The issue of nurse absenteeism is a critical factor that significantly impacts the quality of nursing services. As a result, identifying these factors are of paramount importance for nursing managers. Therefore, the aim of this research was to investigate and identify the factors associated with nurses' absenteeism in clinical settings. This review study identified 194 English and Persian articles by searching PubMed, Google Scholar search engine, and the Scientific Information Database using the keywords of Absenteeism, Hospital, and Nurses from 2015 to 2021, with no restrictions on the type of research. After carefully reading and evaluating the articles, eight papers were included in the study based on the research aims and objectives. Based on the findings, several factors contribute to nurses' absenteeism, including illness, managerial and organizational issues, prolonged work shifts and fatigue caused by working with patients, stress and job dissatisfaction, and psychological factors. Nursing managers need to ensure that nurses have good working conditions by considering different factors affecting their physical and mental well-being. They should also align the organization's goals with the nurses' objectives as much as possible.
1 │ Introduction
Absenteeism be defined as the nonattendance of an employee during their scheduled working hours, regardless of whether planned or unplanned, due to various reasons and quantified by the total number of missed workdays . Over recent years, the rise in employee absenteeism has significantly impacted both financial issues and organizational performance. Absenteeism can serve as an appropriate criterion for evaluating the health and well-being of a society's system while also providing a helpful tool for examining the physical and mental health of employees and healthcare providers . The global shortage of nurses in recent years has brought attention to the significant impact of nurse absenteeism. In Europe, nurse absenteeism has resulted in low patient satisfaction and incurred millions of dollars in healthcare costs. In South Africa, nurse absenteeism is one of the factors contributing to job dissatisfaction, increased workload, and displacement of other nurses . Also, inadequate human resource management, job stress, and burnout are the primary factors contributing to nurse absenteeism in Iran. As a result, nurses in Iran are more likely to miss work due to work-related stress and pressure compared to other professions .
Recent studies have shown that various factors significantly contribute to absenteeism among healthcare and medical staff. These factors can be categorized into three groups: personal, workplace, and organizational. Personal factors include physical and mental illnesses, whereas workplace factors include long and excessive working hours, frequent nurse displacement, stress, and emergencies. Additionally, organizational factors, such as job satisfaction and motivation, also play a significant role in absenteeism . The effective functioning of a healthcare organization necessitates management capable of achieving optimal productivity and quality while considering these considerations. Conversely, personnel absence indicates that organizations lack the necessary resources and conditions to perform tasks safely, making them susceptible to poor performance, high costs, and low-quality care [6, 7]. Organizations can reap countless benefits from strategies that successfully reduce employee absenteeism. By implementing appropriate methods and healthcare measures, organizations can assist their employees in continuing their work and optimize their overall performance .
Considering the significant impact of nurse absenteeism on job satisfaction, patient satisfaction, cost savings for organizations, improving the quality of care, and preventing nurse turnover, it is crucial to comprehend the factors contributing to absenteeism in nursing. However, to the best of our knowledge, a broad review has yet to be conducted on nurse absenteeism in Iran. In this regard, this research aimed to investigate and identify the factors associated with nurses' absenteeism in clinical settings.
2 │ Methods
The current narrative review was conducted in 2021, focusing on factors contributing to nurse absenteeism. To gather relevant articles, searches were conducted in Persian databases (Magiran and the Scientific Information Database) and international databases (PubMed and Google Scholar search engine) using a combination of keywords including "Absenteeism" and "Nurses", along with Boolean operators such as "OR" and "AND" in the title and abstract. Manual searches were also conducted in reputable journals, and reference lists of selected papers were checked for comprehensive coverage. Only studies published between January 2015 and February 2021 were included. Inclusion criteria considered publication within the specified timeframe, relevance to nurse absenteeism, geographic location in Iran, and publication in Persian or English with full-text availability. Exclusion criteria involved conference presentations, educational articles, non-reputable journal publications, and letters to the editor. Initially, 19,576 articles were screened, with eight pieces meeting the eligibility criteria after eliminating duplicates and irrelevant studies. Data were extracted using a checklist, including sample size, study location, period, type, and results. Duplicate studies were removed, and three experienced researchers assessed the articles for quality and biases (Figure 1). Ethical principles were observed throughout the process, and the results related to nurse absenteeism were summarized in an Extraction Table and analyzed. The Endnote V.7 reference management software was used for organization and duplicate identification .
3 │ Results
The present study examined and identified the factors influencing nurse absenteeism. The results indicated that various factors play a significant role in nurse absenteeism. Therefore, the present study investigated and identified the influential factors in nurse absenteeism and proposed solutions to address the issue.
One methodological challenge in analyzing studies related to nurse absenteeism is interpreting the collected data on absenteeism. Comparing studies using questionnaires and similar approaches may lead to results distortion. Individual characteristics of managers and internal organizational policies in healthcare services are among the incompatible factors preventing results publication. Most studies use a quantitative approach, which sometimes limits the analysis of absenteeism phenomena or is associated with some shortcomings in statistical analysis.
The chosen studies provided some evidence to support the previous findings that the nursing organization, illness, and management contribute to the rise of absenteeism among nurses [10, 11]. Also, the results showed that the primary reason for increased nurse absenteeism was frequent organizational structure changes compared to patient care processes changes. Research on the determinants of nursing professionals' job retention showed that nurses were prone to resign due to the instability of their work shifts. In addition, workplace policies that reduced employee satisfaction, commitment, and job performance were identified as contributing factors, as many nurses reported unprofessional conduct and expressed a general inclination towards leaving their jobs . Contrary to previous findings, the organization's capacity and flexible behavior towards employees have a lesser impact on job dissatisfaction, lack of professional commitment, high absenteeism, stress indicators, and low motivation. Also, the necessity of the nurses' work within a healthcare system is influenced by the work's physical environment, the activities needed, personnel and organization, and cultural aspects. The reason for absenteeism was the conflicting relationship between these factors, which resulted from differences in the study backgrounds. However, based on multiple reasons for absenteeism in some studies, physical and mental health indicators, work-related health, nurses' health, influenced by the work's physical environment, activities that need to be performed, personnel, and cultural aspects. The incompatible relationship between these factors was identified as the cause of absenteeism due to differences in the background of the studies.
From a sociological perspective, young individuals, smokers, people with a history of mental disorders, those with low physical activity levels, and individual’s dependent on alcohol are more susceptible to absenteeism . Unfavorable work environment, longer working hours, excessive workload, unsuitable working conditions, equipment shortages, inadequate staffing, lack of reward system, and inconsistent decision-making were identified as other causes of absenteeism. Also, factors related to health, such as the effects of work on the family, negative emotional symptoms, changes in work and salary, and similar reasons, have been acknowledged as significant determinants for explaining an individual's professional performance.
Additionally, evidence suggested that musculoskeletal disorders are the third most common reason for nursing absenteeism. These issues were attributed to added strain during patient transfers and other care activities due to inadequate staffing, unfair workload distribution, and interpersonal conflicts within the same team. However, back pain was shown to be a reason for work absence in two one-year studies, with personnel having turnover indicators for at least one day, including chronic and acute pain [13, 14].
Furthermore, no evidence was found regarding the effectiveness of technical training programs related to patient immobility, such as solutions for preventing back injuries. Other musculoskeletal disorders were associated with individual characteristics such as gender, age, body mass index, other illnesses, and lack of regular exercise [14, 15].
Burnout syndrome was another factor in nurses' absenteeism that was identified. While burnout was not confirmed as a reason for absenteeism, however was recognized as a result of role conflicts. Also, psychological and mental health aspects and the impact of job satisfaction were reported and evaluated  (Supplementary Table 1).
Figure 1. Data collection procedure.
4 │ Limitations
This study on nurse absenteeism has several limitations that should be considered. It primarily focused on articles published in a narrow timeframe (January 2015 to February 2021) within the geographical context of Iran, potentially missing relevant research from other time periods or regions. The study's language bias towards Persian and English may have excluded valuable findings in other languages. Publication bias, methodological heterogeneity, and data quality variations among the included articles could impact the reliability and generalizability of the findings. The study also does not extensively address qualitative aspects of nurse absenteeism or the interrelationships among the identified factors.
5 │ Clinical implications to nursing practice
The findings of the study have important implications for nursing practice in addressing and mitigating nurse absenteeism. In this regard, healthcare institutions should prioritize creating supportive workplace policies that ensure employee satisfaction, minimize job dissatisfaction, and reduce unprofessional conduct. Promoting the physical and mental health of nursing staff, along with individualized interventions, is crucial to combat absenteeism. Also, essential factors include preventing burnout, addressing role conflicts, providing mental health support and stress management programs.
6 │ Recommendations for future research
The findings of the study have important implications for nursing research. There are several areas that future research should focus on to better understand nurse absenteeism. Longitudinal studies should be conducted to track the evolution of factors contributing to absenteeism. It is also crucial to evaluate the effectiveness of interventions, such as wellness programs and policy changes, designed to reduce absenteeism. Psychological well-being, burnout, job satisfaction and absenteeism should also be prioritized for in-depth exploration. Research should assess the long-term health outcomes of nurses who experience absenteeism and evaluate the impact of different demographic and risk factors. Preventive measures for musculoskeletal disorders, comparative international studies, and methodological advances to enhance understanding of absenteeism in the nursing profession should also be addressed. These research areas hold significant potential to inform evidence-based strategies to reduce absenteeism and enhance the overall well-being of nursing professionals.
7 │ Conclusions
While knowledge of barriers and interventions can significantly reduce absenteeism, they cannot fully address the issue. Most studies have concluded that individual factors are the primary reason for absenteeism. This study investigates the independent factors contributing to absenteeism, including macro dimensions like the organization and micro dimensions like interpersonal relationships, individual factors, and location. Other factors examined include workflow, stress, burnout, overwork, bullying, job satisfaction, and the specific work environment.
Substantial contributions to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work: ZS, HJ, FB, RSM; Drafting the work or revising it critically for important intellectual content: ZS, HJ, FB, RSM; Final approval of the version to be published: ZS, HJ, FB, RSM; Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved: ZS, HJ, FB, RSM.
Ethics approval and consent to participate
The research was approved by the ethics committee of Golestan University of Medical Sciences, Gorgan, Iran (IR.GOUMS.REC.1400.063).
We do not have potential conflicts of interest with respect to the research, authorship, and publication of this article.
Availability of data and materials
The datasets used during the current study are available from the corresponding author on request.
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This is an open access article under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (CC BY-NC 4.0).
© 2023 The Author(s).