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Nurse Managers’ Strategies to Reduce Absenteeism amongst Nurses at Selected Public Hospitals in Limpopo Province, South Africa
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Thifhelimbilu I Ramavhoya1
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Authors Info & Affiliations
Abstract
Background
Nursing absenteeism is a global challenge creating an obstacle in the provision of quality patient care in most healthcare institutions. To ensure that the quality of patient care is not compromised, the potential reasons for nursing staff absenteeism must be thoroughly investigated. This will allow nurse managers to develop intervention methods to lower absenteeism.
Objective
The objective of this study is to explore and describe strategies that nurse managers can use to reduce nurses’ absenteeism at selected public hospitals in Limpopo Province, South Africa.
Methodology
The study used a qualitative, exploratory, and descriptive research design. A non-probability purposive sampling technique was employed to select participants for the study. Data was collected using semi-structured interviews using an interview guide until data saturation. Interviews were audio recorded, and field notes were taken to capture the non-verbal cues. Tesch's open coding approach was used for analysis with the involvement of an independent coder, where themes and sub-themes were developed. Measures to ensure trustworthiness were adhered to. The ethical issues were ensured throughout the study.
Results
The study findings demonstrated that the hospital's ability to deliver quality patient care is hindered by nurses' absenteeism, which require strategies from nurse managers. The study recommends strategies nurse managers may utilize to improve absenteeism among nurses.
Conclusion
The study concluded that there is a need for hospital management to motivate for adequate human and material resources and to improve their managerial skills to effectively address absenteeism in line with hospital policies.
1. INTRODUCTION AND BACKGROUND
Absenteeism amongst nurses is a global concern that needs collaborative intervention efforts due to its impact on the quality of patient care in healthcare institutions. The continuous occurrence of professional nurses being absent from work has drawn significant attention as a contributing factor to low hospital productivity and, in turn, inadequate quality of care rendered to patients. The study concluded that there is a very high impact of absenteeism on productivity in hospitals [1]. Shortages of staff are the most common cause of hospital absenteeism among nurses and their effect on the daily management of human resources [2, 3]. Professional nurses typically have the highest absenteeism rates among healthcare professionals [4].
The findings of a study conducted on nurses’ absenteeism have a wide impact on workers who remain at work in the provision of the quality of care who end up compromising the quality of care. The study further recommends the introduction of policies to deal with workplace absenteeism and how to assist nurses who remain on duty with aspects of overload [5, 6]. Poor quality of care is currently estimated to account for roughly half of all agreeable deaths in sub-Saharan Africa [7]. This was further supported by a study [8], which discovered that although many studies have looked at the causes of nurses' absenteeism, comparatively little has been done to investigate the effects of absenteeism on nurses who are on duty while others are not. Nurses may skip work for a variety of reasons, such as illness or obligations to their families. Precautions must, therefore, be taken to reduce the adverse impacts that professional nurses may have on their professional development while they are on duty, as high workloads are major threats to nursing retention [9].
There is an increasing cost associated with nurses' absence in terms of recruitment, orientation, and appointment of provisional work to cover for vacant nurses' positions, as those nurses remaining on duty usually resign due to burnout and stress. When stress is more, there are increased turnover costs associated with temporary replacement of staff [10]. When absenteeism happens, hospitals typically have to pay high financial expenditures to maintain patient care [11, 12]. Advanced rates of nurse absenteeism have an impact on the cost and quality of healthcare services provided, as well as the productivity of the healthcare facility [11]. Furthermore, it frequently results in a high nurse-to-patient ratio and work overload, which both worsen patient outcomes and raise mortality rates [13]. Staff contentment and income are also correlated with nurses' absenteeism [13]. When covering for their absent colleagues, professional nurses are frequently overworked, which can lower their motivation for their jobs, reduce productivity, and result in more absences [14]. Even though professional nurse absenteeism varies by geographical area, it is frequently a major problem in the nursing workforce worldwide and should be taken very seriously [15].
2. MATERIALS AND METHODS
2.1. Problem Statement
Quality patient care in hospitals is dependent on the availability of human resources, of which nurses constitute the largest number of this workforce. Inadequate management of absenteeism by nurse managers requires immediate intervention to improve the care rendered to the public. Continuous public outcry for poor service delivery in hospitals triggers a need to enhance the professional competency skills of nurse managers in managing the scarce workforce. With the current changes and developments in nursing practice, there is a need for nurse managers to utilize recommended strategies to improve the handling and management of absenteeism. Research studies have revealed increasing nurse absenteeism in hospitals aggravated by inappropriate execution of strategies to manage absenteeism. Thus, the study pursues to explore and describe the intervention strategies that nurse managers can use to reduce nurses’ absenteeism at selected public hospitals in Limpopo Province, South Africa.
2.2. Objectives of the Study
This study aimed to explore and describe intervention strategies that nurse managers can use to reduce nurses’ absenteeism at selected public hospitals in Limpopo Province, South Africa.
2.3. Significance of the Study
The findings are relevant to the nursing profession as they may provide considerable and needed direction to the provincial department to monitor, manage, and evaluate absenteeism in hospitals as a means to achieve quality patient care. The researcher is a nursing Lecturer managing a department and is interested in the improvement of nursing care in hospitals through management strategies to reduce absenteeism.
2.4. Research Methods and Design
A qualitative, explorative, descriptive research design was utilized to explore and describe the recommended strategies that nurse managers may use to control absenteeism in public hospitals of Limpopo province, South Africa. The professional nurses were permitted to explain and describe broadly their recommended strategies that nurse managers may use to control absenteeism in public hospitals of Limpopo province.
2.5. Sampling and Sample
The study population was all professional nurses working in selected public regional hospitals of Limpopo province, South Africa. The 24 professional nurses who participated in the study were selected using a non-probability purposive homogenous sampling method where all participants shared similar characteristics to assist with the recommended strategies to reduce absenteeism [16]. The sample size was determined by data saturation achieved at twenty-four participants, with none refusing to participate.
2.6. Setting
The study setting was two regional hospitals in Limpopo province, South Africa. The study participants were nominated from the two regional hospitals for the researcher to find out if they have the same suggestions on strategies nurse managers may use to reduce absenteeism within different contexts.
2.7. Data Collection
Data was collected by the researcher, using semi-structured face-to-face interviews with the interview guide having a series of questions where the main question asked was: “Can you share with me the strategies which you can recommend for nurse managers to reduce absenteeism among nurses in hospitals?”. More probing questions were asked from the participants to get in-depth information on absenteeism issues based on the participants' responses. The interview guide was piloted on five participants before it was used for data collection of the main study. Data were collected until saturation, which included 24 participants. Data quality was attained by using various communication skills, listening, probing, paraphrasing, and summarising [17]. A voice recorder was used to record the interviews, field notes were taken to capture the non-verbal cues during the interview sessions, and transcribed verbatims were made of captured data [16]. The interviews were conducted for about 30 to 45 minutes to ensure rich data was collected with no participant refusing to be interviewed. Data collection was conducted from February 2023 to May 2023. The researcher used bracketing to avoid the inclusion of the researcher's preconceived ideas [18]. The information that was not related to the study was removed. No repeat interviews were conducted.
2.8. Data Analysis
The analysis of collected data was done using Tesch's open coding method to obtain qualitative data where theme and sub-themes were identified. No software was utilized in the management of collected data [16]. The involvement of an independent coder was sought during data analysis where an agreement on the identified themes and sub-themes was reached [16]. All similar topics were grouped and arranged as the main theme and sub-themes were developed on the recommended strategies nurse managers may use to reduce nurses' absenteeism in hospitals. Feedback on the findings has not been provided to the participants yet. Theme and sub-themes are represented in Table 1.
| Main Theme | Sub-Theme |
|---|---|
| 1. Recommended intervention strategies for nurse managers to manage and reduce absenteeism amongst nurses. | 1.1 Monitoring and evaluation of absenteeism 1.2 Consultation with nurses as a means to manage absenteeism 1.3 Acknowledgement, support and motivation of nurses 1.4 Appropriate referral to Employee Assistance Programme for support 1.5 Provision of conducive conditions of service 1.6 Implementation of policies to manage absenteeism 3.7 Implementation of disciplinary procedures to manage absenteeism. |
2.9. Trustworthiness of the Study
Measures to ensure trustworthiness were followed during the study to ensure the correctness and truth value of the study [19]. Field notes taken during interviews, the use of a voice recording device, and keeping the audit trail were all aimed at ensuring confirmability and an independent coder was involved in the coding of data to ensure the study's dependability. A non-purposive homogenous sampling was used to select participants adhering to predetermined inclusion criteria to enhance transferability. Credibility was ensured through a detailed methodology followed, minimizing bias through bracketing and prolonged engagement with participants during the data collection period.
2.10. Ethical Consideration
Ethical clearance was received from the Turfloop Research and Ethics Committee (TREC/558/2022: PG), and permission to conduct the study was obtained from the Limpopo Provincial Department of Health, Chief Executive Officers of hospitals, and nursing managers and the participants. All the necessary information was discussed with participants, including the rationale for conducting the study, the benefits, the use of a voice recorder and field notes to get their voluntary participation and consent. The issues of privacy, confidentiality and anonymity were all ensured in the study.
3. RESULTS
3.1. Presentations of Research Findings
The theme and sub-themes of the recommended strategies that nurse managers may use to reduce absenteeism in hospitals of Limpopo province are presented in Table 1.
3.1.1. Theme 1: Recommended Intervention Strategies for Nurse Managers to Manage and Reduce Nurses’ Absenteeism
The study revealed that there are recommended strategies that nurse managers can use to manage and reduce nurses’ absenteeism in hospitals. The sub-themes developed include monitoring and evaluation of abseneeism; consultation of nurses to manage absenteeism; acknowledgment, appreciation, and motivation of nurses; appropriate referral to Employee Assistance Programme for support; provision of conducive conditions of service; enforcement and implementation of policies to manage absenteeism and implementation of disciplinary procedures to manage absenteeism.
3.1.1.1. Sub-theme 1.1 Monitoring and Evaluation of Absenteeism
The results of the study showed that managers need to promptly monitor and evaluate the absenteeism of nurses in different hospital units to ensure nurses are constantly on duty as per their schedule. The findings further reveal that some nurses absent themselves without any explanation and still report for work the following day with no follow-up from managers. This implies that there is no continuous monitoring and observation of nurses' absenteeism by unit managers contributing to absenteeism that impacts on provision of quality patient care. The findings are supported by the following direct quotes:
Participant 19 said: “Monitoring of the staff by management can be another strategy that can assist to reduce absenteeism. For instance, if there is a checkbook which is supposed to be signed when you come on duty and when you knock off.”.
Participant 24 said: “Monitoring of nurses by checking the off duties and time register, not only in the morning but also during the day, can assist because nurses take it thatchecklists are checked only in the morning, during the day, some of the nurses can get lost doing their own business”.
3.1.1.2. Sub-theme 1.2 Consultation with Nurses as Means to Manage Absenteeism
The study found that professional nurses' absenteeism rates continue to increase and the managers do not consult with nurses to get information contributing to such behaviours. This denotes that there is no consultation with nurses to get a reasonable explanation for absenteeism. Therefore, supervisors should speak with professional nurses to determine the reason behind their absences from work.
Participant 3 said:” If you are a professional nurse and you need to sit with the person who is always absent and dig more information as to why is he/she always absent from work.”
Participant 6 said: “If a co-worker consistently misses work, the manager needs to speak with the employee to find out why they are away from work”.
Participant 18 said: “The manager should have time to communicate with those who are always absent and find out the main cause of being absence from work.
3.1.1.3. Sub-theme 1.3 Acknowledgement, Support, and Motivation of Nurses
The study findings revealed that nurses working harder while others are absent are not recognized and appraised by management as a way to inspire courage. Participants added that despite their efforts, management remains silent and does not express gratitude. Participants disclosed that professional nurses are experiencing a lack of support from their supervisors, which leaves them feeling unappreciated for their job. This suggests that for nurses there is no acknowledgment, appraisal, support, and motivation from nurse managers leading to more episodes of absenteeism.
Participant 1 stated: “Requesting the presence of an outside motivational speaker who is unfamiliar with the hospital's atmosphere to inspire all employees will be much appreciated.
This was supported by Participant 10 : “Managers have to give support to the subordinates because if they are not given support, they feel like they are not being taken into consideration and end up being absent.
Participant 14: “By appreciating the staff members who are working harder and handing them the certificate of best professional nurse within the unit. Recognition of those who have no record of being absent from work can reduce absenteeism.”
3.1.1.4. Sub-theme 1.4 Appropriate Referral to Employee Assistance Programme for Support
The results of the study showed that professional nurses are missing work because of personal problems as well. Some nurses end up deciding to quit their jobs to deal with such personal and psychological matters for which they are unable to get assistance from their managers through referral to appropriate services for assistance like the Employee Assisted Programme (EAP). This means that nurse managers are not referring nurses with psychosocial problems for assistance and if such are properly referred, this may contribute to reducing absenteeism.
Participant 6 said: “Those who are always absent can be referred to the relevant personnel like the Employees Assistant Programme where they will give them counselling. Because that person needs the support so that one day we will find her doing the right thing”.
Participant 10 said: “And if they have problems, their problems should be attended to, like referring them to counselling offices if the problem needs counselling”.
Participant 16 supported and elaborated: “Those who are found to be having problems are to be sent to the psychologist for counselling so that they can be assisted and they can improve.”
3.1.1.5. Sub-theme 1.5 Provision of Conducive Conditions of Service
The study findings confirmed that workers are absent from work as they are not satisfied with the working conditions, such as working overtime, being paid with hours instead of money, and also lacking increments. The working environment is also not safe due to poor infrastructure and inadequate resources. Despite their working harder, they are not paid for their efforts and they resort to part-time jobs in private facilities, further contributing to absenteeism.
Participant 6 illustrated: “Managers must advocate the nurses for the Government to pay enough money to the employees to avoid this absenteeism, especially when you work overtime they pay you in hours instead of money, good infrastructure and provide adequate materials and supplies to make us work safe.”.
Participant 9 said: “Another thing is increment of salary which can reduce absenteeism and improve the working conditions by boosting morale for nurses. If you are working in good environment and safe, also getting money for overtime and night duty, even if working harder, you can’t feel the heaviness ”.
3.1.1.6. Sub-theme 1.6 Implementation of Policies to Manage Absenteeism
The findings of this study indicated that the supervisors are not disciplining professional nurses who miss work without a valid reason. The results of the study show that most professional nurses, especially those that are favored by the managers, are not held responsible for missing work, even when they do not present any documentation of their absence. There are regulations and policies in place to manage absenteeism, but nurse managers shy away from implementing them hence putting patient care at risk. Consistent implementation of policies against absenteeism by nurse managers could lower absenteeism in hospitals.
This was supported by participant 1: “And the supervisor will also look at the trend of absenteeism always after payday this person doesn’t come to work, or after a long weekend, a holiday. That’s where managers they will have to implement that policy of absenteeism, no work no pay”.
Participant 3 said: ”The policies in this hospital for if she didn’t report that she won’t be on duty when she comes back she will have to sign a leave without pay, so that she doesn’t repeat or take it as a trend.”
Participant 5 said: “if we can successfully implement the strategy of leave without pay to all nurses, no one will be able to miss work because they will deduct a certain amount from their pay”.
3.1.1.7. Sub-theme 3.7 Implementation of Disciplinary Procedures to Manage Absenteeism
According to the study findings, professional nurses' absenteeism can be decreased by disciplinary actions. The findings further stated that nurses who choose to be absent from work without adequate justification must face disciplinary actions as a means to manage absenteeism. This implies that to deliver high-quality patient care, the nurse managers have to detect nurses who are discovered to have missed work without a good reason and may face disciplinary action. This action may also serve as an incentive for them to modify how they notify absenteeism promptly.
The findings were supported by Participant 2 who indicated: “I think if you are absent and you didn’t report that you won’t be on duty and without a valid reason maybe for days you will be given a leave without pay.
Participant 10 supported: “Implementation of disciplinary measures based on policies can assist to reduce absenteeism to those who use to be absent at all times because they will refrain from being absent and start doing the right thing. “
Participant 24 said: “And if a leave without pay has been implemented and you still continue, a verbal warning must be given, if not improving a written warning. If one fails to respect that written warning it means that is dismissing him/herself from duty.”
4. DISCUSSION
The study found that there are recommended strategies nurse managers can use to reduce absenteeism, which include monitoring and evaluation of absenteeism consultation with nurses; appreciation, and motivation of nurses; appropriate referral to other structures for support; provision of conducive working conditions; and implementation of policies and instituting disciplinary measures as means to manage absenteeism.
The same findings were reported in a study [20] that concluded that there is a negative connotation between absenteeism and nursing management's failure to recognize, value, and motivate professional nurses. Nursing management must thus provide a system to ensure a positive relationship with nurses and recognize them for delivering excellent patient care. Nurse leaders build positive relationships with employees to improve absenteeism [21]. The most important way to manage absenteeism effectively includes communication between managers and employees to clarify the reasons for absences, and such discussions may result in better personal and professional relationships, hence reducing absenteeism [22].
Low morale and a lack of support from nurse management reduce the morale of nurses, leading to poor performance when providing nursing care services [23]. Furthermore, another study [24] also alluded that professional nurses experience distress when managers don't provide them with appropriate support and hence resort to absenteeism. Incentives should be used to boost the morale of professional nurses who choose to stay on duty [6]. Managers need to be more conscious of the need to create and put into effect procedures and policies that will lower professional nurses’ absenteeism and raise productivity, commitment, and profitability [6]. Another study revealed that any strict measures for absenteeism from management’s viewpoint should take into account absenteeism tendency, analysis and the work environment as this will assist managers to come with adequate intervention measures [3].
A study [25] showed that nurses should operate in a healthy physical setting. Additionally, the same study demonstrated that workplace safety, such as the infrastructure, not only lowers maintenance costs but also boosts staff morale and increases professional nurses' productivity, which reduces incidents and absence rates. Stress and absenteeism are caused by a lack of resources and/or equipment [26]. Another study recommends that nurses should be involved when nurse managers make decisions that affect them [27]. Professional nurses who experience stress have emotional and psychological issues that are related to their absenteeism, job demands and pressure. As a result, psychologists should provide them more attention [28]. The relationships with managers, discussions, and meeting the physical and emotional difficulties of professionals were reflected as important factors in absenteeism. Inadequate treatment of nurses at the workplace and unfair discipline forced on the nurses at the workplace contributed to absenteeism [29].
Exhaustive hospital work environments can affect staff and organizational outcomes and thus, staff's participation in hospital affairs appears vital for organizational success [30]. Furthermore, there are effects of the work environment that impact negatively on the health of the staff members thus the need for the work environment to be conducive to ensuring optimal health of staff [31]. Hospitals need to better understand how the perceptions of registered nurses relate to their work environment to improve staff absenteeism and turnover intent [32]. A study [33] recommends that work environment and staffing adjustments are needed as strategies to alleviate patient care compromise. When there is heavy workload due to shortages and concurrent compromised professional standards, there is inevitable stress leading to workplace exhaustion and illness-related absenteeism [34]. Shortage of staff in hospitals leads to increased workload and nurses are overworked, and they end up absenting themselves from work [6]. Furthermore, nurse managers should investigate work settings to identify weaknesses that need immediate intervention and improvement to keep the work environment worker-friendly. Nurses’ work environment is one of the greatest influences on the quality of care provided to patients and has a major impact on nurses’ well-being [35]. Unfortunately, the hospital work environment continues to be problematic, with constrained available resources and increased job needs and requirements [35].
Another study recommended that for absenteeism among nurses to be reduced, there needs to be improvement in the working conditions, and time management and training should be provided to nurses [35]. The impact of nurse absenteeism on the quality of care rendered to patients and the financial drain experienced by households in sub-Saharan Africa is extensive, requiring immediate attention from nurse managers [7]. A study conducted in Nigeria found that absenteeism ranks highly among types of dishonesty in health systems, which requires vertical top-down enforcement of rules using a holistic approach at different administrative levels of rules where insufficiencies are identified and addressed effectively [36]. Since absenteeism in the health sector is reaching an alarming stage, with workers being paid for work not done, intensive interventions to tackle absenteeism and other forms of health sector dishonesty should be sensitive to socio-cultural and political contexts that influence people’s daily lives and should be addressed to improve service delivery [37].
CONCLUSION
According to the study findings, nurses who stay on duty are burdened by absenteeism since they must cover for themselves and their absentee colleagues. Additionally, nurses who stay on duty suffer from an uncomfortable work environment as a result of absenteeism since they want managers to support them, show them gratitude, and provide financial incentives for them to feel inspired to pull up their socks. The research study findings might help managers develop and put into action the strategies and plans needed to successfully carry out their action plan for improving the mental, physical, and financial health of professional nurses to reduce absenteeism. The study may prompt future researchers to explore more on nurses’ absenteeism, and its impact on patient care and develop models and programmes that can be validated and adopted by health departments to ensure quality patient care is not compromised. Furthermore, future research should be initiated to explore more on the role policymakers that can effectively develop policies relevant in addressing nurses’ absenteeism and how their effective implementation in practice can be monitored and evaluated.
STRENGTHS AND LIMITATIONS OF THE STUDY
The study results show there is insufficient management support for professional nurses who remain on duty while others are absent. Professional nurses become disengaged from their employment for a variety of reasons. Managers therefore, need to use ways to reduce the effects and repercussions that high absence rates have in hospitals. The study findings are limited to the selected regional hospitals of Limpopo province where the study was undertaken, and the findings may not be generalized to other regional hospitals in the province and also those in other provinces.
AUTHORS’ CONTRIBUTION
T.M: interviewed participants during data collection, analyzed the data, conceptualized the research idea and initial drafting of the manuscript;, T.E.M: Supervised the Doctor of Philosophy in Health Sciences and reviewed the manuscript; T.I.R.: Co-supervised the study and revised the manuscript, and all authors approved the manuscript to be published in the journal.
ETHICS APPROVAL AND CONSENT TO PARTICIPATE
The Turf Loop Research Ethics Committee granted the study’s ethical permission with the ethical clearance certificate number (TREC/558/2022: PG), and the study involves human subjects. Permission to collect data was obtained from the Limpopo Provincial Department of Health, District managers, Chief executive officers, and nursing managers of the selected regional hospitals.
HUMAN AND ANIMAL RIGHTS
All procedures performed in studies involving human participants were in accordance with the ethical standards of institutional and/or research committee and with the 1975 Declaration of Helsinki, as revised in 2013.
CONSENT FOR PUBLICATION
The participants were fully voluntary in their participation, and they gave their informed consent after being informed that the data would be published. Consent was obtained from professional nurses of regional hospitals, provided anonymity issues were adhered to.
AVAILABILITY OF DATA AND MATERIALS
The data that support the findings of this study are available from the corresponding author [T.M] upon request.
ACKNOWLEDGMENTS
The professional nurses who took part in the study, operational managers and the hospital management who were permitted to perform the study are thanked by the authors.
