Abstract
BACKGROUND:
Nurses and personal support workers (PSWs) have high sickness absence rates in Canada. Whilst the evidence-based literature helped to identify the variables related to sickness absenteeism, understanding “why” remains unknown. This information could benefit the healthcare sector in northeastern Ontario and in locations where healthcare is one of the largest employment sectors and where nursing staff have high absence and turnover rates.
OBJECTIVE:
To identify and understand the factors associated with sickness absence among nurses and PSWs through several experiences while investigating if there are northern-related reasons to explain the high rates of sickness absence.
METHODS:
In this descriptive qualitative study, focus group sessions took place with registered nurses (n = 6), registered practical nurses (n = 4), PSWs (n = 8), and key informants who specialize in occupational health and nursing unions (n = 5). Focus group sessions were transcribed verbatim followed by inductive thematic analysis.
RESULTS:
Four main themes emerged, which were occupational/organizational challenges, physical health, emotional toll on mental well-being, and northern-related challenges. Descriptions of why such factors lead to sickness absence were addressed with staff shortage serving as an underlying factor.
CONCLUSION:
Despite the complexity of the manifestations of sickness absence, work support and timely debriefing could reduce sickness absence and by extension, staff shortage.
Introduction
The nursing profession is considered to be a stressful occupation with physical and psychosocial stressors that are seen as inherent to its practice [1–3]. In addition to the ‘everyday’ concerns within the profession, additional challenges have emerged in light of the recent global outbreak as a result of the Coronavirus Disease 2019 (COVID-19), adding additional stressors to the healthcare field across the globe. Nurses and personal support workers (PSWs) have the highest injury and sickness absence rates in Canada [4]. This finding is concerning for areas such as the City of Greater Sudbury, located in northeastern Ontario, Canada, where healthcare is one of its largest employer [4–6].
This undertaking served as one part of a larger project that aimed to: (1) identify factors related to sickness absenteeism; (2) understand how or why such factors may eventually lead to sickness absenteeism through lived experiences; and (3) determine if there are factors specifically related to sickness absence in northern regions with a particular focus on northeastern Ontario. By way of a systematic review and meta-analysis, we identified several factors associated with sickness absenteeism [7, 8]. Factors that increased the odds of sickness absenteeism included job role with PSWs having greater odds of absenteeism than nurses, working nightshift, and those working in pediatric or psychiatric units. Additionally, nursing personnel who perceived their health as poor and who had been on previous sick leaves were also at risk of absenteeism. Moreover, experiencing poor mental health, increased physical or mental fatigue, high work demand, poor work support, and musculoskeletal pain were also associated with sick leave [7, 8].
While our systematic review helped address our first objective, we also identified three additional main issues. Firstly, recent research on the antecedents of sickness absenteeism of nursing staff with sufficient data was lacking. Our systematic review revealed 27 studies that met the eligibility criteria, with only eight studies having been published past 2010 [7, 8]. Similarly, apart from identifying the correlates of sickness absenteeism in this population, research that examined why such factors were associated with sick leave was even more scarce and outdated [9]. This is of concern as many of the practices within the medical field, particularly in nursing, is rapidly evolving [10].
Lastly, rates of sickness absenteeism and issues with staff retention in healthcare are of particular concern in northeastern Ontario compared to the rest of the province [11, 12] and thereby merits special consideration. In this region, the City of Greater Sudbury is the largest urban city. In Sudbury, healthcare is the largest employment sector, and accounts for almost 15% of the entire workforce with approximately 6,000 healthcare workers [6]. Over 50% of those healthcare workers are nurses and PSWs. Given their strong representation in the city’s workforce, it would be of benefit to gain their insight regarding the correlates of absenteeism found in the literature and understand their views of sickness absence and potential northern-specific factors. As noted, research on sickness absenteeism in northeastern Ontario nurses and PSWs is scarce. Our search identified two studies both focusing on specialized healthcare staff and thus, are not inclusive of other types of nurses or PSWS [11, 13]. A study by Nowrouzi et al. (2015) examined work and home-related factors that were linked to work ability in obstetric nurses [11]. The authors determined that work satisfaction and a supportive work environment, that allows them to be engaged in decision-making processes, could reduce work disability and absenteeism. Furthermore, Carosi and Lightfoot (2009) conducted a retrospective review to examine factors associated with sickness absence among cancer care workers in the City of Greater Sudbury [13]. In this latter study, female workers were at greater risk of sickness absence than male workers. It was also determined that employees younger than 40 years had higher sickness rates than older staff. Furthermore, those who had been employed for less than five years had significantly lower odds of sickness absence [13].
Aim of the study
Based on the issues highlighted previously, this qualitative study had three objectives: (1) to examine the factors related to sickness absence that may not have been identified in the literature (as per our systematic review) among nurses and PSWs; (2) to gain a better understanding of why such factors occur through lived experiences; and (3) to determine if there are additional risk factors to keep in mind when considering nurses and PSWs in northeastern Ontario, particularly, in The City of Greater Sudbury.
Methods
This was a descriptive qualitative study and was analyzed using inductive thematic analysis. Nurses and PSWs were the two groups of interest in this study. For this study, the term “nurse” includes registered nurses (RNs) and registered practical nurses (RPNs) [14]. PSWs are Canadian workers who assist patients with daily personal care and often work under the direction of a RN or RPN [15]. Also, we defined sickness absence as an approved time off from the workplace, subsequent to an injury or illness [7]. Focus group (FG) discussions which are helpful in exploring different opinions in an interactive way were undertaken using a semi-structured FG guide. Specifically, we conducted three different FG discussions with frontline healthcare workers, including nurses, PSWs, and key informants. Except for the key informant group, participants were grouped based on their job title (i.e., RN, RPN, PSW) to ensure homogeneity in terms of education and job levels.
Sampling and setting
The definition of Northeastern Ontario was operationalized using the Ministry of Health and Long-term Care’s demarcations [16]. These geographical separations are based on the 14 Local Health Integrated Networks that provide health services in Ontario. The City of Greater Sudbury is located in the northeastern region of Ontario, which represents approximately 4.5% of Ontario’s population and nearly 40% of total land area [16].
For nurse and PSW recruitment, advertisements for participation were placed in one hospital and long-term care facilities Individuals were eligible for participation if they had worked for a minimum of five years in their respective role. Researchers involved in this study held formal discussions in efforts to set criteria for key informants and to identify potential candidates. We determined that key informants had to be individuals who worked with or supported nursing personnel in northeastern Ontario. To this end, we selected union representatives, individuals who work with disability claims and occupational health and safety in healthcare, and specialists who provide rehabilitative services to nursing staff as part of their Employee and Family Assistance Program. Invitation letters were sent electronically to each individual identified as a potential key informant. A total of six invitations were sent and five individuals agreed to partake in a FG discussion. This study received ethics approval from the Research Ethics Boards at Laurentian University and Health Sciences North in Sudbury, ON, Canada.
Procedure
In each FG session, the moderator (BG) and a research assistant (JD) were present. The research assistant who transcribed the audio data attended the sessions in order to handle the digital audio recording and also to be familiar with the content in efforts to make the transcription as accurate as possible. All sessions took place at Laurentian University’s Centre for Research in Occupational Health and Safety conference room in 2016. They were approximately 90 minutes in duration. Participants were asked to discuss what factors could lead to sickness absence in nurses and PSWs with follow-up questions to gain an understanding of why sickness absence may occur through their experiences. The second question sought to identify any risk factors that were “northern” specific that particularly contributes to sickness absence in northeastern Ontario (“In your opinion, are there any potential risk factors that you think are specific to northeastern Ontario and why?”). Each participant was assigned a code to ensure confidentiality. To improve credibility, the moderator reviewed the transcription completed by the research assistant while listening to the recoding. Participants were also asked to validate the transcripts.
Thematic analysis
An inductive thematic analysis was used to analyze the data. We chose to use thematic analysis as it provides flexibility in analyzing meaning across a whole dataset or concentrate on one specific area in depth, which compliments this study. We applied the six stages recommended by Braun and Clarke (2006) for thematic analysis [17] by one author (BG) and reviewed by a second author (NL). Firstly, transcripts were read several times to ensure a sound understanding of each session as a whole, as well as from each participant. They were also read while listening to the audio recording to ensure accuracy and context while at the same time carefully noticing content that was directly related to this study’s research questions. Initial codes were then generated based on the participants’ comments as well as their implications as they related to this study. Based on the codes generated from the previous step, they were then aligned with specific themes and converted into meaningful units, which were then coded into themes using NVivo Version 11 [18]. The themes were then compared to the coded data, then were defined accordingly. Notably, all reported themes were to some degree discussed in all four FG sessions. Upon completion of the aforementioned stages, we completed a final check of the entire process, seeking any contradicting statements or textual data that could be misinterpreted to ensure the study’s objectivity (i.e., confirmability) [19].
Results
A total of 20 participants took part in the FG sessions (RN n = 6, RPN n = 4, PSW n = 5, Key Informants n = 5); one session per group (4 groups). Most participants were females (n = 18) and 60% were from a hospital setting (n = 12). Table 1 describes work characteristics of participants in each group. The analysis of the FG discussions resulted in three major themes: (1) occupational and organizational challenges; (2) impact on physical health; and (3) the emotional toll on mental well-being with several subthemes (Table 2). We also examined the possibility of northern-specific challenges related to sickness absence, which served as the fourth theme.
Characteristics of Participants Involved in Focus Groups
Characteristics of Participants Involved in Focus Groups
Themes and Subthemes Emerged From Focus Groups VIA Thematic Analysis
Results from the analysis revealed that organizational factors play a significant role in the likelihood of a nurse or a PSW experiencing sickness absence. To this end, we identified three subthemes: (a) concerns with infectious disease; (b) concerns with shiftwork and its consequences; and (c) issues with workplace safety and support.
Exposure to infectious diseases
Exposure to infectious diseases was reported as a widely common issue. Participants, largely nurses and PSWs, reported that the nursing personnel are frequently exposed to viruses and infections. Participants describe that it is often difficult to protect against contamination.
... When flu season’s around, we have a lot of isolations, and like sometimes we get one nurse, we call the “dirty nurse” and she takes care of all the isolation so we try to minimize the contamination as much as possible. But you know, once one person gets sick and especially in a long-term care home it’s like a day care and everybody gets sick and the staff get sick and you know, staff come in sick anyways because they got to make a living. And they just keep spreading and it’s very bad for the staff and the patient.
Participants expressed that while policies are put in place to prevent infectious diseases, they are still challenging to implement and manage. They noted that several precautions are taken to prevent the spread of infectious diseases by wearing masks, gloves, and frequently washing their hands during their shifts. However, the patients do not always follow instructions of keeping masks on and washing their hands.
We have to gown and mask and do all the proper fit, stuff that needs to be done but because of a patient’s rights, the patient is allowed out of the room and they go out without the equipment.
Furthermore, it was determined that the under reporting of feeling sick (e.g., the influenza virus), could lead to sickness absence, as working while feeling sick often leads to spreading viruses to other staff members and patients. However, participants noted that staff shortages are frequent and that, as a result of guilt, some nurses and PSWs choose to come to work when sick, recognizing that their absence might have more severe implications for their colleagues. That is, a nursing staff ending his or her shift might be asked to extend their hours or the team would be faced with working short staffed, and naturally, increases the demand on the team:
I wasn’t feeling well but [if I] go home and just leave them short because I knew nobody’s going to come in ... . So I felt bad leaving them short. And it was like a Saturday and it was very busy. So I had to stay ...
Shiftwork
Shiftwork, whether nightshift, rotating shifts, or working overtime, were all considered to be strong factors related to sickness absence for reasons that would be considered as multifactorial. Participants indicated that shiftwork is a contributor to poorer health and chronic conditions (e.g., diabetes). These issues, including fatigue reportedly led to serious injuries to staff members driving home after their shift. These issues, including fatigue, reportedly led to serious injuries to staff members at work or leaving work (e.g., while driving home following a shift).
Working shiftwork is a risk factor for nurses. I mean 7 years off your life ... you have to take into consideration that amount of stress, you’re not at your peak when you’re working night shifts, so you know you’re putting yourself in jeopardy and you’re doing it for patients, of course that they’re cared for, but you know it, has an impact on your health from switching back and forth.
It was indicated that in order to do shiftwork, the nurse or PSW must make time to have adequate sleep, which at times is quite challenging due to personal commitments such as caring for family members. However, participants indicated that this is often difficult to maintain given the level of fatigue adjusting to rotating shifts or working nightshifts. Furthermore, unplanned overtime, when a staff member calls in sick, was found to further exacerbate fatigue levels and associated wellbeing concerns.
We were short and [a nurse] had to stay overnight. We didn’t have any RN to cover for the nightshift and she was only afternoon shift. [The nurse] had to stay overnight. And she wasn’t prepared, she had no lunch, she had nothing.
Working shiftwork, particularly nightshifts or rotating shifts also causes nursing personnel to find means to adjust their internal clocks or to cope with pains and aches resulting from long hours of work. As such, self-medicating was found to be a frequent “self-care” method by some staff.
... They’re medicating with things [such as] caffeine. They can go to work and they’re drinking 10 cups of coffee a day because that’s what keeps them alert ...
It’s hard to flip the body when you you’re supposed to be awake and you’re supposed to be sleeping. So, sometimes you have to take a sleep aid to get good sleep. So you can get up for your nightshift.
Safety climate and work support
An issue that is reportedly common in the nursing profession is poor safety climate, which is the perceived value of safety within an organization. Participants expressed that this concept is not specific to their current workplace, but it is a widely common issue within the healthcare profession. Key informants also noted that such issues are seen in other areas of Canada and North America. Unlike other types of work where there is no patient contact, it is difficult for nursing personnel to refuse to work, as they have an obligation to care for their patients. One key informant offered an example by comparing how a miner might choose to refuse work, as per Occupational Health and Safety regulations; however, it becomes more complicated when dealing with human beings, as their health could deteriorate, leading to adverse outcomes. The concern with this issue is that there appears to be public acceptance that patient violence is part and parcel of the nurses working environment.
... Whether you get punched in the face, whether you injure your back, there is a certain expectation from the general population that it’s part of your job ... I’ve had police called in when a staff had been assaulted and they said, “Well, it’s a part of your job”.
We’re supposed to put up with things because we are nurses and nothing else.
A closely related issue is the hectic environment within the nursing profession that at times does not provide staff with effective post-incident debriefing. Participants stressed the importance of debriefing given the nature of their work, and their inability to share their experiences outside the workplace since they are bound by confidentiality.
... [We] do very poorly in debriefing people in the moment. So we have, you know the nurse who’s just lost a child. We don’t debrief, it’s [a] part of the job.
You bring it home but you’re not allowed to talk about it. I’m not allowed to bring my work home. I’m not allowed to come home and have a conversation about all the stuff that went on because that’s a breach of my work.
Work setting was also viewed as factor that was felt to be highly related to sickness absence. In long-term care facilities, nursing staff, particularly PSWs are faced with violent behaviours. Given their job role, they help patients with self-care tasks. With this in mind, participants indicated that a large number of the patients they work with are to some degree incapacitated, and can be violent:
... A lot of patients that we work with have either dementia or delirium and some of them could be aggressive ... Personally I did get hit once ... . I knew some of my co-workers that got hit pretty [badly] and they had to stop working for about a month.
Our findings revealed that acute care settings were also deemed as hazardous. Specifically, nurses were found to be at risk of sickness absence due to patient violence if working in units such as emergency departments and psychiatric units. These hospital units are known for their unpredictable risks such as intoxicated patients or patient psychotic outbreak. Pediatric units were different given the level of emotional strain that is placed on the nurses when fatalities occur. This is further discussed in the third theme (emotional toll on mental well-being).
There’s a lot of guilt. In children [death] is not supposed to happen ... I think for us there’s a pretty big component of burnout.
Participants in the FGs also stressed that no matter which acute unit it might be, there is always a risk and that it is not always provoked by the patient, but other individuals such as patients’ family members.
Whether it’s the father that’s coming in to find out if their son was killed in a car accident, or the wife that just lost a spouse, or the person that has dementia ... Any individual should be considered a risk because they’re coming into an acute setting or they’re coming into a setting where they don’t have control of what’s going on.
Impact on physical health
Results from the analysis suggest that nurses and PSWs considered physical health factors, specifically musculoskeletal disorders (MSD), as a large contributor to sickness absence among nurses and PSWs. Data from the FG session indicated several nursing staff members suffer with MSD, whether at a tolerable level or to an extent that requires rehabilitative services and time away from work. A key informant described MSD as a “career ender for a nurse”. Participants explained that there are several factors that lead to the manifestation of absenteeism due to MSD. First is the age and level of experience of the staff. For instance, participants from the key informant FG noted that MSD is generally attributed to age, especially with older PSWs that are new to the field. In addition, history of MSD appears to predict future MSD and sickness absenteeism.
... For some PSWs, it’s a second or maybe third career. So they’re already older when coming into the position and they’re new ... . There is also the fact that the older you get, the less able you are to heal. So they may have a smaller injury, that’s not necessarily at the beginning worthy of note, but [then] it aggravates [and] gets worse over time.
Repetitive and awkward movements were reported as an antecedent to the development of MSD.
I came from a surgical unit and we repeatedly moved patients from a stretcher to a bed and a lot of times, they just had surgery so they don’t move well on their own so you’re literally pulling them from one bed to the other.
For us on rehab, we do a lot of transferring patients to go to their therapy, so we’re constantly getting the patient from the bed to the wheelchair and then back to the bed to get dressed after the therapy and so back up in the wheelchair for supper. So we’re doing so many transfers during the day just for one patient.
Insufficient staffing was described as a precursor to experiencing MSD. Specifically, working on a team that is not at full capacity often translates to working faster and harder, which leads to not using the proper form and technique during lifts and transfers. In addition, with irregular and short sleep durations due to shiftwork, staff members do not have sufficient recovery time after experiencing a physical ache or strain.
... Shift work is hell on the ability to sleep and if you don’t sleep you don’t heal, if you don’t heal, then that MSD injury is much more likely to happen.
Emotional toll on mental well-being
Participants from all four groups considered mental health as a factor that could lead to sickness absence. A key informant who is in charge of disability claims noted the significance of mental health and disability claims. Results revealed that mental health is a problem in the workplace as its symptoms are typically variable among nursing staff, and unlike physical factors, they are difficult to envisage. Likewise, it was indicated that psychological issues could manifest in a physical form. Interchangeably, a physical disability could then lead to stress and depression or anxiety, specifically with the preparation to return to work or fear of re-injury. As such, key informants warned that sometimes workplace statistics might not tell the “entire story”, as data might not depict a “comprehensive picture” of how the relationship between physical health and mental health develop.
Many of the disabilities that people experience as physical, really have their roots in psychological ... So we’re really only seeing the tip of the iceberg.
... It starts off as back pain and then turns into a mental health issue. From short-term back pain to long-term depression, anxiety ...
As previously stated, working in a pediatric facility was found to encompass emotional distress and burnout following fatal events such as the death of children. Participants explained that there is a degree of compassion when working children, as most nursing staff, are parents with children of their own.
Like for example us, being in the Children’s Treatment Centre, if you don’t have children, you may not be as compassionate as someone like me that has a child.
Discussions with participants revealed that personality is a contributing factor in experiencing mental health concerns that could be significant enough to result in a sick leave. To this end, they explained that personalities and compassion are often tied together. Some staff can be compassionate, but can detach after a shift ending while others cannot.
Limited staffing once again was tied to sick leave. Only this time, the lack of staffing could trigger anxiety/stress in nursing personnel even when they are off duty, as many reported that they anticipated a call requesting their support due to staff shortage.
Maybe anxiety. That would be because [you’re] anxious about work. The uncertainty of if you’re gonna get called ... should I go to bed earlier? ... and it just increases and you just stop going to work or you might miss days.
Northern-specific challenges
Participants commented that overall, the nursing profession is similar, irrespective of setting. Organizational factors such as shiftwork, developing MSD, and mental health concerns were described as “global issues”. However, there were two factors that might be classified as “northern-specific”. In comparison to the north, larger urban centres in southern Ontario have interconnected networks. Accordingly, participants noted that nurses’ names could be placed on alternate lists of connected hospitals in the event of being short-staffed. This in turn, generates a large list of available nursing staff and thus, lowers the risk of working overtime or consecutive shifts, and being short-staffed.
Some participants suggested that the City of Greater Sudbury is quite large in its landmass, and some staff might be living far from their place of employment. Reportedly, Sudbury’s roads were considered to be hazardous and this hazard becomes more significant during winter conditions. To add to this issue, cellular receptions are often weak in some areas. Participants also noted that PSWs are at greater risk, as they commonly provide home care services to patients. Unlike other services a nursing personnel might offer, assisting patients with every day needs such as feeding or cleaning are essential, and thus, it was perceived to be more difficult to cancel appointments in light of poor weather conditions.
We have a friend that does um at-home care and it’s like driving far away. Or ... you know how Sudbury road conditions are like ...
... A PSW has to be there because this person won’t get the personal daily needs so they really have to be there ...
Discussion
This qualitative study sought to examine the risk factors of sickness absence as well as their causes and consequences, while considering northern-specific factors for areas such as northeastern Ontario for nurses and PSWs. Our results confirm that there are several factors perceived to cause sickness in these workers with major themes including occupational and organizational factors, the impact on physical health, the emotional toll on mental well-being, and northern-specific challenges that could contribute to higher levels of sickness absenteeism. Within each identified theme, we gained a deeper understanding of why sickness absence occurs. Some of the results resembled less recent Canadian qualitative research that sought to examine the causes of absenteeism among nurses [9]. The authors collected data from 10 Ontario acute care hospitals, where five had high lost-time claim rates and their counterparts had lower claim rates. They conducted focus groups with nurses, chief executive officers, chief nursing officers, and occupational health and safety specialists. The main concerns expressed by all group members included: physical health, psychosocial/mental health, scheduling issues, workload, and respect between colleagues and employers [9]. However, this paper did not offer deep explanation as to how the aforementioned factors resulted in sickness absence and did not offer insight with respect to geographical differences (i.e., northern vs. southern Ontario).
Recognizing that identifying factors related to sickness absence has been widely addressed in the literature, this paper highlights why such factors could then turn into sickness absence. Through a deeper, intricate understanding of how such factors lead to sickness absence, better preventative strategies could be implemented. Furthermore, findings obtained from this paper offers insight on the additional risks involved with nurses and PSWs working in northeastern Ontario.
Perhaps the most important finding from this current study is that while these major themes are relevant in and of themselves, they are also quite intertwined with professional, personal and environmental factors. From our findings, we discovered that staff shortage was indeed an underlying factor that posed a great deal of threat on nursing staff. Specifically, working short-staffed adds demand on the employee and increases the risk of not exercising all safety precautions, leading to musculoskeletal pain, which could be further exacerbated if the employee had a history of such complaints. Additionally, working short-staffed might lead employees to work longer or irregular shifts, increasing levels of fatigue, and thereby, increasing the risk of accidents in the workplace and limiting the resting period after work. Given the negative implications of working short-staffed, employees feel guilty, and thus, go to work while sick, increasing the risk of exposure to airway infections. Lastly, some staff members expressed distress even when not working, as from their experience, they might be called to work due to staff shortage.
Staff shortage has been found to be an area of concern in Canada and across the globe [20–23]. Specifically, increased sickness absenteeism due to a wide range of organizational, physical, and emotional reasons causes staff shortage, which leads to additional working demands, and further sick leaves and poor job retention. This cyclical paradigm affects service provision and has adverse fiscal implications on the healthcare system [7, 24].
Vis-à-vis organizational factors, exposure to infectious diseases was found to be an area of concern with other factors also contributing such as patients refusing to follow hospital policy or staff members arriving at work sick motivated to prevent their team from working short-staffed. Although this study was conducted well before the COVID-19 pandemic, concerns related to exposures to infectious diseases were already highlighted by staff. Exposure to contaminations is indeed a serious threat to the health of frontline workers. As an example, in Ontario, approximately 1 in 6 COVID-19 cases were frontline healthcare workers with several outbreaks in hospitals and long-term care facilities [25]. Nevertheless, healthcare workers have risen to the challenge, playing a vital role in maintaining public health and safety, and responding to calls, in the face of the COVID-19 health crisis. However, the impact of the pandemic on their mental health including but not limited to their psychosocial work environment (e.g., work stress, job satisfaction and work demands) and their means of coping remains unknown. Prolonged exposure to deleterious mental health outcomes are associated with negative physical and mental health outcomes [26–30]. These are significant to healthcare organizations because of their correlations to worker retention, turnover, patient satisfaction, and patient safety. The expected outcomes of this current research study could help inform strategies to effectively manage stress and to manage mental health needs of registered nurses and registered practical nurses through data-driven findings. Healthcare organizations may utilize the findings to develop policies for pandemic planning, programs, services and practices designed specifically for a public health crisis such as the COVID-19 pandemic.
Results from the FG sessions also described that shiftwork is strongly connected to sickness absence. This is consistent with results from our systematic review [6, 7]. However, participants in this study were able to offer more explanations about why shiftwork can be hazardous. Working nightshift or rotating shifts was described to be unhealthy primarily as a result of poor sleep and self-care. This is consistent with the literature, where an observational study found that newly hired nurses working nightshift or overtime where at greater risk of self-injuries such as needle stick injuries [31]. Furthermore, participants described that poor sleep leaves insufficient time to heal from aches and pains, which then predisposes a worker to MSD. Evidence suggests that poor quality or quantity of sleep increase the odds of developing MSD, including back, neck, and shoulder pain [32, 33]. Thus, nurses and PSWs are at greater risk of developing MSD not only due to repetitive movements such as lifting patients, but also due to poor sleeping habits.
Aside from working nightshifts or rotating shifts, poor sleep is an outcome of working short-staffed, where staff members have to work overtime to compensate for missing members. It was also reported that nurses and PSWs are distressed following their shift out of fear or anticipation of being called back to work as a result of staff shortages. As such, this further explains why some employees feel guilty not attending their shift when they are sick and thus, might work while feeling unwell. This issue might have even greater implications in northeastern Ontario, where there are limited connected healthcare facilities to pool a larger nursing alternate list compared to southern Ontario.
Safety climate and a supportive work environment were found to be critical in terms of sickness absenteeism. Participants stressed that there is a certain degree of acceptance that patient violence and harassment are “a part of the job”. Ineffective or unavailable debriefing related to patient violence was reported by key informants, nurses and PSW to contribute to both work-related and personal burnout of nursing staff. This is concerning since burnout has been found to increase the odds of sickness absence in nursing staff [34]. This matter is worsened when there is lack of support in the workplace by way of proper debriefing after certain incidents from staff leaders. Consistent with our findings, a study examining leadership and sickness absence determined that leadership styles that were mostly task-oriented, whether the work demands were high or low, increased the odds of sickness absence [35]. Alternatively, having strong relationships with staff, irrespective of the work demand, decreased the odds of sickness absence. This is particularly important in settings where nurses report higher levels of compassion fatigue and guilt such as working in pediatric units or hospices.
Nursing staff working in northeastern Ontario, particularly the City of Greater Sudbury might be at an extra disadvantage during winter months due to poor weather and road conditions. PSWs providing home care services were viewed to be at higher risk during winter. This is due to how essential their services are for patients who are unable to complete self-care duties. This issue has great implications to northeastern Ontario given its demographics. Specifically, northeastern Ontario’s seniors (65+) population is expected to increase from 18% to 30% by 2036 [16]. Collectively, the estimated number of seniors is expected to increase by 42% therefore the demand for the services of PSWs will surely escalate.
Limitations
This study has some limitations that require consideration. Firstly, given the methodological approach used in this study, it may pose challenge on the findings’ transferability. While we suspect that other northern regions may be facing similar challenges, we would like to offer some caution when considering these results for other regions. This is particularly the case, as there is limited recent research addressing the disparities in service provision of nurses and PSWs in northern communities as well as the way “northern” is being operationalized. Secondly, while the use of thematic analysis may offer a clear and direct approach to investigate certain research questions, it could be subject to biases [36]. For this reason, coding was reviewed by a second author and participants were given the option to review the transcript prior to interpretation. Moreover, some informants could not attend our focus groups (e.g., occupational health and safety specialist). As such, their valuable perspective could not be included in this study. Those participants who did not take part in the FG may have particular characteristics and perspectives that we could not identify. Our work explored intimate topics that are difficult to discuss and disclose. Therefore, the quality of our analyzes was influenced by the quality of the data supplied by the participants and the rapport established with the moderator.
Recommendations
This study highlighted some of the challenges that nursing populations encounter that can lead to sickness absence. Nevertheless, researchers and policy makers need to consider a broader view of the risk factors associated with sickness absence rather than making efforts to pinpoint specific factors. For instance, results from this study revealed that staff shortage is an underlying factor to several physical and emotional issues causing sickness absence. While healthcare organizations are not often well funded to provide a full team of nursing staff, recommending the hiring of more staff members is likely unrealistic. However, researchers, employers, and policy makers should consider the costs involved to hire more staff members in comparison to the costs associated with disability claims due to staff shortage. Hiring more staff that work slightly less hours could also remedy sickness absence attributed to staff shortage. Perhaps, longitudinal studies should examine the difference between working shorter hours, staff incentives etc. While recruitment might be fiscally challenging, it could reduce sick leave costs that have been shown to be on the rise in Canada [24].
Our findings also underscore the importance of positive relationships between nursing staff and their leadership team. This can be done through scheduled meetings focusing on employee relations and team-building. Through a good relationship, leaders can better assess the health and performance of their staff, and potentially recognize and prevent antecedents of sickness absence. Additionally, it allows for better debriefing when difficult situations occur. Evidence from the literature suggests that due to the fast-paced environment in the healthcare field, debriefing is not commonly exercised [37]. However, Nocera and Meritt (2017) explained that debriefing has several benefits, which include reviewing the team’s performance, education, identification of what went wrong and how it could have been prevented, if possible, and better planning for future events [38]. We also recommend that in light of the COVID-19 pandemic, employers should check in more frequently with their team, as it is expected that employees may be experiencing additional personal and work-related stressors.
This study allowed for nursing staff and key informants to offer their input on workplace matters, specifically sickness absence. While this study offered insightful information on the factors associated with sickness absence and how they may evolve, it is felt that this is merely a steppingstone in finding means to keep nurses and PSWs healthy and able to return to work. In context, further discussions with nursing personnel and key informants along with policymakers should take place to collaboratively find practical solutions to minimize the risks associated with sickness absence.
Conclusion
Results from this study suggest that factors associated with sickness absence are multifactorial, interconnected, and difficult to manage. Our findings have been consistent with the literature concerning the factors related to sickness absence, which include challenges with organizational structure, the job’s impact on one’s physical health, specifically with the development of musculoskeletal disorders, the emotional toll on one’s mental well-being, and challenges that were described as unique to northern regions. Underlying reasons why such factors may lead to sickness absence were also revealed through participants’ work experiences. For instance, staff shortages were found to be a root cause of many upstream risk factors for sickness absenteeism. Work support and timelier debriefs, among other recommendations, could help reduce sickness absence especially as they navigate through the COVID-19 pandemic.
Conflict of interest
None to report.
Footnotes
Acknowledgments
The authors would like to thank Mr. Justin Desroches for his work in transcribing audio data into text form.