The problem and management of sickness absence in the NHS: considerations for nurse managers

The problem and management of sickness absence in the NHS:considerations for nurse managers

C.J. JOHNSON R G N , B S C ( H O N S ) , M S C1, EMMA CROGHAN R G N , R S C N , B A ( H O N S ) , M P H

2 and JOANNECRAWFORD P H D , M S C ( E N G ) , B S C ( H O N S ) , M E N G S

3

1Research Nurse, Institute of Occupational Health, 2Research Fellow, Department of Public Health andEpidemiology and 3Lecturer, Institute of Occupational Health, The University of Birmingham, Edgbaston,Birmingham, UK

Introduction

Sickness absence has attracted attention in response to

competitive pressures and tightening labour markets; by

managing their absence, organizations can achieve a

competitive edge (Grundemann & Vuuren 1997).

Sickness absence levels are financially significant and

subsequently those (Government, managers, taxpayers,

etc.) who pay the economic burden of these costs want

to reduce them. Absence and ill-health retirement rates

for public sector employees have been higher than for

employees in the private sectors (Confederation of

British Industry (CBI) 2001, Dibben et al. 2001, HM

Treasury 2001). Paradoxically, healthcare workers have

the highest rate of �sickness presence� (contrary to

sickness absence) compared with other industrial sec-

Correspondence

C.J. Johnson

Research Nurse

Institute of Occupational Health

The University of Birmingham

Edgbaston

Birmingham

B15 2TT

UK

E-mail: [email protected]

J O H N S O N C . J . , C R O G H A N E . & C R A W F O R D J . (2003) Journal of Nursing Management 11,

336–342

The problem and management of sickness absence in the NHS: considerationsfor nurse managers

Aim This paper examines the topic of sickness absence management in the contextof the healthcare sector.

Background National Health Service (NHS) employee absenteeism is an

expensive and difficult problem. Nurse managers need to assess the extent and

characteristics of absenteeism, be aware of their organization’s sickness policies,

evaluate the effectiveness of these policies and contribute to the development of

related initiatives to ensure prudent management of sickness absence.

Method A literature review has been undertaken, providing a broad

conceptual context by which the problem of sickness absence in the NHS can be

examined. The focus of this paper is to examine the accumulation of research based

knowledge to provide a healthcare perspective on the problem of sickness absence

management.

Conclusion Sickness absence management within the NHS is challenging but

provides opportunities to improve the working lives of NHS employees. Sickness

absence cannot be eradicated but it can be reduced by a selection of measures that

reflect the uniqueness of the NHS. The many and diverse causes of sickness absence

need acknowledgement, when devising strategies that can effectively provide solu-

tions to the problems of sickness absence.

Keywords: management of sickness absence, NHS, sickness absence

Accepted for publication: 7 March 2003

Journal of Nursing Management, 2003, 11, 336–342

336 ª 2003 Blackwell Publishing Ltd

tors, i.e. they would work even when they felt that they

were sick (Hasselhorn et al. 1999, Aronsson et al.

2000). There is no exact explanation for these differ-

ences, there are some research papers that suggests that

items such as lower job satisfaction, current sick pay

arrangements and less demanding performance stand-

ards might be the factors (Wooden 1990; Vandenheuvel

1994).

The National Health Service (NHS) is the largest

employer in Europe; nurses, midwives and health visi-

tors are the largest staff group in the NHS. The average

days lost, because of work-related illness, in the nursing

profession is one of the highest for any occupa-

tional group (Health & Safety Executive 1995).

The absenteeism of nurses is an important phenomen-

on; not only for the nurses themselves, but also because

of its adverse affect on health care work environments

(Landeweerd & Boumans 1994, Borda & Norma

1997). Absence attributed to sickness cannot be wholly

eradicated because of the inevitability of disease and ill

health. The management of attendance is important in

respect to not only its financial costs and service impact,

but also to the health and well-being of NHS employ-

ees. Action is required at all levels; commitment and

investment from government, leadership by the NHS

Executive, commitment from Trust Boards, NHS

managers, trade unions, involvement of employees,

guidance by occupational health (OH) professionals,

etc. The literature presents the benefits to the NHS for

improved health and attendance of its employees and

provides a useful resource for the management of NHS

sickness absence (Seccombe 1995, Buchan & Seccombe

1995, Williams et al. 1998, Health Education Authority

1997, Cabinet Office 1999, Department of Health

1999a, Health Education Authority 1999, Department

of Health 1999b, Department of Health 2001).

NHS sickness absence policies

A number of Department of Health policy documents

(Department of Health 1999a, Department of Health

2000, Department of Health Service Agreement (July

2000), Department of Health 2001, Department of

Health 2002) have responded to the necessity to provide

a modern framework for those managing the health

service and, need to facilitate improved conditions of

employment for those working in the NHS. The Cabinet

Office published Working Well Together: Managing

Attendance in the Public Sector, determining that public

sector organizations should reduce sickness absence

rates by 20% by 2001 and by 30% over the period to

2003. This document provides a menu of interventions

to reduce sickness absence, ranging from flexible

working hours to OH activities. A further directive to

adopt best practice in sickness absence management and

OH has been supported by the launch of the Health and

Safety Commission’s strategy documents, Revitalising

Health and Safety (2000a) and Securing Health

Together (Health and Safety Commission 2000b).

The Improving Working Lives (IWL) Standard

(Department of Health 2000) depicts that, health ser-

vices require modern employment practices and that,

staff work best when they are able to strike a healthy

balance between work and other aspects of their lives.

The standard accepted that staff should have access to a

range of policies and practices to enable them to achieve

a healthy work-life balance. There are difficulties in

successfully implementing IWL, such as achieving

equity for all staff and effectively communicating the

benefits of abstract concepts such as �improved morale�.One thing is for certain – IWL is not going to go away;

managers need to demonstrate how they are improving

the working lives of their staff.

The management of people is a key component of

modernization and improvement in the NHS plan

(Department of Health 2000, Secretary of State for

Health 1997). Current public perception is that the

NHS is a somewhat poor place to work (Bell 2000).

Making the NHS a good place to work and attracting

and retaining quality staff are key issues in delivery of

performance improvements. Working Together Secur-

ing a Quality Workforce for the NHS (Department of

Health 1998), part of The NHS Human Resources

Performance Framework, announced that a priority

area for action is to create healthy NHS workplaces;

targets were included to achieve year on year

improvement in sickness absence rates. The govern-

ment’s commitment in measuring NHS progress has

seen the inclusion of sickness absence rates as part of

annual national performance improvement targets.

Definitions

Sickness absence has been defined as, absence attributed

by the employee to illness or injury and accepted as such

by the employer (Searle 1997). The main reason for

absenteeism from work is ill health, although, ill health

does not always equate to incapability for work

(Grundemann & Vuuren 1997). The ability to work is

greatly influenced by a person’s own perception about

his/her capability or incapability and absence can be

viewed as a very personal decision based on both the

ability to attend and the motivation to attend (Kris-

tensen 1991). There is cynicism in regard to employee

Problem and management of sickness absence in the NHS

ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 336–342 337

absenteeism expressed commonly as �malingering�.There is difficulty in differentiating a case of ill health

from one of misconduct (Kloss 1998). The health belief

model (Rosenstock 1966, Becker 1974), which is a

theoretical construct of health related actions, is useful

in understanding employee sickness absence behav-

iours. The literature acknowledges the multi-causal

explanations of sickness absence and attendance ability

within an organization (Rhodes & Steers 1990, Evans

& Walters 2002).

The causes of sickness absence

Within the context of a modern society, the receipt of

sickness benefits, when work capacity is reduced by ill

health, is seen as a fundamental right (Alexanderson

1998). The design and practice of the sickness insurance

system and other forms of social insurance have been

found to have a major impact on sickness absence

(Taylor 1974, Hensing et al. 1995, Evans & Walters

2002). Absence policies purely aimed at controlling

absence have been found to actually cause higher ab-

sence levels by undermining employee commitment

(Evans & Walters 2002). It is rational to conceive that

employees make decision based on the cost and benefits

associated with sickness absence; policies to increase

attendance have included rewards for good attendance

(e.g. attendance bonuses) the evidence for their effect-

iveness is inconsistent (Gee 1999, Confederation of

British Industry (CBI) 2001).

Stresses and strains of modern working life in today’s

fast paced society, have been put forward as an

explanation for sickness absence. A paradox has

emerged, where improvements in the standards of living,

health care provision, and the working environment has

been associated with rising trends in medically certified

incapacity in the UK and several other developed

countries. This may reflect changing expectations of

society, for example, people would expect to be absent

when ill than to be ill at work.

It is vital to analyse comprehensively the character-

istics of an organization’s sickness absence problem;

failure results in policies and procedures insensitive to

the organization’s unique cultural features and exacer-

bate the problem. The most appropriate way to gain a

comprehensive insight into sickness absence is by using

a combination of quantitative and qualitative research

methodologies.

Long-term absence is most likely to be associated

with medical problems; short-term absence is likely to

be because of social and personal factors rather than

illness and is therefore more open to management

control (Searle 1997, Evans & Walters 2002). There is

no single explanation for absence; the cause may be

simple, or multiple, complex and inter-related. Causes

vary between different groups of employees in the same

organization, and fluctuate for the same employees over

their working life. Absence is a problem related to a

minority of employees, certain groups within a work-

force, for example, young people and women have been

found to be major contributors to absenteeism rates

(Pines et al. 1985, Kristensen 1991, Akerlind et al.

1996).

Studies on NHS employees have found that females

were more likely to experience sickness absence than

males (Ritchie et al. 1999, Sharp & Watt 1995, Pines

et al. 1985). Physical, psychosocial and organizational

factors are important determinants of incidence of

sickness, some of the associations are found to be sex

specific, for example, amongst women, bullying at the

workplace has been linked with a doubled risk of high

incidence of sickness (Voss et al. 2001). The reporting

of OH problems and symptoms, as well as illness and

injury rates vary by sex, primarily a result of social and

economic factors that affect women and men differ-

ently. There is evidence that the biological differences

between men and women contribute to them having

different OH experiences (Quinn et al. 2000). It is

inevitable that pressures emerge because of the multiple

roles of female homemaker, family caretaker, carer of

sick children, and wage earner. Such pressures are at

times exacerbated by inflexible work schedules and lack

of access to childcare.

The common finding of sex differences in sickness

absence is highly interrelated to custody of small chil-

dren (Akerlind et al. 1996), which introduces the issue

of a �double work hypothesis�. The large gender differ-

ences in the sickness absence literature are weakened

due to lack of adjustment for income and income-rela-

ted factors. Studies on sickness absence among women

should also contain information on the proportion of

sick-listed pregnant women, as a small proportion of

pregnant women may have a deep impact on the results

and conclusions among all women (Table 1).

The costs of sickness absence

In the UK, 177 million days were lost in 1994 (Table 2)

and this has been calculated at £11 billion (Grund-

emann & Vuuren 1997). The cost of sickness absence to

the British economy has been estimated as similar to the

total annual expenditure for the National Health Ser-

vices (NHS) (Taylor 1974). Such cost estimates have

pressurized the government to set targets to reduce

C.J. Johnson et al.

338 ª 2003 Blackwell Publishing Ltd, Journal of Nursing Management, 11, 336–342

sickness absence in the public sector. It is estimated that

sickness among nurses in England costs £90.5 million

per year and £714 million per year when all NHS costs

are considered (Williams et al. 1998). Nurse’s with-

drawal behaviours (turnover and absenteeism) are

costly, destabilizing in terms of patient care and

undermine employee morale (Cavanagh 1989). If the

NHS could cut down sickness by only one percentage

point, or about two and a half days per staff member

per year, it could save itself over £140 million a year or

the equivalent of 1% of pay (Williams et al. 1998).

The NHS and sickness absence

The NHS context regarding sickness absence is unique;

its sickness absence rates are higher than other indus-

trial sectors, and healthcare requires the need for

employees to be away from work when ill, to protect

patients. The healthcare industry is highly labour

intensive; hence the considerable negative impact of

high sickness absence levels (Wright 1997). From an

OH and safety perspective, healthcare work constructs

diverse physical, psychological and social health haz-

ards; the responsibility for people’s lives, dealing with

distressing illness and death, shiftwork, violence, bul-

lying, uncontrolled exposure to chemical, physical and

biological hazards, and constant organizational change.

Current NHS management strategies, today’s political

agenda, issues of finances and the crisis of nurse short-

ages, elevate the importance of sickness absenteeism

amongst nurses. Although, concern about sickness

absence within the NHS is reflected in the current

literature, quality data on the full incidence, patterns

and impact of NHS sickness absence is not available.

NHS occupational health services

Healthcare settings are dangerous workplaces (Hassel-

horn et al. 1999), the OH provision for the NHS and

Table 1Factors causing and contributing to sickness absence

Geographical Organizational Individual Pressures to attend work

Climate/weather Nature Age Economic conditionsRegion Size Sex Incentive/reward systemEthnic origin Industrial relations Occupation Work groups normsSocial insurance Personnel policy Personality Personal work ethicHealth services Sick pay Life crises Organizational commitmentEpidemics Management quality Job satisfaction Job role and responsibilitiesUnemployment rate Leadership style Medical condition,

illness, accidentsSocial attitudes Working conditions Family responsibilitiesPension age Environmental hazards Alcohol/drugs

OH service provision Social activitiesLabour turnover Length of serviceShift work Personal work ethicWork group dynamics, norms Past absence patternsWorking conditions Job expectationsIncentive and rewardsystems (including overtime)

Journey to work, distance ofwork from home, difficulty ingetting to work – transport

Co-worker relationships EducationOpportunity for advancement Values and expectationsThe level of workplace morale Hobbies

Table 2The costs of employee absence

Direct costsSick pay inclusive of the continued payment of employmentbenefits (e.g. annual leave, pension, insurance)OvertimeCosts of overstaffing in order to cope with the problemspresented by absenceAgency/locum staff costsManagement and administration costsLoss of service provision (e.g. closure of beds, wards/units dueto staff shortage)

Indirect costsDisruption to service provisionReduced patient care quality – if replacement staff are notcompetent, are tired or unwell themselvesIncrease in complaints due to failure to meet service demands/expectationsCost of recruitment, selection, training and management of thosewho replace absent staffLowers moraleLoss of valuable skills and experiencePain and suffering for those absent



the level of provision has been criticized as being

insufficient (Williams et al. 1998, Rogers et al. 1999).

The majority of services are provided by NHS Trusts,

who provide the service in-house and may also provide

the service to other Trusts, other NHS bodies, and non-

NHS enterprises in the local community. The special-

ized OH team is an existing resource within the NHS,

that should be further facilitated to deliver quality evi-

dence-based OH interventions to reduce sickness

absence. NHS OH providers have a lead role to perform

in helping the NHS achieve a healthy workplace and

workforce.

Approaches to absence control or attendancemanagement

The NHS needs to devise a range of interventions, to

address the problem of sickness absence. The effect-

iveness of each one will be determined by the man-

ager’s ability to analyse the unique features of her/his

absence problem and to select the most appropriate

approach to deal with it. Successful strategies begin

and persist with the genuine belief by management

that something can be done to reduce absence. Selec-

tion of absence control interventions must reflect the

uniqueness of the particular work environment and be

based on a systematic understanding of the absence

problem and employee characteristics. Specifically to

the NHS, is the recognition of long established high

levels of ill health in all groups of NHS staff, nature of

healthcare work, major organizational change, high

levels of staff turnover, increasing overwork, pressures

of patient expectations and increasing litigation, viol-

ence against healthcare workers, demographical profile

of NHS employees, length of service, education and

career opportunities, employee attitudes and values,

work cultures, work design, family responsibilities,

management style and sick pay policies. Possible

solutions to sickness absence in the NHS would

therefore need to include strategies to proactively

address the health and safety problems of healthcare

work, initiatives to reduce labour turnover, introduc-

tion of childcare support and other forms of family-

friendly policies, improve the educational profile of its

workforce, reduce stress through organizational chan-

ges in areas, such as work design, management style

and resourcing, and health promoting initiatives.

The identification of who actually is responsible for

leading the management of sickness absence in the NHS is

unclear – there is a need for a sickness absence leader in each

NHS Trust. The formation of a sickness absence project

team that involves all stakeholders (managers, employees,

trade unions, OH professionals), which also seeks expert

guidance, is recommended. The problems associated with

sickness absence need to be viewed from an organization-

wide perspective, aids communication, reduces resistance

to change and diminishes the fear that individuals may have

about the impact the changes will have on them.

Assessment of the size and trends of absence provides

evidence to persuade others that sickness absence is a

problem and, the basis for devising effective absence

management interventions. There is evidence that many

organizations still do not generate complete records of

sickness absence, subsequently quality data to estimate the

cost, or research utilization are limited and incomplete.

Useful quantitative measures of absence include frequency

of sick-leave, length of absence, incidence rate, cumulative

incidence and duration of a sick-leave spell (Hensing et al.

1995). Items such as (a) reasons for absence (e.g. back

pain, depression, stress), (b) employee characteristics (e.g.

age, sex), (c) different departments within the organization

(e.g. ITU, individual wards) and (d) seniority (e.g. nursing

grades), would be useful to include.

A comprehensive description of an organization’s

absence problem allows for benchmarking using external

and internal comparisons, aids the calculation of costs,

e.g. the costs of overtime payments and informs the

design and evaluation of interventions. The investment of

time and effort to determine where, in the organization,

the major absence problem exists is important; helpful

information may already be within the organization’s

personnel department or payroll system. Accurate

recording and monitoring of appropriate data are the

foundation to any comprehensive policy of attendance

management, however, there needs a balance of efforts.

Problem sickness absence rates will not reduce unless

managers ensure that the organization they represent

prevents work-related illness and injuries and provides a

first class OH and safety service for employees.

The most common interventions aimed at managing

absence are those which exert some form of control

over an employee’s absence; holding an interview with

an employee immediately on return to work, filling in

appropriate forms, setting individual trigger points,

counselling for poor attendees and the uses of an

organizations disciplinary policy. Caution regarding the

effectiveness of such techniques needs to be employed;

there is a gap within the literature that provides a sci-

entific evidence base for the management of sickness

absence. Policies that create a work environment that

employees want to work in (flexible working arrange-

ments, OH programmes, job redesign, rewards for good

attendance), have been found to reduce sickness absence

(Evans & Walters 2002).

C.J. Johnson et al.


Interventions aimed at reducing sickness absence can

be categorized as (a) procedural measures (monitoring

absenteeism, absenteeism procedures and policies), (b)

preventatitive work-orientated measures (e.g. health and

safety initiatives, management training, better organiza-

tion of work, flexible working hours, job enrichment), (c)

preventatitive person-orientated measures (counselling,

information on bullying, stress management, manual

handling training) and (d) reintegration measures (e.g.

rehabilitation procedures, phased re-integration, reduc-

tion of working hours, return to work interviews, phy-

siotherapy treatment) (Grundemann & Vuuren 1997).

Key to the successful implementation of an absence

control programme is to ensure good information pro-

vision and communication, involvement of all relevant

groups and individuals, efforts to gain support and

commitment from those who will be affected by the

changes, care to dispel fears where possible and publi-

cation of the benefits (Evans & Walters 2002). Once the

programme to reduce sickness absence has been imple-

mented, it is important to monitor its effectiveness,

ensure that it is having the desired effect and to formulate

corrective action as required. Evaluation does not just

include monitoring absence rates, but must consider

other outcome measures for example, economics,

effectiveness of the activities in relation to the intended

goal, employee health gains, degree of satisfaction with

the OH and safety services (Table 3).

Conclusions

The literature reveals that sickness absence levels are a

problem within the NHS, concerns arises from the huge

economic-cost sickness absence incurs and the poor

health of the NHS workforce. These concerns have been

translated into several key documents, produced by the

Department of Health, which provide the new human

resource framework for the NHS. This has created a

demand for an evidence base, regarding the manage-

ment of this absence in the NHS context. It is clear

within the literature that sickness absence by its very

nature is multi-causal and highly variable, and therefore

difficult to manage. It is impossible to separate

the social, physical and psychological causes of sickness

absence; therefore, sickness absence research and man-

agement strategies to reduce sickness absence needs to

be designed to reflect this.

Today’s nurse managers need to consider their role in

relation to the multifaceted problem sickness absence

presents within the NHS. The current approach in

managing sickness absence has been predominately

shaped by employment law and traditional manage-

ment practices have responded to this source of influ-

ence. Managerial activities required to effectively deal

with the problems posed by sickness absence are

demanding, but the challenge is achievable. Indeed,

there is an enormous opportunity to be seized in the

NHS, powerfully motivated by the concern for the

welfare of the staff of the NHS. Commitments to sup-

port the much needed improvements, regarding NHS

employee health and employment conditions, is required

to support the necessary and achievable positive out-

comes of quality sickness absence management.

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Table 3Stages of absence management

Stage Activities

1 Familiarize yourself with your organization'slong-term strategic aims regarding sickness absence

2 Gain senior management commitment3 Appoint a sickness absence lead to direct the

management of attendance in your organization4 Evaluate own role in relation to sickness absence

management5 Form a multi-disciplinary project team6 Determine the extent of the problem (quantitatively)7 Identify absence problem areas8 Analyse the causes of absence (quantitatively and

qualitatively)9 Evaluate the effectiveness of current absence control

policies and procedures10 Explore alternative interventions available11 Select interventions12 Integrate interventions into overall absence control

strategy13 Implement absence management programme14 Clearly communicate the standard of attendance

required15 Monitor and evaluate effectiveness of the absence

management system devised



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Documents

The problem and management of sickness absence in the NHS: considerations for nurse managers