for men and women.