Managing absenteeism in public hospitals: the harmful effects of overly fragile solutions
In 2020, the absenteeism rate in French hospitals averaged between 9.5% and 11.5% according to figures from the French Hospital Federation survey, compared with a level of between 8.5% and 10% in 2019, before the Covid-19 crisis.
Nathalie Commeiras, University of Montpellier and Véronique Achmet, University of Montpellier
Even though the health crisis has only led to a relatively small increase, these figures stand in stark contrast to the rest of the economy.
According to the results of the12th Ayming absenteeism and engagement barometer, France had an absenteeism rate of 5.11% in 2019.
To understand this discrepancy, we conducted research analyzing absenteeism management in public hospitals and its effects on nursing staff, healthcare managers, and patients, in a context of budget cuts and deteriorating working conditions: increased workloads, time pressure, computer-controlled work schedules, fragmented work, aggression from patients and their families, etc.
Resourcefulness
Our study shows that this approach to managing absenteeism has certain shortcomings: it is generally implemented internally, at the departmental and/or divisional level. In addition, the solutions tend to be based on "resourcefulness" and direct arrangements between the parties involved, which can have harmful consequences for staff.
Healthcare managers therefore demonstrate a high degree of responsiveness and inventiveness in managing absenteeism in emergency situations. As we have shown in our research, they prioritize self-replacement and schedule adjustments to manage all absences, not just short-term ones. With self-replacement, healthcare managers call on staff during their time off (weekly or reduced working hours). With self-adjustment, they manage absenteeism by mobilizing the staff they have available. Managers also use interdepartmental mobility and, where it exists and is large enough, the replacement pool.
Cooperation thus appears to be developing between human resources management, senior healthcare executives, and healthcare executives in certain institutions to manage absenteeism in a more collegial manner.
As evidenced by a senior healthcare executive interviewed in our study:
Every two weeks, we have a staffing meeting where the six senior healthcare managers meet with the Director of Care, the HR Director, her assistant, and each senior manager outlines their staffing challenges for the next two weeks.
Absenteeism management thus tends to foster cooperation between the various stakeholders. Far from dividing them and pitting them against each other, the budgetary restrictions imposed on healthcare institutions force staff to work together to find solutions and arrangements in a context of deteriorating working conditions.
Managing absenteeism therefore strengthens interpersonal relationships. Strong social support develops both within the team, between nurses, and between nurses and the healthcare manager.
Detrimental consequences
However, this management approach has a number of negative consequences for caregivers and patients, as we have seen. The main effects are as follows:
- Extreme fatigue among healthcare workers
With the use of self-replacement, working hours are continually lengthening, exceeding the amount of work chosen by the employee, accompanied by an inability to take leave, use RTT days, or rest, and thus leading to presenteeism.
The latter causes extreme fatigue among nurses, as one nurse testifies:
"Let's just say that when colleagues work five days in a row, the fifth day is tough."
This situation can lead to long-term sick leave due to physical and emotional exhaustion among nursing staff. With self-adjusting schedules, nursing staff are subject to constant changes in their schedules, which is a source of dissatisfaction and discomfort at work.
- Psychological violence against nursing staff
The results of our research, and more specifically of the netnographic study (based on messages taken from discussion forums), indicate that if an agent refuses to replace one of their colleagues during their break time (self-replacement), they may be subjected to psychological abuse by the healthcare manager, and more specifically, psychological pressure or even telephone harassment.
A testimony posted on a forum illustrates this:
"If continuity of care is disrupted because we don't come in on our days off, it's certainly not our fault. The rest is intimidation, emotional blackmail."
- Risks to the safety and quality of patient care
The use of interdepartmental mobility may lead to a reduction in the quality of care, as the staff member involved is unfamiliar with both the department in question and the patients.
A nurse interviewed for the study testified:
"We don't know the patients, so we do what we can. We don't know where the medicines are [...] we can feel completely useless."
Finally, the aforementioned moral absence of nursing staff raises questions about the safety of care. Although as researchers we were unable to obtain the number of incidents linked to nurse fatigue (confidential data), a union representative was able to recount an incident with alarming consequences:
Not long ago, we had a chemotherapy treatment that was supposed to take eight hours, but the staff did it in half an hour. The patient almost died, quite clearly... and there have been even more serious incidents, but of course, that doesn't leave the facility.
Shortage of professionals
In response to the COVID-19 crisis, new "resourceful" solutions (mobilizing medical students, calling back retired healthcare professionals, using temporary staff, resorting to overtime, etc.) have been implemented in parallel. But they remain insufficient.
The measures used before the health crisis are not sufficient to compensate for the shortage of healthcare professionals. Although additional financial resources have been made available (2020 and 2021 Social Security Financing Bills, Ségur healthcare agreements, ONDAM Hospitalier, etc.), hospitals have been able to launch external recruitment campaigns, which have had limited success due to the shortage of medical staff and specialized caregivers linked to the just-in-time strategy deployed to meet the requirements of New Public Management.
Of course, healthcare professionals are as committed and dedicated as ever, but they are also exhausted by this situation, with no end in sight. As the director of the Thau Basin hospitals said (in an article by France 3 Occitanie in September 2020):
"Severe physical and psychological fatigue among professionals who have not recovered from the first wave."
As a result, there is a high probability that absenteeism rates will increase, which will complicate the management of the health crisis.
The hospital must therefore quickly inspire vocations, particularly among young doctors. In-depth consideration must be given to the employment and skills management policy for healthcare professionals, as well as to the revaluation of professions, leading to concrete results. The agreements of the Ségur Health Summit and more specifically the slight increase in wages last September, may nevertheless constitute a first step in the right direction.
Nathalie Commeiras, University Professor in Human Resources Management, Montpellier Research (MRM), University of Montpellier and Véronique Achmet, Doctor of Management Sciences, Montpellier Research (MRM), University of Montpellier
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