Annotated bibliography 12 articles

RESEARCH ARTICLE

Critical care nurses’ communication

experiences with patients and families in an

intensive care unit: A qualitative study

Hye Jin Yoo
1
, Oak Bun Lim

1
, Jae Lan ShimID

2*

1 Department of Nursing, Asan Medical Center, Seoul, South Korea, 2 College of Medicine, Department of

Nursing, Dongguk University, Gyeongju, South Korea

* [email protected]

Abstract

This study evaluated the communication experiences of critical care nurses while caring for

patients in an intensive care unit setting. We have collected qualitative data from 16 critical

care nurses working in the intensive care unit of a tertiary hospital in Seoul, Korea, through

two focus-group discussions and four in-depth individual interviews. All interviews were

recorded and transcribed verbatim, and data were analyzed using the Colaizzi’s method.

Three themes of nurses’ communication experiences were identified: facing unexpected

communication difficulties, learning through trial and error, and recognizing communication

experiences as being essential for care. Nurses recognized that communication is essential

for quality care. Our findings indicate that critical care nurses should continuously aim to

improve their existing skills regarding communication with patients and their care givers and

acquire new communication skills to aid patient care.

Introduction

Critical care nurses working in intensive care units (ICUs) care for critically-ill patients, and

their work scope can include communicating with patients’ loved ones and care givers [1]. In

such settings, nurses must make timely judgments based on their expertise, and this requires a

high level of communication competency to comprehensively evaluate the needs of patients

and their families [2,3]. The objective of nurses’ communication is to optimize the care pro-

vided to patients [4]. Therapeutic communication, a fundamental component of nursing,

involves the use of specific strategies to encourage patients to express feelings and ideas and to

convey acceptance and respect. In building an effective therapeutic relationship, a focus on the

patient and a genuine display of empathy is required [5]. Empathy is the ability to understand

and share another person’s emotions. To convey empathy towards a patient, one must accu-

rately perceive the patient’s situation, communicate that perception to the patient, and act on

the perception to help the patient [6]. Effective communication based on empathy not only

contributes greatly to the patient’s recovery [3,5–7], but also has a positive effect of improving

job satisfaction by nursing with confidence [8] In contrast, inefficient communication leads to

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OPEN ACCESS

Citation: Yoo HJ, Lim OB, Shim JL (2020) Critical

care nurses’ communication experiences with

patients and families in an intensive care unit: A

qualitative study. PLoS ONE 15(7): e0235694.

https://doi.org/10.1371/journal.pone.0235694

Editor: Liza Heslop, Victoria University,

AUSTRALIA

Received: January 21, 2020

Accepted: June 21, 2020

Published: July 9, 2020

Copyright: © 2020 Yoo et al. This is an open
access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the manuscript.

Funding: This work was supported by the Dongguk

University Nursing Academy-Industry Cooperation

Research Fund of 2018.The funder had no role in

study design, data collectionand analysis, decision

to publish, or preparation of the manuscript

Competing interests: The authors have declared

that no competing interests exist.

complaints and anxiety in patients and can also lead to other negative outcomes, such as

extended hospital stays, increased mortality, burnout, job stress, and turnover [9,10].

Therefore, communication experiences need investigation since effective communication is

an essential for critical care nurses. Nurses use curative communication skills to provide new

information, encourage understanding of patient’s responses to health troubles, explore

choices for care, help in decision making, and facilitate patient wellbeing [11]. Particularly,

patient- and family-centered communication contributes to promoting patient safety and

improving the quality of care [12,13]. However, communication skills are relatively poorly

developed among critical care nurses compared to nurses in wards and younger and less expe-

rienced nurses than in their older and more experienced counterparts [3,7,14–16]. This calls

for an examination of the overall communication experiences of critical care nurses.

To date, most studies on the communication of critical care nurses have been quantitative

and have evaluated work performance, association with burnout, and factors that hinder com-

munication [2–4,7]. A qualitative study has examined communications with families of ICU

patients in Korea [17], while an international study has identified factors that promote or hin-

der communication between nurses and families of ICU patients [16,18]; however, few studies

have been conducted on participant-oriented communication (including patients and fami-

lies). Nurses’ communication with patients and their families in a clinical setting is complex

and cannot be understood solely on the basis of questionnaire surveys; therefore, these com-

munication experiences must be studied in depth.

This study explored critical care nurses’ communication experiences with patients and their

families using an in-depth qualitative research methodology. This study will help to enhance

communication skills of critical care nurses, thereby improving the quality of care in an ICU

setting.

Materials and methods

Design

This study employed a qualitative descriptive design using focus-group interviews (FGIs) and

in-depth individual interviews and was performed according to the consolidated criteria for

reporting qualitative research (COREQ) checklist [19]. An FGI is a research methodology in

which individuals engage in an intensive and in-depth discussion of a specific topic to explore

their experiences and identify common themes based on the interactions among group mem-

bers [20]. Individual in-depth interviews were also conducted to complement the content

identified in FGIs and further explore the deeper information developed based on experiences

at the individual level.

Participants

Sixteen critical care trained nurses providing direct care to patients in an ICU of a tertiary hos-

pital in Seoul were included in this study. The purpose of this study and the contents of the

questionnaire were explained to them, and they voluntarily agreed to participate and complete

the questionnaire. The exclusion criteria were as follows: 1) nurses with a hearing problem; 2)

nurses with less than 1 year of clinical experience; and 3) nurses diagnosed with psychiatric

disorders.

Snowball sampling—in which participants recruit other participants who can vividly share

their experiences regarding the topic under investigation—was used. Six participants for the

first FGI, six for the second FGI, and four for the individual in-depth interviews were

recruited. All participants were women (mean age = 29.0 years old; mean nursing experi-

ence = 4.5 years). Their characteristics are listed in Table 1.

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Data collection

Developing interview questions. The interview questions were structured according to

the guidelines developed for the focus-group methodology [21]: 1) introductory questions, 2)

transitional questions, 3) key questions, and 4) ending questions. The questions were reviewed

by a nursing professor with extensive experience in qualitative research and three critical care

nurses with more than 10 years of ICU experience (Table 2). These questions were also used

for individual face-to-face in-depth interviews.

Conducting FGIs and individual interviews. The two FGIs and four individual inter-

views were conducted between July 20, 2019 and September 30, 2019. The FGIs were moder-

ated by the principal female investigator and were conducted in a quiet conference room

where participants were gathered around a table to encourage them to talk freely. The FGIs

were audio-recorded with the participants’ consent, and the recordings were transcribed and

analyzed immediately after. Similar content was observed from the two rounds of FGIs, and

we continued the discussion until no new topics emerged.

To complement the FGIs and verify the results of the analysis, we also conducted individual

interviews of four participants. One assistant helped in facilitating the interviews and took

notes. The duration of each interview was about 60–90 minutes.

Ethical considerations and investigator training and preparation. This study was

approved by the institutional review board of the Asan Medical Center (approval no. 2019–

0859). Prior to data collection, participants provided written informed consent and were

informed in advance that the interviews would be audio-recorded, their participation would

remain confidential, the recordings and transcripts would only be used for research purposes,

the data would be securely stored under a double lock and would be accessed by the investiga-

tors only, and personal information would be deleted upon the completion of the study to

eliminate any possibility of a privacy breach. The collected data were coded and stored to be

accessed by the investigators only to prevent leakage of any personal information.

The authors of this study are nurses with more than 10 years of ICU experience and a deep

understanding of critical care. The principal investigator took a qualitative research course in

Table 1. Participant characteristics.

No. Sex Age (years old) Intensive care unit experience (months) Marital status Highest Educational Level

1 F 28 30 Single University

2 F 27 30 Single University

3 F 27 29 Single University

4 F 29 27 Single University

5 F 27 24 Single University

6 F 26 24 Single University

7 F 26 22 Single University

8 F 26 22 Single University

9 F 26 22 Single University

10 F 26 20 Single University

11 F 27 20 Single University

12 F 26 20 Single University

13 F 29 40 Single University

14 F 37 168 Married Master’s

15 F 38 180 Married Master’s

16 F 39 188 Married Master’s

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graduate school and has conducted multiple qualitative studies to enhance her qualitative

research experience.

Data analysis

We utilized Colaizzi’s [22] method of phenomenological analysis to understand and describe

the fundamentals and meaning of nurses’ communication experiences with patients and fami-

lies. Data analysis was conducted in seven steps: 1) Recording and transcription of the in-

depth interviews (all authors read the transcripts repeatedly to better understand the partici-

pants’ meaning); 2) Collection of meaningful statements from phrases and sentences contain-

ing phenomena relating to the communication experiences in the ICU. We extracted

statements overlapping with statements of similar meaning—taking representative ones of

similar statements—and omitted the rest; 3) Searching for other interpretations of participant

statements using various contexts; 4) Extraction of themes from relevant meanings and devel-

opment of a coding tree, with the meanings organized into themes; 5) Organization of similar

topics into a more general and abstract collection of themes; 6) Validation of the collection of

themes by cross-checking and comparing with the original data; 7) After integrating the ana-

lyzed content into one technique, the overall structure of the findings was described.

During data analysis, we received advice on the use of language or result of analyzing from

a nursing professor with extensive experience in qualitative research and had the data verified

by three participants to establish the universality and validity of the identified themes.

Establishing precision

The credibility, fittingness, auditability, and confirmability of the study were evaluated to ana-

lyze our findings [23]. To increase credibility, we conducted the interviews in a quiet place to

Table 2. List of interview questions.

Question

Type

Questions

Introductory What kind of care do you provide to your patients and their families as an ICU nurse?

Transitional As an ICU nurse, how is your communication with your family now?

Key What is your primary focus when communicating with patients and their families?

Do you have memorable experiences in your communication with your patients’ families?

a) If so, what were these experiences?

b) How do you feel about those experiences?

Do you have your own strengths in communicating with patients and their families?

a) If so, what are their advantages?

b) What role do your strengths play in communication?

c) What is the impact of communication on nursing?

Have you ever faced difficulties in communicating with patients’ families?

a) If so, please specify them.

b) What is the impact of these communication difficulties on your patients and their families?

c) How do these communication difficulties affect nursing?

Have you made any personal effort to communicate effectively with patients and their families?

a) If so, what have you done specifically?

b) How does the effort/s you have made affect your communication with patients and their

families?

Do you need hospital or external help to improve communication with your patients and their

families?

a) If so, what specific help do you need?

b) How do you feel about the changes in communication style with patients and families when

support and help are provided?

What does communication with the patients and their families mean to the nurse?

Ending Is there anything you would like to add?

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focus on participants’ statements and help participants feel comfortable during interviews; to

establish the universality and validity of the identified themes, data verification was performed

by three participants. To ensure uniformity in data, participants who could provide detailed

accounts of their experiences were selected, and the data were collected and analyzed until sat-

uration was achieved (i.e., no new content emerged). To ensure auditability, the raw data for

the identified themes were presented in the results, such that the readers could understand the

decision-making process. To ensure confirmability, our preconceptions or biases regarding

the participants’ statements were consistently reviewed to minimize the impact of bias and

maintain neutrality.

Results

After analyzing the communication experiences of 16 critical care nurses, three major themes

emerged: facing unexpected communication difficulties, learning through trial and error, and

recognizing communication experiences as being essential for care. The results are summa-

rized in Table 3.

The results of this study are schematized based on Travelbee’s Human-to-Human Relation-

ship Model [24,25] (Fig 1), which suggests that human-to-human interaction is at a develop-

mental stage. In this study, communication between patients and their families and

experienced nurses in ICUs promotes human-to-human connections, leading to a genuine

caring relationship through interaction, empathy, listening, sharing, and respect, which are all

therapeutic communication skills.

Theme 1: Facing unexpected communication difficulties

Nurses experienced more difficulties in communicating with patients and their families and

caregivers than in performing essential nursing activities (e.g., medication administration, suc-

tion, and various mechanical operations) The communication difficulties they experienced

were either nurse-, patient- and family-, or system-related. Distinct problems in an ICU are

related to urgency; for example, hemodynamically unstable patients or patients with respira-

tory failure or those suffering from a cardiac arrest may be prioritized.

Nurse-related factor: True intentions were not conveyed as wished. Although nurses

intend to treat patients and their families with empathy, they frequently lead one-way conver-

sations when pressed for time in the ICU. In addition, their usual way of talking, such as their

dialect and intonation, can sometimes be misunderstood and cause offense. Participants expe-

rienced difficulties communicating their sincerity to patients and their families.

“Oftentimes, I only say what I have to say instead of what the caregivers really want to know

when I’m pressed for time to convey my thoughts and go on to the next patient to explain

things to the other patient.” (Participant 2)

“I usually speak loudly, and I speak in dialect; so, things I say are not delivered gently. . .I

try to be careful because my dialect can seem more aggressive than the Seoul dialect; but it’s

not easy to fix what I have used for all my life at once.” (Participant 3)

Nurse-related factor: Hesitant to provide physical comfort. Participants were not famil-

iar with using non-verbal communication. The participants realized the importance of both

verbal communication and physical contact in providing care, but the application of both

these communication styles was not easy in clinical practice.

“I want to console the caregivers of patients who pass away; but I just can’t because I get

shy. I feel like I’m overstepping, and when I’m contemplating whether I can really speak to

their emotions, the caregiver has already left the ICU in many cases.” (Participant 6)

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Table 3. Critical care nurses’ communication experience with patients and their families.

Sub-category Category Theme

Theme 1: Facing unexpected communication

difficulties

In critical care, communication with patients and their

family is burdensome

1.1. True intentions not conveyed as wished Nurse-related

Misunderstanding because of the linguistic characteristics

of a nurse (e.g., dialect, voice tone, etc.)

Impatience/lack of care for patients and caregivers

ICU nurses need both verbal and nonverbal

communication skills

1.2. Hesitant to provide physical comfort

Nonverbal communication is unfamiliar

Not sure how to effectively provide nonverbal

communication

Patient in ventilator feels frustrated because he or she

cannot speak

1.3. Mechanical ventilation hindering communication

with the patient

Patient- and family-related

Difficulty understanding because the patient is on a

ventilator and thus cannot speak

Ventilator interferes with the communication between

nurse and patient

ICU patient’s caregiver is sensitive 1.4. Caregivers’ negative responses to nurses

Normal communication is impossible owing to caregivers’

aggressive attitude

As an ICU nurse, I have no choice but to respond to the

conversation

I have not learned properly about communication in the

clinic

1.5. Lack of experience and a mismatch between

theory and practice

System-related

Communication is the most difficult task for less

experienced, young nurses

The scheduled visit time in the intensive care unit is when

most communication occurs

1.6. Intense visiting hours in limited time

One-way conversation with the caregiver in a short period

Life-dependent care is a priority in the intensive care unit 1.7. Urgent workplace that deprioritizes

communication

Insufficient time to talk with patients and caregivers owing

to heavy workload

Nurses are hurt by distrustful patients and caregivers 2.1. Fundamental doubts about the nursing profession Theme 2: Learning through trial and error

Difficulty in nursing because of trauma from patients and

caregivers

Follow senior nurses and learn practical communication 2.2. Finding out which communication style is better

suited for patients and their families

Explains the patient’s daily life in detail

Communication is indispensable to nursing 2.3. Knowhow learned through persistent effort

Studying the lack of communication by searching books

and videos

Understand the anxiety and difficulties experienced by the

critically ill and their caregivers

3.1. Empathy garnered through various clinical

experiences

Theme 3: Recognizing communication

experiences as being essential for care

Nurse’s words have the power to make the patients and

their families cry or laugh

Listening as an intensive care nurse is more important than

talking

3.2. The power of active listening

Nurse empathy strengthens patients and caregivers and

enhances their feelings of control

Patients and caregivers are easy to reach 3.3. Mediator between physicians, patients, and

caregivers

(Continued)

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“I’m really bad at physical contact even with my close friends; but I’m even worse when it

comes to patients and caregivers. Because of my tendency, there are times when I hesitate to

touch patients while providing care.” (Participant 7)

Patient- and family-related factor: Mechanical ventilation hindering communication

with the patient. Mechanical ventilators were the greatest obstruction to communication in

ICU. Although it is normal for patients on a mechanical ventilator to lose the ability to speak,

patients and their families did not understand how mechanical ventilators work and were frus-

trated that they could not communicate freely with the patient. Participants expressed diffi-

culty in communicating with patients in ways other than verbal communication as well.

“Patients who are on mechanical ventilation can’t talk as they want and do not have enough

strength in their hands to write correctly; so, even if I try to listen to them, I just can’t

Table 3. (Continued )

Sub-category Category Theme

Nurses use words that are easy to understand

Nurses convey sincerity to others with respect and

understanding

3.4. Expressing warmth and respect

Nurses’ heartfelt expressions promote trust

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Fig 1. Summary of communication experiences encountered by intensive care unit nurses.

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understand what they are saying. You know in that game where people wear headphones play-

ing loud music and try to communicate with one another—words completely deviant from the

original word are conveyed. It just feels like that.” (Participant 9)

“Patients on mechanical ventilation and who thus cannot communicate are the most diffi-

cult. The patient keeps talking; so, it hinders respiration—the ventilator alarm keeps going off,

the stomach becomes gassy, and the patient has to take the tube off and vomit later. No matter

how much I explain, there are patients or caregivers who tell me that the tube in the throat is

making [it] hard [for them] to breathe or [they] ask me to take it off just once and put it back

on, and these patients are really difficult. There is no way to communicate if they cannot accept

mechanical ventilators even if I explain.” (Participant 8)

Patient- and family-related factor: Caregivers’ negative responses to nurses. It was also

burdensome for nurses to communicate with extremely stressed caregivers and loved ones,

especially when patients were in a critical state. Despite the role of nurses in helping patients

during health recovery, caregivers’ negative responses to nurses, such as blaming them and

speaking and behaving aggressively, intimidated the participants and ultimately discouraged

conversations.

“I can manage the patients’ poor vital signs by working hard but communicating with sensi-

tive caregivers who project their anxiety about the patient’s state onto nurses doesn’t go as I

wish, so, it’s really difficult and burdensome.” (Participant 6)

“When the patient is in a bad state, caregivers sometimes want to not accept it and project

their feelings onto the nurses, and in such cases, there are no words that can console them.

Even approaching the caregivers is a burden, and I get kind of intimidated.” (Participant 5)

System-related factor: Lack of experience and a mismatch between theory and prac-

tice. Participants have learned the importance of communication during training; however,

they had trouble appropriately applying the learned concepts in their workplace. Participants

in this study were in their 20s and 30s, with limited life and social experiences, and felt the gap

between theory and practice in communicating with patients and families in ICU.

“Talking to the patient or caregiver was the most challenging thing when I was new. . .it is

impossible for nurses with not much life experience to communicate skillfully.” (Participant

10)

“It would be nice if the real-world conversation proceeds in the way shown in our textbook;

but it doesn’t in most cases. So, it is more practical to observe and learn from what other nurses

do in the actual field.” (Participant 2)

System-related factor: Intense visiting hours in limited time. The 30-minute ICU visit-

ing period is the only time when patients and families can talk to one another. Although nurses

are well trained to care for the patients to the best of their ability, caregivers distrust the nurses’

ability to care for patients since caregivers only have a limited amount of visiting time, thus

hindering effective communication. Some participants even experienced mental trauma fol-

lowing short but unforgettable interactions with caregivers.

“. . .the caregiver browbeat me and intimidated me for doing so. This gave me a mental

trauma for visiting hours. . .I didn’t know how to start a conversation and the visiting hours

were really stressful for me.” (Participant 3)

“The caregivers don’t stay in the ICU for 24 hours; so, once they begin to doubt our nursing

practice, we cannot continue our conversation with them. . .” (Participant 11)

System-related factor: Urgent workplace that deprioritizes communication. The ICU

is a unit for treating critically-ill patients; therefore, ICU nurses were more focused on tasks

directly linked to maintaining patients’ health, such as stabilizing vital signs, than on commu-

nication. Participants frequently encountered emergency situations, in which they could not

idly stay around to communicate with one patient because another required immediate

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assistance, i.e., they faced a reality in which they had to prioritize another patients’ health over

communication with one.

“. . .I’m really pressed for time when the patient keeps writing things I can’t understand

with their weak hands. . .I don’t have time to spare even if I want to listen to them.” (Partici-

pant 12)

“Vital signs are the utmost priority in [the] ICU. I’m on my feet the entire shift and don’t

even have time to go to the restroom. . .During early ICU treatment, there are a lot of emer-

gency situations; so, communication is way down in the priority list.” (Participant 5)

Theme 2: Learning through trial and error

The negative experiences arising from communicating with various individuals sometimes

forced nurses to think twice about their vocation; however, due to a sense of responsibility,

they tried to engage in therapeutic communication and to overcome difficulties.

Fundamental doubts about the nursing profession. Experiencing unfriendly and con-

frontational conversations with patients and caregivers was intolerable for participants. These

experiences were shocking enough to make them fundamentally question their decision to

choose and stay in the nursing profession.

“I felt so disappointed and frustrated when patients or caregivers bombard[ed] rude com-

ments at me with complete disregard of what I have done over a long period. . .I can’t sleep

well at night and my values as [a] nurse are shaken from their root.” (Participant 14)

“It becomes so difficult the moment communication fails and mutual trust is lost. Maybe I

could survive if this is just with one patient or caregiver; but the afterimage lingers with me persis-

tently while I’m working. . .I came to think whether I could continue nursing.” (Participant 7)

Finding out which communication style is better suited for patients and their fami-

lies. Nurses learned how to resolve communication-related difficulties that they encountered

from their seniors and mentors and tried to communicate better from their position at the

nursing station.

“A senior nurse of mine was talking to a caregiver who was really concerned, and she was

using affirmations like ‘Oh, really’ and ‘I see’ with a relaxed facial expression, and the caregiver

would spill her heart out to her. That’s when I thought that empathy is to express responses to

what the other person is saying.” (Participant 10)

“I can feel that I am able to bond with patients’ families when I tell them about the patient’s

daily living, such as how much the patient had slept, eaten, and whether the patient was not in

pain, during visiting hours.” (Participant 13)

Knowhow learned through persistent effort. Nursing activities, such as taking vital signs

and performing aspiration and intravenous injection, are learned over time; however, it is

impossible to acquire therapeutic communication skills without personal effort and interactive

experiences in the field.

“I’m reading a book about conversation and am learning about how to express empathy and

understand other people. . .Nursing skills are developed and improved over time; but it’s not easy

to enhance communication without personal effort or change in perception.” (Participant 16)

“Communication is an indispensable part of nursing. If you want to provide high-quality

care, you need to enhance your communication skills first.” (Participant 15)

Theme 3: Recognizing communication experiences as being essential for

care

Nursing and communication are inseparable. Although communication is a challenge while

caring for ICU patients, therapeutic communication is important for the patients’ and their

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families’ overall wellbeing. In an ICU, communication based on empathy and experience is a

significant component that helps patients perceive their illnesses more positively.

Empathy garnered through various clinical experiences. Since participants met many

patients and their families in the ICU, they were able to communicate. Participants understood

patients’ discomfort and learn why it was difficult for them to communicate and to comfort

and assure unease families who could not observe the patient’s condition. However, it was a

necessary communication method in the ICU. Participants realized the value and importance

of their words.

“. . .his endotracheal tube was touching his throat and was so uncomfortable: his mouth

was dry, he couldn’t talk, and his arms were tied; so, he thought the only way to communicate

was to use his legs and that’s why he was kicking. I felt really sorry. . .” (Participant 7)

“I gave a little detailed explanation to the caregiver during visiting hours and she thanked

me overwhelmingly. I feel that, because this is the ICU, patients and caregivers can be encour-

aged and discouraged by the words of the medical professionals.” (Participant 9)

The power of active listening. Although the ability to handle tasks promptly is important,

listening to patients amid the hectic work schedule in the ICU is also an important nursing

skill. Critical care nurses realized that listening to patients and caregivers without saying any-

thing is also meaningful and therapeutic.

“I was listening to the caregiver the entire duration of the visiting hour. . .She said that she

just had to open up to someone to talk about her frustrations, and that my listening to her was

a huge consolation for her.” (Participant 12)

“While listening to the caregiver and showing empathy every day at the same time, I was

able to witness that the caregiver who had been aggressive and edgy changed in a way to trust

in and depend on the nurse more.” (Participant 16)

Mediator between physicians, patients, and caregivers. Participants were at the center

of communication, serving as the bridge connecting physicians to patients and patients to

caregivers. They served as mediators, explaining the doctors’ comments to the caregivers, and

providing details regarding the patients’ state to families. Participants helped maintain a close

and balanced relationship between the doctor, the patients, and their families by conveying

messages not effectively communicated by the doctor or patients.

“Caregivers would not ask any questions to the doctor in the ICU and would ask me instead

once the doctor is gone. They would ask, ‘what did the doctor say?’ and ask me for an explana-

tion.” (Participant 4)

“The patients can’t say everything they want; so, as nurses, we are the mediators between

patients and caregivers. . .Tell[ing] the family about things that happened when they were not

around the patient is meaningful.” (Participant 14)

Expressing warmth and respect. Participants have experienced sharing emotions with

the patient’s family as well as with the patient during disease improvement and exacerbation.

In particular, sincere actions, such as staying with the families of patients who died or those

whose condition was deteriorating, led to more genuine relationships, as respect for human

life was expressed.

“When patients whom we have spent a long time [with] are about to pass away, we cry for

them and we stay beside them in their final moments. . .Showing respect for a person’s final

moments of life and expressing our hearts is meaningful, and it is something critical care

nurses must do.” (Participant 16)

“When the patient’s state worsened and. . .his daughter was sobbing next to him. . .I softly

touched her shoulder, and she really thanked me. As I saw the patient’s family grieve, I just

expressed how I felt, and, fortunately, my intention was well conveyed” (Participant 4)

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Discussion

This study evaluated critical care nurses’ communication skills and experiences with patients

and their caregivers. Based on the two FGIs and four individual in-depth interviews, three

themes have been identified: 1) facing unexpected communication difficulties; 2) learning

through trial and error; and 3) recognizing communication experiences as being essential for

care

For theme 1, we examined nurse-, patient-, family-, and system-related (i.e., pertaining to

hospital resources and education) factors. Theme 1 can be considered as the communication

involving human-to-human interaction, as mentioned in Travelbee [24,25], that takes place at

an incomplete stage. First, critical care nurses struggled with balancing their heavy workload

and communicating with patients and their families. In Korea, an ICU nurse, on an average,

cares for two to four patients, which is higher than in some other countries, wherein an ICU

nurse cares for one or two patients at the most; thus, the Korean work environment for ICU

nurses is more stressful [26]. This limits the amount of time nurses may have to communicate

and interact with their patients and caregivers. Misunderstandings are also common owing to

the patients’ inability to speak while intubated and to use of regional dialects. Patients and

caregivers want to hear specific and comprehensible information from health professionals

regarding the treatment procedures in the ICU [17,27]. However, previous studies [4,28] have

reported that critical care nurses experience communication difficulties due to high mental

pressure due to work, time constraints, and the inability to use their own language; these are

consistent with our findings. As nurses are required to interact with patients having various

needs, they need to learn how to communicate verbally and nonverbally in a sophisticated

manner [27], and hospital managers should implement practical communication programs in

the ICU.

Communication between nurses and their patients in the ICU is also often adversely

affected by the therapeutic environment, such as patient emergencies and the use of mechani-

cal ventilation [27,28]. Mechanical ventilators are one of the greatest obstacles to communica-

tion. Although they are essential for critically-ill patients who are incapable of spontaneous

breathing, they affect their ability to speak [29]; therefore, these patients need to employ other

strategies for communication, such as using facial expressions and lip movements, which

make communication extremely difficult [27,30]. Our participants strived to understand the

needs of critically-ill patients through verbal and nonverbal communication, such as writing

and body language. However, when the intentions were not conveyed properly, some patients

responded aggressively, hindering respiratory treatment and ultimately prolonging treatment.

This is in line with many previous findings [29,31,32] indicating that patients’ failure to effec-

tively express their needs to nurses or their family members triggers negative emotions. In

addition, participants had trouble interacting with caregivers who were extremely tense and

sensitive. According to Lee and Yi [17], families of critically-ill patients experience fear and

anxiety regarding the patients’ health state and strive to save the patient. Thus, nurses must

consider this when addressing vulnerable patients and their families and must actively identify

and resolve causes of discomfort in patients on mechanical ventilation (i.e., by using appropri-

ate analgesics/sedatives and removing the ventilator). Further, considering a systematic review

revealing that electronic communication devices enable efficient communication with criti-

cally-ill patients through touch or eye blinks [33], Korea should also keep abreast with techno-

logical advances in communication technology.

Concerning theme 2, as participants experienced emotional exhaustion from being misun-

derstood or unfairly criticized by patients and their families, they contemplated and doubted

the occupational values of nursing. Park and Lee [7] found that higher job satisfaction for ICU

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nurses is associated with better communication. This is consistent with our participants’ doubt

for choosing the nursing profession. However, instead of giving up on this profession, they

closely observed the effective communication skills of more experienced nurses, actively

learned about therapeutic communication through books and videos, and applied their learn-

ings during practice. Similar results were reported by Park and Oh [3] that patient-centered

communication competency among critical care nurses was the highest when a biopsychoso-

cial perspective, focused on delivery of factual information, was followed and the lowest in the

therapeutic alliance domain, which is required for performing cooperative care with patients.

Therapeutic communication provided by nurses to patients and their families in the ICU effec-

tively diminished their psychological burden and fostered positive responses from families

[34]. Currently, ICUs implement a systematic education system for nurses that focuses on

therapeutic techniques, such as hemodynamic monitoring, mechanical ventilation care, aspi-

ration, and extracorporeal membrane oxygenation; however, they lack a program targeting

effective therapeutic communication with patients and caregivers. The communication diffi-

culties experienced by nurses will persist without this additional program; thus, its implemen-

tation is critical to improve patient satisfaction and nursing quality of care. Further, instead of

coercing unilateral effort from critical care nurses, nurse managers should pay attention to

nurses’ emotional wellbeing and promptly develop systems to offset potential burnout, such as

voluntary counseling systems or measures to “refresh” nurses.

Concerning theme 3, participants learned that communication is a challenging but essential

aspect of critical care. The concept of communication resonates through Travelbee’s model

[24,25]. Getting to know another human being is as important as performing procedures. A

nurse must establish a rapport with the patient and the patient’s caregivers, otherwise he or she

will not know the patient’s needs. As a place where life-and-death decisions are made, the ICU

induces anxiety in critically-ill patients and their caregivers. Hence, nurses should fully empa-

thize with patients and their caregivers [4,5,17].

Travelbee [24,25] emphasized the relationship between the nurse and the patient by estab-

lishing the Human-to-Human relationship model, which gives meaning to disease and suffer-

ing based on empathy, compassion, and rapport building. In addition, it presents concepts,

such as disease, hope, human-to-human relations, communication, interaction, patient’s

needs, perception, pain, finding meaning, therapeutic use of communication, and self-actuali-

zation. The participants cultivated empathy and active listening skills when speaking with

patients and their families, and, as they spend more time doing so, their quality of care and

nonverbal communication skills (such as eye contact, soft touch, and tears) improve and

became more genuine. Our findings are consistent with the meaning of human-centered care

suggested by Jang and Kim [35], which involves paying close attention to and protecting

patients’ lives, deeply empathizing with patients from a humanistic perspective, and being sin-

cere. The experience of nursing, including active interaction, has a positive impact on estab-

lishing the roles and caring attitudes of professional nurses [36], which is significant for critical

care nurses. Patient-family-centered care, which has been confirmed to positively promote

critically-ill patients’ recovery worldwide [1], is possible when nurses engage in therapeutic

communication with patients and their families through dynamic interactions [34,37]. There-

fore, critical care nurses and nurse managers should pay attention to communication and

develop an effective communication course that can be applied in clinical practice. To do this,

first, it is necessary to hire appropriate nursing personnel for active therapeutic communica-

tion with the patients and their families in an ICU. Second, continuous, and diverse educa-

tional opportunities should be provided to critical care nurses, along with policy strategies. For

example, at the organizational level, it is necessary to develop manuals on how to deal with dif-

ficult situations by gathering challenging communication cases from actual clinical practice.

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Simulation education for communication is an important component of the nursing

curriculum.

Limitations

First, this study included a small number of participants; however, we ensured that the maxi-

mum data was collected from these participants. Second, specific information was collected

from only those nurses who provided direct care in the ICU of a general hospital in a large city

in Korea. The homogeneity and dynamics of the focus groups may have resulted in congruent

opinions. Third, because the experiences of nurses from only one hospital were analyzed, cau-

tion should be exercised in generalizing our results and applying them to other hospitals in

Korea. Therefore, follow-up studies with larger sample sizes and more representative partici-

pants are warranted.

Conclusion

This qualitative study explored critical care nurses’ communication skills and experiences with

patients and caregivers from various perspectives. Although these nurses felt discouraged by

the unexpected communication difficulties with patients and their families, they recognized

that they could address these difficulties by improving their communication skills over time

through experience and learning. They realized that empathy, active listening, and physical

interaction with patients and their families enabled meaningful communication and have

gradually learned that effective communication is an indispensable tool in providing nursing

care to critically-ill patients.

Supporting information

S1 File. COREQ checklist and coding tree.

(DOCX)

Acknowledgments

The authors would like to thank all the participants for their time and contribution in this

study.

Author Contributions

Conceptualization: Hye Jin Yoo, Jae Lan Shim.

Data curation: Hye Jin Yoo, Jae Lan Shim.

Formal analysis: Oak Bun Lim, Jae Lan Shim.

Funding acquisition: Jae Lan Shim.

Investigation: Hye Jin Yoo, Oak Bun Lim.

Methodology: Hye Jin Yoo, Jae Lan Shim.

Resources: Oak Bun Lim.

Supervision: Jae Lan Shim.

Validation: Hye Jin Yoo, Oak Bun Lim, Jae Lan Shim.

Writing – original draft: Hye Jin Yoo.

Writing – review & editing: Jae Lan Shim.

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74

Resigning: How nurses work within constraints

Claire O’Donnell, University of Limerick

Tom Andrews, University College Cork

Abstract

This study explores and explains how nurses care for patients with stroke in the acute care setting
and how they process these challenges to enable delivery of care. Using a classic grounded theory
methodology, 32 nurses were interviewed who cared for patients with stroke and twenty hours of
observations were undertaken. Nurses’ main concern is how to work within constraints. In dealing
with this challenge, nurses engage in a process conceptualised as resigning and do so through
idealistic striving, resourcing and care accommodation. Resigning acts as an energy maintenance
and coping strategy, enabling nurses to continue working within constraints. This theory has the
potential to enhance nursing care while reducing burnout and making better use of resources,
while advocating for stroke care improvements.

Keywords: Care provision, constraints, classic grounded theory, nursing, resigning, stroke

Introduction

Quality and safety of patient care is a continued area of concern in healthcare services where
constraints on health expenditure prevail (Aiken et al., 2014; Kirwan et al., 2019). Work envi-
ronments influence patient outcomes where limited nursing staff and resources have a resultant
negative impact on patient care outcomes (Aiken et al., 2014; Griffiths et al., 2021; Jangland et
al. 2018; Rochefort & Clarke, 2010; Schubert et al., 2009). Stroke care in designated specialised
stroke units is associated with improved patient outcomes (Langhorne et al., 2020) however,
despite international consensus on optimum stroke care, wide variations in the delivery of stroke
care across Europe persist (Stroke Alliance for Europe, 2020). Such variations in the location of
stroke care adversely influence care delivery and patient mortality and morbidity (West et al.,
2013; Stroke Alliance for Europe, 2020).

Background

Constraints in the work environment such as reduced staff, lack of time and a lack of resources
are reasons for concern regarding their negative impact on patient care delivery (Chan et al. 2013;
Winsett et al., 2016; Blackman et al., 2018; Griffiths et al., 2021). Nurses caring for patients with
stroke are aware of what optimum stroke care entails however, they often provide a reduced level
of care due to the presence of constraints (Clarke & Holt, 2014; Seneviratne et al., 2009). One
constraint commonly reported as a barrier to optimal nursing is a lack of time (Blackman et al.,

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75

2018; Chan et al., 2013; Clarke & Holt, 2014) and this includes the area of stroke care (Sen-
eviratne et al., 2009). Reduced nurse staffing levels is another constraint associated with in-
creased levels of mortality (Cho et al., 2015; Department of Health, 2018; Fagerström et al.,
2018; Griffiths et al., 2016). Morality also increases with incidence of pressure ulcers and nos-
ocomial infections reported when inadequate nurse staffing levels are present (Cho et al., 2015;
He et al., 2016). In addition, increases in nurses’ workloads demonstrate statistically significant
increase in mortality (Aiken et al., 2014; Fagerström et al., 2018). Limited availability of space,
time and interprofessional support in stroke care has a similar effect (Seneviratne et al., 2009).
Stroke unit care addresses all elements of the staffing and infrastructure required to create safe
specialized care delivery for patients with stroke.

Despite the benefits of stroke unit care, many patients continue to be cared for in the
general acute setting. A national audit of stroke services in Ireland found 29% of patients were
cared for on wards other than stroke units (National Office of Clinical Audit, 2020), similar to
other European countries (Kings College London, 2017). Stroke care provided on non-specialist
wards demonstrates poorer patient outcomes such as higher mortality rates and reduced func-
tional ability compared to specialised stroke units (Langhorne et al., 2020; Stroke Unit Trialists,
2013). Few studies have directly explored or examined how nurses care for patients with stroke
in the general acute setting (Gibbon, 1991; Gibbon & Little, 1995; Hamrin, 1982; Hamrin &
Lindmark, 1990). To our knowledge, no studies have explored this in recent times even though
figures continue to demonstrate substantial variations in location of care delivery for patients with
stroke across Europe.

Methodology

A classic grounded theory methodology was selected as this area is relatively underexplored with
little or no theory to guide practice. As Glaser (2003) suggested, classic grounded theory com-
bines the need for and the promise of relevancy about what is happening within a specific area of
research.

Ethical considerations

Ethical approval was granted from two hospital research ethics committees. Anonymity was
ensured by using pseudonyms and only the researcher had access to the data consistent with the
Nursing and Midwifery Board of Ireland ethical guidelines (2014).

Before engaging in non-participant observations, staff were informed that patient safety
was a priority. Consistent with ethical approval, verbal agreement was sought from nurses and
patients before each observation period. Nobody who was approached refused permission.
During observation periods, the researcher remained as unobtrusive to staff and patients as
possible, where the focus was on viewing nurses delivering care in trying to ensure that
nurses and patients were respected and protected during the process. Nurses and ward
managers were aware of the researcher’s presence and consented to the observation pe-
riods. It was agreed with the nurse manager and the participants that if unsafe care was ob-
served, then the researcher would intervene and the episode reported.

Data collection

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Glaser (2004) highlighted that any form of data can be used to generate theory, however the-
oretical sensitivity is required to ensure the concepts are generated from the data. For this study,
data were collected using interviews and non-participant observations, which took place at ward
level.

Once ethical approval was granted, formal letters of invitation and accompanying in-
formation sheets were delivered in person to all relevant medical and surgical wards where
clinical nurse managers distributed them to all nursing staff during handover. Nurses who were
interested in participating in the study were asked to contact the researcher via the contact
details on the information sheet. Unstructured interviews were used to gather data for analysis in
keeping with the principle of having no pre-determined questions in classic grounded theory
(Glaser, 1978). Following discussion about participation and clarification of any points of concern
about the study, dates, times and a location of choice were arranged individually to meet with
participants. Again, any further queries participants had were answered in relation to the study
prior to the consent form being signed. Encouraging participants to speak freely and listening to
what they were saying directed the follow up questions. Time was spent putting the participants
at ease so they would feel comfortable to speak truthfully and honestly. Murphy et al. (1998)
referred to the importance of a conversational style interview to encourage openness. This was
achieved through general introductions, general social conversation and thanking participants for
their time. Then the aim of the study was discussed answering any questions the participant may
have had on reading the information sheet. Interviews commenced with an open question such as
such as “Can you think back to when you last had a patient with stroke on your ward, and can you
tell me what that was like?” This is what Glaser (1998) referred to as a grand tour question.

Initially, interviews were digitally recorded and transcribed, varying in length from 30 to
60 minutes. Each interview was analysed prior to the next one, enabling the researcher to
generate follow up questions and issues to be explored in what is termed theoretical sampling
(Glaser, 1978). This process was further enhanced by making field notes following each interview,
including nurses with varying levels of experience and sampling in a number of wards (7 wards).

Sampling continued until data saturation, where no new properties emerged for the core
category or sub core categories (Glaser & Strauss 1967; Glaser 1978). A total of 32 nurses; 30
females and 2 males participated ranging in experience from 1 year–40 years, with varying
professional positions (staff nurses, ward managers, clinical nurse specialists) and qualifications
(BSc Nursing, postgraduate diplomas and masters) working on either general medical or surgical
wards caring for patients with stroke (O’Donnell & Andrews, 2020).

As data emerged from interviews, theory generation was further supported by
non-participant observations providing a different dimension. Simultaneous to interviews a total
of 20 hours of non-participant observations were undertaken in one medical and one surgical
ward. Observations are another way of gathering data for analysis when undertaking qualitative
studies through observing people, behaviours and/or events (Salmon, 2014; Watson et al., 2010).
Observations are a common method of data collection in grounded theory (Pergert, 2009).
Non-participant observations were undertaken as they allowed the researcher to observe in real
time nurses caring for patients in the general acute care setting and not influence care delivery
through involvement (Watson et al., 2010). Much of the literature reviewed on stroke care re-

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ferred to how nurses spoke of the care they delivered. Undertaking non-participant observations
enabled the researcher to see if this was substantiated in practice and to observe at first-hand
how participants deliver care rather than relying on their self-reports. Time sampling was chosen
as an appropriate method of observation as the timing of non-participant observations was to
cover a full day’s nursing shift providing an overview of the care interactions and behaviours
delivered during different times as well as providing context. A total of 20 hours of
non-participant observations were undertaken. During non-participant observations the re-
searcher took field notes noting date, time, place of observation, details regarding number of
nurses on duty and patients on the ward.

Data analysis

In classic grounded theory data analysis is simultaneous with data collection. It is this constant
analysis that supports theoretical sampling in saturating codes and categories to achieve theo-
retical coverage. Constant comparison occurs within the interview and between interviews,
comparing incident to incident establishing uniformity and varying conditions. Following an in-
terview data was coded before the next interview, thereby facilitating theoretical sampling.

The first phase of data analysis is substantive coding which involves open coding. This is
where Glaser (1978) spoke of analysing line by line for incidents and concepts. Following each
interview data was coded line by line, meaning that each transcript was carefully read and coded.
One continuous pattern of behaviour throughout all interviews, referred to by all participants, was
nurses speaking of how they washed patients, descriptively coded as washing patients; helped
patients to eat, coded as helping patients to eat and/or helped patients to the toilet, coded as
helping patients with toileting. Cognisant that codes are independent of people, time and place,
which makes them enduring these codes were grouped together as they all referred to the same
pattern of behaviour of physically caring for the patient. Collectively these codes then were
conceptualised as functional caring. This concept was subsumed under the sub core category of
Care Accommodation. Using constant comparison, subsequent interviews were coded similarly,
meaning that interviews were coded with previous codes in mind. Once the core category
emerged of “working within constraints,” theoretical sampling and selective coding began in
order to saturate the core category, which was reached following 32 interviews.

Memos were written throughout data collection and analysis. Codes were refined and
became more conceptual in what Glaser (1992) termed conceptual refit. Once relevant theo-
retical codes were identified, the theory met the four classic grounded theory judging criteria of
fit, work, relevance and modifiability representing methodological rigour. The theory of resigning
explains nurses behaviors when caring within constraints meeting the criteria of work. Vigorous
analysis of data from interviews ensured fit, affirmed also during non-participant observations
when nurses patterns of behaviors were observed consistent with concepts already generated
from data collected during interviews. Relevance is evident as the concepts resonate with nurses
in their daily challenges in trying to deliver best patient care and finally modifiability is achieved
through the principle of conceptualisation undertaken in classic grounded theory.

What was observed during non-participatory observation periods was as nurses had
discussed during interviews; no disparities were evident only further evidence of the busy care
environment which nurses deliver care in on a daily basis and their challenge of working within

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constraints. Field notes taken during observation periods were analysed and coded similarly to
interviews. Coding of observation data were undertaken with constant comparison in mind of the
concepts and categories emerging from interviews thus strongly corroborating theory devel-
opment grounding the emergent theory in the participants’ worlds.

The theory of resigning

The theory of resigning explains how nurses work within constraints to deliver best care to pa-
tients with stroke in the acute care setting. Once nurses acknowledge the presence of constraints
such as reduced staff, lack of resources, and time they engage in resigning. Resigning is a re-
luctant acceptance to compromise the quality of the care they deliver, in the interests of patient
safety and to maintain a basic level of care. Resigning acts as energy maintenance and coping
strategy and enacted through idealistic striving, resourcing, and care accommodation.

Idealistic striving

Idealistic striving involves nurses endeavouring to provide the best care possible to their patients.
It comprises of professional connecting, knowledge seeking and cluing in. A precondition of
idealistic striving is having the commitment to provide the best care possible. To support them in
idealistic striving, nurses engage in professional connecting, whereby they initiate and sustain
communication with nursing colleagues and other healthcare professionals identified as being
able to support optimal care for patients. This is achieved by fostering personal relations and
maintaining good working relations with fellow health care professionals by spending time
working with others. Time and staff shortages limit the opportunities available to meet and in-
teract with others.

Professional connecting also helps nurses identify the support they need in idealistic
striving such as knowledge seeking, where nurses continuously look for opportunities through
formal and informal routes to further their knowledge. This may be through structured, evidence
based educational programmes and by learning from others such as fellow nurses, physicians,
and other health care professionals. Knowledge seeking through informal routes is self-directed
and opportunistic and is contingent on being motivated to learn, of which one nurse spoke: “It is
really up to yourself, to show that you are interested in this area, showing that you want to learn
and seeing available opportunities to learn from” (Participant 8).

Knowledge seeking also promotes focused care through being aware of the specifics and
complexities of stroke care such as impaired swallowing, lack of mobility and speech impairment.
Through knowledge seeking, nurses learn what to observe in stroke care, essential for cluing in
where they are constantly alert and responsive to changes in the patient’s condition. Nurses
pre-empt physiological and/or psychological changes in the patient’s condition and respond
appropriately. Cluing in facilitates idealistic striving with its focus on pre-empting changes
through monitoring a patient’s condition to detect changes from normal or sourcing equipment to
support care. One nurse stated:

Once we get a patient with a stroke on the ward we start ringing around to the other
medical wards looking for equipment usually mattresses for the patient as we wouldn’t
have them or they may all be in use at that time. (Participant 9)

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Idealistic striving enables nurses to coordinate, direct and prioritise care, in an attempt to
reduce potential complications.

Resourcing

When resourcing, nurses actively resist the effects of constraints, seeking to overcome con-
straints through time borrowing and badgering in trying to maintain idealistic striving. When
working within constraints, resourcing is always required to ensure a safe level of care. The
greater the degree of resourcing the higher the expenditure of energy for nurses. Continuous
resourcing may result in burnout; therefore, engaging in resourcing is only an interim position for
nurses trying to continue delivering best care.

Resourcing aims to improve care delivery while also protecting nurses from professional
recrimination by senior staff and patients’ family. It acts as a preserving and coping mechanism
enabling nurses to work successfully within constraints. The greater the degree of constraints the
greater the resourcing. Continuous resourcing with no change in circumstances may lead to
exhaustion and burn out. When nurses become too tired to resource continuously, patient care
may be compromised however, they must still engage in a level of resourcing to support patient
safety.

Time borrowing facilitates resourcing to ensure a certain level of care is delivered. It
involves taking time from one area of work to gain more time in another, aiming to optimise and
prioritise care. It is a short-term coping mechanism and demonstrates nurses’ determination to
optimise care. Time borrowing happens when nurses’ reduce their breaks or skip them, com-
mencing work earlier or finishing later or taking time from one activity of care to give time to
another which, may compromise the activities of daily living, as one nurse mentioned: “Some-
times it’s just faster to wheel the patient to the bathroom then assisting them to walk out to the
toilet as we just wouldn’t have the time you know. It’s my way of making up on time” (Participant
2).

Nurses’ commitment to giving the best care influences time borrowing. The greater the
degree of commitment to idealistic striving the greater the degree of time borrowing and when
successful, care delivery is improved.

Resourcing is further increased by badgering, which explains continuous verbal and
written reporting nurses engage in with senior management when highlighting their concerns at
having to compromise care delivery. Through badgering, nurses try to prevent the impact of
compromised care. Knowledge seeking strengthens the need for badgering since nurses know the
care patients require and understand that compromising care is potentially risky. Badgering is
used to protect nurses from recrimination from patient’s family and other healthcare profes-
sionals by providing documentation supporting their concerns to management in trying to im-
prove patient care delivery. The aim is to have their concerns acknowledged and appropriately
acted on so that they can engage in idealistic striving. If successful, badgering reduces con-
straints, enabling optimal care, which is more likely to succeed when nurses identify to man-
agement, that patients are at risk and have documented evidence to support this such as clinical
risk forms. However, if unsuccessful and nurses engage in continuous badgering, this may lead to
possible burnout.

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Badgering through written reporting is time consuming, compromising time with patients,
therefore badgering is often opportunistic, in the form of verbalising concerns to ward managers
and unit managers. However, if nurses want a visible record of badgering then they make a
written submission, since they perceive this as providing some legal protection from accusations
in the event of an untoward event. Through badgering, nurses are trying to preserve their in-
tegrity and show their commitment to delivering optimal care, while mitigating against adverse
events.

A level of resourcing is essential when working within constraints in providing optimal care.
In the theory of resigning, resourcing coexists with idealistic striving, which supports care ac-
commodation.

Care accommodation

Care accommodation provides a typology of caring as a means of dealing with constraints until
they are resolved or reduced, comprising of functional caring, assisted self-caring and ideal caring.
The aim is to provide the best level of care feasible at a given moment. The degree of engagement
in idealistic striving and the success of resourcing determines the type of care accommodation
provided. For example, a reduced level of care may result when the degree of constraint is high
and there is a reduced level of commitment to idealistic striving. One nurse voiced: “I am happy
to be able to just give basic nursing care as the norm to all patients given the circumstances I find
myself in when we are down in staff” (Participant 23).

Functional caring is attending to basic but essential components of care such as hygiene,
dressing, assisting a person to eat and toileting as well as monitoring patients’ physical condition
(vital signs). Functional caring involves nurses actively carrying out care tasks for patients.
Functional caring ensures patients’ comfort, wellbeing and safety. It occurs as a result of prior-
itising care and can be delivered individually or with colleagues.

Functional caring is more likely when there is less capacity to provide care as it ensures
the immediate care needs of patients are met. The greater the capacity the greater the oppor-
tunity to provide more than functional care. Functional caring demonstrates what nursing is for
some people. Nurses are aware that more types of caring exist and view functional caring as only
one type of nursing care.

Functional caring is acknowledged by nurses to be a basic level of patient care because it
ensures that minimum needs are met. As constraints increase, functional caring may become the
best level of care nurses can provide, until such time as they can provide more care.

Assisted self-caring involves giving time to patients: encouraging and assisting them to
self-care in a rehabilitative way. It involves two aspects of care, the nurse providing some el-
ement of care such as assisting with hygiene and the patient also taking an active part in care.
However, it depends on the degree of constraint and the nurse’s self-responsibility to providing
the best care possible, but when time constraints predominate; nurses frequently revert to
functional caring. Patients view assisted-self caring, as part of other healthcare professional’s
occupation such as physiotherapists.

Ideal caring incorporates functional caring and assisted self-caring but additionally in-

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volves assessment and planning of individualised quality care. Successful resourcing makes ideal
caring more likely, but when unsuccessful, nurses revert to functional or assisted self-caring,
depending on the degree of constraint present. Nurses’ commitment to providing the best care
enhances ideal caring as nurses take pride in their care delivery. In the presence of constraints,
care accommodation ensures that at least basic care needs are met.

Conclusion

The theory of resigning processes the main concern of how nurses work within constraints when
caring for patients with stroke in the general acute care setting. In this context, resigning is a new
concept in healthcare and the theory of resigning has the potential to provide new insights for
nurses in care provision of patients with stroke while working within constraints.

There is a dearth of literature in healthcare on the concept of resigning. The understanding
of resigning in the literature is context dependent and generally has negative connotations such
as, relinquishing and giving up on beliefs and values. Resigning generally refers to a kind of
submission, a reluctant acceptance or a surrender to some condition (Lundh et al., 2011; O’Reilly
et al., 2009; Räty & Wilde Larsson, 2011) or situation (Josephson et al., 2008; Lundh et al., 2011;
Sandgren et al., 2007) or in the context of leaving a position (Bragg & Bonner, 2014; Josephson
et al., 2008; Ohue 2014; Webster et al., 2009).

The theory of resigning explains how nurses work within constraints offering an alterna-
tive way of coping with the circumstances. This is comparable to Takase’s (2010) study where
nurses did not always physically leave their jobs but instead withdrew psychologically, disen-
gaging in trying to provide care in their attempt to continue working with opposing attitudes and
beliefs. The theory of resigning suggests how nurses can remain committed to ideal care when
delivering the care that constraints permit, rather than leaving their position. Continuous working
within constraints is tiring; the theory of resigning as an energy maintenance strategy suggests
another way of doing so successfully.

Bragg and Bonner (2014), using a classic grounded theory methodology, generated the
theory of the degree of value alignment which explains why nurses resign from their hospital jobs.
These nurses did so when their personal values conflicted with those of the hospital organisation.
The theory of resigning supports and corroborates Bragg’s and Bonner’s (2014) theory of the
degree of value alignment as both theories are similar where nurses suffer from conflicting
personal and professional values. Both theories hold the ideal of providing a high level of patient
care as a priority while suffering from conflicting personal and professional values and both
theories use to the concept of resigning. However, they differ in the understanding of resigning;
the nurses in Bragg and Bonner (2014) conceded their values whereas in the theory of resigning
nurses do not concede their values but actively try and deal with constraints to maintain their
values through resourcing and care accommodation. This current theory expands on Bragg’s and
Bonner’s (2014) theory of the degree of value alignment as it explains where nurses’ personal
values can be accommodated through care accommodation and resourcing where nurses learn
how to work within constraints. This theory explains resigning as a more positive way of dealing
with constraints rather than getting to the stage of conflicting values where nurses leave their
position, feeling relieved but also frustrated and angry.

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Cook and Hayes (2008) discussed the automatic acceptance of a situation, not attempting
to change the situation or protest against it. For Cook and Hayes (2008), acceptance is associated
with better outcomes than resignation. The theory of resigning supports this position as it offers
a new positive perspective of resigning enabling nurses to remain working in the challenging
environment of working within constraints. This is supported also by Yao et al. (2013) who
discussed psychological acceptance in their group of nursing participants and infer that active
acceptance of negatives experiences may produce positive effects. Psychological acceptance is
viewed as a major individual factor in determining the behavioural effects on nurses. In common
with the findings of Yao et al. (2013), the current theory suggests that a positive attitude
maintained through idealistic striving has a positive effect on care if nurses engage in resourcing
rather than passively accepting the presence of constraints and their consequences.

The theory of resigning enables nurses to cope within the circumstances often presented
in the general acute setting such as a lack of staff, equipment and finances. When working within
constraints care can be reduced or is often of a poorer quality (Papastavrou, 2012; Rochefort &
Clarke, 2010; Schubert et al., 2007). The presence of constraints in the workplace influences
nurses’ provision of care (Papastavrou, 2012; Rochefort & Clarke, 2010; Schubert et al., 2007).
The theory of resigning resonates with this, as a care environment under constraints has difficulty
in delivering quality patient care. The theory of resigning identified issues such as lack of time,
staff and resources with regards constraints as similarly identified by Haigh and Ormandy (2011).
Collectively, these factors were found to impact negatively on patient care delivery resulting in a
compromised level of care and poor patient outcomes. In the theory of resigning working within
constraints was found to influence stroke care provision in the general acute setting where care
provision was found to be reduced to functional caring in the presence of constraints concurring
with findings of Haigh and Ormandy (2011).

Patient safety is of utmost importance in healthcare delivery and movement towards
ensuring avoidance of low quality healthcare delivery is a priority (Kalisch et al., 2014). Ensuring
patient safety is cited as a factor in nurses prioritising care for their patients. Nurses’ in the theory
of resigning aim to deliver the best care possible within the circumstances always ensuring that
patients’ safety is adhered to. The theory of resigning is the first time a study has explained how
nurses’ work within constraints as literature to date identifies constraints in the care environment
and how this influences care delivery but does not explain how nurses continue to provide care in
this environment.

Given the current high demand of modern healthcare nurses need to understand and be
able to work within constraints. Tensions for nurses between wanting to provide quality patient
care and the reality of working in care environments constrained by a lack of time, lack of
equipment and reduced staff levels can result in a reduced level of care provision. The theory of
resigning suggests another way of explaining and understanding how nurses deliver care in a
resource scare environment.

Nurses always need to work within constraints. This theory of resigning explains how they
can provide optimal care through identifying and explaining the process of resigning. By iden-
tifying the process of resigning nurses can recognise their behaviours, making necessary changes
to ensure optimal care of patients with stroke. Resigning is an energy maintenance and coping

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83

process, which supports nurses in such situations. The theory has the potential to enhance
nursing care and make better use of resources while advocating for improvement.

Implications for Practice

The theory of resigning offers a unique contribution capturing and explaining what is currently
happening in practice for nurses caring for patients with stroke in the acute general care setting.
Knowledge of this theory can assist nurses caring for patients with stroke on how to work through
and deal with constraints and how to deliver care within these circumstances. The theory of
resigning explains nurses’ patterns of behavior, illuminating three levels of care that nurses can
provide, dependent on the care environment they work within. This has not been previously
explored therefore, generating a new theory adding to the body of knowledge on stroke care
provision. The theory of resigning provides a strategy for nurses when working within constraints
in supporting them in daily delivery of care. As Glaser and Strauss (1967) stated, grounded
theory offers a “broader guide to what they already tend to do, and perhaps help them to be more
effective in doing it” (p. 248), therefore it is envisioned that the theory of resigning will help
nurses recognise the situation of working within limited resources earlier. This could potentially
help nurses to maintain best care delivery for their patients while working in resource scare
environments.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or
publication of this article.

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RESEARCH ARTICLE Open Access

Why so stressed? A comparative study on
stressors and stress between hospital and
non-hospital nurses
Rosnawati Muhamad Robat1†, Mohd Fadhli Mohd Fauzi2,3†, Nur Adibah Mat Saruan2,3, Hanizah Mohd Yusoff3* and
Abdul Aziz Harith4

Abstract

Background: Stress, which can be attributed to household and workplace stressors, is prevalent among nurses.
However, these stressors’ attribution may differ between hospital and non-hospital nurses. It is currently unknown
whether there are significant differences in the sociodemographic and occupational characteristics between
hospital and non-hospital nurses which may potentially influence the type and magnitude of stressors, and
subsequently the stress status. Therefore, this study aims to estimate the prevalence of stress and compare the roles
of sociodemograhic characteristics, occupational profiles, workplace stressors and household stressors in
determining the stress status between hospital and non-hospital female nurses in Malaysia.

Methods: This cross-sectional study was conducted among randomly-selected 715 female nurses in Malaysia using
pencil-and-paper self-reported questionnaires.

Results: The majority of participants were ever married (87.0%), having children (76.2%), and work in hospital
setting (64.8%). The level of household stressors was generally similar between hospital and non-hospital nurses.
However, hospital nurses significantly perceived higher level of workplace stressors. Shift work is significantly
associated with higher level of household and workplace stressors among nurses in both groups. The level of stress
was significantly higher among hospital nurses. Both household and workplace stressors explained about 40% of
stress status in both hospital and non-hospital nurses.

Conclusion: Hospital nurses are at higher risk of having stressors and stress as compared to non-hospital nurses,
probably due to higher proportion of them involved in shift work. Hospital nurses should be given high priority in
mitigating stress among nurses.

Keywords: Stress, Stressor, Workplace, Household, Nurse, Hospital, Shift work

© The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License,
which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if
changes were made. The images or other third party material in this article are included in the article’s Creative Commons
licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons
licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain
permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the
data made available in this article, unless otherwise stated in a credit line to the data.

* Correspondence: [email protected]
†(Rosnawati Muhamad Robat and Mohd Fadhli Mohd Fauzi should be
considered joint first author).
3Department of Community Health, Faculty of Medicine, Universiti
Kebangsaan Malaysia, Jalan Yaacob Latiff, Bandar Tun Razak, 56000 Kuala
Lumpur, Malaysia
Full list of author information is available at the end of the article

Muhamad Robat et al. BMC Nursing (2021) 20:2
https://doi.org/10.1186/s12912-020-00511-0

Background
Nurses play a vital role in Malaysia’s healthcare sys-
tem and are an essential part of medical workforce
[1]. The nursing profession is regarded as one of the
most demanding and stressful occupations [2].
Within their occupation, nurses are exposed to
physical, mental, temporal, and emotional demands
which exert sustained physical and psychological ef-
fort [3–5]. Nurses, who are mostly women [6], are
also more likely to be exposed to household/family
demands such as childcare and household chores [7].
Both workplace and household demands results in a
build-up stressors which are associated with physio-
logical and/or psychological burden, which conse-
quently contributes to increased stress [3, 8].
Stress is a psychological result of an imbalance be-

tween perceptions of external demands and the internal
resources available to meet those demands [9]. In other
words, the workplace or household demands are not ne-
cessarily the causes of stress; they become stressors if
they cause excessive exertion which is then not followed
by adequate recovery due to poor resilience or ineffect-
ive coping strategies [9, 10]. A recent study among Aus-
tralian nurses reported a 41.2% stress prevalence; with
24.51%, 10.8% and 5.88% being categorized as mild/
moderate, severe, and extremely severe stress, respect-
ively [11]. Among the predictive factors of stress include
job satisfaction [11], high workloads [12], shift work
[13], sleep quality [13], and nurse’s practice environment
[14]. Unmanaged stress can be harmful to a nurse’s
health leading to unwanted consequences such as burn-
out [15] and work performance issues such as absentee-
ism or presenteeism [16].
This current study focusses on female nurses work-

ing at government health facilities because workplace
stress is more likely among the public service em-
ployee [17], while household stress is more common
among women [7]. Women, as compared to men, are
at a higher risk of having stress as they perceive
stressors to be more threatening [18–20]. Female
nurses as working women take on multiple roles sim-
ultaneously in their daily life; these include the im-
portant roles at home as a mother involved in
childcare, as a wife, as an informal care-giver to fam-
ily members who need help such as parents, as a
breadwinner supporting the financial needs of herself
and/or her family, and as a house member who is
mutually responsible to do household chores as well
as ensuring safety of all members [21–24]. The roles
she plays in her occupation include nursing role such
as documentation, education, medication administra-
tion, patient care, and communication, employee roles
who plays a vital act in achieving the organization’s
goal, and roles as a colleague who part of a team

with other nurses, doctors, and other staff [25, 26]. In
general, having multiple roles can create work-home
and role conflict, leading to an increased risk of psy-
chological distress [21, 24].
Although given the same job title ‘nurse’, stressors

differ vastly between those employed in the hospital
setting versus those who aren’t. Such an instance is
the shift system employed by hospital nurses. This
shift system has the consequence of limiting time
spent with family members which can be a cause of
conflict with them [27, 28]. It can also trigger conten-
tion with fellow doctors and nurses during pass-over
session [27, 28]. Nurses in hospital setting also have
to handle the high workload related to the care of
acute patients with complicated medical procedures,
and occasionally, they have to handle events related
to the death of these patients [27–29]. In contrast,
nurses at non-hospital setting which typically operate
in non-shift schedule may have better staff support
and less workplace conflict as they are more likely to
work in a same team every day [30]. They may also
have better preparation to deal with their work as
their work is more likely involve non-acute patients
and patient with long-term follow-up [30]. Due to the
non-acute nature of patients, non-hospital nurses also
have higher autonomy as they are less likely to com-
municate their findings to the doctors [30, 31]. With
an exception of one study [28], most comparisons be-
tween hospital and non-hospital nurses described
above were not statistically examined.
Although the roles of stressors towards stress

among nurses have generally been widely established,
there are limited studies that analytically compare
their relationship in different work conditions, par-
ticularly hospital and non-hospital settings among
nurses. It is unknown whether there are significant
differences in the sociodemographic and occupational
characteristics between both groups. As the back-
ground characteristic may potentially influence the
type and magnitude of stressors, and subsequently the
stress status, it is also unknown whether stressors and
stress status are significantly differing between hos-
pital and non-hospital nurses. The establishment of
evidence on these differences is important to support
the need of targeted intervention which may differ
between the workplace setting. Therefore, this study
aims to examine and compare the sociodemograhic
and occupational profiles, workplace and household
stressors, and the stress status between hospital and
non-hospital nurses. This study also aims to identify
and compare the roles of sociodemograhic character-
istics, occupational profiles, workplace stressors and
household stressors in determining the stress status
between both groups.

Muhamad Robat et al. BMC Nursing (2021) 20:2 Page 2 of 10

Methods
Study design and sampling
This is a comparative analytic cross-sectional study con-
ducted in year 2018 among registered nurses working at
all government health facilities in the state of Selangor,
Malaysia. The inclusion criteria are all registered
Malaysian female nurses from various position including
matrons, sisters, staff nurses, midwives and community
nurses who have been working at their current work-
place for at least 6 months. Matrons and sisters are cate-
gorized as nurse managers; a matron is responsible in
ensuring the smooth function of respective departments,
hospitals, or districts, while a sister is responsible in ad-
ministration of patient care in respective patient care
unit such as ward or clinic. Staff nurses, midwives and
community nurses can be classified as implementers; a
staff nurse and a midwife are responsible to provide in-
dividualized care for all patients in their respective pa-
tient care units, while community nurses are responsible
to assist staff nurses and midwifes in the delivery of pa-
tient care. Those who are medically-diagnosed as having
psychiatric illnesses or on psychiatric medication were
excluded. Eligible nurses’ name was randomly chosen by
using Microsoft Excel software. Based on the stress
prevalence of 0.25 [32, 33] and 0.49 [34] among Malay-
sian nurses, precision of 0.05, and power of 0.8, the
minimum sample size required was 289 and 385. Since
this is a comparative cross-sectional study, the sample
size was doubled to 770 nurses.

Study instruments
Data on participants’ sociodemographic and occupa-
tional profile were collected using a self-reported ques-
tionnaire containing 18 items that inquire on the age,
marital status, number of children, work tenure, job pos-
ition, workplace, schedule system and others (Additional
file 1).
Stress status was measured by using validated Malay

version of Personal Stress Inventory: Sign and Symp-
toms of Stress questionnaire [35, 36] by asking the
frequency of signs and symptoms of stress experi-
enced by the participants. The inventory consisted of
51 items with 11 subscales using a four-point Likert
scale i.e. ‘never’ (0), ‘once or twice’ (1), ‘every week’
(2) and ‘nearly every day’ (3). A total score was ob-
tained by adding the nurse’s responses to all 51 items,
ranging from 0 to 153. Those who scored ≥36 were
classified as stressed. Numerically, a higher score indi-
cates a higher level of stress. The Cronbach alpha of
this instrument is 0.968.
Household stressors were measured by using validated

Malay version of Personal Stress Inventory: Pressures
and Demands from Family and Household [35, 36]. This
is a brief instrument that assesses the degree to which

the situation in a family and household perceived as a
stressor for the respondent. The inventory consisted of
12 items which included ‘not enough money’, ‘conflict
with spouse’, ‘conflicts over household tasks’, ‘problems
or conflict with children’, ‘pressure from relatives or in-
laws’, ‘fixing up of the house’, ‘not enough time to spend
with family’, ‘sexual conflict or frustration’, ‘dangerous
or stressful surroundings and neighbourhood’, ‘conflict
with close friend or relatives’, ‘personal problem causing
strain in family’ and ‘no babysitter’. This questionnaire
used a four-point Likert-type scale i.e. ‘none at all’ (0), ‘a
little’ (1), ‘some’ (2) and ‘a great deal’ (3). A total score
was obtained by adding the nurse’s responses to all 12
questions. A total score ranged from 0 to 36. Higher
scores indicated a higher level of household stressors.
The Cronbach alpha of this instrument is 0.875.
Workplace stressors were measured by using a vali-

dated Malay version of Nursing Stress Scale (NSS) [37,
38]. It measures the perceived frequency of the occur-
rence of stress in the nursing environment. The scale
consisted of 34 items with seven subscales, namely
‘workload’ (α = 0.808), ‘dealing with death and dying’
(α = 0.856), ‘conflict with doctors’ (α = 0.798), ‘uncer-
tainty concerning treatment’ (α = 0.844), ‘lack of staff
support’ (α = 0.865), ‘conflict with other nurses or super-
visors’ (α = 0.759) and ‘inadequate preparation to deal
with emotional needs of the patients and their families’
(α = 0.838). The Cronbach alpha of this instrument is
0.832. The NSS was scored on a four-point Likert-type
scale from ‘never’ (0), ‘occasionally’ (1), ‘frequently’ (2) to
‘very frequently’ (3). All items were about potentially
stressful situations in the nursing workplace. Scoring
was conducted by adding up the individual item re-
sponses for each subscale. High scores indicated the fre-
quent presence of a specific source of stress. Overall
score was determined by adding up all 34-item re-
sponses. The total score represented the overall fre-
quency of stress as experienced by a nurse which ranged
from 0 to 102.

Data collection
Participants were approached at their workplace and
were given explanation on this study. They were given
adequate time of about 1 week to make decision. If they
agreed to participate, they were given a set of question-
naires. They were given another day and up to 3 days, to
complete the questionnaires.

Data analysis
Data was initially analyzed descriptively to demonstrate
the representativeness of participants involved in this
study. Bivariable analysis was then conducted to compare
the sociodemographic and occupational characteristic,
stressors profile, and stress status/level between the two

Muhamad Robat et al. BMC Nursing (2021) 20:2 Page 3 of 10

groups. Next, multiple linear regression using enter
method was conducted to determine the significant deter-
minants of stressors for hospital and non-hospital nurses.
Hierarchical regression was then conducted in four steps
to determine the determinants associated with stress level.
In the first step, sociodemographic variables i.e. age, mari-
tal status and children were entered. In the second step,
occupational variables i.e. work tenure, job position, and
work schedule were entered. In the third step, both work-
place and household stressors were entered. In the fourth
step, interaction term between workplace and household
stressors were entered. Statistically significant result was
set at p < 0.05.

Results
Participants characteristic
The response rate was 92.9% (n = 715). Participants were
generally in middle aged with a mean age of 34.63 (SD =

8.050) years and a mean work tenure of 11.40 (SD =
7.461) years. The majority of participants were married
(87.0%) and have at least one child (76.2%). Most of
them hold a position as community nurse or staff nurse
(85.0%), work in hospital setting (64.8%) and involved in
shift schedule (64.8%).

Group comparisons
Table 1 and Table 2 demonstrates the comparison of
sociodemographic and occupational profiles, workplace
and household stressors, and stress status between hos-
pital and non-hospital nurses. There was no significant
difference in the sociodemographic and occupational
profiles of the two groups except for work schedule and
job position. The proportion of participants working in
shift and holding a job position as a community nurse or
a staff nurse was significantly higher among hospital

Table 1 Comparison of numerical variables using Student’s T-test

Variables Mean (SD) Mean Difference 95% CI t df p

Total
(n = 715)

Non-Hospital
(n = 252)

Hospital
(n = 463)

Sociodemographic profile

Age, in years 34.63 (8.050) 34.42 (7.718) 34.74 (8.232) −0.32 − 1.56, 0.92 − 0.508 713 0.61

No. of children 1.87 (1.497) 1.84 (1.464) 1.88 (1.516) −0.04 − 0.27, 0.19 − 0.322 713 0.75

Work tenure, in years 11.40 (7.461) 11.11 (7.364) 11.56 (7.517) −0.45 −1.60, 0.70 − 0.767 713 0.44

Household stressors 5.91 (5.468) 5.71 (5.747) 6.02 (5.314) −0.31 − 1.15, 0.53 − 0.727 713 0.47

Not enough money 0.68 (0.794) 0.62 (0.803) 0.72 (0.788) −0.11 − 0.23, 0.02 −1.712 713 0.09

Conflict with spouse 0.49 (0.689) 0.48 (0.676) 0.49 (0.696) −0.02 − 0.12, 0.09 − 0.301 713 0.76

Conflict over household task 0.48 (0.678) 0.45 (0.675) 0.50 (0.680) −0.05 − 0.16, 0.05 − 0.992 713 0.32

Conflict with children 0.37 (0.596) 0.41 (0.653) 0.34 (0.562) 0.07 −0.02, 0.17 1.511 453.79 0.13

Pressure from relatives 0.44 (0.712) 0.49 (0.770) 0.42 (0.678) 0.07 −0.04, 0.18 1.231 462.73 0.22

Fixing up house 0.42 (0.672) 0.48 (0.770) 0.39 (0.611) 0.09 −0.03, 0.20 1.517 425.11 0.13

No time with family 1.08 (0.961) 0.98 (0.972) 1.13 (0.951) −0.15 −0.30, 0.00 −1.991 713 0.05

Sexual conflict 0.21 (0.510) 0.23 (0.560) 0.20 (0.482) 0.03 −0.04, 0.11 0.841 713 0.40

Dangerous surroundings 0.43 (0.675) 0.41 (0.683) 0.44 (0.671) −0.02 −0.13, 0.08 − 0.446 713 0.66

Conflict with close friends 0.40 (0.607) 0.36 (0.578) 0.42 (0.622) −0.06 − 0.16, 0.03 −1.302 713 0.19

Personal problem cause strain 0.41 (0.631) 0.34 (0.559) 0.44 (0.665) −0.11 −0.20, − 0.01 −2.252 595.07 0.02

No babysitter 0.51 (0.793) 0.48 (0.733) 0.54 (0.823) −0.06 −0.18, 0.06 − 0.958 713 0.34

Workplace stressors 25.86 (13.384) 20.85 (11.983) 28.59 (13.330) −7.74 −9.66, −5.82 −7.924 563.98 0.00

Workload 8.36 (3.593) 7.63 (3.468) 8.75 (3.601) −1.13 −1.67, − 0.58 −4.049 713 0.00

Death and dying 4.35 (3.784) 2.44 (2.706) 5.39 (3.882) −2.95 −3.44, −2.47 −11.896 670.90 0.00

Inadequate preparation 1.79 (1.570) 1.35 (1.405) 2.02 (1.605) −0.67 − 0.91, − 0.43 −5.570 713 0.00

Lack of staff support 2.12 (1.895) 1.70 (1.734) 2.35 (1.941) −0.65 −0.93, − 0.36 −4.406 713 0.00

Uncertain treatment 3.20 (2.418) 2.51 (2.354) 3.57 (2.372) −1.06 −1.42, −0.69 −5.714 713 0.00

Conflict with doctors 3.24 (2.493) 2.75 (2.412) 3.50 (2.499) −0.76 −1.14, − 0.38 −3.918 713 0.00

Conflict with nurses 2.81 (2.454) 2.47 (2.536) 3.00 (2.390) −0.53 −0.90, − 0.15 −2.758 713 0.01

Stress score 25.47 (20.704) 22.04 (18.472) 27.34 (21.613) −5.31 −8.47, −2.15 −3.296 713 0.00

Muhamad Robat et al. BMC Nursing (2021) 20:2 Page 4 of 10

nurses as compared to non-hospital nurses. There was
no significant difference in the overall score of house-
hold stressor between hospital and non-hospital nurses.
However, hospital nurses had significantly higher level of
household stressors related to ‘not enough money’, ‘no
time with family’ and ‘personal problem cause strain’.
With regards to workplace stressors, hospital nurses had
significantly higher overall score of workplace stressors
and each of its components namely ‘workload’, ‘death
and dying’, ‘inadequate preparation’, lack of staff sup-
port’, ‘uncertain treatment’, ‘conflict with doctors’, and
‘conflict with nurses’. The overall prevalence of stress
among participants was 27.3%. Although the hospital
nurses had significantly higher level of stress score as
compared to non-hospital nurses, there is no significant

difference in the prevalence of stress between both
groups.

Inter-correlation among the study measures in the two
study groups
Table 3 shows the inter-correlation among sociode-
mographic profiles (i.e. age, children), occupational
profiles (i.e. work tenure), stressors (i.e. workplace
and household) and stress levels. Age, number of chil-
dren, and work tenure were negatively correlated with
workplace stressors. In contrast, number of children
and workplace stressors were positively correlated
with household stressors. Both workplace and house-
hold stressors were moderately and positively corre-
lated with stress score.

Table 2 Comparison of categorical variables using chi square test

n (%)a n (%)b χ2 df p

Total (n = 715) Non-Hospital (n = 252) Hospital (n = 463)

Marital status

Never married 93 (13.0) 30 (32.3) 63 (67.7) 0.418 1 0.518

Ever married 622 (87.0) 222 (35.7) 400 (64.3)

Having children

None 170 (23.8) 55 (32.4) 115 (67.6) 0.817 1 0.366

At least one 545 (76.2) 197 (36.1) 348 (63.9)

Work tenure

Less than 10 years 332 (46.4) 123 (37.0) 209 (63.0) 0.883 1 0.347

10 years and above 383 (53.6) 129 (33.7) 254 (66.3)

Work schedule

Non-shift 252 (35.2) 176 (69.8) 76 (30.2) 204.090 1 < 0.001

Shift 463 (64.8) 76 (16.4) 387 (83.6)

Position

Staff nurse / community nurse 608 (85.0) 229 (37.7) 379 (62.3) 10.423 1 0.001

Nurse manager 107 (15.0) 23 (21.5) 84 (78.5)

Stress status

Not stress 520 (72.7) 194 (37.3) 326 (62.7) 3.555 1 0.059

Stress 195 (27.3) 58 (29.7) 137 (70.3)
acolumn percent; b row percent

Table 3 Correlation among sociodemographic profile, occupational profile, stressors and stress score

Variables Age Children Work tenure Workplace stressors Household stressors Stress score

Age 1

Children .479a 1

Work tenure .949a .481a 1

Workplace stressors −.110a −.090b −.101a 1

Household stressors −0.015 .085b −0.017 .449a 1

Stress score −0.059 −0.034 −.076b .535a .561a 1
a Correlation is significant at the 0.01 level (2-tailed); b Correlation is significant at the 0.05 level (2-tailed)

Muhamad Robat et al. BMC Nursing (2021) 20:2 Page 5 of 10

Linear regression analysis predicting stressors among the
two study groups
Table 4 demonstrates the determinants of household
and workplace stressors. Marriage is associated with
higher household stressors regardless of workplace. In
contrast, job position of nurse manager and involvement
in shift schedule are associated with higher workplace
stressors only among hospital nurses. Shift work is also
associated with higher household stressors only among
hospital nurses.

Hierarchical regression analysis predicting stress among
the two study groups
Table 5 demonstrates the hierarchical linear regression
analysis which aims to identify the determinants of stress
level among hospital and non-hospital nurses. It was
found that workplace and household stressors signifi-
cantly explained about 38% to 40% variance of the stress
level of all participants regardless of their workplace.
The stress level is higher among those non-hospital
nurses who are of older age, and those who were junior,
with concurrent higher magnitude of workplace and
household stressors. In contrast, the stress level is higher
among nurse managers in hospital settings and those
hospital nurses who had higher magnitudes of workplace
and household stressors. The interaction between work-
place and household stressors did not significantly influ-
ence the stress level.

Discussion
This study aims to compare the stress determinants be-
tween hospital and non-hospital nurses. The principal

findings are: (1) there is not much difference in house-
hold stressors between both groups, (2) hospital nurses
had significantly higher levels of workplace stressors, (3)
the level of stress is higher amongst hospital nurses, (4)
shift work is associated with higher household and work-
place stressors among hospital nurses, (5) nurse man-
agers in hospital settings are associated with higher level
of workplace stressors and stress, (6) marriage is associ-
ated with higher household stressors among nurses in
both groups, (7) older age and a junior position are asso-
ciated with higher stress levels among non-hospital
nurses, (8) both workplace and household stressors are
significantly associated with stress status with 40% ex-
plained variance. Overall, hospital nurses are at a higher
risk of having workplace stressors, household stressors,
and stress.
The hospital nurses had significantly higher stress level

in spite of similar prevalence of stress status. This find-
ing is consistent with the evidence from other geograph-
ical regions such as Saudi Arabia [39] and Australia [40]
which reported higher stress levels among hospital
nurses. It could be due to the higher level of all compo-
nents of workplace stressors and several aspects of
household stressors among hospital nurses in our study
which explained 40% of variance in stress level. This is
supported by a previous finding which found that stress
level was significantly and positively correlated with all
components of workplace stressors among nurses [40].
Previous studies also reported that hospital nurses may
face higher stressors related to workload, death and
dying, and conflict with family members or colleagues
[27–29]. The stressors could also be implicated by shift
work which could adversely impact social, personal,

Table 4 Multiple linear regression to identify determinants of stressors

Variables Adj. β (95%CI)

Household Stressors Workplace Stressors

All (n = 715) Non-Hospital
(n = 252)

Hospital (n = 463) All (n = 715) Non-Hospital
(n = 252)

Hospital (n = 463)

Age −0.029
(− 0.187, 0.129)

0.041
(− 0.257, 0.340)

−0.052
(− 0.239, 0.136)

−0.205
(− 0.577, 0.167)

−0.132
(− 0.756, 0.493)

−0.194 (− 0.652, 0.264)

Marital statusa 2.250 (0.905, 3.595)
***

2.932 (0.421, 5.444)
*

1.883 (0.280, 3.485)
*

0.585 (−2.581, 3.752) −1.222
(−6.479, 4.036)

1.219 (−2.696, 5.134)

No. of children 0.266 (−0.057, 0.589) 0.154 (−0.431,
0.738)

0.319
(− 0.618, 0.707)

−0.384
(−1.145, 0.377)

0.227 (− 0.996,
1.449)

−0.791 (− 1.737, 0.156)

Work tenure − 0.031
(− 0.204, 0.142)

−0.009
(− 0.319, 0.300)

−0.050
(− 0.262, 0.163)

−0.049
(− 0.457, 0.359)

−0.200
(− 0.848, 0.447)

0.046 (− 0.473, 0.565)

Job positionb −0.122
(− 1.497, 1.254)

−1.589
(−4.571, 1.393)

0.510
(− 1.056, 2.076)

6.310 (3.070, 9.550)
***

1.730 (−4.511,
7.971)

6.086 (2.260, 9.912) **

Work
schedulec

0.896 (0.056, 1.737) * 0.316
(−1.237, 1.869)

1.370 (0.020, 2.719)
*

7.470 (5.491, 9.449)
***

0.759 (−2.491,
4.010)

8.647 (5.349, 11.944)
***

R2 0.024 0.020 0.026 0.097 0.012 0.076

*** p < 0.001 (2-tailed); ** p < 0.01 (2-tailed); * p < 0.05 (2-tailed); a Marital status (0 = never married, 1 = ever married); b Job position (0 = staff nurse/community
nurse, 1 = nurse manager); c Work schedule (0 = non-shift, 1 = shift)

Muhamad Robat et al. BMC Nursing (2021) 20:2 Page 6 of 10

family and occupational life [41, 42] and made compli-
cated by marriage life [39, 42, 43].
Shift work is significantly associated with higher stress

level among nurses; however, the significant association
is diminished when workplace setting is considered. This
is consistent with study by Lin et al. (2015) that reported
higher stress level among nurses who work in shift [44].
The diminishing effect could be due to the differential
level in proportion of nurses involved in shift work be-
tween the two groups. The nature of round-the-clock
nursing work seen in hospitals exposes a higher propor-
tion of hospital nurses to shift work which is associated
with stressors and stress. Our study further emphasizes
that shift schedule is associated with higher risk of hav-
ing both household and workplace stressors among hos-
pital nurses. This is supported by a study by Ferri et al.
(2016) which concludes that shift work, particularly

rotating shift work, is a potential stressor for nurses [45].
This finding implies that those involved in shift sched-
ule, particularly hospital nurses, should be given high
priority in stress intervention, and the intervention itself
should include evaluation and improvement of shift
schedule design. For instance, Lin et al. (2015) reported
that 2 days-off after night shift will improve the stress
level among nurses who are involved in rotating shift
work [44].
We also found that nurse managers in hospital settings

are associated with higher level of workplace stressors
and stress. This could be due to the heavier workload,
inadequate resources, and role conflict in fulfilling the
demands of their subordinates and superiors [46, 47]. In
contrast, an elder age and junior positions are associated
with higher stress levels among non-hospital nurses.
This is consistent with findings among community

Table 5 Hierarchical linear regression to identify determinants of stress level
Variables All (n = 715) Non-Hospital (n = 252) Hospital (n = 463)

β in step … a Final β b β in step … a Final β b β in step … a Final β b

Step 1

Age −0.157 (− 0.375, 0.062) 0.477
(0.014, 0.939) *

0.014 (− 0.326, 0.354) 1.074
(0.337, 1.812) **

− 0.249 (− 0.527, 0.030) 0.212
(− 0.381, 0.804)

Marital
statusc

1.966 (−3.168, 7.100) −1.300
(−5.267, 2.667)

7.537 (− 0.436, 15.511) 3.138
(−3.188, 9.464)

−0.271 (− 6.828., 6.286) −3.441 (−8.528,
1.646)

Having
childrend

− 0.268 (− 1.500, 0.964) −0.327
(− 1.276, 0.622)

−0.710 (− 2.590, 1.169) −0.823
(− 2.267, 0.620)

−0.086 (− 1.672, 1.500) −0.106 (− 1.343,
1.130)

Δ R2 0.004 0.014 0.010

Δ F 1.026 1.209 1.530

Step 2

Work tenure −0.741 (− 1.396, − 0.085) * −0.665
(− 1.172, − 0.158) **

−1.084 (− 2.084, − 0.085) * −0.978
(− 1.743, − 0.214) *

−0.573 (− 1.435, 0.289) −0.496
(− 1.167, 0.175)

Job positione 7.755 (2.553, 12.957) ** 4.644 (0.565, 8.723)
*

−1.574 (− 11.204, 8.056) − 0.128
(−7.542, 7.286)

10.192 (3.840, 16.545) ** 6.156
(1.158, 11.155) *

Work
schedulef

5.250 (2.073, 8.428) *** −0.057
(− 2.612, 2.497)

− 0.654 (− 5.670, 4.362) −1.385
(− 5.223, 2.452)

6.556 (1.081, 12.031) * −0.236
(− 4.617, 4.146)

Δ R2 0.031 0.020 0.034

Δ F 7.562 *** 1.653 5.365 ***

Step 3

Workplace
stressor (WS)

0.522 (0.419, 0.625) *** 0.514 (0.376, 0.652)
***

0.543 (0.370, 0.716) *** 0.678
(0.449, 0.907) ***

0.513 (0.379, 0.647) *** 0.446
(0.263, 0.628) ***

Household
stressor (HS)

1.573 (1.330, 1.817) *** 1.531 (1.006, 2.055)
***

1.260 (0.898, 1.622) *** 1.722
(1.091, 2.352) ***

1.725 (1.397, 2.052) *** 1.310
(0.480, 2.139) **

Δ R2 0.390 0.401 0.380

Δ F 239.816 *** 86.347 *** 149.765 ***

Step 4

WS*HS 0.001 (−0.014, 0.017) 0.001
(−0.014, 0.017)

−0.018 (− 0.039, 0.002) −0.018 (− 0.039,
0.002)

0.012 (− 0.011, 0.035) 0.012
(− 0.011, 0.035)

Δ R2 0.000 0.007 0.001

Δ F 0.032 23.089 1.147

*** p < 0.001 (2-tailed); ** p < 0.01 (2-tailed); * p < 0.05 (2-tailed); a β in step.. = β of the particular step at which the variable initially entered the
equation; b Final β = β in the final (4th step); c Marital status (0 = never married, 1 = ever married); d Having children (0 = none, 1 = at least one child); e

Job position (0 = staff nurse/community nurse, 1 = nurse manager); f Work schedule (0 = non-shift, 1 = shift)

Muhamad Robat et al. BMC Nursing (2021) 20:2 Page 7 of 10

health nurses in China and Saudi Arabia [39, 43] which
may be explained by low work ability and overstretched
among older workers [48] and lower training or compe-
tency among junior workers [43]. Nevertheless, all these
postulations need to be confirmed in future studies as
previous studies did not conduct a comparative study to
enable statistical measurement of significant difference.
Our study strengthens the previously gained know-

ledge that proves difference in mental health status and
its determinants between hospital and non-hospital
nurses. For instance, a study by Dor et al. (2018) found
that hospital nurses had a significantly higher level of
emotional exhaustion and depersonalization as com-
pared to community nurses [28]. Another study by Starc
(2018) found that nurses from secondary level of health-
care reported higher level of stressors related to dealing
with death, working with difficult patients, exposure to
infection, working at night, lack of personnel, and work-
ing hours as compared to nurses from primary care [49].
Our findings also suggest that working conditions for
nurses are not similar, thus, necessary adjustment to ac-
commodate the demands of hospital and non-hospital
work should be carried out to ensure a healthy working
condition and lower risk of stress.
The workplace stressors and stress levels are signifi-

cantly higher among hospital nurses. Thus it is necessary
to place a high priority on stress level intervention
amongst hospital nurses. Intervention should be initially
conducted by identifying the root causes of workplace and
household stressors such as shift work which could affect
work and family life. Further intervention such as schedule
redesign should be initiated, and its efficacy should be
tested. Apart from hospital nurses, targeted intervention
should also focus on high risk groups such as managerial
nurse groups in hospital settings, older workers, and ju-
niors in non-hospital settings. Finally, the intervention
should consider both household and workplace stressors
as both can significantly influence the level of stress
among nurses in both hospital and non-hospital settings.
To do so, policy makers should first acknowledge that the
stressors and stress among nurses are generally different
between hospital and non-hospital nurses. Stress-
reduction policies that are specifically tailored to hospital
and non-hospital nurses should be introduced. This in-
cludes conducting training on coping strategies and resili-
ence against workplace and household stressors,
consideration of flexible working arrangements for those
with conflicting work-home roles, cultivating a stress-free
work environment, ‘active case detection’ of nurses with
stress at workplace, and provision of psychological sup-
port groups at the workplace.
This study has several limitations. First, the use of self-

reported data exposes the results to common method
bias [50] and social-desirability bias [51]. However, the

use of validated questionnaire and guarantee in anonym-
ity may reduce such biases [50, 51]. Second, this study is
limited to female nurses and thus cannot be generalized
to male nurses. Thirdly, this study was conducted in
Malaysia only and may not represent other geographical
regions which have different work systems or social
cultures.

Conclusion
Hospital nurses have a higher perceived level of work-
place stressors compared to those not in the hospital
setting although there is not much difference in house-
hold stressors. They also reported higher level of stress
score and higher prevalence of stress compared to non-
hospital nurses. More attention should be given to
hospital nurses in managing stress, particularly those in-
volved in shift system.

Supplementary Information
The online version contains supplementary material available at https://doi.
org/10.1186/s12912-020-00511-0.

Additional file 1.

Abbreviations
NSS: Nursing Stress Scale; HS: Household stressor; WS: Workplace stressor

Acknowledgements
The author would like to thank the Director General of Health Malaysia for
his permission to publish this article. In addition, we would like to thank all
the respective healthcare personnel from occupational health and
environmental health unit at all health facilities under Selangor State Health
Department who involved in the data collection. We also extend our
gratitude to nursing unit and department for their support and assistance in
this research.

Authors’ contributions
RMR, MFMF and NAMS involved in the conception and design of study. RMR,
MFMF, NAMS and AZH involved in acquisition of data. RMR, MFMF, and HMY
involved in the data analysis and interpretation. RMR and MFMF involved in
drafting the manuscript. NAMS, HMY and AZH involved in revising the
manuscript critically for important intellectual content. RMR and MFMF were
equally major contributors in this study. All authors approved the final version
of the manuscript to be published. All authors have agreed both to be
personally accountable for the author’s own contributions and to ensure that
questions related to the accuracy or integrity of any part of the work, even
ones in which the author was not personally involved, are appropriately
investigated, resolved, and the resolution documented in the literature.

Funding
None.

Availability of data and materials
The data that support the findings of this study are available from Ministry of
Health Malaysia, but restrictions apply to the availability of these data, which
were used under license for the current study, and so are not publicly
available. Data are however available from the authors upon reasonable
request and with permission of Ministry of Health Malaysia.

Ethics approval and consent to participate
This study was registered with National Medical Research Register (NMRR-17-
3481-37407) and obtained ethical approval from Medical Research and Ethics
Committee, Ministry of Health Malaysia (KKM.NIHSEC.P19–22(6)). Informed consent
was obtained in written from each participants prior to the data collection.

Muhamad Robat et al. BMC Nursing (2021) 20:2 Page 8 of 10

Competing interests
All authors declare that they have no conflict of interest.

Author details
1Occupational and Environmental Health Unit, Selangor State Health
Department, No 1 Wisma Sunway, Jalan Tengku Ampuan Zabedah C 9/C,
Seksyen 9, 40100 Shah Alam, Selangor, Malaysia. 2Ministry of Health Malaysia,
Block E1, E3, E6, E7 & E10, Complex E, Federal Government Administrative
Centre, 62590 Putrajaya, Malaysia. 3Department of Community Health, Faculty
of Medicine, Universiti Kebangsaan Malaysia, Jalan Yaacob Latiff, Bandar Tun
Razak, 56000 Kuala Lumpur, Malaysia. 4Occupational Health Research Centre,
Institute for Public Health Malaysia, Blok B5 & B6, Kompleks NIH, No1, Jalan
Setia Murni U13/52, Seksyen U13 Bandar Setia Alam, 40170 Shah Alam,
Selangor, Malaysia.

Received: 19 August 2020 Accepted: 29 November 2020

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International Journal of

Environmental Research

and Public Health

Article

Unplanned Absenteeism: The Role of Workplace and
Non-Workplace Stressors

Nur Adibah Mat Saruan 1,2,† , Hanizah Mohd Yusoff 1,*, Mohd Fadhli Mohd Fauzi 1,2,† ,
Sharifa Ezat Wan Puteh 1 and Rosnawati Muhamad Robat 3

1 Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre,
Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia;
[email protected] (N.A.M.S.); [email protected] (M.F.M.F.);
[email protected] (S.E.W.P.)

2 Ministry of Health Malaysia, Federal Government Administrative Centre, Putrajaya 62590, Malaysia
3 Occupational and Environmental Health Unit, Selangor State Health Department, No. 1 Wisma Sunway,

Jalan Tengku Ampuan Zabedah C 9/C, Seksyen 9, Shah Alam 40100, Malaysia; [email protected]
* Correspondence: [email protected]; Tel.: +60-3-9145-5904
† These authors contributed equally to this work.

Received: 14 July 2020; Accepted: 20 August 2020; Published: 24 August 2020
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Abstract: Unplanned absenteeism (UA), which includes medically certified leave (MC) or emergency
leave (EL), among nurses may disturb the work performance of their team and disrupt the quality
of patient care. Currently, there is limited study in Malaysia that examines the role of stressors in
determining absenteeism among nurses. Therefore, apart from estimating the prevalence and the
reasons of UA among nurses in Malaysia, this study aims to determine its stressor-related determinants.
A cross-sectional study was conducted among 697 randomly sampled nurses working in Selangor,
Malaysia. Most of them were female (97.3%), married (83.4%), and working in shifts (64.4%) in
hospital settings (64.3%). In the past year, the prevalence of ever taking MC and EL were 49.1% and
48.4%, respectively. The mean frequency of MC and EL were 1.80 (SD = 1.593) and 1.92 (SD = 1.272)
times, respectively. Meanwhile, the mean duration of MC and EL were 4.24 (SD = 10.355) and
2.39 (SD = 1.966) days, respectively. The most common reason for MC and EL was unspecified
fever (39.2%) and child sickness (51.9%), respectively. The stressor-related determinants of durations
of MC were inadequate preparation at the workplace (Adj.b = −1.065) and conflict with doctors
(adjusted regression coefficient (Adj.b) = 0.491). On the other hand, the stressor-related determinants
of durations of EL were conflict with spouse (Adj.b = 0.536), sexual conflict (Adj.b = −0.435),
no babysitter (Adj.b = 0.440), inadequate preparation at workplace (Adj.b = 0.257), lack of staff
support (Adj.b = −0.190) and conflict with doctors (Adj.b = −0.112). The stressor-related determinants
of the frequency of MC were conflicts over household tasks (Adj.b = −0.261), no time with family
(Adj.b = 0.257), dangerous surroundings (Adj.b = 0.734), conflict with close friends (Adj.b = −0.467),
and death and dying (Adj.b = 0.051). In contrast, the stressor-related determinants of frequency of
EL were not enough money (Adj.b = −0.334), conflicts with spouse (Adj.b = 0.383), pressure from
relatives (Adj.b = 0.207), and inadequate preparation (Adj.b = 0.090). In conclusion, apart from the
considerably high prevalence of unplanned absenteeism and its varying frequency, duration and
reasons, there is no clear distinction in the role between workplace and non-workplace stressors in
determining MC or EL among nurses in Malaysia; thus, preventive measures that target both type
of stressors are warranted. Future studies should consider longitudinal design and mixed-method
approaches using a comprehensive model of absenteeism.

Keywords: absenteeism; stress; stressor; nurse; hospital; conflict

Int. J. Environ. Res. Public Health 2020, 17, 6132; doi:10.3390/ijerph17176132 www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2020, 17, 6132 2 of 16

1. Introduction

Absenteeism can be a good measure of the health system’s performance and a useful tool in
measuring the psychological and physical wellbeing of healthcare workers [1]. It is defined as a failure to
attend work according to an established work schedule [2]. Various classifications have been suggested
when exploring absenteeism. A few studies categorized it into voluntary and involuntary absenteeism,
based on the control ability of the employee [3–5]. Other studies have further sub-classified it into the
planned and unplanned forms [2]. Planned voluntary absenteeism includes annual leave, study leave,
and being off-duty [6]. In contrast, unplanned voluntary absenteeism includes short-term self-certified
sickness absence [7], medically certified sickness [8], and others including vehicle breakdown and
taking care of a sick child [2,6]. Meanwhile, planned involuntary absenteeism includes absence caused
by social obligations such as attending a community meeting [7]. In Malaysia, planned absenteeism
is commonly known as annual leave or rest leave, which is typically applied a few days before the
intended leave days. In contrast, unplanned absenteeism can be further subdivided into two: (a) sick
leave or medically-certified leave (MC) with an accompanying legitimate medical certificate from
registered medical practitioners [9] and (b) emergency leave (EL) for any other reasons such as family
matters and self-certified sickness [10]. Furthermore, the previous study also has used the term
health-related workplace absenteeism to describe the workers’ phenomenon of not attending to work
as per working schedule which had been counted by the loss of the number of working hours due to
injury or illness [11,12].

Most of the studies conducted abroad to assess sickness absenteeism recorded high prevalence,
ranging from 68% to 75% among nurses [5,13,14]. Multiple factors and outcomes of absenteeism among
nurses have been identified in previous research. Absenteeism is a side effect of personnel problems,
ineffective management, poor working relationships, lack of control over decisions, and overwork [15].
A systematic review found 29 antecedents and nine outcome variables for absenteeism and proposed
the Job, Organization, Individual, National and inTerpersonal (JOINT) multilevel conceptual model
for investigating absenteeism among nurses. The levels include individual (demographic, personal
characteristic, job attitudes, health, and wellbeing), interpersonal (management style and relationship),
job (job demand and job control), organization (human resource practices and structure), and national
(labor supply and legislation) [1].

In Malaysia, as of 31 December 2017, there were 71,480 and 34,809 nurses working in the public
and private sectors, respectively. A total of 106,289 nurses nationwide is equivalent to one nurse to
302 individuals in the population [16]. As for community nurses, 23,771 and 742 community nurses
worked in the public and private sectors, respectively. Nurses are described as the main primary
workforce in the hospital, as most of the tasks of maintaining continuous support for patients in the
wards are performed by nurses [17]. The factors contributing to their absenteeism should, therefore,
be taken into account to ensure that healthcare services are well managed. Previous absenteeism
studies among nurses working in University hospitals in Malaysia exhibited a higher percentage of EL
(65%) compared to MC (52%) [13]. The significant reasons that contributed to both conditions were
due to the demand of additional home responsibilities [13]. A study among public service employees
in Malaysia also found that stress and personal life problems accounted for up to 69% of the MC [18].
The economic burden often forced them to take up additional jobs and spent more hours working,
causing inadequate rest, thus leading to stress [19].

MC and EL can also be an indication of underlying issues of work-related stress [20]. High job
demands, organizational injustice and lack of reward are among the job stressors that relate to increased
absence due to illnesses [21]. Nevertheless, work stressors specific to the job of nurses are seldom
assessed for their associations with unplanned absenteeism. A study on the association of job stress and
sickness absence among the general working population in Denmark found that female workers had
different strength of association for perceived stress between long-term sickness absence and all-length
sickness absence [22]. Thus, to study the association of work stress and unplanned absenteeism among
nurses, of whom the majority are female, the duration of MC or EL needs to be analyzed too.

Int. J. Environ. Res. Public Health 2020, 17, 6132 3 of 16

Duclay et al. (2015) found that having less healthcare personnel present at work due to absenteeism
would mean that those workers left at work assumed an excessive workload, which caused an
imbalance in their health and resulted in a pathological cycle of absenteeism within the institution [23].
A qualitative study found that in addition to the inadequate staffing and workload, absenteeism
added pressure during work hours that led to job dissatisfaction [24]. A study among 186 nurses in
Limpopo, South Africa also found that absenteeism affected the nurses who remained on duty while
their colleagues were absent in the aspect of low morale, psychological stress, and increased workload,
consequently jeopardizing patient care with the risk of medical errors [25].

In view of the lack of knowledge on the prevalence and predictors of unplanned absenteeism
among nurses, this study was conducted to determine the prevalence (including frequency and
duration) of MC and EL among nurses in Malaysia and their reasons for unplanned absenteeism.
It aimed to identify potential predictors in terms of workplace and non-workplace stressors, controlling
for sociodemographic and occupational profiles. This study is expected to provide initial evidence to
health managers to develop strategies that could reduce the number of absent nurses and benefit the
organization and the healthcare system.

2. Materials and Methods

This study was conducted in the state of Selangor which is the most densely populated state in
Malaysia [26]. Selangor has an area of 7950.9 km2 with a population density of 819 people per km2 [27]
with a total population of 5.46 million [26]. The study sample was recruited by simple random
sampling. The name list of nurses from all positions working at public hospitals, health clinics (primary
healthcare) and district health offices was arranged in one master sheet. Using a prevalence sample
size by the Kish formula [28], a reference prevalence of 78% of unplanned absenteeism among nurses
in Malaysia [13] was used. Using precision of 3%, the sample size needed was 733 respondents. Next,
the respondents were randomly selected using Microsoft Excel (Microsoft, Washington, DC, USA)
according to the number of the sample size required.

The inclusion criteria were all Malaysian-nationality registered nurses from the different levels of
positions, including matrons, sisters, staff nurses, assistant nurses, midwives/community nurses who
have worked at the current workplace for at least six months. Meanwhile, the exclusion criteria were
those medically diagnosed with a psychiatric illness or on psychiatric medications for illnesses such as
depression, bipolar disorder, anxiety disorder, schizophrenia, and those on long-term sick leave or
maternity leave during the study period.

We utilized pencil-and-paper self-reported questionnaires containing sociodemographic
(age, gender, marital status, number of children, weight, height, hypertension status and diabetes
mellitus status), occupational (workplace setting, work tenure, position, and work schedule),
psychological stress (stress status, non-workplace stressor, and workplace stressor), and unplanned
absenteeism (frequency, duration, and reason up to the third time taking MC and EL) variables.

MC is operationally defined as self-reported medically certified absenteeism due to medical
reasons whereas EL is operationally defined as any other self-reported unplanned absenteeism without
prior approval from managers and medical certificate. The frequency and duration of absenteeism
were defined as the frequency and the total number of days taking unplanned absenteeism in the past
one year for each MC and EL. Reasons for unplanned absenteeism were asked up to the third time of
absenteeism (three data points).

Stress status was measured using a validated four-point Likert scale Malay Version of the Personal
Stress Inventory: Sign and Symptoms of Stress containing 52 items with 11 subscales. This inventory
has been validated in the Malaysian population with a sensitivity of 95.1% and specificity of 77%.
The reliability measured by Cronbach alpha was 0.97. The total score of more than 36 indicated that
the respondents were having stress [29].

Subsequently, a validated four-point Likert scale Malay Version of the Personal Stress Inventory:
Pressures and Demands from Family and Household was used. The inventory contained 12 items

Int. J. Environ. Res. Public Health 2020, 17, 6132 4 of 16

which were used to assess the sources of pressure in the non-workplace setting [30]. The inventory
consisted of 12 items which included “Not enough money”, “Conflict with spouse”, “Conflicts over
household tasks”, “Problems or conflict with children”, “Pressure from relatives or in-laws”, “Fixing
up the house”, “Not enough time to spend with family”, “Sexual conflict or frustration”, “Dangerous
or stressful surroundings and neighbourhood”, “Conflict with close friend or relatives”, “Personal
problem causing strain in family” and “No babysitter”. This questionnaire used a four-point Likert-type
scale from “none at all” (0), “a little” (1), “some” (2) and “a great deal” (3). Higher scores indicated
higher non-workplace stressors. A total score (ranging from 0 to 36) was obtained by adding the
nurse’s responses to all 12 questions. The score above the mean value was categorized as a high score
and vice versa. The coverage and relevance of the content were validated by experts in occupational
health from academic (university) and service (state health department) side. The reliability using
Cronbach alpha was 0.88.

A validated four-points Likert scale Malay Version of Nursing Stress Scale containing 34 items
with 7 subscales was used to identify the sources of stress experienced by nurses [30]. It measured
the perceived frequency of the occurrence of stress in the nursing environment. The subscales were
categorized as; “Workload” (6 items), “Dealing with death and dying” (7 items), “Conflict with doctors”
(5 items), “Uncertainty concerning treatment” (5 items), “Lack of staff support” (3 items), “Conflict
with other nurses or supervisors” (5 items) and “Inadequate preparation to deal with emotional needs
of the patients and their families” (3 items). All items were on potentially stressful situations in the
nursing workplace, and the rating was made according to their perceived occurrence. Every item was
scored on a four-point Likert-type scale from “never” (0), “occasionally” (1), “frequently” (2) to “very
frequently” (3). High scores indicated the more frequent presence of a specific source of stress. A total
score ranged from 0 to 102. The score above the mean was categorized as a high score and vice versa.
The content was approved by the occupational health experts and the reliability using Cronbach alpha
was 0.93.

Data analysis was conducted using SPSS Version 21 (IBM, New York, NY, USA). The incomplete
data were dealt with by using multiple imputation techniques whereby the missing data were replaced
with the predicted imputed values which correlate with the variables of missing data. This technique
was used to ensure the natural variability of the data for valid statistical inference [31]. Statistical
analysis began with univariable descriptive analysis, where continuous variables were summarized as
mean and standard deviation while categorical variables were presented as frequencies and percentages.
Data were further analyzed using simple linear regression, followed by multiple linear regression to
identify predictors of frequency and duration of each type of unplanned absenteeism. All potential
predictors were initially included, and the elimination was done by the stepwise method. Data were
presented as adjusted regression coefficient (Adj.b), 95% CI and p-value. Significant level was set at
p < 0.05. Whereas data were collected using dichotomous outcome whether yes or no to determine the
predictors between taking MC or not, taking EL or not, taking both MC and EL or not and whether
not taking any unplanned leave at all against taking either one leave. The dichotomous outcome was
further analyzed using simple logistic regression followed by multiple logistic regression. Data were
presented as the adjusted odds ratio (Adj. OR), 95% CI and p-value. Significant level was set at
p < 0.05. This study obtained ethical approval from the Medical Research and Ethics Committee
(KKM.NIHSEC.P19-22(6)).

3. Results

3.1. Descriptive Statistics

The response rate was 95.1% accounts for 697 respondents. Table 1 describes the participants’
sociodemographic profile. The majority of the respondents were female (97.3%) and married (83.4%).
Most of them had at least one child (74.8%). Although the majority had no hypertension or diabetes
mellitus, more than half of them were overweight/obese.

Int. J. Environ. Res. Public Health 2020, 17, 6132 5 of 16

Table 1. Participants’ sociodemographic profile.

Variables, n = 697 Min. Max. n (%) Mean (SD)

Age, in years 20 59 34.67 (8.148)

Gender
Male 19 (2.73)

Female 678 (97.27)

Marital Status
Single 100 (14.35)

Married 581 (83.36)
Separated/Divorced/Others 16 (2.30)

No. of Children 0 7 1.84 (1.516)
None 176 (25.25)

At least one child 521 (74.75)

Body Mass Index (BMI), in kg/m2 25.79 (5.508)
Underweight (<18.50 kg/m2) 32 (4.59)
Normal (18.50 to 24.99 kg/m2) 321 (46.05)

Overweight (25.00 to 29.99 kg/m2) 205 (29.41)
Obese (30.00 kg/m2 and above) 139 (19.94)

Other Comorbid
Having hypertension 53 (7.60)

Having diabetes mellitus 34 (4.88)

Table 2 describes the participants’ occupational profile. Most of the respondents worked in a
hospital (64.3%) and held positions as staff nurses (61.4%). The majority of them worked in a shift-based
work schedule (64.4%) with a mean work tenure of 11.42 (SD = 7.591) years.

Table 2. Participants’ occupational profile.

Variables, n = 697 Min. Max. n (%) Mean (SD)

Workplace
Hospital 448 (64.28)

Public Health and Primary Healthcare 249 (35.72)

Work tenure as nurse, in years 11.42 (7.591)
Position

Community Nurse 162 (23.24)
Staff Nurse/Midwife 428 (61.41)

Sister a 90 (12.91)
Matron b 17 (2.44)

Work Schedule
Non-Shift Work 248 (35.58)

Shift Work 449 (64.42)
a ‘Sister’: A nurse in charge who is responsible for the immediate functioning of the unit; b ‘Matron’: chief nurse
who in charge of nursing in a hospital and the head of the nursing staff.

Table 3 describes the stressor profiles and stress status. The majority of respondents recorded
having no stress (71.88%) with the mean stress score of 25.69 (SD = 20.836). The mean score for
non-workplace and workplace stressors was 5.90 (SD = 5.497) and 25.92 (SD = 13.549), respectively.

Int. J. Environ. Res. Public Health 2020, 17, 6132 6 of 16

Table 3. Stressors profile and stress status.

Variables, n = 697 n (%) Mean (SD)

STRESS STATUS 25.69 (20.836)
Non-stress (Score less than 36) 501 (71.88)

Stress (Score 36 and above) 196 (28.12)

NON-WORKPLACE STRESSOR 5.90 (5.497)
Not enough money 0.68 (0.796)

Conflicts with spouse 0.48 (0.693)
Conflicts over household tasks 0.48 (0.682)

Conflicts with children 0.36 (0.598)
Pressure from relatives 0.44 (0.713)

Fixing up of house 0.43 (0.681)
No time with family 1.08 (0.966)

Sexual conflicts 0.21 (0.513)
Dangerous surroundings 0.42 (0.663)

Conflict with close friends 0.40 (0.603)
Personal problems cause strain 0.40 (0.636)

No babysitter 0.51 (0.797)

WORKPLACE STRESSOR 25.92 (13.549)
Workload 8.39 (3.640)

Death and dying 4.39 (3.831)
Inadequate preparation 1.80 (1.572)

Lack of staff support 2.11 (1.908)
Uncertainty concerning treatment 3.19 (2.429)

Conflict with doctors 3.22 (2.552)
Conflict with other nurses 2.81 (2.453)

Table 4 describes the characteristic of MC and EL in term of their prevalence, duration and
frequency. The prevalence of ever taking MC and EL in the past one year was 49.07% and 48.35%,
respectively. Most respondents took only one-day MC (32.16%) and only once (53.22%). Similarly,
most respondents took only one-day EL (45.10%) and only once (52.52%). Subsequently, Figure 1
demonstrates the number of respondents taking leave based on leave duration in days and Figure 2
demonstrates the number of respondents taking leave based on leave frequency.

Table 4. Unplanned absenteeism profile.

Variables,
n = 697

Medically-Certified Leave (MC) Emergency Leave (EL)

n (%) Min. Max. Mean (SD) n (%) Min. Max. Mean (SD)

Prevalence
Never taken 355 (50.93) 360 (51.65)
Ever taken 342 (49.07) 337 (48.35)

Duration in days
of taking leave a

1 140
4.24

(10.355)
1 16 2.39 (1.966)

Frequency of
taking leave a

1 25 1.80 (1.593) 1 8 1.92 (1.272)

a Among those who had ever taken a medically certified leave (n = 342) or emergency leave (n = 337), respectively.

Int. J. Environ. Res. Public Health 2020, 17, 6132 7 of 16
Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 7 of 16

Figure 1. Number of respondents taking leave based on leave duration in days.

Figure 2. Number of respondents taking leave based on leave frequency.

Table 5 demonstrates the reasons for taking MC and EL. The reasons for MC were mostly
medical-related, while the reasons for EL were family-related. The highest reasons for MC were due

0

20

40

60

80

100

120

140

160

1 2 3 4 5 6 7 8 9 10 >10

N
u

m
b

er
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f
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sp
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ts

Leave duration, in days

Number of respondents taking leave based on leave
duration in days

MC EL

0

20

40

60

80

100

120

140

160

180

200

1 2 3 4 5 6 7 8 10 25

N
u

m
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sp
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Leave frequency

Number of respondents taking leave based on leave
frequency

MC EL

Figure 1. Number of respondents taking leave based on leave duration in days.

Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 7 of 16

Figure 1. Number of respondents taking leave based on leave duration in days.

Figure 2. Number of respondents taking leave based on leave frequency.

Table 5 demonstrates the reasons for taking MC and EL. The reasons for MC were mostly
medical-related, while the reasons for EL were family-related. The highest reasons for MC were due

0

20

40

60

80

100

120

140

160

1 2 3 4 5 6 7 8 9 10 >10

N
u

m
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sp
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ts

Leave duration, in days

Number of respondents taking leave based on leave
duration in days

MC EL

0

20

40

60

80

100

120

140

160

180

200

1 2 3 4 5 6 7 8 10 25

N
u

m
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sp
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Leave frequency

Number of respondents taking leave based on leave
frequency

MC EL

Figure 2. Number of respondents taking leave based on leave frequency.

Int. J. Environ. Res. Public Health 2020, 17, 6132 8 of 16

Table 5 demonstrates the reasons for taking MC and EL. The reasons for MC were mostly
medical-related, while the reasons for EL were family-related. The highest reasons for MC were
due to unspecified fever (39.18%), non-specified reasons (12.28%), upper respiratory tract infection
(URTI)/sinusitis (9.65%) followed by acute gastroenteritis or food poisoning (8.48%) and unspecified
dizziness, headache, vertigo, migraine (8.48%). On the other hand, the highest reasons for EL were
sick children (51.93%), followed by sick family members (18.10%), and death of family members or
relatives (15.73%). Surgery-related MC showed the highest minimum and maximum number of leave
days for MC i.e., 10 days and 140 days. Child sickness has been reported as the reason for both MC
and EL, which ranges between 5 and 6 days for MC and 1 to 16 days for EL.

Table 5. Reasons for unplanned absenteeism a.

Variables n (%)
No. of Leave Days for Each Reason

Min Max Mean (SD) Total

MEDICALLY-CERTIFIED LEAVE (MC) b

Unspecified fever 134 (39.18) 1 4 1.54 (0.732) 206
Non-specified 42 (12.28) 1 33 3.17 (5.231) 133

Upper respiratory tract infection, sinusitis 33 (9.65) 1 9 2.00 (1.581) 66
AGE, food poisoning 29 (8.48) 1 4 1.38 (0.820) 40

Dizziness, headache, vertigo, migraine 29 (8.48) 1 4 1.72 (0.751) 50
Unspecified symptoms (ache, cough) 26 (7.60) 1 5 1.73 (1.079) 45

Tooth-related pain and procedure 23 (6.73) 1 5 1.65 (1.027) 38
Eye-related (e.g., conjunctivitis) 18 (5.26) 1 5 2.44 (1.338) 44

Trauma-related (fracture, tissue injury) 16 (4.68) 1 60 8.25 (15.159) 132
Medical appointment/procedure 15 (4.29) 1 4 1.80 (1.014) 27

Others (otitis, pneumonia, burn, allergy) 12 (3.51) 1 10 3.33 (2.964) 40
Surgery (I&D, laparotomy, TAHBSO) 11 (3.22) 10 140 39.45 (38.816) 434

AEBA 10 (2.92) 1 7 2.50 (2.121) 25
CVS-related (ACS, hypertension, stroke) 8 (2.34) 1 30 5.75 (9.867) 46

MSD (CTS, PID, backache) 7 (2.05) 1 16 4.71 (5.499) 33
Viral fever, dengue fever 7 (2.05) 1 7 3.71 (2.498) 26

GERD, gastritis 5 (1.46) 1 3 2.00 (1.000) 10
Urinary tract infection 4 (1.17) 1 7 3.25 (2.630) 13

Menstrual-related 3 (0.88) 1 1 1.00 (0.000) 3
Child sickness 2 (0.58) 5 6 5.50 (0.707) 11

EMERGENCY LEAVE (EL) c

Child sickness 175 (51.93) 1 16 2.23 (1.789) 390
Sick family members or relatives 61 (18.10) 1 7 2.18 (1.658) 133

Death of family members 53 (15.73) 1 5 1.51 (0.993) 80
Unspecified reasons 35 (10.39) 1 5 1.71 (1.073) 60

Child matters except sickness 31 (9.20) 1 3 1.35 (0.709) 42
Self-certified health problem 21 (6.23) 1 3 1.33 (0.658) 28

Unspecified family- or self-related matters 16 (4.75) 1 3 1.38 (0.719) 22
Vehicle problem or MVA 9 (2.67) 1 1 1.00 (0.000) 9

Medical appointment 1 (0.30) 1 1 1.00 (0.000) 1
Others 1 (0.30) 1 1 1.00 (0.000) 1

a We sampled only the first three unscheduled absenteeism; b Denominator is the respondents who took MC
(n = 342); c Denominator is the respondents who took EL (n = 337); AGE: acute gastroenteritis; MVA: motor
vehicle accident; MSD: musculoskeletal disease; CTS: carpal tunnel syndrome; PID: prolapse intervertebral
disc; GERD: gastroesophageal disease; I&D: incision and drainage; TAHBSO: total abdominal hysterectomy and
bilateral salpingo-oophorectomy; AEBA: acute exacerbation bronchial asthma; ACS: acute coronary syndrome;
CVS: cardiovascular.

3.2. Predictors of Those Taking MC, Taking EL, Those Taking MC and EL, and Those neither Take MC nor EL

Table 6 describes the determinants of taking MC, EL, both MC and EL, and neither MC nor EL.
Those with older age, and no children, had a higher magnitude of non-workplace stressor related to
conflict with close friends and had a lower magnitude of workplace stressor related to inadequate

Int. J. Environ. Res. Public Health 2020, 17, 6132 9 of 16

preparation, had higher odds of taking MC. Meanwhile, those who had children and had a higher
level of non-workplace stressors related to pressure from relatives had higher odds of taking EL. As for
the odds of taking combined MC and EL, the odds are higher among those who ever married, worked
in a non-hospital setting, had a lower magnitude of non-workplace stressors related to dangerous
surroundings, and had a higher magnitude of workplace stressor related to inadequate preparation.

Table 6. Predictors of taking medically certified leave (MC), emergency leave (EL), both MC and EL,
and neither took MC nor EL.

Variables, n = 697
Exp (B) (95% CI) a

MC b EL c MC + EL d None e

SOCIODEMOGRAPHIC

Age
1.029

(1.004, 1.056)

Marital status (Ref. = ever married)
0.252

(0.135, 0.473)
2.193

(1.404, 3.425)

Having children (Ref. = have children)
2.120

(1.323, 3.395)
0.414

(0.238, 0.718)

BMI (Ref. = overweight/obese)

OCCUPATIONAL

Workplace (Ref. = hospital)
1.696

(1.195, 2.407)
0.625

(0.432, 0.905)

Work schedule (Ref. = non-shift)

STRESS STATUS (Ref. = yes)

NON-WORKPLACE STRESSOR

Not enough money

Conflicts with spouse

Conflicts over household tasks

Conflicts with children

Pressure from relatives
1.658

(1.228, 2.239)
0.687

(0.516, 0.916)

Fixing up of house

No time with family

Sexual conflicts

Dangerous surrounding
0.712

(0.542, 0.936)

Conflict with close friends
1.394

(1.007, 1.928)

Personal problems cause strain

No babysitter

WORKPLACE STRESSOR

Workload

Death and dying
0.921

(0.875, 0.969)

Inadequate preparation
0.754

(0.644, 0.820)
1.210

(1.082, 1.353)

Lack of staff support

Uncertainty concerning treatment

Conflict with doctors

Conflict with other nurses
a Although all variables in the table were included in the adjusted model, only significant results were presented;
b adj.R2 = 0.071; c adj.R2 = 0.060; d adj.R2 = 0.083; e adj.R2 = 0.091.

Int. J. Environ. Res. Public Health 2020, 17, 6132 10 of 16

3.3. Predictors of Durations in Days of MC and EL among Those Who Ever Took MC and EL

Table 7 demonstrates the determinants of MC and EL durations among those who ever took MC
and EL. The determinants of longer durations of MC were working in a hospital, lower stressors of
inadequate preparation and higher stressors of conflict with doctors. In contrast, the determinants of
longer durations of EL were having children, being overweight/obese, working in non-shift schedule,
higher stressor of conflict with spouse, no babysitter, and inadequate preparation, and lower stressors
of sexual conflict, lack of staff support and conflict with doctors.

Table 7. Predictors of duration in days of MC and EL among those ever took MC and EL.

Variables

Adj.b (95% CI) a

Duration of MC
among Those Ever

Took MC (n = 342) b

Duration of EL among
Those Ever Took EL

(n = 337) c

SOCIODEMOGRAPHIC PROFILE
Age

Marital status (0 = never married; 1 = ever married)
Having children (0 = no children; 1 = have children) 0.781 (0.242, 1.320)

Body mass index (0 = underweight/normal; 1 = overweight/obese) 0.417 (0.019, 0.816)

OCCUPATIONAL PROFILE
Workplace (0 = non-hospital; 1 = hospital) 3.411 (0.721, 6.101)

Work schedule (0 = shift; 1 = non-shift) 0.463 (0.039, 0.888)

STRESS STATUS (0 = no; 1 = yes)

NON-WORKPLACE STRESSOR
Not enough money

Conflicts with spouse 0.536 (0.184, 0.888)
Conflicts over household task

Conflicts with children
Pressure from relatives

Fixing up of house
No time with family

Sexual conflict −0.435 (−0.848, −0.022)
Dangerous surrounding

Conflict with close friends
Personal problem cause strain

No babysitter 0.440 (0.166, 0.714)

WORKPLACE STRESSOR
Workload

Death and dying
Inadequate preparation −1.065 (−1.849, −0.282) 0.257 (0.104, 0.409)

Lack of staff support −0.190 (−0.322, −0.059)
Uncertainty concerning treatment

Conflict with doctors 0.491 (0.000, 0.982) −0.112 (−0.220, −0.003)
Conflict with other nurses

a Adjusted regression coefficient (all variables in the table were included in this adjusted model; however only
significant results were presented); b Multiple linear regression (Constant = 1.526; adj.R2 = 0.027; model assumptions
are met); c Multiple linear regression (Constant = 1.129; adj.R2 = 0.132; model assumptions are met).

3.4. Predictors of Frequency of MC and EL among Those Who Ever Took MC and EL

Table 8 demonstrates the determinants of MC and EL frequency among those who ever took
MC and EL. The determinants of higher frequency of MC were having children, higher magnitude of
stressors of no time with family, dangerous surroundings, and death and dying, and lower magnitude
of stressors related to conflicts over household tasks and conflict with close friends. On the other hand,
the determinants of higher frequency of EL were younger age, having children, being overweight/obese,
working in a non-hospital setting, having no stress, a higher level of stressors related to conflicts with
spouse, pressure from relatives, and inadequate preparation, and a lower level of stressors related to
not enough money.

Int. J. Environ. Res. Public Health 2020, 17, 6132 11 of 16

Table 8. Predictors of frequency of MC and EL among those ever took MC and EL.

Adj.b (95% CI) a

Variables, n = 337
Frequency of MC
among Those Ever

Took MC (n = 342) b

Frequency of EL
among Those Ever
Took EL (n = 337) c

SOCIODEMOGRAPHIC PROFILE
Age −0.024 (−0.042, −0.006)

Marital status (0 = never married; 1 = ever married)
Having children (0 = no children; 1 = have children) 0.601 (0.210, 0.991) 0.521 (0.161, 0.881)

OCCUPATIONAL PROFILE
Body mass index (0 = underweight/normal; 1 = overweight/obese) 0.385 (0.121, 0.648)

Workplace (0 = non-hospital; 1 = hospital) −0.327 (−0.594, −0.060)
Work schedule (0 = shift; 1 = non-shift)

STRESS STATUS (0 = no; 1 = yes) −0.368 (−0.661, −0.076)

NON-WORKPLACE STRESSOR
Not enough money −0.334 (−0.523, −0.145)

Conflicts with spouse 0.383 (0.157, 0.610)
Conflicts over household task −0.261 (−0.519, −0.002)

Conflicts with children
Pressure from relatives 0.207 (0.015, 0.398)

Fixing up of house
No time with family 0.257 (0.066, 0.448)

Sexual conflict
Dangerous surrounding 0.734 (0.438, 1.031)

Conflict with close friends −0.467 (−0.779, −0.154)
Personal problem cause strain

No babysitter

WORKPLACE STRESSOR
Workload

Death and dying 0.051 (0.004, 0.099)
Inadequate preparation 0.090 (0.006, 0.173)

Lack of staff support
Uncertainty concerning treatment

Conflict with doctors
Conflict with other nurses

a Adjusted regression coefficient (all variables in the table were included in this adjusted model; however only
significant results were presented); b Multiple linear regression (Constant = 0.912; adj.R2 = 0.116; model assumptions
are met); c Multiple linear regression (Constant = 2.077; adj.R2 = 0.151; model assumptions are met).

4. Discussions

This study was conducted to determine the prevalence, frequency, duration, and reasons for
MC and EL (unplanned absenteeism) and further identify their determinants particularly related to
workplace and non-workplace stressors. It was found that almost half of respondents reported ever
taking MC or EL which is similar with another study [32]. The mean frequency of MC and EL were two
days each, while the mean duration of MC and EL were four and two days, respectively. The top reasons
for MC, as the name implied, were mostly medical-related such as unspecified fever, URTI/sinusitis,
and acute gastroenteritis (AGE)/food poisoning which is consistent with another study [18]. In contrast,
the most common reasons for EL were family-related matters such as child sickness, sick family
members, and death of family members. Although most of them were categorised as not having
stress (71.9%), both workplace and non-workplace stressors were significantly associated with either
MC or EL. These findings signify that MC or EL were not only determined by the direct medical- or
family-related reasons mentioned earlier; but stressors may also indirectly play an important role in
unplanned absenteeism.

Sociodemographically, it was found that married nurses had higher odds of taking both MC and
EL. This finding is similar to a study that showed marriage had a significant effect on absenteeism,
as they had to be responsible for other additional family members [33]. On the other hand, nurses with
children had higher odds of taking EL, longer duration of EL, and higher frequency of MC. This is

Int. J. Environ. Res. Public Health 2020, 17, 6132 12 of 16

consistent with studies that shown that larger family sizes will increase the amount of responsibilities
and increase work–family conflict, subsequently resulting in absenteeism [13,34,35]. Apart from
that, being overweight/obese had contributed to an increase in frequency and duration of EL. This is
supported by one study that reported that overweight increased the risk of absenteeism which may be
contributed by the lack of enthusiasm at work [36].

Occupationally, it was found that non-hospital nurses had higher odds of taking both MC and EL.
In addition, non-hospital nurses had higher frequency of taking EL but lesser duration of MC. This is
consistent with a previous study which reported that those working in the primary care covering
clinics had reported a 41% higher incidence of absence during the second year and an increase to 50%
in the following year compared to those working in the wards [37]. Our study also found that nurses
who worked in a non-shift schedule had higher duration of EL. This finding contradicts with previous
studies that showed that the shift schedule had a significant association with absenteeism [38] which
could be due to the conflicting responsibilities between working in shifts and attending to family
members which could lead to absenteeism [39]. We postulate that this contradictory finding was
contributed to by the fact that essential services including child education, banking, and administrative
services are provided during office hours, which may influence the decision of nurses who work in a
non-shift schedule to take EL to settle their essential non-work-related matters.

Although stress was one of the main culprits of absenteeism which can jeopardise the
organisation [40], our study found that stress was associated with lower frequency of EL. We postulate
that this could be due to the differential in root causes of stress that indirectly influence absenteeism.
For instance, those who experience financial constraints which have been shown to be associated with
stress [19] may or may not be absent from work; those who absent may be due to the involvement in
part-time job that jeopardize their attendance at work, while those who present may be due to the fear
in losing the current job and income. However, this postulation needs to be confirmed in future study
using a longitudinal study involving multiple interrelated occupational and non-occupational variables.

Nurses with workplace stressors of inadequate preparation had lower odds of taking MC and had
shorter durations of MC but higher duration and frequency of EL. Inadequate preparation in handling
work tasks in terms of mental readiness in treating patients tend to make nurses feel irresponsible
when managing patients and leave them vulnerable to making mistakes, leaving them no choice but
to take the EL. Recent advances in technology and an increasing demand in care requires nurses to
develop increasingly higher skill levels that only expose them to more stress than other healthcare
professionals [41]. Krohne and Magnussen (2011) stated that those who are equipped with knowledge
and preparation for work would promote a good healthy working environment, which prevents
withdrawal behaviour [42]. On the other hand, the workplace stressor related to lack of staff support
was significantly associated with shorter durations of EL. The lack of managerial support for a work–life
balance leads to added pressure for workers to return to work as soon as possible, perhaps even before
they are ready to do so. This was in line with a study suggesting that supervisor positive attitudes
towards the aspect of the non-work domain will support their employees in handling the competing
family demands thus reducing the degree of presenteeism [39].

Conflicts with doctors significantly increased the duration of taking MC but lower duration of
EL. Nurses might not have the benefits of taking MC especially during the earlier phases of an illness
which result in the nurse being severely ill resulting in a prolonged duration of MC [43]. Accordingly,
a study among the Chinese population found that supervisors tend not to believe the reasons given
by the workers on sick leave, thus leading to presenteeism which causes further disruption in work
productivity [44]. Finally, nurses who were occupationally stressed about death and dying had higher
odds of not taking neither MC nor EL. However, if nurses who were stressed about death and dying
took MC, they were more likely to have a higher frequency of MC. Facing real-life tragedies left them
emotionally disturbed and unable to continue working due to mental illness or disorder [45].

Non-workplace stressors were associated with the frequency or duration of MC and EL in varying
directions of influence. For instance, no time with family and dangerous surroundings were associated

Int. J. Environ. Res. Public Health 2020, 17, 6132 13 of 16

with a higher frequency of MC but conflict with close friends and conflicts over household tasks were
associated with a lower frequency of MC. In addition, pressure from relatives and conflict with spouse
were associated with a higher frequency of EL, while conflicts with spouse and no babysitter were
associated with a higher duration of EL. Moreover, sexual conflict was associated with a lower duration
of EL, but insufficient money was associated with a lower frequency of EL. Similar findings were
recorded for workplace stressors which have been discussed earlier. These findings may suggest that
the origin of stressors plays an important role in influencing medical- or family-related outcome which
consequently determine the aspect of MC and EL. Another possible reason could be the cross-sectional
design that is unable to infer causation [46], and it is thus unknown which comes first either the MC/EL
or the non-workplace stressors. This could also be due to the interaction between workplace and
non-workplace stressors that influence the MC or EL.

In view of the possible interaction of workplace and non-workplace stressors with absenteeism,
some working organisations support the introduction of a family-friendly organisational culture by
encouraging managers to support family life [47]. Modifying the workplace environment, which is
the responsibility of both employees and managers, is necessary given potential for modifiable
determinants to control unplanned absenteeism. An absenteeism policy should be in place to ensure
that rules are stated clearly, and the daily work process should continue as usual [48]. Flexible working
time arrangements can be considered for those who have conflicting responsibilities between work
and family and can be applied to those who have illnesses as well. A family-supportive organisational
culture at the workplace should be created by getting managers to support the work–life balance.
Despite the need to reduce unplanned absenteeism, managers should be concerned for their workers’
general well-being; therefore, MC should be encouraged to those who have acute minor illness or else
the upcoming health-related consequences will lead to a worse impact. For instance, those with URTI
which could be easily transmitted in a healthcare setting could lead to a longer duration of MC or
higher number of workers taking MC if the source workers continue to work despite having the illness.

This study has limitations related to the cross-sectional design that could neither infer causation
nor examine the mediating/moderating effect of other variables. Therefore, there is a need to conduct a
longitudinal design to examine the interrelationship among workplace and non-workplace stressors,
and their causal effects towards absenteeism. The subsequent study should also comprehensively refer
to the model of absenteeism to guide researchers on how to tackle the possible determinants acquired
from the respondents to explore other factors of unplanned absenteeism. Other than that, future studies
can be commenced qualitatively to determine the specific reasons for unplanned absenteeism at a
different hospital setting.

Apart from cross sectional design, the other limitation of this study was in the exploration of
reasons for leave and days of leave for each reason was only up to the third time of frequency. Therefore,
we were unable to capture the reasons for unplanned absenteeism that exceeded more than three times.
Furthermore, the findings were self-reported; hence, we could not verify the validity of the number of
days, frequency, and reasons for unplanned absenteeism. Other than that, this study had induced recall
bias as respondents tended to remember obvious common reasons instead of uncommon ones; thus,
the absolute reasons for unplanned absenteeism should be interpreted with caution. Another limitation
was a misclassification on the reasons for unplanned absenteeism that might have been wrongly stated
by respondents including medical appointments/procedure and surgery. Having advanced notice of
an upcoming leave due to these reasons could be classified under planned absenteeism.

5. Conclusions

To conclude, the prevalence of MC and EL among nurses working in Malaysia for the past one
year was 49% and 48%, respectively. A majority of the subjects took both MC and EL for only once
and for only a one-day duration for the past year. The most common reason for MC and EL was
unspecified fever and sick children, respectively. There is no clear distinction between workplace and
non-workplace stressors for MC, EL or both. Both workplace and non-workplace stressors showed

Int. J. Environ. Res. Public Health 2020, 17, 6132 14 of 16

different significance, magnitude and direction of association towards the duration or frequency
for MC and EL. Nevertheless, preventive measures should be taken by targeting modifiable factors,
which involve getting managers on board and promoting a stress-free environment in the workplace.
Future study should consider employing a longitudinal design that combines both qualitative and
quantitative method based on a comprehensive model of absenteeism.

Author Contributions: Project Administration, H.M.Y., N.A.M.S., M.F.M.F., R.M.R. and S.E.W.P.;
Conceptualization, N.A.M.S., M.F.M.F., R.M.R. and H.M.Y.; Methodology, N.A.M.S., M.F.M.F. and R.M.R.;
software, N.A.M.S. and M.F.M.F.; validation, N.A.M.S., M.F.M.F., H.M.Y. and S.E.W.P.; formal analysis, N.A.M.S.,
M.F.M.F., H.M.Y. and R.M.R.; investigation, N.A.M.S. and M.F.M.F.; resources, H.M.Y., N.A.M.S., M.F.M.F.,
R.M.R. and S.E.W.P.; data curation, M.F.M.F., N.A.M.S. and R.M.R.; writing—original draft preparation, N.A.M.S.,
M.F.M.F., H.M.Y.; writing—review and editing, N.A.M.S., M.F.M.F., H.M.Y., R.M.R. and S.E.W.P.; All authors have
read and agreed to the published version of the manuscript.

Funding: This research received no external funding.

Acknowledgments: We would like to express our gratitude to the Occupational and Environmental Health Unit
and Nursing Unit in each district health office and public hospital in Selangor for their assistance in this research.

Conflicts of Interest: The authors declare no conflict of interest.

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© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).

RESEARCH ARTICLE

Critical care nurses’ communication

experiences with patients and families in an

intensive care unit: A qualitative study

Hye Jin Yoo
1
, Oak Bun Lim

1
, Jae Lan ShimID

2*

1 Department of Nursing, Asan Medical Center, Seoul, South Korea, 2 College of Medicine, Department of

Nursing, Dongguk University, Gyeongju, South Korea

* [email protected]

Abstract

This study evaluated the communication experiences of critical care nurses while caring for

patients in an intensive care unit setting. We have collected qualitative data from 16 critical

care nurses working in the intensive care unit of a tertiary hospital in Seoul, Korea, through

two focus-group discussions and four in-depth individual interviews. All interviews were

recorded and transcribed verbatim, and data were analyzed using the Colaizzi’s method.

Three themes of nurses’ communication experiences were identified: facing unexpected

communication difficulties, learning through trial and error, and recognizing communication

experiences as being essential for care. Nurses recognized that communication is essential

for quality care. Our findings indicate that critical care nurses should continuously aim to

improve their existing skills regarding communication with patients and their care givers and

acquire new communication skills to aid patient care.

Introduction

Critical care nurses working in intensive care units (ICUs) care for critically-ill patients, and

their work scope can include communicating with patients’ loved ones and care givers [1]. In

such settings, nurses must make timely judgments based on their expertise, and this requires a

high level of communication competency to comprehensively evaluate the needs of patients

and their families [2,3]. The objective of nurses’ communication is to optimize the care pro-

vided to patients [4]. Therapeutic communication, a fundamental component of nursing,

involves the use of specific strategies to encourage patients to express feelings and ideas and to

convey acceptance and respect. In building an effective therapeutic relationship, a focus on the

patient and a genuine display of empathy is required [5]. Empathy is the ability to understand

and share another person’s emotions. To convey empathy towards a patient, one must accu-

rately perceive the patient’s situation, communicate that perception to the patient, and act on

the perception to help the patient [6]. Effective communication based on empathy not only

contributes greatly to the patient’s recovery [3,5–7], but also has a positive effect of improving

job satisfaction by nursing with confidence [8] In contrast, inefficient communication leads to

PLOS ONE

PLOS ONE | https://doi.org/10.1371/journal.pone.0235694 July 9, 2020 1 / 15

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OPEN ACCESS

Citation: Yoo HJ, Lim OB, Shim JL (2020) Critical

care nurses’ communication experiences with

patients and families in an intensive care unit: A

qualitative study. PLoS ONE 15(7): e0235694.

https://doi.org/10.1371/journal.pone.0235694

Editor: Liza Heslop, Victoria University,

AUSTRALIA

Received: January 21, 2020

Accepted: June 21, 2020

Published: July 9, 2020

Copyright: © 2020 Yoo et al. This is an open
access article distributed under the terms of the

Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the manuscript.

Funding: This work was supported by the Dongguk

University Nursing Academy-Industry Cooperation

Research Fund of 2018.The funder had no role in

study design, data collectionand analysis, decision

to publish, or preparation of the manuscript

Competing interests: The authors have declared

that no competing interests exist.

complaints and anxiety in patients and can also lead to other negative outcomes, such as

extended hospital stays, increased mortality, burnout, job stress, and turnover [9,10].

Therefore, communication experiences need investigation since effective communication is

an essential for critical care nurses. Nurses use curative communication skills to provide new

information, encourage understanding of patient’s responses to health troubles, explore

choices for care, help in decision making, and facilitate patient wellbeing [11]. Particularly,

patient- and family-centered communication contributes to promoting patient safety and

improving the quality of care [12,13]. However, communication skills are relatively poorly

developed among critical care nurses compared to nurses in wards and younger and less expe-

rienced nurses than in their older and more experienced counterparts [3,7,14–16]. This calls

for an examination of the overall communication experiences of critical care nurses.

To date, most studies on the communication of critical care nurses have been quantitative

and have evaluated work performance, association with burnout, and factors that hinder com-

munication [2–4,7]. A qualitative study has examined communications with families of ICU

patients in Korea [17], while an international study has identified factors that promote or hin-

der communication between nurses and families of ICU patients [16,18]; however, few studies

have been conducted on participant-oriented communication (including patients and fami-

lies). Nurses’ communication with patients and their families in a clinical setting is complex

and cannot be understood solely on the basis of questionnaire surveys; therefore, these com-

munication experiences must be studied in depth.

This study explored critical care nurses’ communication experiences with patients and their

families using an in-depth qualitative research methodology. This study will help to enhance

communication skills of critical care nurses, thereby improving the quality of care in an ICU

setting.

Materials and methods

Design

This study employed a qualitative descriptive design using focus-group interviews (FGIs) and

in-depth individual interviews and was performed according to the consolidated criteria for

reporting qualitative research (COREQ) checklist [19]. An FGI is a research methodology in

which individuals engage in an intensive and in-depth discussion of a specific topic to explore

their experiences and identify common themes based on the interactions among group mem-

bers [20]. Individual in-depth interviews were also conducted to complement the content

identified in FGIs and further explore the deeper information developed based on experiences

at the individual level.

Participants

Sixteen critical care trained nurses providing direct care to patients in an ICU of a tertiary hos-

pital in Seoul were included in this study. The purpose of this study and the contents of the

questionnaire were explained to them, and they voluntarily agreed to participate and complete

the questionnaire. The exclusion criteria were as follows: 1) nurses with a hearing problem; 2)

nurses with less than 1 year of clinical experience; and 3) nurses diagnosed with psychiatric

disorders.

Snowball sampling—in which participants recruit other participants who can vividly share

their experiences regarding the topic under investigation—was used. Six participants for the

first FGI, six for the second FGI, and four for the individual in-depth interviews were

recruited. All participants were women (mean age = 29.0 years old; mean nursing experi-

ence = 4.5 years). Their characteristics are listed in Table 1.

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PLOS ONE | https://doi.org/10.1371/journal.pone.0235694 July 9, 2020 2 / 15

Data collection

Developing interview questions. The interview questions were structured according to

the guidelines developed for the focus-group methodology [21]: 1) introductory questions, 2)

transitional questions, 3) key questions, and 4) ending questions. The questions were reviewed

by a nursing professor with extensive experience in qualitative research and three critical care

nurses with more than 10 years of ICU experience (Table 2). These questions were also used

for individual face-to-face in-depth interviews.

Conducting FGIs and individual interviews. The two FGIs and four individual inter-

views were conducted between July 20, 2019 and September 30, 2019. The FGIs were moder-

ated by the principal female investigator and were conducted in a quiet conference room

where participants were gathered around a table to encourage them to talk freely. The FGIs

were audio-recorded with the participants’ consent, and the recordings were transcribed and

analyzed immediately after. Similar content was observed from the two rounds of FGIs, and

we continued the discussion until no new topics emerged.

To complement the FGIs and verify the results of the analysis, we also conducted individual

interviews of four participants. One assistant helped in facilitating the interviews and took

notes. The duration of each interview was about 60–90 minutes.

Ethical considerations and investigator training and preparation. This study was

approved by the institutional review board of the Asan Medical Center (approval no. 2019–

0859). Prior to data collection, participants provided written informed consent and were

informed in advance that the interviews would be audio-recorded, their participation would

remain confidential, the recordings and transcripts would only be used for research purposes,

the data would be securely stored under a double lock and would be accessed by the investiga-

tors only, and personal information would be deleted upon the completion of the study to

eliminate any possibility of a privacy breach. The collected data were coded and stored to be

accessed by the investigators only to prevent leakage of any personal information.

The authors of this study are nurses with more than 10 years of ICU experience and a deep

understanding of critical care. The principal investigator took a qualitative research course in

Table 1. Participant characteristics.

No. Sex Age (years old) Intensive care unit experience (months) Marital status Highest Educational Level

1 F 28 30 Single University

2 F 27 30 Single University

3 F 27 29 Single University

4 F 29 27 Single University

5 F 27 24 Single University

6 F 26 24 Single University

7 F 26 22 Single University

8 F 26 22 Single University

9 F 26 22 Single University

10 F 26 20 Single University

11 F 27 20 Single University

12 F 26 20 Single University

13 F 29 40 Single University

14 F 37 168 Married Master’s

15 F 38 180 Married Master’s

16 F 39 188 Married Master’s

https://doi.org/10.1371/journal.pone.0235694.t001

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PLOS ONE | https://doi.org/10.1371/journal.pone.0235694 July 9, 2020 3 / 15

graduate school and has conducted multiple qualitative studies to enhance her qualitative

research experience.

Data analysis

We utilized Colaizzi’s [22] method of phenomenological analysis to understand and describe

the fundamentals and meaning of nurses’ communication experiences with patients and fami-

lies. Data analysis was conducted in seven steps: 1) Recording and transcription of the in-

depth interviews (all authors read the transcripts repeatedly to better understand the partici-

pants’ meaning); 2) Collection of meaningful statements from phrases and sentences contain-

ing phenomena relating to the communication experiences in the ICU. We extracted

statements overlapping with statements of similar meaning—taking representative ones of

similar statements—and omitted the rest; 3) Searching for other interpretations of participant

statements using various contexts; 4) Extraction of themes from relevant meanings and devel-

opment of a coding tree, with the meanings organized into themes; 5) Organization of similar

topics into a more general and abstract collection of themes; 6) Validation of the collection of

themes by cross-checking and comparing with the original data; 7) After integrating the ana-

lyzed content into one technique, the overall structure of the findings was described.

During data analysis, we received advice on the use of language or result of analyzing from

a nursing professor with extensive experience in qualitative research and had the data verified

by three participants to establish the universality and validity of the identified themes.

Establishing precision

The credibility, fittingness, auditability, and confirmability of the study were evaluated to ana-

lyze our findings [23]. To increase credibility, we conducted the interviews in a quiet place to

Table 2. List of interview questions.

Question

Type

Questions

Introductory What kind of care do you provide to your patients and their families as an ICU nurse?

Transitional As an ICU nurse, how is your communication with your family now?

Key What is your primary focus when communicating with patients and their families?

Do you have memorable experiences in your communication with your patients’ families?

a) If so, what were these experiences?

b) How do you feel about those experiences?

Do you have your own strengths in communicating with patients and their families?

a) If so, what are their advantages?

b) What role do your strengths play in communication?

c) What is the impact of communication on nursing?

Have you ever faced difficulties in communicating with patients’ families?

a) If so, please specify them.

b) What is the impact of these communication difficulties on your patients and their families?

c) How do these communication difficulties affect nursing?

Have you made any personal effort to communicate effectively with patients and their families?

a) If so, what have you done specifically?

b) How does the effort/s you have made affect your communication with patients and their

families?

Do you need hospital or external help to improve communication with your patients and their

families?

a) If so, what specific help do you need?

b) How do you feel about the changes in communication style with patients and families when

support and help are provided?

What does communication with the patients and their families mean to the nurse?

Ending Is there anything you would like to add?

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focus on participants’ statements and help participants feel comfortable during interviews; to

establish the universality and validity of the identified themes, data verification was performed

by three participants. To ensure uniformity in data, participants who could provide detailed

accounts of their experiences were selected, and the data were collected and analyzed until sat-

uration was achieved (i.e., no new content emerged). To ensure auditability, the raw data for

the identified themes were presented in the results, such that the readers could understand the

decision-making process. To ensure confirmability, our preconceptions or biases regarding

the participants’ statements were consistently reviewed to minimize the impact of bias and

maintain neutrality.

Results

After analyzing the communication experiences of 16 critical care nurses, three major themes

emerged: facing unexpected communication difficulties, learning through trial and error, and

recognizing communication experiences as being essential for care. The results are summa-

rized in Table 3.

The results of this study are schematized based on Travelbee’s Human-to-Human Relation-

ship Model [24,25] (Fig 1), which suggests that human-to-human interaction is at a develop-

mental stage. In this study, communication between patients and their families and

experienced nurses in ICUs promotes human-to-human connections, leading to a genuine

caring relationship through interaction, empathy, listening, sharing, and respect, which are all

therapeutic communication skills.

Theme 1: Facing unexpected communication difficulties

Nurses experienced more difficulties in communicating with patients and their families and

caregivers than in performing essential nursing activities (e.g., medication administration, suc-

tion, and various mechanical operations) The communication difficulties they experienced

were either nurse-, patient- and family-, or system-related. Distinct problems in an ICU are

related to urgency; for example, hemodynamically unstable patients or patients with respira-

tory failure or those suffering from a cardiac arrest may be prioritized.

Nurse-related factor: True intentions were not conveyed as wished. Although nurses

intend to treat patients and their families with empathy, they frequently lead one-way conver-

sations when pressed for time in the ICU. In addition, their usual way of talking, such as their

dialect and intonation, can sometimes be misunderstood and cause offense. Participants expe-

rienced difficulties communicating their sincerity to patients and their families.

“Oftentimes, I only say what I have to say instead of what the caregivers really want to know

when I’m pressed for time to convey my thoughts and go on to the next patient to explain

things to the other patient.” (Participant 2)

“I usually speak loudly, and I speak in dialect; so, things I say are not delivered gently. . .I

try to be careful because my dialect can seem more aggressive than the Seoul dialect; but it’s

not easy to fix what I have used for all my life at once.” (Participant 3)

Nurse-related factor: Hesitant to provide physical comfort. Participants were not famil-

iar with using non-verbal communication. The participants realized the importance of both

verbal communication and physical contact in providing care, but the application of both

these communication styles was not easy in clinical practice.

“I want to console the caregivers of patients who pass away; but I just can’t because I get

shy. I feel like I’m overstepping, and when I’m contemplating whether I can really speak to

their emotions, the caregiver has already left the ICU in many cases.” (Participant 6)

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Table 3. Critical care nurses’ communication experience with patients and their families.

Sub-category Category Theme

Theme 1: Facing unexpected communication

difficulties

In critical care, communication with patients and their

family is burdensome

1.1. True intentions not conveyed as wished Nurse-related

Misunderstanding because of the linguistic characteristics

of a nurse (e.g., dialect, voice tone, etc.)

Impatience/lack of care for patients and caregivers

ICU nurses need both verbal and nonverbal

communication skills

1.2. Hesitant to provide physical comfort

Nonverbal communication is unfamiliar

Not sure how to effectively provide nonverbal

communication

Patient in ventilator feels frustrated because he or she

cannot speak

1.3. Mechanical ventilation hindering communication

with the patient

Patient- and family-related

Difficulty understanding because the patient is on a

ventilator and thus cannot speak

Ventilator interferes with the communication between

nurse and patient

ICU patient’s caregiver is sensitive 1.4. Caregivers’ negative responses to nurses

Normal communication is impossible owing to caregivers’

aggressive attitude

As an ICU nurse, I have no choice but to respond to the

conversation

I have not learned properly about communication in the

clinic

1.5. Lack of experience and a mismatch between

theory and practice

System-related

Communication is the most difficult task for less

experienced, young nurses

The scheduled visit time in the intensive care unit is when

most communication occurs

1.6. Intense visiting hours in limited time

One-way conversation with the caregiver in a short period

Life-dependent care is a priority in the intensive care unit 1.7. Urgent workplace that deprioritizes

communication

Insufficient time to talk with patients and caregivers owing

to heavy workload

Nurses are hurt by distrustful patients and caregivers 2.1. Fundamental doubts about the nursing profession Theme 2: Learning through trial and error

Difficulty in nursing because of trauma from patients and

caregivers

Follow senior nurses and learn practical communication 2.2. Finding out which communication style is better

suited for patients and their families

Explains the patient’s daily life in detail

Communication is indispensable to nursing 2.3. Knowhow learned through persistent effort

Studying the lack of communication by searching books

and videos

Understand the anxiety and difficulties experienced by the

critically ill and their caregivers

3.1. Empathy garnered through various clinical

experiences

Theme 3: Recognizing communication

experiences as being essential for care

Nurse’s words have the power to make the patients and

their families cry or laugh

Listening as an intensive care nurse is more important than

talking

3.2. The power of active listening

Nurse empathy strengthens patients and caregivers and

enhances their feelings of control

Patients and caregivers are easy to reach 3.3. Mediator between physicians, patients, and

caregivers

(Continued)

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“I’m really bad at physical contact even with my close friends; but I’m even worse when it

comes to patients and caregivers. Because of my tendency, there are times when I hesitate to

touch patients while providing care.” (Participant 7)

Patient- and family-related factor: Mechanical ventilation hindering communication

with the patient. Mechanical ventilators were the greatest obstruction to communication in

ICU. Although it is normal for patients on a mechanical ventilator to lose the ability to speak,

patients and their families did not understand how mechanical ventilators work and were frus-

trated that they could not communicate freely with the patient. Participants expressed diffi-

culty in communicating with patients in ways other than verbal communication as well.

“Patients who are on mechanical ventilation can’t talk as they want and do not have enough

strength in their hands to write correctly; so, even if I try to listen to them, I just can’t

Table 3. (Continued )

Sub-category Category Theme

Nurses use words that are easy to understand

Nurses convey sincerity to others with respect and

understanding

3.4. Expressing warmth and respect

Nurses’ heartfelt expressions promote trust

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Fig 1. Summary of communication experiences encountered by intensive care unit nurses.

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understand what they are saying. You know in that game where people wear headphones play-

ing loud music and try to communicate with one another—words completely deviant from the

original word are conveyed. It just feels like that.” (Participant 9)

“Patients on mechanical ventilation and who thus cannot communicate are the most diffi-

cult. The patient keeps talking; so, it hinders respiration—the ventilator alarm keeps going off,

the stomach becomes gassy, and the patient has to take the tube off and vomit later. No matter

how much I explain, there are patients or caregivers who tell me that the tube in the throat is

making [it] hard [for them] to breathe or [they] ask me to take it off just once and put it back

on, and these patients are really difficult. There is no way to communicate if they cannot accept

mechanical ventilators even if I explain.” (Participant 8)

Patient- and family-related factor: Caregivers’ negative responses to nurses. It was also

burdensome for nurses to communicate with extremely stressed caregivers and loved ones,

especially when patients were in a critical state. Despite the role of nurses in helping patients

during health recovery, caregivers’ negative responses to nurses, such as blaming them and

speaking and behaving aggressively, intimidated the participants and ultimately discouraged

conversations.

“I can manage the patients’ poor vital signs by working hard but communicating with sensi-

tive caregivers who project their anxiety about the patient’s state onto nurses doesn’t go as I

wish, so, it’s really difficult and burdensome.” (Participant 6)

“When the patient is in a bad state, caregivers sometimes want to not accept it and project

their feelings onto the nurses, and in such cases, there are no words that can console them.

Even approaching the caregivers is a burden, and I get kind of intimidated.” (Participant 5)

System-related factor: Lack of experience and a mismatch between theory and prac-

tice. Participants have learned the importance of communication during training; however,

they had trouble appropriately applying the learned concepts in their workplace. Participants

in this study were in their 20s and 30s, with limited life and social experiences, and felt the gap

between theory and practice in communicating with patients and families in ICU.

“Talking to the patient or caregiver was the most challenging thing when I was new. . .it is

impossible for nurses with not much life experience to communicate skillfully.” (Participant

10)

“It would be nice if the real-world conversation proceeds in the way shown in our textbook;

but it doesn’t in most cases. So, it is more practical to observe and learn from what other nurses

do in the actual field.” (Participant 2)

System-related factor: Intense visiting hours in limited time. The 30-minute ICU visit-

ing period is the only time when patients and families can talk to one another. Although nurses

are well trained to care for the patients to the best of their ability, caregivers distrust the nurses’

ability to care for patients since caregivers only have a limited amount of visiting time, thus

hindering effective communication. Some participants even experienced mental trauma fol-

lowing short but unforgettable interactions with caregivers.

“. . .the caregiver browbeat me and intimidated me for doing so. This gave me a mental

trauma for visiting hours. . .I didn’t know how to start a conversation and the visiting hours

were really stressful for me.” (Participant 3)

“The caregivers don’t stay in the ICU for 24 hours; so, once they begin to doubt our nursing

practice, we cannot continue our conversation with them. . .” (Participant 11)

System-related factor: Urgent workplace that deprioritizes communication. The ICU

is a unit for treating critically-ill patients; therefore, ICU nurses were more focused on tasks

directly linked to maintaining patients’ health, such as stabilizing vital signs, than on commu-

nication. Participants frequently encountered emergency situations, in which they could not

idly stay around to communicate with one patient because another required immediate

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assistance, i.e., they faced a reality in which they had to prioritize another patients’ health over

communication with one.

“. . .I’m really pressed for time when the patient keeps writing things I can’t understand

with their weak hands. . .I don’t have time to spare even if I want to listen to them.” (Partici-

pant 12)

“Vital signs are the utmost priority in [the] ICU. I’m on my feet the entire shift and don’t

even have time to go to the restroom. . .During early ICU treatment, there are a lot of emer-

gency situations; so, communication is way down in the priority list.” (Participant 5)

Theme 2: Learning through trial and error

The negative experiences arising from communicating with various individuals sometimes

forced nurses to think twice about their vocation; however, due to a sense of responsibility,

they tried to engage in therapeutic communication and to overcome difficulties.

Fundamental doubts about the nursing profession. Experiencing unfriendly and con-

frontational conversations with patients and caregivers was intolerable for participants. These

experiences were shocking enough to make them fundamentally question their decision to

choose and stay in the nursing profession.

“I felt so disappointed and frustrated when patients or caregivers bombard[ed] rude com-

ments at me with complete disregard of what I have done over a long period. . .I can’t sleep

well at night and my values as [a] nurse are shaken from their root.” (Participant 14)

“It becomes so difficult the moment communication fails and mutual trust is lost. Maybe I

could survive if this is just with one patient or caregiver; but the afterimage lingers with me persis-

tently while I’m working. . .I came to think whether I could continue nursing.” (Participant 7)

Finding out which communication style is better suited for patients and their fami-

lies. Nurses learned how to resolve communication-related difficulties that they encountered

from their seniors and mentors and tried to communicate better from their position at the

nursing station.

“A senior nurse of mine was talking to a caregiver who was really concerned, and she was

using affirmations like ‘Oh, really’ and ‘I see’ with a relaxed facial expression, and the caregiver

would spill her heart out to her. That’s when I thought that empathy is to express responses to

what the other person is saying.” (Participant 10)

“I can feel that I am able to bond with patients’ families when I tell them about the patient’s

daily living, such as how much the patient had slept, eaten, and whether the patient was not in

pain, during visiting hours.” (Participant 13)

Knowhow learned through persistent effort. Nursing activities, such as taking vital signs

and performing aspiration and intravenous injection, are learned over time; however, it is

impossible to acquire therapeutic communication skills without personal effort and interactive

experiences in the field.

“I’m reading a book about conversation and am learning about how to express empathy and

understand other people. . .Nursing skills are developed and improved over time; but it’s not easy

to enhance communication without personal effort or change in perception.” (Participant 16)

“Communication is an indispensable part of nursing. If you want to provide high-quality

care, you need to enhance your communication skills first.” (Participant 15)

Theme 3: Recognizing communication experiences as being essential for

care

Nursing and communication are inseparable. Although communication is a challenge while

caring for ICU patients, therapeutic communication is important for the patients’ and their

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families’ overall wellbeing. In an ICU, communication based on empathy and experience is a

significant component that helps patients perceive their illnesses more positively.

Empathy garnered through various clinical experiences. Since participants met many

patients and their families in the ICU, they were able to communicate. Participants understood

patients’ discomfort and learn why it was difficult for them to communicate and to comfort

and assure unease families who could not observe the patient’s condition. However, it was a

necessary communication method in the ICU. Participants realized the value and importance

of their words.

“. . .his endotracheal tube was touching his throat and was so uncomfortable: his mouth

was dry, he couldn’t talk, and his arms were tied; so, he thought the only way to communicate

was to use his legs and that’s why he was kicking. I felt really sorry. . .” (Participant 7)

“I gave a little detailed explanation to the caregiver during visiting hours and she thanked

me overwhelmingly. I feel that, because this is the ICU, patients and caregivers can be encour-

aged and discouraged by the words of the medical professionals.” (Participant 9)

The power of active listening. Although the ability to handle tasks promptly is important,

listening to patients amid the hectic work schedule in the ICU is also an important nursing

skill. Critical care nurses realized that listening to patients and caregivers without saying any-

thing is also meaningful and therapeutic.

“I was listening to the caregiver the entire duration of the visiting hour. . .She said that she

just had to open up to someone to talk about her frustrations, and that my listening to her was

a huge consolation for her.” (Participant 12)

“While listening to the caregiver and showing empathy every day at the same time, I was

able to witness that the caregiver who had been aggressive and edgy changed in a way to trust

in and depend on the nurse more.” (Participant 16)

Mediator between physicians, patients, and caregivers. Participants were at the center

of communication, serving as the bridge connecting physicians to patients and patients to

caregivers. They served as mediators, explaining the doctors’ comments to the caregivers, and

providing details regarding the patients’ state to families. Participants helped maintain a close

and balanced relationship between the doctor, the patients, and their families by conveying

messages not effectively communicated by the doctor or patients.

“Caregivers would not ask any questions to the doctor in the ICU and would ask me instead

once the doctor is gone. They would ask, ‘what did the doctor say?’ and ask me for an explana-

tion.” (Participant 4)

“The patients can’t say everything they want; so, as nurses, we are the mediators between

patients and caregivers. . .Tell[ing] the family about things that happened when they were not

around the patient is meaningful.” (Participant 14)

Expressing warmth and respect. Participants have experienced sharing emotions with

the patient’s family as well as with the patient during disease improvement and exacerbation.

In particular, sincere actions, such as staying with the families of patients who died or those

whose condition was deteriorating, led to more genuine relationships, as respect for human

life was expressed.

“When patients whom we have spent a long time [with] are about to pass away, we cry for

them and we stay beside them in their final moments. . .Showing respect for a person’s final

moments of life and expressing our hearts is meaningful, and it is something critical care

nurses must do.” (Participant 16)

“When the patient’s state worsened and. . .his daughter was sobbing next to him. . .I softly

touched her shoulder, and she really thanked me. As I saw the patient’s family grieve, I just

expressed how I felt, and, fortunately, my intention was well conveyed” (Participant 4)

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Discussion

This study evaluated critical care nurses’ communication skills and experiences with patients

and their caregivers. Based on the two FGIs and four individual in-depth interviews, three

themes have been identified: 1) facing unexpected communication difficulties; 2) learning

through trial and error; and 3) recognizing communication experiences as being essential for

care

For theme 1, we examined nurse-, patient-, family-, and system-related (i.e., pertaining to

hospital resources and education) factors. Theme 1 can be considered as the communication

involving human-to-human interaction, as mentioned in Travelbee [24,25], that takes place at

an incomplete stage. First, critical care nurses struggled with balancing their heavy workload

and communicating with patients and their families. In Korea, an ICU nurse, on an average,

cares for two to four patients, which is higher than in some other countries, wherein an ICU

nurse cares for one or two patients at the most; thus, the Korean work environment for ICU

nurses is more stressful [26]. This limits the amount of time nurses may have to communicate

and interact with their patients and caregivers. Misunderstandings are also common owing to

the patients’ inability to speak while intubated and to use of regional dialects. Patients and

caregivers want to hear specific and comprehensible information from health professionals

regarding the treatment procedures in the ICU [17,27]. However, previous studies [4,28] have

reported that critical care nurses experience communication difficulties due to high mental

pressure due to work, time constraints, and the inability to use their own language; these are

consistent with our findings. As nurses are required to interact with patients having various

needs, they need to learn how to communicate verbally and nonverbally in a sophisticated

manner [27], and hospital managers should implement practical communication programs in

the ICU.

Communication between nurses and their patients in the ICU is also often adversely

affected by the therapeutic environment, such as patient emergencies and the use of mechani-

cal ventilation [27,28]. Mechanical ventilators are one of the greatest obstacles to communica-

tion. Although they are essential for critically-ill patients who are incapable of spontaneous

breathing, they affect their ability to speak [29]; therefore, these patients need to employ other

strategies for communication, such as using facial expressions and lip movements, which

make communication extremely difficult [27,30]. Our participants strived to understand the

needs of critically-ill patients through verbal and nonverbal communication, such as writing

and body language. However, when the intentions were not conveyed properly, some patients

responded aggressively, hindering respiratory treatment and ultimately prolonging treatment.

This is in line with many previous findings [29,31,32] indicating that patients’ failure to effec-

tively express their needs to nurses or their family members triggers negative emotions. In

addition, participants had trouble interacting with caregivers who were extremely tense and

sensitive. According to Lee and Yi [17], families of critically-ill patients experience fear and

anxiety regarding the patients’ health state and strive to save the patient. Thus, nurses must

consider this when addressing vulnerable patients and their families and must actively identify

and resolve causes of discomfort in patients on mechanical ventilation (i.e., by using appropri-

ate analgesics/sedatives and removing the ventilator). Further, considering a systematic review

revealing that electronic communication devices enable efficient communication with criti-

cally-ill patients through touch or eye blinks [33], Korea should also keep abreast with techno-

logical advances in communication technology.

Concerning theme 2, as participants experienced emotional exhaustion from being misun-

derstood or unfairly criticized by patients and their families, they contemplated and doubted

the occupational values of nursing. Park and Lee [7] found that higher job satisfaction for ICU

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nurses is associated with better communication. This is consistent with our participants’ doubt

for choosing the nursing profession. However, instead of giving up on this profession, they

closely observed the effective communication skills of more experienced nurses, actively

learned about therapeutic communication through books and videos, and applied their learn-

ings during practice. Similar results were reported by Park and Oh [3] that patient-centered

communication competency among critical care nurses was the highest when a biopsychoso-

cial perspective, focused on delivery of factual information, was followed and the lowest in the

therapeutic alliance domain, which is required for performing cooperative care with patients.

Therapeutic communication provided by nurses to patients and their families in the ICU effec-

tively diminished their psychological burden and fostered positive responses from families

[34]. Currently, ICUs implement a systematic education system for nurses that focuses on

therapeutic techniques, such as hemodynamic monitoring, mechanical ventilation care, aspi-

ration, and extracorporeal membrane oxygenation; however, they lack a program targeting

effective therapeutic communication with patients and caregivers. The communication diffi-

culties experienced by nurses will persist without this additional program; thus, its implemen-

tation is critical to improve patient satisfaction and nursing quality of care. Further, instead of

coercing unilateral effort from critical care nurses, nurse managers should pay attention to

nurses’ emotional wellbeing and promptly develop systems to offset potential burnout, such as

voluntary counseling systems or measures to “refresh” nurses.

Concerning theme 3, participants learned that communication is a challenging but essential

aspect of critical care. The concept of communication resonates through Travelbee’s model

[24,25]. Getting to know another human being is as important as performing procedures. A

nurse must establish a rapport with the patient and the patient’s caregivers, otherwise he or she

will not know the patient’s needs. As a place where life-and-death decisions are made, the ICU

induces anxiety in critically-ill patients and their caregivers. Hence, nurses should fully empa-

thize with patients and their caregivers [4,5,17].

Travelbee [24,25] emphasized the relationship between the nurse and the patient by estab-

lishing the Human-to-Human relationship model, which gives meaning to disease and suffer-

ing based on empathy, compassion, and rapport building. In addition, it presents concepts,

such as disease, hope, human-to-human relations, communication, interaction, patient’s

needs, perception, pain, finding meaning, therapeutic use of communication, and self-actuali-

zation. The participants cultivated empathy and active listening skills when speaking with

patients and their families, and, as they spend more time doing so, their quality of care and

nonverbal communication skills (such as eye contact, soft touch, and tears) improve and

became more genuine. Our findings are consistent with the meaning of human-centered care

suggested by Jang and Kim [35], which involves paying close attention to and protecting

patients’ lives, deeply empathizing with patients from a humanistic perspective, and being sin-

cere. The experience of nursing, including active interaction, has a positive impact on estab-

lishing the roles and caring attitudes of professional nurses [36], which is significant for critical

care nurses. Patient-family-centered care, which has been confirmed to positively promote

critically-ill patients’ recovery worldwide [1], is possible when nurses engage in therapeutic

communication with patients and their families through dynamic interactions [34,37]. There-

fore, critical care nurses and nurse managers should pay attention to communication and

develop an effective communication course that can be applied in clinical practice. To do this,

first, it is necessary to hire appropriate nursing personnel for active therapeutic communica-

tion with the patients and their families in an ICU. Second, continuous, and diverse educa-

tional opportunities should be provided to critical care nurses, along with policy strategies. For

example, at the organizational level, it is necessary to develop manuals on how to deal with dif-

ficult situations by gathering challenging communication cases from actual clinical practice.

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Simulation education for communication is an important component of the nursing

curriculum.

Limitations

First, this study included a small number of participants; however, we ensured that the maxi-

mum data was collected from these participants. Second, specific information was collected

from only those nurses who provided direct care in the ICU of a general hospital in a large city

in Korea. The homogeneity and dynamics of the focus groups may have resulted in congruent

opinions. Third, because the experiences of nurses from only one hospital were analyzed, cau-

tion should be exercised in generalizing our results and applying them to other hospitals in

Korea. Therefore, follow-up studies with larger sample sizes and more representative partici-

pants are warranted.

Conclusion

This qualitative study explored critical care nurses’ communication skills and experiences with

patients and caregivers from various perspectives. Although these nurses felt discouraged by

the unexpected communication difficulties with patients and their families, they recognized

that they could address these difficulties by improving their communication skills over time

through experience and learning. They realized that empathy, active listening, and physical

interaction with patients and their families enabled meaningful communication and have

gradually learned that effective communication is an indispensable tool in providing nursing

care to critically-ill patients.

Supporting information

S1 File. COREQ checklist and coding tree.

(DOCX)

Acknowledgments

The authors would like to thank all the participants for their time and contribution in this

study.

Author Contributions

Conceptualization: Hye Jin Yoo, Jae Lan Shim.

Data curation: Hye Jin Yoo, Jae Lan Shim.

Formal analysis: Oak Bun Lim, Jae Lan Shim.

Funding acquisition: Jae Lan Shim.

Investigation: Hye Jin Yoo, Oak Bun Lim.

Methodology: Hye Jin Yoo, Jae Lan Shim.

Resources: Oak Bun Lim.

Supervision: Jae Lan Shim.

Validation: Hye Jin Yoo, Oak Bun Lim, Jae Lan Shim.

Writing – original draft: Hye Jin Yoo.

Writing – review & editing: Jae Lan Shim.

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International Journal of

Environmental Research

and Public Health

Article

Unplanned Absenteeism: The Role of Workplace and
Non-Workplace Stressors

Nur Adibah Mat Saruan 1,2,† , Hanizah Mohd Yusoff 1,*, Mohd Fadhli Mohd Fauzi 1,2,† ,
Sharifa Ezat Wan Puteh 1 and Rosnawati Muhamad Robat 3

1 Department of Community Health, Faculty of Medicine, Universiti Kebangsaan Malaysia Medical Centre,
Jalan Yaacob Latiff, Bandar Tun Razak, Cheras, Kuala Lumpur 56000, Malaysia;
[email protected] (N.A.M.S.); [email protected] (M.F.M.F.);
[email protected] (S.E.W.P.)

2 Ministry of Health Malaysia, Federal Government Administrative Centre, Putrajaya 62590, Malaysia
3 Occupational and Environmental Health Unit, Selangor State Health Department, No. 1 Wisma Sunway,

Jalan Tengku Ampuan Zabedah C 9/C, Seksyen 9, Shah Alam 40100, Malaysia; [email protected]
* Correspondence: [email protected]; Tel.: +60-3-9145-5904
† These authors contributed equally to this work.

Received: 14 July 2020; Accepted: 20 August 2020; Published: 24 August 2020
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Abstract: Unplanned absenteeism (UA), which includes medically certified leave (MC) or emergency
leave (EL), among nurses may disturb the work performance of their team and disrupt the quality
of patient care. Currently, there is limited study in Malaysia that examines the role of stressors in
determining absenteeism among nurses. Therefore, apart from estimating the prevalence and the
reasons of UA among nurses in Malaysia, this study aims to determine its stressor-related determinants.
A cross-sectional study was conducted among 697 randomly sampled nurses working in Selangor,
Malaysia. Most of them were female (97.3%), married (83.4%), and working in shifts (64.4%) in
hospital settings (64.3%). In the past year, the prevalence of ever taking MC and EL were 49.1% and
48.4%, respectively. The mean frequency of MC and EL were 1.80 (SD = 1.593) and 1.92 (SD = 1.272)
times, respectively. Meanwhile, the mean duration of MC and EL were 4.24 (SD = 10.355) and
2.39 (SD = 1.966) days, respectively. The most common reason for MC and EL was unspecified
fever (39.2%) and child sickness (51.9%), respectively. The stressor-related determinants of durations
of MC were inadequate preparation at the workplace (Adj.b = −1.065) and conflict with doctors
(adjusted regression coefficient (Adj.b) = 0.491). On the other hand, the stressor-related determinants
of durations of EL were conflict with spouse (Adj.b = 0.536), sexual conflict (Adj.b = −0.435),
no babysitter (Adj.b = 0.440), inadequate preparation at workplace (Adj.b = 0.257), lack of staff
support (Adj.b = −0.190) and conflict with doctors (Adj.b = −0.112). The stressor-related determinants
of the frequency of MC were conflicts over household tasks (Adj.b = −0.261), no time with family
(Adj.b = 0.257), dangerous surroundings (Adj.b = 0.734), conflict with close friends (Adj.b = −0.467),
and death and dying (Adj.b = 0.051). In contrast, the stressor-related determinants of frequency of
EL were not enough money (Adj.b = −0.334), conflicts with spouse (Adj.b = 0.383), pressure from
relatives (Adj.b = 0.207), and inadequate preparation (Adj.b = 0.090). In conclusion, apart from the
considerably high prevalence of unplanned absenteeism and its varying frequency, duration and
reasons, there is no clear distinction in the role between workplace and non-workplace stressors in
determining MC or EL among nurses in Malaysia; thus, preventive measures that target both type
of stressors are warranted. Future studies should consider longitudinal design and mixed-method
approaches using a comprehensive model of absenteeism.

Keywords: absenteeism; stress; stressor; nurse; hospital; conflict

Int. J. Environ. Res. Public Health 2020, 17, 6132; doi:10.3390/ijerph17176132 www.mdpi.com/journal/ijerph

Int. J. Environ. Res. Public Health 2020, 17, 6132 2 of 16

1. Introduction

Absenteeism can be a good measure of the health system’s performance and a useful tool in
measuring the psychological and physical wellbeing of healthcare workers [1]. It is defined as a failure to
attend work according to an established work schedule [2]. Various classifications have been suggested
when exploring absenteeism. A few studies categorized it into voluntary and involuntary absenteeism,
based on the control ability of the employee [3–5]. Other studies have further sub-classified it into the
planned and unplanned forms [2]. Planned voluntary absenteeism includes annual leave, study leave,
and being off-duty [6]. In contrast, unplanned voluntary absenteeism includes short-term self-certified
sickness absence [7], medically certified sickness [8], and others including vehicle breakdown and
taking care of a sick child [2,6]. Meanwhile, planned involuntary absenteeism includes absence caused
by social obligations such as attending a community meeting [7]. In Malaysia, planned absenteeism
is commonly known as annual leave or rest leave, which is typically applied a few days before the
intended leave days. In contrast, unplanned absenteeism can be further subdivided into two: (a) sick
leave or medically-certified leave (MC) with an accompanying legitimate medical certificate from
registered medical practitioners [9] and (b) emergency leave (EL) for any other reasons such as family
matters and self-certified sickness [10]. Furthermore, the previous study also has used the term
health-related workplace absenteeism to describe the workers’ phenomenon of not attending to work
as per working schedule which had been counted by the loss of the number of working hours due to
injury or illness [11,12].

Most of the studies conducted abroad to assess sickness absenteeism recorded high prevalence,
ranging from 68% to 75% among nurses [5,13,14]. Multiple factors and outcomes of absenteeism among
nurses have been identified in previous research. Absenteeism is a side effect of personnel problems,
ineffective management, poor working relationships, lack of control over decisions, and overwork [15].
A systematic review found 29 antecedents and nine outcome variables for absenteeism and proposed
the Job, Organization, Individual, National and inTerpersonal (JOINT) multilevel conceptual model
for investigating absenteeism among nurses. The levels include individual (demographic, personal
characteristic, job attitudes, health, and wellbeing), interpersonal (management style and relationship),
job (job demand and job control), organization (human resource practices and structure), and national
(labor supply and legislation) [1].

In Malaysia, as of 31 December 2017, there were 71,480 and 34,809 nurses working in the public
and private sectors, respectively. A total of 106,289 nurses nationwide is equivalent to one nurse to
302 individuals in the population [16]. As for community nurses, 23,771 and 742 community nurses
worked in the public and private sectors, respectively. Nurses are described as the main primary
workforce in the hospital, as most of the tasks of maintaining continuous support for patients in the
wards are performed by nurses [17]. The factors contributing to their absenteeism should, therefore,
be taken into account to ensure that healthcare services are well managed. Previous absenteeism
studies among nurses working in University hospitals in Malaysia exhibited a higher percentage of EL
(65%) compared to MC (52%) [13]. The significant reasons that contributed to both conditions were
due to the demand of additional home responsibilities [13]. A study among public service employees
in Malaysia also found that stress and personal life problems accounted for up to 69% of the MC [18].
The economic burden often forced them to take up additional jobs and spent more hours working,
causing inadequate rest, thus leading to stress [19].

MC and EL can also be an indication of underlying issues of work-related stress [20]. High job
demands, organizational injustice and lack of reward are among the job stressors that relate to increased
absence due to illnesses [21]. Nevertheless, work stressors specific to the job of nurses are seldom
assessed for their associations with unplanned absenteeism. A study on the association of job stress and
sickness absence among the general working population in Denmark found that female workers had
different strength of association for perceived stress between long-term sickness absence and all-length
sickness absence [22]. Thus, to study the association of work stress and unplanned absenteeism among
nurses, of whom the majority are female, the duration of MC or EL needs to be analyzed too.

Int. J. Environ. Res. Public Health 2020, 17, 6132 3 of 16

Duclay et al. (2015) found that having less healthcare personnel present at work due to absenteeism
would mean that those workers left at work assumed an excessive workload, which caused an
imbalance in their health and resulted in a pathological cycle of absenteeism within the institution [23].
A qualitative study found that in addition to the inadequate staffing and workload, absenteeism
added pressure during work hours that led to job dissatisfaction [24]. A study among 186 nurses in
Limpopo, South Africa also found that absenteeism affected the nurses who remained on duty while
their colleagues were absent in the aspect of low morale, psychological stress, and increased workload,
consequently jeopardizing patient care with the risk of medical errors [25].

In view of the lack of knowledge on the prevalence and predictors of unplanned absenteeism
among nurses, this study was conducted to determine the prevalence (including frequency and
duration) of MC and EL among nurses in Malaysia and their reasons for unplanned absenteeism.
It aimed to identify potential predictors in terms of workplace and non-workplace stressors, controlling
for sociodemographic and occupational profiles. This study is expected to provide initial evidence to
health managers to develop strategies that could reduce the number of absent nurses and benefit the
organization and the healthcare system.

2. Materials and Methods

This study was conducted in the state of Selangor which is the most densely populated state in
Malaysia [26]. Selangor has an area of 7950.9 km2 with a population density of 819 people per km2 [27]
with a total population of 5.46 million [26]. The study sample was recruited by simple random
sampling. The name list of nurses from all positions working at public hospitals, health clinics (primary
healthcare) and district health offices was arranged in one master sheet. Using a prevalence sample
size by the Kish formula [28], a reference prevalence of 78% of unplanned absenteeism among nurses
in Malaysia [13] was used. Using precision of 3%, the sample size needed was 733 respondents. Next,
the respondents were randomly selected using Microsoft Excel (Microsoft, Washington, DC, USA)
according to the number of the sample size required.

The inclusion criteria were all Malaysian-nationality registered nurses from the different levels of
positions, including matrons, sisters, staff nurses, assistant nurses, midwives/community nurses who
have worked at the current workplace for at least six months. Meanwhile, the exclusion criteria were
those medically diagnosed with a psychiatric illness or on psychiatric medications for illnesses such as
depression, bipolar disorder, anxiety disorder, schizophrenia, and those on long-term sick leave or
maternity leave during the study period.

We utilized pencil-and-paper self-reported questionnaires containing sociodemographic
(age, gender, marital status, number of children, weight, height, hypertension status and diabetes
mellitus status), occupational (workplace setting, work tenure, position, and work schedule),
psychological stress (stress status, non-workplace stressor, and workplace stressor), and unplanned
absenteeism (frequency, duration, and reason up to the third time taking MC and EL) variables.

MC is operationally defined as self-reported medically certified absenteeism due to medical
reasons whereas EL is operationally defined as any other self-reported unplanned absenteeism without
prior approval from managers and medical certificate. The frequency and duration of absenteeism
were defined as the frequency and the total number of days taking unplanned absenteeism in the past
one year for each MC and EL. Reasons for unplanned absenteeism were asked up to the third time of
absenteeism (three data points).

Stress status was measured using a validated four-point Likert scale Malay Version of the Personal
Stress Inventory: Sign and Symptoms of Stress containing 52 items with 11 subscales. This inventory
has been validated in the Malaysian population with a sensitivity of 95.1% and specificity of 77%.
The reliability measured by Cronbach alpha was 0.97. The total score of more than 36 indicated that
the respondents were having stress [29].

Subsequently, a validated four-point Likert scale Malay Version of the Personal Stress Inventory:
Pressures and Demands from Family and Household was used. The inventory contained 12 items

Int. J. Environ. Res. Public Health 2020, 17, 6132 4 of 16

which were used to assess the sources of pressure in the non-workplace setting [30]. The inventory
consisted of 12 items which included “Not enough money”, “Conflict with spouse”, “Conflicts over
household tasks”, “Problems or conflict with children”, “Pressure from relatives or in-laws”, “Fixing
up the house”, “Not enough time to spend with family”, “Sexual conflict or frustration”, “Dangerous
or stressful surroundings and neighbourhood”, “Conflict with close friend or relatives”, “Personal
problem causing strain in family” and “No babysitter”. This questionnaire used a four-point Likert-type
scale from “none at all” (0), “a little” (1), “some” (2) and “a great deal” (3). Higher scores indicated
higher non-workplace stressors. A total score (ranging from 0 to 36) was obtained by adding the
nurse’s responses to all 12 questions. The score above the mean value was categorized as a high score
and vice versa. The coverage and relevance of the content were validated by experts in occupational
health from academic (university) and service (state health department) side. The reliability using
Cronbach alpha was 0.88.

A validated four-points Likert scale Malay Version of Nursing Stress Scale containing 34 items
with 7 subscales was used to identify the sources of stress experienced by nurses [30]. It measured
the perceived frequency of the occurrence of stress in the nursing environment. The subscales were
categorized as; “Workload” (6 items), “Dealing with death and dying” (7 items), “Conflict with doctors”
(5 items), “Uncertainty concerning treatment” (5 items), “Lack of staff support” (3 items), “Conflict
with other nurses or supervisors” (5 items) and “Inadequate preparation to deal with emotional needs
of the patients and their families” (3 items). All items were on potentially stressful situations in the
nursing workplace, and the rating was made according to their perceived occurrence. Every item was
scored on a four-point Likert-type scale from “never” (0), “occasionally” (1), “frequently” (2) to “very
frequently” (3). High scores indicated the more frequent presence of a specific source of stress. A total
score ranged from 0 to 102. The score above the mean was categorized as a high score and vice versa.
The content was approved by the occupational health experts and the reliability using Cronbach alpha
was 0.93.

Data analysis was conducted using SPSS Version 21 (IBM, New York, NY, USA). The incomplete
data were dealt with by using multiple imputation techniques whereby the missing data were replaced
with the predicted imputed values which correlate with the variables of missing data. This technique
was used to ensure the natural variability of the data for valid statistical inference [31]. Statistical
analysis began with univariable descriptive analysis, where continuous variables were summarized as
mean and standard deviation while categorical variables were presented as frequencies and percentages.
Data were further analyzed using simple linear regression, followed by multiple linear regression to
identify predictors of frequency and duration of each type of unplanned absenteeism. All potential
predictors were initially included, and the elimination was done by the stepwise method. Data were
presented as adjusted regression coefficient (Adj.b), 95% CI and p-value. Significant level was set at
p < 0.05. Whereas data were collected using dichotomous outcome whether yes or no to determine the
predictors between taking MC or not, taking EL or not, taking both MC and EL or not and whether
not taking any unplanned leave at all against taking either one leave. The dichotomous outcome was
further analyzed using simple logistic regression followed by multiple logistic regression. Data were
presented as the adjusted odds ratio (Adj. OR), 95% CI and p-value. Significant level was set at
p < 0.05. This study obtained ethical approval from the Medical Research and Ethics Committee
(KKM.NIHSEC.P19-22(6)).

3. Results

3.1. Descriptive Statistics

The response rate was 95.1% accounts for 697 respondents. Table 1 describes the participants’
sociodemographic profile. The majority of the respondents were female (97.3%) and married (83.4%).
Most of them had at least one child (74.8%). Although the majority had no hypertension or diabetes
mellitus, more than half of them were overweight/obese.

Int. J. Environ. Res. Public Health 2020, 17, 6132 5 of 16

Table 1. Participants’ sociodemographic profile.

Variables, n = 697 Min. Max. n (%) Mean (SD)

Age, in years 20 59 34.67 (8.148)

Gender
Male 19 (2.73)

Female 678 (97.27)

Marital Status
Single 100 (14.35)

Married 581 (83.36)
Separated/Divorced/Others 16 (2.30)

No. of Children 0 7 1.84 (1.516)
None 176 (25.25)

At least one child 521 (74.75)

Body Mass Index (BMI), in kg/m2 25.79 (5.508)
Underweight (<18.50 kg/m2) 32 (4.59)
Normal (18.50 to 24.99 kg/m2) 321 (46.05)

Overweight (25.00 to 29.99 kg/m2) 205 (29.41)
Obese (30.00 kg/m2 and above) 139 (19.94)

Other Comorbid
Having hypertension 53 (7.60)

Having diabetes mellitus 34 (4.88)

Table 2 describes the participants’ occupational profile. Most of the respondents worked in a
hospital (64.3%) and held positions as staff nurses (61.4%). The majority of them worked in a shift-based
work schedule (64.4%) with a mean work tenure of 11.42 (SD = 7.591) years.

Table 2. Participants’ occupational profile.

Variables, n = 697 Min. Max. n (%) Mean (SD)

Workplace
Hospital 448 (64.28)

Public Health and Primary Healthcare 249 (35.72)

Work tenure as nurse, in years 11.42 (7.591)
Position

Community Nurse 162 (23.24)
Staff Nurse/Midwife 428 (61.41)

Sister a 90 (12.91)
Matron b 17 (2.44)

Work Schedule
Non-Shift Work 248 (35.58)

Shift Work 449 (64.42)
a ‘Sister’: A nurse in charge who is responsible for the immediate functioning of the unit; b ‘Matron’: chief nurse
who in charge of nursing in a hospital and the head of the nursing staff.

Table 3 describes the stressor profiles and stress status. The majority of respondents recorded
having no stress (71.88%) with the mean stress score of 25.69 (SD = 20.836). The mean score for
non-workplace and workplace stressors was 5.90 (SD = 5.497) and 25.92 (SD = 13.549), respectively.

Int. J. Environ. Res. Public Health 2020, 17, 6132 6 of 16

Table 3. Stressors profile and stress status.

Variables, n = 697 n (%) Mean (SD)

STRESS STATUS 25.69 (20.836)
Non-stress (Score less than 36) 501 (71.88)

Stress (Score 36 and above) 196 (28.12)

NON-WORKPLACE STRESSOR 5.90 (5.497)
Not enough money 0.68 (0.796)

Conflicts with spouse 0.48 (0.693)
Conflicts over household tasks 0.48 (0.682)

Conflicts with children 0.36 (0.598)
Pressure from relatives 0.44 (0.713)

Fixing up of house 0.43 (0.681)
No time with family 1.08 (0.966)

Sexual conflicts 0.21 (0.513)
Dangerous surroundings 0.42 (0.663)

Conflict with close friends 0.40 (0.603)
Personal problems cause strain 0.40 (0.636)

No babysitter 0.51 (0.797)

WORKPLACE STRESSOR 25.92 (13.549)
Workload 8.39 (3.640)

Death and dying 4.39 (3.831)
Inadequate preparation 1.80 (1.572)

Lack of staff support 2.11 (1.908)
Uncertainty concerning treatment 3.19 (2.429)

Conflict with doctors 3.22 (2.552)
Conflict with other nurses 2.81 (2.453)

Table 4 describes the characteristic of MC and EL in term of their prevalence, duration and
frequency. The prevalence of ever taking MC and EL in the past one year was 49.07% and 48.35%,
respectively. Most respondents took only one-day MC (32.16%) and only once (53.22%). Similarly,
most respondents took only one-day EL (45.10%) and only once (52.52%). Subsequently, Figure 1
demonstrates the number of respondents taking leave based on leave duration in days and Figure 2
demonstrates the number of respondents taking leave based on leave frequency.

Table 4. Unplanned absenteeism profile.

Variables,
n = 697

Medically-Certified Leave (MC) Emergency Leave (EL)

n (%) Min. Max. Mean (SD) n (%) Min. Max. Mean (SD)

Prevalence
Never taken 355 (50.93) 360 (51.65)
Ever taken 342 (49.07) 337 (48.35)

Duration in days
of taking leave a

1 140
4.24

(10.355)
1 16 2.39 (1.966)

Frequency of
taking leave a

1 25 1.80 (1.593) 1 8 1.92 (1.272)

a Among those who had ever taken a medically certified leave (n = 342) or emergency leave (n = 337), respectively.

Int. J. Environ. Res. Public Health 2020, 17, 6132 7 of 16
Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 7 of 16

Figure 1. Number of respondents taking leave based on leave duration in days.

Figure 2. Number of respondents taking leave based on leave frequency.

Table 5 demonstrates the reasons for taking MC and EL. The reasons for MC were mostly
medical-related, while the reasons for EL were family-related. The highest reasons for MC were due

0

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Figure 1. Number of respondents taking leave based on leave duration in days.

Int. J. Environ. Res. Public Health 2020, 17, x FOR PEER REVIEW 7 of 16

Figure 1. Number of respondents taking leave based on leave duration in days.

Figure 2. Number of respondents taking leave based on leave frequency.

Table 5 demonstrates the reasons for taking MC and EL. The reasons for MC were mostly
medical-related, while the reasons for EL were family-related. The highest reasons for MC were due

0

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on

d
en

ts

Leave frequency

Number of respondents taking leave based on leave
frequency

MC EL

Figure 2. Number of respondents taking leave based on leave frequency.

Int. J. Environ. Res. Public Health 2020, 17, 6132 8 of 16

Table 5 demonstrates the reasons for taking MC and EL. The reasons for MC were mostly
medical-related, while the reasons for EL were family-related. The highest reasons for MC were
due to unspecified fever (39.18%), non-specified reasons (12.28%), upper respiratory tract infection
(URTI)/sinusitis (9.65%) followed by acute gastroenteritis or food poisoning (8.48%) and unspecified
dizziness, headache, vertigo, migraine (8.48%). On the other hand, the highest reasons for EL were
sick children (51.93%), followed by sick family members (18.10%), and death of family members or
relatives (15.73%). Surgery-related MC showed the highest minimum and maximum number of leave
days for MC i.e., 10 days and 140 days. Child sickness has been reported as the reason for both MC
and EL, which ranges between 5 and 6 days for MC and 1 to 16 days for EL.

Table 5. Reasons for unplanned absenteeism a.

Variables n (%)
No. of Leave Days for Each Reason

Min Max Mean (SD) Total

MEDICALLY-CERTIFIED LEAVE (MC) b

Unspecified fever 134 (39.18) 1 4 1.54 (0.732) 206
Non-specified 42 (12.28) 1 33 3.17 (5.231) 133

Upper respiratory tract infection, sinusitis 33 (9.65) 1 9 2.00 (1.581) 66
AGE, food poisoning 29 (8.48) 1 4 1.38 (0.820) 40

Dizziness, headache, vertigo, migraine 29 (8.48) 1 4 1.72 (0.751) 50
Unspecified symptoms (ache, cough) 26 (7.60) 1 5 1.73 (1.079) 45

Tooth-related pain and procedure 23 (6.73) 1 5 1.65 (1.027) 38
Eye-related (e.g., conjunctivitis) 18 (5.26) 1 5 2.44 (1.338) 44

Trauma-related (fracture, tissue injury) 16 (4.68) 1 60 8.25 (15.159) 132
Medical appointment/procedure 15 (4.29) 1 4 1.80 (1.014) 27

Others (otitis, pneumonia, burn, allergy) 12 (3.51) 1 10 3.33 (2.964) 40
Surgery (I&D, laparotomy, TAHBSO) 11 (3.22) 10 140 39.45 (38.816) 434

AEBA 10 (2.92) 1 7 2.50 (2.121) 25
CVS-related (ACS, hypertension, stroke) 8 (2.34) 1 30 5.75 (9.867) 46

MSD (CTS, PID, backache) 7 (2.05) 1 16 4.71 (5.499) 33
Viral fever, dengue fever 7 (2.05) 1 7 3.71 (2.498) 26

GERD, gastritis 5 (1.46) 1 3 2.00 (1.000) 10
Urinary tract infection 4 (1.17) 1 7 3.25 (2.630) 13

Menstrual-related 3 (0.88) 1 1 1.00 (0.000) 3
Child sickness 2 (0.58) 5 6 5.50 (0.707) 11

EMERGENCY LEAVE (EL) c

Child sickness 175 (51.93) 1 16 2.23 (1.789) 390
Sick family members or relatives 61 (18.10) 1 7 2.18 (1.658) 133

Death of family members 53 (15.73) 1 5 1.51 (0.993) 80
Unspecified reasons 35 (10.39) 1 5 1.71 (1.073) 60

Child matters except sickness 31 (9.20) 1 3 1.35 (0.709) 42
Self-certified health problem 21 (6.23) 1 3 1.33 (0.658) 28

Unspecified family- or self-related matters 16 (4.75) 1 3 1.38 (0.719) 22
Vehicle problem or MVA 9 (2.67) 1 1 1.00 (0.000) 9

Medical appointment 1 (0.30) 1 1 1.00 (0.000) 1
Others 1 (0.30) 1 1 1.00 (0.000) 1

a We sampled only the first three unscheduled absenteeism; b Denominator is the respondents who took MC
(n = 342); c Denominator is the respondents who took EL (n = 337); AGE: acute gastroenteritis; MVA: motor
vehicle accident; MSD: musculoskeletal disease; CTS: carpal tunnel syndrome; PID: prolapse intervertebral
disc; GERD: gastroesophageal disease; I&D: incision and drainage; TAHBSO: total abdominal hysterectomy and
bilateral salpingo-oophorectomy; AEBA: acute exacerbation bronchial asthma; ACS: acute coronary syndrome;
CVS: cardiovascular.

3.2. Predictors of Those Taking MC, Taking EL, Those Taking MC and EL, and Those neither Take MC nor EL

Table 6 describes the determinants of taking MC, EL, both MC and EL, and neither MC nor EL.
Those with older age, and no children, had a higher magnitude of non-workplace stressor related to
conflict with close friends and had a lower magnitude of workplace stressor related to inadequate

Int. J. Environ. Res. Public Health 2020, 17, 6132 9 of 16

preparation, had higher odds of taking MC. Meanwhile, those who had children and had a higher
level of non-workplace stressors related to pressure from relatives had higher odds of taking EL. As for
the odds of taking combined MC and EL, the odds are higher among those who ever married, worked
in a non-hospital setting, had a lower magnitude of non-workplace stressors related to dangerous
surroundings, and had a higher magnitude of workplace stressor related to inadequate preparation.

Table 6. Predictors of taking medically certified leave (MC), emergency leave (EL), both MC and EL,
and neither took MC nor EL.

Variables, n = 697
Exp (B) (95% CI) a

MC b EL c MC + EL d None e

SOCIODEMOGRAPHIC

Age
1.029

(1.004, 1.056)

Marital status (Ref. = ever married)
0.252

(0.135, 0.473)
2.193

(1.404, 3.425)

Having children (Ref. = have children)
2.120

(1.323, 3.395)
0.414

(0.238, 0.718)

BMI (Ref. = overweight/obese)

OCCUPATIONAL

Workplace (Ref. = hospital)
1.696

(1.195, 2.407)
0.625

(0.432, 0.905)

Work schedule (Ref. = non-shift)

STRESS STATUS (Ref. = yes)

NON-WORKPLACE STRESSOR

Not enough money

Conflicts with spouse

Conflicts over household tasks

Conflicts with children

Pressure from relatives
1.658

(1.228, 2.239)
0.687

(0.516, 0.916)

Fixing up of house

No time with family

Sexual conflicts

Dangerous surrounding
0.712

(0.542, 0.936)

Conflict with close friends
1.394

(1.007, 1.928)

Personal problems cause strain

No babysitter

WORKPLACE STRESSOR

Workload

Death and dying
0.921

(0.875, 0.969)

Inadequate preparation
0.754

(0.644, 0.820)
1.210

(1.082, 1.353)

Lack of staff support

Uncertainty concerning treatment

Conflict with doctors

Conflict with other nurses
a Although all variables in the table were included in the adjusted model, only significant results were presented;
b adj.R2 = 0.071; c adj.R2 = 0.060; d adj.R2 = 0.083; e adj.R2 = 0.091.

Int. J. Environ. Res. Public Health 2020, 17, 6132 10 of 16

3.3. Predictors of Durations in Days of MC and EL among Those Who Ever Took MC and EL

Table 7 demonstrates the determinants of MC and EL durations among those who ever took MC
and EL. The determinants of longer durations of MC were working in a hospital, lower stressors of
inadequate preparation and higher stressors of conflict with doctors. In contrast, the determinants of
longer durations of EL were having children, being overweight/obese, working in non-shift schedule,
higher stressor of conflict with spouse, no babysitter, and inadequate preparation, and lower stressors
of sexual conflict, lack of staff support and conflict with doctors.

Table 7. Predictors of duration in days of MC and EL among those ever took MC and EL.

Variables

Adj.b (95% CI) a

Duration of MC
among Those Ever

Took MC (n = 342) b

Duration of EL among
Those Ever Took EL

(n = 337) c

SOCIODEMOGRAPHIC PROFILE
Age

Marital status (0 = never married; 1 = ever married)
Having children (0 = no children; 1 = have children) 0.781 (0.242, 1.320)

Body mass index (0 = underweight/normal; 1 = overweight/obese) 0.417 (0.019, 0.816)

OCCUPATIONAL PROFILE
Workplace (0 = non-hospital; 1 = hospital) 3.411 (0.721, 6.101)

Work schedule (0 = shift; 1 = non-shift) 0.463 (0.039, 0.888)

STRESS STATUS (0 = no; 1 = yes)

NON-WORKPLACE STRESSOR
Not enough money

Conflicts with spouse 0.536 (0.184, 0.888)
Conflicts over household task

Conflicts with children
Pressure from relatives

Fixing up of house
No time with family

Sexual conflict −0.435 (−0.848, −0.022)
Dangerous surrounding

Conflict with close friends
Personal problem cause strain

No babysitter 0.440 (0.166, 0.714)

WORKPLACE STRESSOR
Workload

Death and dying
Inadequate preparation −1.065 (−1.849, −0.282) 0.257 (0.104, 0.409)

Lack of staff support −0.190 (−0.322, −0.059)
Uncertainty concerning treatment

Conflict with doctors 0.491 (0.000, 0.982) −0.112 (−0.220, −0.003)
Conflict with other nurses

a Adjusted regression coefficient (all variables in the table were included in this adjusted model; however only
significant results were presented); b Multiple linear regression (Constant = 1.526; adj.R2 = 0.027; model assumptions
are met); c Multiple linear regression (Constant = 1.129; adj.R2 = 0.132; model assumptions are met).

3.4. Predictors of Frequency of MC and EL among Those Who Ever Took MC and EL

Table 8 demonstrates the determinants of MC and EL frequency among those who ever took
MC and EL. The determinants of higher frequency of MC were having children, higher magnitude of
stressors of no time with family, dangerous surroundings, and death and dying, and lower magnitude
of stressors related to conflicts over household tasks and conflict with close friends. On the other hand,
the determinants of higher frequency of EL were younger age, having children, being overweight/obese,
working in a non-hospital setting, having no stress, a higher level of stressors related to conflicts with
spouse, pressure from relatives, and inadequate preparation, and a lower level of stressors related to
not enough money.

Int. J. Environ. Res. Public Health 2020, 17, 6132 11 of 16

Table 8. Predictors of frequency of MC and EL among those ever took MC and EL.

Adj.b (95% CI) a

Variables, n = 337
Frequency of MC
among Those Ever

Took MC (n = 342) b

Frequency of EL
among Those Ever
Took EL (n = 337) c

SOCIODEMOGRAPHIC PROFILE
Age −0.024 (−0.042, −0.006)

Marital status (0 = never married; 1 = ever married)
Having children (0 = no children; 1 = have children) 0.601 (0.210, 0.991) 0.521 (0.161, 0.881)

OCCUPATIONAL PROFILE
Body mass index (0 = underweight/normal; 1 = overweight/obese) 0.385 (0.121, 0.648)

Workplace (0 = non-hospital; 1 = hospital) −0.327 (−0.594, −0.060)
Work schedule (0 = shift; 1 = non-shift)

STRESS STATUS (0 = no; 1 = yes) −0.368 (−0.661, −0.076)

NON-WORKPLACE STRESSOR
Not enough money −0.334 (−0.523, −0.145)

Conflicts with spouse 0.383 (0.157, 0.610)
Conflicts over household task −0.261 (−0.519, −0.002)

Conflicts with children
Pressure from relatives 0.207 (0.015, 0.398)

Fixing up of house
No time with family 0.257 (0.066, 0.448)

Sexual conflict
Dangerous surrounding 0.734 (0.438, 1.031)

Conflict with close friends −0.467 (−0.779, −0.154)
Personal problem cause strain

No babysitter

WORKPLACE STRESSOR
Workload

Death and dying 0.051 (0.004, 0.099)
Inadequate preparation 0.090 (0.006, 0.173)

Lack of staff support
Uncertainty concerning treatment

Conflict with doctors
Conflict with other nurses

a Adjusted regression coefficient (all variables in the table were included in this adjusted model; however only
significant results were presented); b Multiple linear regression (Constant = 0.912; adj.R2 = 0.116; model assumptions
are met); c Multiple linear regression (Constant = 2.077; adj.R2 = 0.151; model assumptions are met).

4. Discussions

This study was conducted to determine the prevalence, frequency, duration, and reasons for
MC and EL (unplanned absenteeism) and further identify their determinants particularly related to
workplace and non-workplace stressors. It was found that almost half of respondents reported ever
taking MC or EL which is similar with another study [32]. The mean frequency of MC and EL were two
days each, while the mean duration of MC and EL were four and two days, respectively. The top reasons
for MC, as the name implied, were mostly medical-related such as unspecified fever, URTI/sinusitis,
and acute gastroenteritis (AGE)/food poisoning which is consistent with another study [18]. In contrast,
the most common reasons for EL were family-related matters such as child sickness, sick family
members, and death of family members. Although most of them were categorised as not having
stress (71.9%), both workplace and non-workplace stressors were significantly associated with either
MC or EL. These findings signify that MC or EL were not only determined by the direct medical- or
family-related reasons mentioned earlier; but stressors may also indirectly play an important role in
unplanned absenteeism.

Sociodemographically, it was found that married nurses had higher odds of taking both MC and
EL. This finding is similar to a study that showed marriage had a significant effect on absenteeism,
as they had to be responsible for other additional family members [33]. On the other hand, nurses with
children had higher odds of taking EL, longer duration of EL, and higher frequency of MC. This is

Int. J. Environ. Res. Public Health 2020, 17, 6132 12 of 16

consistent with studies that shown that larger family sizes will increase the amount of responsibilities
and increase work–family conflict, subsequently resulting in absenteeism [13,34,35]. Apart from
that, being overweight/obese had contributed to an increase in frequency and duration of EL. This is
supported by one study that reported that overweight increased the risk of absenteeism which may be
contributed by the lack of enthusiasm at work [36].

Occupationally, it was found that non-hospital nurses had higher odds of taking both MC and EL.
In addition, non-hospital nurses had higher frequency of taking EL but lesser duration of MC. This is
consistent with a previous study which reported that those working in the primary care covering
clinics had reported a 41% higher incidence of absence during the second year and an increase to 50%
in the following year compared to those working in the wards [37]. Our study also found that nurses
who worked in a non-shift schedule had higher duration of EL. This finding contradicts with previous
studies that showed that the shift schedule had a significant association with absenteeism [38] which
could be due to the conflicting responsibilities between working in shifts and attending to family
members which could lead to absenteeism [39]. We postulate that this contradictory finding was
contributed to by the fact that essential services including child education, banking, and administrative
services are provided during office hours, which may influence the decision of nurses who work in a
non-shift schedule to take EL to settle their essential non-work-related matters.

Although stress was one of the main culprits of absenteeism which can jeopardise the
organisation [40], our study found that stress was associated with lower frequency of EL. We postulate
that this could be due to the differential in root causes of stress that indirectly influence absenteeism.
For instance, those who experience financial constraints which have been shown to be associated with
stress [19] may or may not be absent from work; those who absent may be due to the involvement in
part-time job that jeopardize their attendance at work, while those who present may be due to the fear
in losing the current job and income. However, this postulation needs to be confirmed in future study
using a longitudinal study involving multiple interrelated occupational and non-occupational variables.

Nurses with workplace stressors of inadequate preparation had lower odds of taking MC and had
shorter durations of MC but higher duration and frequency of EL. Inadequate preparation in handling
work tasks in terms of mental readiness in treating patients tend to make nurses feel irresponsible
when managing patients and leave them vulnerable to making mistakes, leaving them no choice but
to take the EL. Recent advances in technology and an increasing demand in care requires nurses to
develop increasingly higher skill levels that only expose them to more stress than other healthcare
professionals [41]. Krohne and Magnussen (2011) stated that those who are equipped with knowledge
and preparation for work would promote a good healthy working environment, which prevents
withdrawal behaviour [42]. On the other hand, the workplace stressor related to lack of staff support
was significantly associated with shorter durations of EL. The lack of managerial support for a work–life
balance leads to added pressure for workers to return to work as soon as possible, perhaps even before
they are ready to do so. This was in line with a study suggesting that supervisor positive attitudes
towards the aspect of the non-work domain will support their employees in handling the competing
family demands thus reducing the degree of presenteeism [39].

Conflicts with doctors significantly increased the duration of taking MC but lower duration of
EL. Nurses might not have the benefits of taking MC especially during the earlier phases of an illness
which result in the nurse being severely ill resulting in a prolonged duration of MC [43]. Accordingly,
a study among the Chinese population found that supervisors tend not to believe the reasons given
by the workers on sick leave, thus leading to presenteeism which causes further disruption in work
productivity [44]. Finally, nurses who were occupationally stressed about death and dying had higher
odds of not taking neither MC nor EL. However, if nurses who were stressed about death and dying
took MC, they were more likely to have a higher frequency of MC. Facing real-life tragedies left them
emotionally disturbed and unable to continue working due to mental illness or disorder [45].

Non-workplace stressors were associated with the frequency or duration of MC and EL in varying
directions of influence. For instance, no time with family and dangerous surroundings were associated

Int. J. Environ. Res. Public Health 2020, 17, 6132 13 of 16

with a higher frequency of MC but conflict with close friends and conflicts over household tasks were
associated with a lower frequency of MC. In addition, pressure from relatives and conflict with spouse
were associated with a higher frequency of EL, while conflicts with spouse and no babysitter were
associated with a higher duration of EL. Moreover, sexual conflict was associated with a lower duration
of EL, but insufficient money was associated with a lower frequency of EL. Similar findings were
recorded for workplace stressors which have been discussed earlier. These findings may suggest that
the origin of stressors plays an important role in influencing medical- or family-related outcome which
consequently determine the aspect of MC and EL. Another possible reason could be the cross-sectional
design that is unable to infer causation [46], and it is thus unknown which comes first either the MC/EL
or the non-workplace stressors. This could also be due to the interaction between workplace and
non-workplace stressors that influence the MC or EL.

In view of the possible interaction of workplace and non-workplace stressors with absenteeism,
some working organisations support the introduction of a family-friendly organisational culture by
encouraging managers to support family life [47]. Modifying the workplace environment, which is
the responsibility of both employees and managers, is necessary given potential for modifiable
determinants to control unplanned absenteeism. An absenteeism policy should be in place to ensure
that rules are stated clearly, and the daily work process should continue as usual [48]. Flexible working
time arrangements can be considered for those who have conflicting responsibilities between work
and family and can be applied to those who have illnesses as well. A family-supportive organisational
culture at the workplace should be created by getting managers to support the work–life balance.
Despite the need to reduce unplanned absenteeism, managers should be concerned for their workers’
general well-being; therefore, MC should be encouraged to those who have acute minor illness or else
the upcoming health-related consequences will lead to a worse impact. For instance, those with URTI
which could be easily transmitted in a healthcare setting could lead to a longer duration of MC or
higher number of workers taking MC if the source workers continue to work despite having the illness.

This study has limitations related to the cross-sectional design that could neither infer causation
nor examine the mediating/moderating effect of other variables. Therefore, there is a need to conduct a
longitudinal design to examine the interrelationship among workplace and non-workplace stressors,
and their causal effects towards absenteeism. The subsequent study should also comprehensively refer
to the model of absenteeism to guide researchers on how to tackle the possible determinants acquired
from the respondents to explore other factors of unplanned absenteeism. Other than that, future studies
can be commenced qualitatively to determine the specific reasons for unplanned absenteeism at a
different hospital setting.

Apart from cross sectional design, the other limitation of this study was in the exploration of
reasons for leave and days of leave for each reason was only up to the third time of frequency. Therefore,
we were unable to capture the reasons for unplanned absenteeism that exceeded more than three times.
Furthermore, the findings were self-reported; hence, we could not verify the validity of the number of
days, frequency, and reasons for unplanned absenteeism. Other than that, this study had induced recall
bias as respondents tended to remember obvious common reasons instead of uncommon ones; thus,
the absolute reasons for unplanned absenteeism should be interpreted with caution. Another limitation
was a misclassification on the reasons for unplanned absenteeism that might have been wrongly stated
by respondents including medical appointments/procedure and surgery. Having advanced notice of
an upcoming leave due to these reasons could be classified under planned absenteeism.

5. Conclusions

To conclude, the prevalence of MC and EL among nurses working in Malaysia for the past one
year was 49% and 48%, respectively. A majority of the subjects took both MC and EL for only once
and for only a one-day duration for the past year. The most common reason for MC and EL was
unspecified fever and sick children, respectively. There is no clear distinction between workplace and
non-workplace stressors for MC, EL or both. Both workplace and non-workplace stressors showed

Int. J. Environ. Res. Public Health 2020, 17, 6132 14 of 16

different significance, magnitude and direction of association towards the duration or frequency
for MC and EL. Nevertheless, preventive measures should be taken by targeting modifiable factors,
which involve getting managers on board and promoting a stress-free environment in the workplace.
Future study should consider employing a longitudinal design that combines both qualitative and
quantitative method based on a comprehensive model of absenteeism.

Author Contributions: Project Administration, H.M.Y., N.A.M.S., M.F.M.F., R.M.R. and S.E.W.P.;
Conceptualization, N.A.M.S., M.F.M.F., R.M.R. and H.M.Y.; Methodology, N.A.M.S., M.F.M.F. and R.M.R.;
software, N.A.M.S. and M.F.M.F.; validation, N.A.M.S., M.F.M.F., H.M.Y. and S.E.W.P.; formal analysis, N.A.M.S.,
M.F.M.F., H.M.Y. and R.M.R.; investigation, N.A.M.S. and M.F.M.F.; resources, H.M.Y., N.A.M.S., M.F.M.F.,
R.M.R. and S.E.W.P.; data curation, M.F.M.F., N.A.M.S. and R.M.R.; writing—original draft preparation, N.A.M.S.,
M.F.M.F., H.M.Y.; writing—review and editing, N.A.M.S., M.F.M.F., H.M.Y., R.M.R. and S.E.W.P.; All authors have
read and agreed to the published version of the manuscript.

Funding: This research received no external funding.

Acknowledgments: We would like to express our gratitude to the Occupational and Environmental Health Unit
and Nursing Unit in each district health office and public hospital in Selangor for their assistance in this research.

Conflicts of Interest: The authors declare no conflict of interest.

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