Journal of Nursing Management, 2015, 23, 623–631
Factors influencing nurse absenteeism in a general hospital in Durban, South Africa P. MUDALY
Hons Nurs Ed, MCUR, BCUR
and Z. Z. NKOSI
PhD, MCUR, BCUR
Academic Development Officer, School of Nursing, University of KwaZulu-Natal, Howard College Campus, Durban, and 2Associate Professor, Department of Health Studies, University of South Africa, Theo van Wyk Building, Pretoria, South Africa
Correspondence P. Mudaly School of Nursing University of KwaZulu-Natal Howard College Campus Durban 4001 South Africa E-mail: [email protected]
(2015) Journal of Nursing Management 23, 623–631. Factors influencing nurse absenteeism in a general hospital in Durban, South Africa
MUDALY P. & NKOSI Z.Z.
Aim To establish reasons for absenteeism amongst professional nurses, enrolled nurses and enrolled nurse auxiliaries in a general hospital in Durban, in order to recommend strategies that could decrease absenteeism. Background Nurses endure increased workload, resulting in burnout and absenteeism in workplace environments that already suffer staff shortages. Method This study was a quantitative, non-experimental survey. The study population consisted of 60 nurses, including professional and enrolled nurses and enrolled nurse auxiliaries. The survey consisted of closed-ended questions to options of ‘agree’ and ‘disagree’ and an open-ended section. Result Family matters, lack of motivation to attend work, illness, finance, favouritism, unfriendly nurse managers, long work hours, increased workload, unsatisfactory work conditions, lack of equipment, unfair promotions and selection of nurses for training, staff shortages, lack of a reward system and incoherent decision-making caused nurse absenteeism. Conclusion Personal, professional and organisational factors may cause nurse absenteeism, crippling the health sector further against the backdrop of human and mechanical resource shortage. Implications for nursing management Nurse managers have an important role in reducing absenteeism by addressing the employees’ concerns, which can lead to productivity, increased staff morale, decreased medical hazards and satisfied patients. Keywords: absenteeism, nurse, nurse manager, organisation, work environment Accepted for publication: 6 September 2013
Introduction Absenteeism, as defined by Martocchio and Jimeno (2003), is a single day of missed work. Josias (2005) defines absenteeism as a failure of an employee to report to work, despite the reason. Globally, absenteeism is a serious occurrence. Workplace data records in Britain in 2006 highlighted that 420 000 employees were absent from work due to stress, depression and anxiety due to work, which has a rebounding effect DOI: 10.1111/jonm.12189 ª 2013 John Wiley & Sons Ltd
on the employer, organisation and society being served by absent employees (Cooper & Dewe 2008). As a result, sessional staff are needed and they need to be retrained, educated and skilled for the temporary work to be done to reduce turnover and increase productivity, which is a doubly costly exercise to employers (Cooper & Dewe 2008). In South Africa, investigations were led by The Commission of Enquiry (2005) at a provincial psychiatric hospital in response to allegations of abuse of 623
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human rights of psychiatric patients. The findings revealed that there were high rates of absenteeism amongst staff at the hospital, especially on paydays on the 15th and 30th of each month. Staff were also absent from work due to abuse of alcohol and poor working conditions (The Commission of Enquiry 2005).
Problem statement Booyens (1998) states that absenteeism is disruptive to patient care and the work environment. Absenteeism of nurses entails patients being cared for by fewer qualified caregivers, which compromises effective care and treatment delivery (Booyens 1998). Health Canada (2004) highlights that the absenteeism rate of registered nurses (RNs) in Canada is steadily increasing. Full-time employed RNs had absenteeism rates due to illness and injury which was 83% higher than other full-time employees for the year 2002. Canada faces severe nurse shortages, causing existing nurses to have an increased workload coupled with increased work hours. All nurses, full- or part-time, suffered high rates of strain due to increased work responsibilities, leading to absenteeism. In South Africa, Takaki et al. (2006) stated that nurse absenteeism is a widespread phenomenon. Causal factors for staff absenteeism could be attributed to increased workloads, worsened due to hospitals being inundated with patients infected with HIV/AIDS-related illnesses. The purpose of this study was to establish reasons for nurse absenteeism amongst the nurse categories of professional nurses (PNs), enrolled nurses (ENs) and enrolled nurse auxiliaries (ENAs) from day and night duty in medical, surgical, maternity and trauma units of a hospital. Conducting this study was an inherent interest towards studying reasons for absence behaviour amongst nurses. This study was conducted in a general hospital located in Chatsworth in the city of the eThekwini City District, South Africa, which primarily serves the population of Chatsworth and the surrounding area (R.K. Khan Hospital 2012). The hospital is a regional and district hospital with 543 beds. At the outset of the study, the researcher was informed by the nurse managers and staff that there was a high absenteeism rate of nurses coupled with severe staff shortages. A report published by Govender (2009) emphasised the problem of nurse absenteeism, highlighting that the general hospital is a busy and a short-staffed one; the report also mentioned that there was already a need for staff, with 128 vacant posts 624
for specialists, 91 for professional nurses, 20 for medical specialists and 17 for pharmacists.
Conceptual framework The conceptual framework of Taunton et al. (1995), adapted by Nyathi (2005), underpinned this study. The independent variables of the nurse, nurse manager, work and organisation, the variables-associated characteristics and dependent variables of nurse absenteeism, guided this study. Nurse characteristics consist of: age and gender of nurses, qualifications, health status, family responsibility, transport problems, work commitment, opportunities outside the workplace and income. With regard to age, Josias (2005) states that younger employees take shorter periods of sick leave than older employees. Alternatively, older workers are more prone to sickness absence than younger workers, possibly due to health deterioration and prolonged periods of recovery. With regard to gender, women display increased rates of absenteeism compared with men, due to being the primary caregiver in most homesteads (Josias 2005). Cullinan (2006) explains that nurses are stressed at work as others are absent from work to ‘moonlight’ for extra income, supplementing their smaller salaries. The nurses remaining at work are burnt out due to the increased workloads. Nurse manager characteristics consist of the leadership styles of the nurse manager. Hayes et al. (2006) claimed that nurse managers’ use of position, power and influence over work coordination had a direct link to employees’ satisfaction in their jobs. Work characteristics consist of autonomy, routine work and group cohesion. Ose (2004) states that if there is work group cohesion in an environment, there is low absenteeism due to high job satisfaction. Regarding performing a job task, Becker and de Oliveira (2008) state that nursing professionals face long working hours and do multiple job functions, which is also intensive and at times physically challenging, subjecting the nurse to accidents and illness, leading to absenteeism. Organisational characteristics consist of facilities, manpower, career development, absence policy, promotion opportunities, incentives and decentralisation. Academic Writing Tips (2012) states that absenteeism from work indicates work dissatisfaction; job satisfaction is how happy or content the individual is with his or her job. Nyathi (2005) highlights that lack of recognition towards employees in terms of promotional opportunities in the workplace can lead to dissatisfaction among employees, also possibly leading to absenteeism. ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 623–631
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Methods Research design This study was a quantitative, non-experimental design. Cooper and Schindler (2006) assert that a quantitative design allows the researcher to use techniques that measure precisely the variable under study. Participants completed a survey questionnaire. According to Brink et al. (2000), a questionnaire allows participants to describe accurately the characteristics of a particular subject so that data collection and information gathering can be elicited.
Research methods These included collecting data by a survey questionnaire that consisted of closed and open-ended questions and were handed to the participants for completion. The questionnaire consisted of six sections: A, biographic data – age and professional details of the participant; B, C, D and E covered separate aspects of the independent variables and their associated characteristics, these being the nurse (seven questions), nurse manager (seven questions), work (eight questions) and organisation (nine questions), totalling 31 closed-ended questions, with options of ‘agree’ and ‘disagree’; F consisted of four open-ended questions about nurse, nurse manager, work and organisation characteristics, aimed to derive additional reasons for absenteeism.
Sample frame There were 233 professional nurses (PNs); 142 enrolled nurses (ENs) and 121 enrolled auxillary nurses (ENAs) employed at the hospital. The researcher was unfortunate in that data was collected during massive strike action in the province and a second data collection phase was done, as the initial data collection produced only few respondents. Hence, the study sample population included only 20 PNs, 20 ENs and 20 ENAs in the study; this constituted 10 PNs, 10 ENs and 10 ENAs on each of the day and night shifts. The sampling technique included stratified and convenience samples. Stratified sampling, according to Brink et al. (2000), is when the population is divided into subgroups according to some variable. The sample size for each category of nurse was chosen on the highest possible availability at the time and their consensus to take part in the study, contributing to the convenience sample. Due to the strike, not ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 623–631
many nurses were on duty, and in order to have a representative sample size, for reasons of nurse absenteeism the researcher sought 20 nurses/nurse category – this was also in aid of establishing uniformity amongst the sample population. In this study, the nurse categories of ENs, ENAs and PNs were stratified to unique nursing groups. Brink et al. (2000) further state that convenience sampling is the selection of the most readily available people or objects for a study.
Data collection This research study took place in a selected general hospital in Durban, KwaZulu-Natal. Data were collected by distributing the questionnaires to the research participants once they had signed to consent for participation in the study. Participants completed the questionnaires at a time convenient to them. The questionnaire was first distributed on 29 May 2007 to 30 nurses. Data were collected from five PNs, ENs and ENAs each on day and night duty. Due to poor response rates for the open-ended section, the questionnaire was resampled to four PNs, ENs and ENAs each on day and night duty on 14 June 2007. On 17 June 2007, one PN, EN and ENA each on day and night duty were approached to complete the questionnaire. Altogether, 60 nurses were approached to complete the questionnaire for the study. The researcher manually sorted the questionnaires into separate piles of PNs, ENs and ENAs, including night and day duty staff. Each questionnaire was numbered as Participant 1, Participant 2, etc. per nurse category until all 60 participants were accounted for. The collected data were arranged into separate piles for PNs, ENs and ENAs and specifically further into participants from day and night duty.
Data analysis Closed-ended data analysis The researcher utilized quantitative methods of the exact binomial test of significance with P = 5% for the closed-ended data. This was to establish a relationship between nursing absenteeism and each factor of the closed-ended questions, statistically and accurately. Bain and Engelhardt (1992) explain that the exact binomial test is an appropriate test for analysing the dichotomous response variable, which is whether an individual agrees or disagrees with the question. The exact binomial test of significance was performed for each question under each factor to determine whether there was, according to the test itself, a 625
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significantly high proportion of ‘agrees’ for that particular factor, in which case that factor could be considered as a cause of nursing absenteeism. Open-ended data analysis The qualitative software package Nvivo v. 9 was used to perform content analysis, code and analyse qualitative data of the open-ended survey by the researcher University of Technology, Sydney (2012). Content analysis of the data entails little interpretation but attributes a class of phenomena to a portion of the text. In this study, key words were identified and an overall concept was formulated symbolizing a cause for absenteeism. The codes were represented in a tabulated format under a specific theme, which allowed for frequency distribution and simple descriptive statistics counts. Newly founded codes outside the coding source-coding scheme were also listed in tabulated form. Comparisons concerning the relative frequency of scores falling into specific coded categories were done and highlighted the number of participants agreed on a code (Brink et al. 2000).
Results For purposes towards understanding the commonality of reasons for nurse absenteeism, the results in the closed and open-ended section only highlight which factors caused nurse absenteeism agreed by PNs, ENs and ENs indicating statistical significance towards nurse absenteeism. Additionally, responses by participants which were 75% and above are considered statistically significant towards nurse absenteeism for the closed-ended results.
Closed-ended and open-ended results Results for the closed-ended section are presented as commonly agreed-upon reasons for nurse absenteeism amongst PNs, ENs and ENAs of the nurse, nurse manager, work and organisation characteristic questions. Results for the open-ended section are highlighted in terms of nurse, nurse manager, work and organisation characteristics which were commonly agreed by ENs, ENAs and PNs. A select few responses by participants are indicated by each professional nurse category. Responses by participants who had more than one theme are highlighted. The percentages were calculated against the total number of participants who answered under a specific open-ended question. For example, 13 participants answered the nurse manager open-ended question. 626
Combining the closed and open-ended results indicates the following reasons for nurse absenteeism. Nurse characteristics Nurses have family responsibilities to attend to. Fifteen ENs (72%), 19 ENAs (95%) and 16 PNs (80%) agreed that this factor causes nurse absenteeism. Josias (2005) indicates absenteeism due to personal or family-related issues where child, eldercare and single-parent families have a profound impact on organisational absenteeism. Nurses lack motivation to work due to stress. Fifteen ENs (72%), 15 ENAs (72%) and 20 PNs (100%) agreed that this factor causes nurse absenteeism. Bakker et al. (2005) state that a job where there is a high job demand and low resources results in burnout, due to exhaustion, and absenteeism. Nurses have financial problems. Three ENs (25%), three PNs (20%) and three ENAs (25%) agreed that this theme causes nurse absenteeism. Excerpts by participants include one EN having stated that: ‘Nurses are moonlighting and therefore they cannot work in the hospital that they are registered to’, whilst one ENA stated that there is ‘Unsatisfying salary given to nurses’ and, similarly, one PN stated that: ‘Nurses are suffering from burnout due to the increase in turnover of patients. Other staff members are moonlighting while their colleagues have to double up their workload’. Davey et al. (2009) state that less pay is a definitive determinant leading to absenteeism. Nurse manager characteristics Nurse managers are unfriendly. Three ENs (23%), two PNs (17%) and two ENAs (20%) agreed that this theme causes nurse absenteeism. An excerpts from one EN stated that: ‘Some of them are unfriendly and nurses feel out of place’, while one ENA stated that: ‘Approaching nurses is important should a nurse be wrong in certain action. Treat all fairly, don’t pick and choose’, ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 623–631
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while one PN stated that: ‘Some nurse managers are unapproachable and not empathetic enough to their staff’. Favouritism. Three ENs (23%), three ENAs (30%) and three PNs (25%) stated that favouritism causes nurse absenteeism. Excerpts by participants include one EN stating that the nurse managers ‘… pick and choose, they are racists. They can make you feel pressure on you because they pick and choose’. One ENA stated that: ‘Approaching nurses is important should a nurse be wrong in certain action. Treat all fairly. Don’t pick and choose’, while one PN stated: ‘Favouritism – gang up with colleagues – showing favouritism with colleagues for extra breaks’.
‘Heavy work load because of short staff, resulting that after doing your work on your ward, you also have to cover another ward in one day’. Furthermore, one PN responded there are: ‘Too few staff for large number of patients, unable to cope with work load’. Becker and de Oliveira (2008) state that organisation-related absenteeism occurs due to poor supervision, task monotony, lack of motivation, poor environmental and working conditions and a nonautonomous environment for the employee in the organisation. Shortage of staff. Five ENs (40%), four ENAs (25%) and two PNs (17%) agreed that this theme causes nurse absenteeism. Excerpts from participants include one EN stating that there is: ‘Too much work and less staff’. Similarly, one ENA stated that there is an: ‘Overload of work and shortage of staff’,
Hayes et al. (2006) claimed that nurse managers’ use of position, power and influence over work coordination had a direct link to employees’ job satisfaction and absenteeism. Work characteristics Nurses are overworked on a ward. All ENs (100%), 20 ENAs (85%) and 19 PNs (95%) agreed that this factor causes nurse absenteeism. According to Dale (2006), reports from Canada highlight that nurses have the highest absenteeism rates of all health care professionals due to work pressure and stress, leading to missing working days due to illness and injury. Dale (2006) emphasises that recruiting nurses in place of the absent staff leads to the newly recruited nurses being overburdened by work duties due to a short-staffed workforce, causing fatigue and absenteeism. An increase of workload. Six ENs (50%), two PNs (17%) and four ENAs (40%) agreed that this theme causes nurse absenteeism. Excerpts by participants include one EN stating: ‘Shortage of staff, this causes overload of work which exhausts nurses’. In addition, one ENA also stated there is a ª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 623–631
whereas one PN emphasised that there are: ‘Too few staff for large number of patients which makes us unable to cope with workload’. Unruh and Strickland (2007) emphasise that absenteeism from the workplace contributes to an ongoing negative effect of causing increased absenteeism by other exhausted employees. No equipment. Two ENs (17%), four ENAs (17%) and two PNs (17%) stated that there is a: ‘Lack of resources, gloves, aprons, daily towels open to infection due to lack of resources’. Excerpts include one EN stating that there is a: ‘Poor working environment, lack of skilled workers and lack of equipment’. Stressing the same, one ENA stated that: ‘Sometimes there is not enough equipment to do their work’. Similarly one PN stated that there is a: 627
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‘Shortage of equipment’. Hobfoll (2001) states that burnout and absenteeism are related to insufficient resources. Becker and de Oliveira (2008) state that absenteeism is related to the work conditions, reflecting on quality and productivity and on the personal life of the nursing professional. In this regard, hospitals provide their employees with work conditions that are far worse than other healthcare services. Becker and de Oliveira (2008) highlight previous studies on absenteeism in hospitals, where a lack of resources (human and equipment) leads to individual physical and emotional stress, leading to absenteeism. Organisation characteristics Organisation is short-staffed and there is an increased workload for nurses. Nineteen ENs (95%), 19 ENAs (95%) and 20 PNs (100%) agreed that this factor causes nurse absenteeism. In the South African context, Cullinan (2006) states that hospitals in KwaZulu-Natal face a huge strain because of the HIV/AIDS epidemic, with very sick people needing specialised treatment and care. Cullinan (2006) further emphasises that an already short-staffed environment means that existing nurses face huge workloads, resulting in tremendous stress, leading to absenteeism. The organisation has no equipment to provide quality patient care. Seventeen ENs (85%), 15 ENAs (75%) and 18 PNs (90%) agreed that this factor causes nurse absenteeism. The organisation has no reward system for nurses. Seventeen ENs (85%), 17 ENAs (85%) and 18 PNs (90%) agreed that this factor causes nurse absenteeism. Nyathi (2005) highlights that a lack of recognition towards employees in terms of promotional opportunities in the workplace can lead to dissatisfaction and possibly absenteeism among employees. Similarly, Takaki et al. (2006) state that when employees perceive that the effort they make to perform their jobs gets little reward, this leads to emotional distress and absenteeism.
this study provided written consent on a consent form, once the research had been explained to them verbally and via an information sheet by the researcher. The study information sheet and consent form were available in isiZulu and English for participants. Participants had a right not to divulge personal details, such as their name and to remain anonymous, which is further supported by Bislimi et al. (2009). Furthermore, in undertaking research, the participant’s well-being must be ensured by avoiding harm and also maximising the possible benefits (Bislimi et al. 2009). Participants in this study were not harmed, neither was any experimentation on their emotional and physical wellbeing done.
Reliability and validity in the research study Validity is the degree to which an instrument measures what it is intended to measure (Phelan & Wren 2005–2006). Content validity was ensured by the instrument representing all the different components of the variables to be measured as debated in the literature review, according to Brink et al. (2000). The questionnaire of this study was guided by the conceptual framework of Taunton et al. (1995), encompassing all the independent variables from the nurse, nurse manager, work and organisation factors as possible causal factors of nurse absenteeism. The questionnaire was also tested for reliability and, specifically, for internal consistency. The guideline of 0.70 was followed as the cut-off point for acceptable Cronbach alpha coefficients by the research. The reliability of the questionnaire was achieved by conducting a pilot study. Prior to the study, the researcher distributed 10 questionnaires with a marking scheme to the pilot study participants. Five questionnaires were given to nurse professionals who were studying at the selected university and five lecturers at the university where the researcher was studying. All participants agreed that the questions met the objectives of understanding, ability, neatness, relevance, sensitivity, satisfaction and length.
Permission to conduct the study was granted by the ethics committee at the selected University (at which the researcher studied towards the Master’s degree), the Department of Health and the selected general hospital in Durban, KwaZulu-Natal. Participants in
New-found reasons from the open-ended data analysis revealed reasons for nurse absenteeism, which were listed as associated characteristics according to the conceptual framework of Taunton et al. (1995). Common findings amongst the closed and open-ended sec-
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tions from multiple groups of PNs, ENs and ENAs formed the basis of highlighting the results for this paper. Findings in the nurse characteristics section highlighted that nurses were absent due to family responsibilities, lacked motivation as they felt tired and stressed, and inadequate remuneration. With regard to the nurses who stated that being tired and stressed led to absenteeism, Eriksen et al. (2002) state that work factors such as job stress, psychological stress, job strain and physical workload are associated with high rates of sickness absenteeism. Similarly, Savery and Luks (2001) agree that stress manifests in the form of low morale, high turnover of employees and absenteeism. In addition, Bennett (2002) states that additional job demands, difficult work environment, and poor social relationships between management and employees coupled with low morale contributed to employees’ stress, directly or indirectly contributing to a high level of absenteeism. Equally as stressful to nurses is inadequate remuneration for work done. Findings from the nurse manager characteristics data indicated that unfriendly nurse managers and favouritism caused absenteeism. Munro (2007) found that under-trained and less experienced supervisors cause stress to employees, resulting in absenteeism. In this regard the stress incurred due to the supervisor is due to performing monotonous work as allocated, low job satisfaction and unfair treatment by the supervisor. Munro (2007) deemed poor leadership as the root cause for job dissatisfaction, leading to stress and absenteeism. Work characteristics results highlighted staff agreeing that they are moved to a new ward every day to cover staff shortages, overworked on a ward, work long hours, face unsatisfactory work conditions and have insufficient equipment to do work, causing nurse absenteeism. Sekhukhune (2005) also states that nurses’ stressors are due to the work environment. There was not enough suitable equipment to deal with patient needs, frustrating nurses as they still had to do patient care with or without equipment. As a result, nurses felt stressed and were absent from work, owing to sickness or frustration. Priest (2006) reiterated that nursing as a profession is faced with a serious understaffing crisis. Nurses are therefore forced to cope with inadequate support from management and the situation at work is worsened, causing absenteeism. In addition to job strain are the long work hours. Chauke (2007) found that an organisational contributor to absence from work was the long shifts. Basu and Gupta (2007) also state that poor working condiª 2013 John Wiley & Sons Ltd Journal of Nursing Management, 2015, 23, 623–631
tions affect staff shortages, as remaining staff burnout further and absent themselves from work. Organisation characteristics results due to nurse absenteeism included that unfair promotions, unfair selection of nurses for training, short-staffed workforce causing a heavy workload for nurses, no equipment to carry out work, no reward system and incoherent decision-making practices for nurses were also reasons to absenteeism. Dieleman and Harnmeijer (2006) highlight that continuous career development, an applicable reward system, satisfactory working conditions, teamwork and management support results in reduced employee absenteeism as job satisfaction and motivation of staff are enhanced. Reward systems also include non-monetary elements, such as appreciation and recognition, as Dieleman and Harnmeijer (2006) highlight. Becker and de Oliveira (2008) state that in a hospital work environment, nurses are susceptible to inappropriate work conditions, affecting their psychological and physical well-being. Work tasks may include long working hours, physical and mental work that may be unbearable, poor interpersonal relations, pressurising time schedules and absence of a career ascension plan for the individual.
Limitations of the study The response rate of the first group of research participants was poor due to the national strike at the time, which also affected all public health care workers. During this time, there was an additional staff shortage and nurses could not afford the time to complete the questionnaires. As a result, a second group of nurses was resampled. It is suggestive that if further studies are done in a hospital setting, the researcher should approach study participants at a time equally conducive to both the researcher and research participant. Study participants, as assumed, will not scuttle through the questionnaire without giving due consideration to their responses, if an appropriate time decided by themselves is chosen. Factors such as strikes, violence and unrest are all limitations in a study and can affect the response rate by study participants and the quality of data produced.
Recommendations The findings suggested that recording absenteeism of each employee throughout the year assists in monitoring absenteeism. This includes recording the duration and reason for an employee’s absenteeism. An organi629
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sation needs to produce policies to address the underlying causes of absenteeism. With regard to findings of lack of recognition and rewards, a career ladder for demonstration of competency, professional recognition and introduction of monetary incentives should be introduced in the hospital. Rewards could be in the form of training programmes or monetary incentives.
Conclusion and implications for nursing management The inclusion of open-ended questions allowing participants to freely express what they thought could have also caused absenteeism. This new information is very useful in understanding the factors of absenteeism which may have missed as questions on the closedended survey questionnaire. A few recommendations have been provided, so that management could apply some of these techniques to reduce absenteeism. Essentially, what can be deduced is that most causes of absenteeism arise from the nature of the organisation. A person working in a better working environment is more likely not to absent him- or herself from work than a person working in a physically exhausting and psychologically depressing environment. Nurse managers employed in the hospital can play an important role in reducing absenteeism by addressing all the factors that were identified by the nurses.
Source of funding The authors did not receive any funding for this paper.
Ethical approval Ethical approval was obtained from UKZN EXPO 18/06.
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