Managing absenteeism in public hospitals: the deleterious 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 Fédération hospitalière française survey, compared with between 8.5% and 10% in 2019, before the Covid-19 crisis.
Nathalie Commeiras, University of Montpellier and Véronique Achmet, University of Montpellier
Even if the health crisis only led to a relatively small increase, these figures stand in stark contrast to the rest of the economic fabric.
According to the results of the 12th Ayming Absenteeism and Engagement Barometer, France recorded an absenteeism rate of 5.11% in 2019.
To understand this discrepancy, we carried out a research project analyzing the management of absenteeism in public hospitals and its effects on nursing staff, healthcare managers and patients, in a context of budget restrictions and deteriorating working conditions: work intensification, time pressure, computer-controlled work rhythm, fragmented work, aggressiveness on the part of patients and their families, etc.
"Resourcefulness
Our study shows that absenteeism management suffers from a number of shortcomings: it is generally implemented internally, within a single department and/or division. What's more, solutions tend to be based on "resourcefulness" and direct arrangements between the players involved, which can have deleterious consequences for staff.
Health care managers are therefore highly responsive and inventive when it comes to managing absenteeism on an urgent basis. As we have shown in our research work, his priority is to mobilize self-replacement and schedule adjustments to manage all absences, not just those of short duration. With self-replacement, the health executive calls staff back on their rest time (weekly or reduced working hours). With self-adjustment, they manage absenteeism by mobilizing the staff they have available. Managers also make use of inter-departmental mobility, and, where available and of sufficient size, of the replacement pool.
In some establishments, cooperation seems to be developing between the human resources department, senior health managers and health managers, to manage absenteeism more collegially.
As a senior health executive interviewed in our study testifies:
"Every 15 days, we have a staffing meeting at which the 6 senior health managers meet with the Director of Care, the HR Director and her deputy, and each senior manager presents his or her staffing difficulties for the next 15 days".
Absenteeism management thus tends to develop cooperation between the various players. Far from dividing and pitting them against each other, the budgetary restrictions imposed on healthcare establishments are forcing staff to find solutions and arrangements together, against a backdrop of worsening working conditions.
Managing absenteeism therefore strengthens interpersonal relations. Strong social support is developing, both within the team, between nurses, and between nurses and the health manager.
Deleterious consequences
However, as we have seen, this management method has its share of negative consequences for caregivers and patients. The main effects are as follows:
- Extreme fatigue among nursing staff
With the use of self-replacement, working hours are continually lengthened, going beyond the agent's chosen working time, making it impossible to take leave, RTT and rest, and thus leading to presenteeism.
The latter causes extreme fatigue in nurses, as one nurse testifies:
"Let's just say that when colleagues work five days in a row, the fifth day is difficult".
This situation can lead to long-term sickness absence and physical and emotional exhaustion among nursing staff. With self-adjusting schedules, nursing staff are subject to incessant variability in their planning, a source of dissatisfaction and unhappiness 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) we carried out, indicate that if an agent refuses to replace one of his colleagues on his time off (self-replacement), he may be subjected to psychological violence by the health manager, and more specifically to psychological pressure or telephone harassment.
A testimonial on a forum illustrates this:
"If the continuity of care is broken because we don't come in on our rest days, it's certainly not our fault. The rest is intimidation and blackmail.
- Risks to the safety and quality of patient care
The use of inter-departmental mobility can lead to a reduction in the quality of care, as the agent who intervenes knows neither the department in question, nor the patients.
One nurse interviewed said:
"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 care safety. Even if, as researchers, we were unable to obtain the number of incidents linked to nurse fatigue (confidential data), a trade unionist was able to relate an incident with alarming consequences:
"Not long ago, we had chemotherapy that was supposed to take 8 hours, but the agents did it in half an hour, and the patient almost died, very clearly... and there have been even worse things, but of course, that doesn't leave the establishment".
Shortage of professionals
Faced with the Covid-19 crisis, new "resourceful" solutions (mobilization of medical students, recall of retired healthcare professionals, use of temporary staff, recourse to overtime, etc.) have been implemented in parallel. But they remain insufficient.
The methods used before the health crisis were not sufficient to offset the shortage of healthcare professionals. Hospitals were able to launch external recruitment campaigns, albeit with additional financial resources(PLFSS 2020 and 2021 - Social Security Financing Bill, Ségur de la Santé agreements, ONDAM Hospitalier, etc.), but their success was limited due to the shortage of medical staff and specialized caregivers resulting from the just-in-time strategy deployed to meet the imperatives of New Public Management.
Certainly, healthcare professionals are as invested and dedicated as ever, but also exhausted in the face of a situation with no end in sight. As the director of the Thau Basin hospitals testified (in a France 3 Occitanie article from September 2020):
"A great deal of physical and psychological fatigue among professionals who have not recovered from the first wave.
As a result, absenteeism rates are likely to rise, complicating the management of the health crisis.
The hospital must therefore quickly inspiring vocationsparticularly among young doctors. In-depth reflection is needed on employment and skills management policies for healthcare professionals, as well as on the upgrading of professions, leading to concrete results. The Ségur de la Santé and, more specifically, the slight increase in salaries last September, can be seen as a first step in this direction.
Nathalie Commeiras, University Professor in Human Resources Management, Montpellier Research Management (MRM), University of Montpellier and Véronique Achmet, Doctor of Management Sciences, Montpellier Research Management (MRM), University of Montpellier
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