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Factors Influencing Voluntary Absenteeism among Healthcare Workers in The Bahamas.

Managing workforce absenteeism may present significant challenges for organizations. Specifically, female-dominated professions such as nursing are generally known to have above-average absenteeism rates, and may even encourage a culture of acceptance as it relates to sickness absenteeism (Malak, 2017). The healthcare environment can be very unpredictable, stressful, and demanding, leading employees to purposely withdraw their services from time to time. Work withdrawal involves any attempt to escape a negative work situation by physically removing oneself from the workplace and can be manifested through behaviors such as being late or absent from work or abusing sick leave benefits (Kao, Ceng, Kuo, & Huang, 2014). Absenteeism results in employee deficits, leading organizations to account for shortages by replacing staff at the risk of incurring substantial financial loss to ensure continuity of care (Gorman & Alamgir, 2010). Shortages of healthcare workers may undermine organizational productivity, threaten financial stability, and jeopardize delivery of quality patient care (Gaudine & Gregory, 2010). This clearly illustrates the importance of giving more attention to absenteeism within healthcare organizations, especially those that may already have preexisting staffing challenges. In The Bahamas, as it is with most countries globally, there is a shortage of nurses and other allied healthcare professionals (State of the Nation Report, 2016). Information about the prevalence of absenteeism among healthcare workers in The Bahamas is not available publicly. However, unplanned absences of employees in the healthcare setting may negatively affect productivity as a result of staffing instability.

Investigating the motivation behind withdrawal behaviors in the workplace involves the assumption that absence from work may be an outcome of circumstances beyond an individual's control, or may be premeditated and planned (Tan & Hart, 2011). As a result, absenteeism has commonly been categorized as being either voluntary or involuntary (Hackett, Bycio, & Guion, 1989). Involuntary absenteeism involves cases whereby an employee lacks control over the decision to attend work due to the influence of external factors such as sickness or emergency (Magee, Caputi, & Lee, 2016). Voluntary absenteeism involves absences for which an employee has a choice to attend work but chooses to take a personal day off instead due to lack of motivation or to attend to some other personal interest (Camden & Ludwig, 2013). The main assumption behind the volitional view of absenteeism is the employee makes rational decisions about attending or being absent from work on a given day (Hackett et al., 1989). Consequently, when confronted with an absence-enticing situation, a conscious evaluation of the costs and benefits of staying away from work is triggered within the employee's mind leading him or her to seriously consider missing work on a given day. From this perspective, any attempt to understand the concept of absenteeism might be geared toward identifying absence-inducing factors that would lead an employee to make the rational choice to miss work (Hackett et al., 1989).

A number of previous authors have explored the concept of absenteeism as a voluntary construct associated with various organizational factors that explain why some organizations have lower absenteeism rates than others. For example, Biron and Saksvik (2009) noted employees were inclined to be absent if there was no provision for a substitute or if they knew their work would pile up upon return to the workplace. Prior studies have also identified organizational features such as psychosocial job demands (Griep, Rotenberg, Chor, Toivanen, Landsbergis, 2010; Rugulies et al., 2007), job satisfaction and organizational commitment (Griffeth, Steel, Allen, & Bryan, 2005; Obasan, 2011; Zimmerman, Swider, Woo, & Allen, 2016), shift work (Jamal, 1981; Markham, Dansereau, & Alutto, 1982), and leadership styles (Cummings et al., 2010; Elshout, Scherp, & van der Feltz-Cornelis, 2013) as influencing workplace attendance.

Therefore, voluntary absenteeism suggests absenteeism is a multifaceted phenomenon having many interconnected factors other than health, which may influence an employee's decision to engage in withdrawal behaviors (Magee et al., 2016). These factors, whether personal or organizational, imply voluntary absenteeism is only a symptom of some other underlying problem (Obasan, 2011). Problems associated with involuntary absenteeism can never be fully eradicated from any organization, as there are circumstances in which employees are genuinely incapable of attending work. However, identifying factors that may influence employees' decisions to miss work even when they are fully capable of attending may assist organizations in developing strategies for managing voluntary absenteeism in the workplace. The current research sought to examine organizational factors contributing to voluntary absenteeism among healthcare workers, whereby employees take leave from work for reasons other than genuine illness, injury, or circumstances beyond their control.

Conceptual Framework

The conceptual framework chosen to underpin the current research was the Organizational Dynamics Paradigm of Nursing Absenteeism (Taunton, Hope, Woods, & Bott, 1995) (see Figure 1). The main assumption of this model is that absenteeism is an outcome related to characteristics present in the nurse, manager, work environment, and organization. According to Taunton and co-authors (1995), these characteristics are believed to predict absenteeism through intervening variables such as job stress, job satisfaction, job involvement, and job commitment, as well as an employee's intent to remain employed within an organization. Thus, the model proposed by Taunton and colleagues (1995) can be used to explain the concept of absenteeism and how the characteristics of nurse, organization, manager, and work environment either act as driving forces or deterrents to withdrawal behaviors in employees.


Study design. This descriptive, cross-sectional study used a questionnaire to examine organizational factors contributing to absenteeism among healthcare workers working at a single healthcare facility in The Bahamas.

Sample. The target population consisted of 408 healthcare workers employed in four different roles at a healthcare facility in The Bahamas: registered nurse (RN) completed a 4-year program and has a license to practice nursing; trained clinical nurse (TCN) completed an 18-month certificate program in nursing; nursing auxiliary (female nursing assistant) and attendant (male nursing assistant). A statistical power analysis was conducted to select an appropriate sample size for a one-way Analysis of Variance (ANOVA) with four groups in GPower 3.0. The analysis indicated a sample size of 180 would be required to obtain a medium effect size (f=0.25) at a power of 0.8 and significance of 0.05. A stratified random sample was used to select a sample of 186 healthcare workers. For this research, the population was divided according to their primary roles.

Procedure. A contact person on each unit of the facility was used to assist in administering questionnaires. Selected employees received detailed verbal and written information about the nature and purpose of the study and were provided with surveys during their work schedule. Participants were informed that surveys would be collected 1 week from the date of distribution. Return of surveys indicated consent to participate in the study. Data were collected from June-August 2016.


A questionnaire was developed based upon information derived from the conceptual framework proposed by Taunton and co-authors (1995) and a review of the literature. It consisted of three sections and a total of 18 questions. Section 1 of the questionnaire consisted of 10 pre-structured statements which solicited responses from participants using a six-point Likert-like scale ranging from strongly agree to strongly disagree. Participants were asked to rate the extent to which they agree certain factors would contribute to their taking sick leave. Section 2 of the questionnaire required participants to indicate if they have ever taken sick leave for reasons other than genuine sickness and to suggest ways to discourage non-sickness related absenteeism among employees at the institution. The questionnaire concluded with six questions about demographic variables. The final survey instrument was tested using Cronbach's alpha to determine reliability. For section 1, Cronbach's alpha was 0.84, indicating a satisfactory reliability score.

Data Analysis Strategy

Descriptive statistics were used to describe and summarize data such as frequencies and percentages. Quantitative data were coded and analyzed using SPSS (version 22). Comparison between groups was initiated using one-way ANOVA. For this study, significance level was set at p=<0.05 for interpreting results of significance. For analysis, in Section 1 the scoring of strongly agree, somewhat agree, and agree were categorized as "a contributing factor" (and coded as 1), while the scoring of strongly disagree, somewhat disagree, and disagree were categorized as "not a contributing factor" (and coded as 0). To analyze the open-ended responses in the questionnaire, data were read/reread a number of times and coded by identifying recurrent themes or concepts.

Ethical Considerations

This study was approved by the country's ethics review board. Prior to conducting the study at the study site, approval was also granted by the institution's hospital administrator. Informed consent was obtained from each participant and confidentiality and anonymity maintained throughout the research process. Participants received both written and verbal information that instructed them of the nature and purpose of the study and were given the option to withdraw from the study at any time. Measures also maintained participant anonymity, such as not disclosing individual names or using personal identifiers.

Sample Description

Surveys were distributed to 186 healthcare workers; 150 completed surveys were received from 150. The largest group of respondents were females (65.3%; n=98). Participants predominantly fell in the 25 to <35 age range (34%; n=51) and had been employed for 20 or more years (31.3%; n=47). Of participants employed at the healthcare facility, 39.3% (n=59) worked as RNs while 14.7% (n=22) were TCNs. The highest educational level of participants was at the high school level (42%; n=63). Participants worked in four different settings at the institution under study: substance abuse (12.7%, n=19), chronic (27.3%, n=41), psychiatric (41.3%, n=62), and geriatric settings (18.7%, n=28).

Participants' demographic characteristics are presented in Table 1.

Organizational Factors Contributing to Absenteeism

Employees were asked to specify the degree to which different factors influence their choice to take sick leave from work for reasons other than legitimate sickness. The most frequently identified factors believed to contribute to workplace absences were disputes over scheduling (66%; n=99), organizational culture (61%; n=91), and having call-in sick benefits (47%; n=70). Table 2 ranks organizational factors contributing to absenteeism in order of importance.

One-way ANOVA was conducted to determine if there were any significant differences in taking sick leave for reasons other than legitimate sickness among staff with different roles in the institution. However, no significant findings were noted (p= >0.5). Participants were also asked to indicate if they had ever taken sick leave from work for reasons other than legitimate sickness. The largest group of responses came from participants who indicated they had taken sick leave from work for reasons other than being genuinely sick (60.7%; n=91). Respondents were also provided with an opportunity to describe their views related to what they believed would discourage the abuse of sick leave benefits. Participants provided 119 responses regarding their views on discouraging non-sickness related absences. The top three themes which arose from participants' responses were scheduling practices, use of incentives, and proper staffing. Table 3 displays the major themes and responses which arose from this item.


Participants commonly indicated they had taken sick leave for reasons other than being genuinely sick (60.7%; n=91). This finding could suggest a culture of acceptance toward absenteeism. According to Johns and Nicholson (1982), organizational absence culture refers to a shared set of beliefs, values, and behavior patterns regarding absenteeism. Johns (1997) posits that absence behaviors result from a collective consensus about how much absence is expected and pressures from other employees to increase or decrease individual absence to socially accepted norms already established within an organization's culture. Johns and Nicholson (1982) further described an absence culture which they termed Type IV Absence Culture, whereby absenteeism is viewed by employees as an entitlement, strong interdependent and cohesive relationships are shared among employees, and there is generally mistrust and defiance toward leadership injunctions.

An entitlement attitude toward absenteeism may lead to persistent withdrawal behaviors among healthcare workers, jeopardizing delivery of quality patient care and influencing patient outcomes. Previous authors agree on the negative impact absenteeism may have on standards of care (Gaudine & Gregory, 2010; Laschinger, Finegan, & Wilk, 2009; Liu et al., 2012). Moreover, consequences of absenteeism, including reduced staffing levels and heavier nursing workloads, are associated with poor patient outcomes such as increased patient mortality and failure-to-rescue rates (Furillo & McEwen, 2012). In contrast, increased RN presence has been linked to lower patient mortality and failure-to-rescue rates, fewer incidences of pressure ulcers, and shorter hospital stays (Chau et al., 2015). These outcomes imply the influence of management practices (e.g., providing safe staffing levels) on the provision of quality nursing care.

In the current study, scheduling grievances were also cited as an explanation for nonsickness related absences. This included factors such as requests not being honored or employees being floated to cover other areas. This finding implies changes to managerial scheduling practices may discourage absenteeism among employees. A review by Davey, Cummings, Newburn-Cook, and Lo (2009) reported absenteeism decreased when leaders showed employees consideration. Previous studies investigating supervisory approaches to professional interaction with employees found effective leadership practices such as conveying respect toward subordinates and creating a supportive organizational climate were associated with lower absenteeism levels (Schreuder et al., 2010; Stone, Du, & Gershon, 2007).

Scheduling grievances among respondents in the current study also imply employee feelings of anger or resentment toward managerial practices. Chadwick-Jones, Nicholson, and Brown (1982) hypothesized absenteeism should be viewed as a form of negative exchange behavior, whereby employees withhold their presence as a means of compensating for negative aspects of their jobs. Robinson and Rousseau (1994) proposed that when expectations of reciprocity are presumed to have been violated, employees may act upon feelings of betrayal and mistrust through withdrawal reactions. Consequently, employees may become demotivated if they perceive inequitable work relationships, which may result in work withdrawal and decreased productivity. The influence of employee absence on productivity has been substantiated in the literature. Kalisch (2006) found absence of healthcare workers contributed to poor employee performance including not meeting patients' hygienic needs, delayed or missed feedings, and failure to implement patient teaching.

Mudaly and Nkosi (2015) supported the influence of managerial practices on absenteeism. In their study, unfriendliness, perceived unfairness, and favoritism by nurse managers increased absenteeism rates. Other researchers found sickness absence was increased in organizations with generous sickness benefits (Markussen, Roed, Rogeberg, & Gaure, 2011). The current study corroborated this finding, as 47% of employees indicated sick leave benefits contributed to absenteeism.

Participants were also given the opportunity to provide their opinions concerning what could be done about the high rate of sickness absences observed within their organization. Respondents stated changing management practices (such as scheduling decisions and providing incentives) were the solution to the high rate of absences. These findings suggest respondents were dissatisfied with certain managerial procedures. Employee dissatisfaction has been linked to absenteeism within organizations. For instance, a study by Gardulf and colleagues (2005) found job dissatisfaction may result in further absenteeism or even encourage professional exit. The unavailability of healthcare workers may also produce an overall negative impact on the financial performance of organizations, especially those with already-constrained budgets who must redirect much needed financial resources toward replacing employees with unscheduled absences. Problems associated with absenteeism may be further compounded by rising healthcare expenditures and competing priorities for healthcare funds.

Finally, respondents noted the institution under study was ineffective in discouraging the abuse of sick leave benefits. Consequently, 66.7% of participants reported the institution did not strongly discourage non-sickness related absences, implying current organizational procedures for controlling absenteeism may be unsuccessful. This finding was consistent with those from a previous study conducted by Walker and Bamford (2011) who found managers were ineffective in handling employee absenteeism. Consequently, the complex nature of absenteeism requires its management be addressed from both employee and managerial standpoints.

Implications for Nursing Management

Findings from this study point to the need for nurse managers to be aware of how their practices may influence workplace attendance. Organizations may benefit from having nurse managers who select practices that encourage work attendance, such as promoting an overall healthy organizational culture and being sensitive to employees' needs and concerns. This is important since organizational commitment to reducing absenteeism may result in improvements to quality of care, organizational productivity, and overall financial stability. Consequently, effective management of absenteeism may require certain management practices be addressed at top organizational levels.


This study involved collection of data from employees at one healthcare institution in The Bahamas. Care should be used in generalizing findings outside of the study setting. Insufficient statistical power due to the small sample size may have contributed to the inability to detect a significant finding in this study. The author did not present any information about the absenteeism rates of employees in the study. Therefore, the findings could be subject to the ability of respondents to self-assess their own attendance trends. A review of absenteeism records may have determined participants' actual absence trends. Use of a quantitative data collection approach was also a limitation of this study. Triangulation of research approaches such as the incorporation of face-to-face interviews or focus group sessions may have provided a deeper insight into the perceptions of healthcare workers concerning the factors influencing absenteeism. Further research is needed to examine how individual organizational factors contribute to absenteeism among employees.


To overcome some challenges associated with workplace absence and improve work attendance, strategies such as promoting an overall healthy organizational culture and being sensitive to employee needs and concerns may be beneficial. However, because a number of interconnected factors exist which can influence an employee's choice to engage in voluntary absenteeism, finding effective solutions to the problem will remain challenging for healthcare organizations. $

Daphne Christine Duncombe, MSC, RN

Research Nurse

Public Hospitals Authority

Nassau, Bahamas


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Caption: Figure 1.

Conceptual Framework: Organizational Dynamics Paradigm of Nursing Absenteeism

Source: Taunton et al., 1995. Reprinted with permission of publisher.
Table 1.
Demographic Characteristics of Participants (n=150)

Characteristic             n     %

  Female                   98   65.3
  Male                     52   34.7
Age Range
  <25                      7    4.7
  25 < 35                  51    34
  35 < 45                  33    22
  45 < 55                  41   27.3
  >55                      17   11.3
Primary Role
  Registered nurse         59   39.3
  Trained clinical nurse   22   14.7
  Nursing auxiliary        28   18.7
  Attendant                41   27.3
Highest Qualification
  High school              63    42
  Certificate              20   13.3
  Diploma                  7    4,7
  Associate                30    20
  Baccalaureate            30    20
Length of Employment
  <5 years                 35   23.3
  5 < 10 years             36    24
  10 < 15 years            11   7.3
  15 < 20 years            21    14
  >20 years                47   31.3
Primary Work Area
  Psychiatric              62   41.3
  Chronic                  41   27.3
  Substance abuse          19   12.7
   Geriatric               28   18.7

Table 2.
Organizational Factors Contributing to Workplace Absence

Rank                                                  Frequency
order                     Factor                         (n)      %

1       Disputes over scheduling                         99       66
2       Organization culture (expectation that           91       61
          colleagues will miss work)
3       Having call-in sick benefits                     70       47
4       Institution does not strongly discourage         67       45
          sick leave abuse
5       Manager's leadership style makes the work        65       43
          environment more stressful
6       Discouragement due to staff/supply               62       41
7       Having split days off                            54       36
8       Manager takes full authority over writing        51       34
          the off-duty schedule
9       Inability to take scheduled breaks               45       30
          without a hassle
10      Lack of motivation                               39       26

Table 3.
Staff Suggestions for Discouraging Non-Sickness Related Absenteeism

Theme             Frequency           Illustrative Responses

Scheduling           44       * They should honor requests
practices                     * Rotate floated staff
                              * Sensitivity to staff needs
                              * Give staff more weekends off

Incentives           32       * Compensation and awards
                              * Motivate staff
                              * Add incentives
                              * Stress days

Proper staffing      16       * Sufficient staff on each ward
                              * Better ward coverage
                              * Ensure adequate staffing

Nothing              12       * Nothing can stop it

Communication/        7       * Talk to staff to find out
Collaboration                 * Individual session with absent staff
                              * Find out from the staff
                              * Work with them to help them
Don't know            5       * I don't know

Penalties             3       * Penalty if found abusing sick leave

Total                119
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Author:Duncombe, Daphne Christine
Publication:Nursing Economics
Article Type:Report
Date:Mar 1, 2019
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