NHS sickness absence: why do nurses carry on working when unwell?

Advice for staff too scared to call in sick for fear of triggering formal sickness policies, or letting down colleagues and patients

Advice for staff too scared to call in sick for fear of triggering formal sickness policies, or letting down colleagues and patients

  • Nursing staff feel they must keep working even when they are sick, surveys suggest
  • A culture of presenteeism and what some see as punitive sickness management policies in the NHS deter staff from taking the time off they need
  • Tips on dealing with your organisation’s sick-leave policy – and why there are signs some employers want to show more compassion
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As many as four out of five nurses go to work despite feeling too sick to do so, according to research.

The most recent RCN employment survey revealed that 77.4% of participating nurses worked when they should have taken sick leave on at least one occasion, as did 80% of respondents to a Nursing Standard survey last year.

Why do nurses feel they have to work when sick?

Many nurses describe feeling a need to ‘carry on’ because of guilt and fear of recriminations if they called in sick. But why is it so hard for nurses to make their own health and well-being a priority and what sick leave are nurses entitled to?

Not wanting to let colleagues and patients down is a key reason for a culture of ‘just carrying on’, says RCN health, safety and well-being national officer Kim Sunley.

‘Nurses do typically feel a lot of guilt about calling in sick,’ she says. ‘They know that even one nurse down can make a lot of difference to the team and to patient care.’

With over 47,000 nursing vacancies in the NHS in England alone, the staffing situation is challenging.

‘Nurses’ commitment to quality of care is such a precious thing, but it does put them at risk because they will put the needs of patients and colleagues first’

Jane Ball, professor of nursing workforce and policy

For nurses on certain types of contract, taking time off sick is something they just cannot afford to do. Many nurses rely financially on overtime and bank shifts, says the RCN, which would not be paid if they were absent.

University of Southampton professor of nursing workforce and policy Jane Ball says: ‘This is what happens across the board when there are not enough nurses on duty.’

One of the consequences of such an ongoing nursing shortage is an additional pressure on nurses to fill that gap, she says.

‘In all the surveys I have done over the last several decades, time and again the thing that comes out really strongly is how committed nurses are to their patients and their jobs,’ says Professor Ball. ‘That commitment is such a precious thing but it does put them at risk because nurses will frequently put the needs of patients, and their colleagues, first – because of their commitment to the quality of care.

‘Nurses are having to compensate for system shortfalls and they are providing a buffer against high vacancy levels to protect patients from the effects of too few nurses.

‘But it’s not fair on anyone – them, their colleagues, or patients – if nurses feel like they have to come in to work when sick.’

Most common reasons for nurse sickness absence

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Across the nursing workforce, anxiety, stress, depression and other mental health issues are the most common reasons for calling in sick, NHS Digital data show.

Mental health problems account for 19.7% of nurses’ sickness absence, whereas infectious diseases accounts for 14%

The pandemic has, of course, had an effect too. RCN analysis in 2021 showed nurses were around 30% more likely to take time off for mental health reasons, and around 50% more likely to take time off for chest and respiratory problems and migraines than before COVID-19.

‘Sick leave soon adds up, and I have become reluctant to take any as one is penalised financially as well as having a mark on your record’

Nurse responding to a 2021 Nursing Standard survey

Colds, flu and norovirus are also common among healthcare staff. In fact, it is estimated that up to one in four healthcare workers will become infected with flu during a mild influenza season; many more than in the general population, according to NHS Employers, which urges staff to take up their annual free flu vaccination.

Ms Sunley says: ‘Long-COVID is also an issue, with nurses who contracted COVID at work still suffering from physical symptoms, alongside mental health issues that have arisen due to the pandemic.’

Researchers at the University of Southampton have found links between the nature of the job of nursing and higher rates of sickness absence. Their study found that working long shifts –12 hours or more – on hospital wards is associated with a higher rate of sickness absence.

Working a high proportion of night shifts has been associated with higher rates of long-term sickness absence, according to research.

Worries about reporting sickness to employers

Nurses also reveal they fear how they will be treated at work if they do call in sick, Ms Sunley adds.

‘Presenteeism is high, especially among nurses. Policies and procedures that are in place can seem punitive.’

In comments to Nursing Standard on this issue, nurses said they fear crossing absence thresholds by having too much sickness absence. One respondent described how they felt threatened by their employer’s sickness absence policy.

Another said: ‘I have always been aware that taking sick leave soon adds up, and have become reluctant to take any as one is penalised financially as well as having a mark on your record.’

These comments are echoed by many others.

5 ways to take the worry out of sickness absence

1. Know your employer’s sickness absence policy Find this information when you are well – that’s when it will be easier to read and understand

2. Be proactive and communicate ‘Our advice to individual nurses is to have conversations about what your employer can do to support you,’ says RCN health, safety and well-being national officer Kim Sunley. ‘Talk to your union rep and seek advice. Be open and honest about seeking advice, whether it’s for your mental health, a long-term condition or another issue.’ If worried about an upcoming formal meeting, talk it through with your union rep and ask them to accompany you

3. Keep your own notes and records These should include symptoms and triggers, absence dates, reasons, conversations with your manager or HR, and doctor’s consultations

4. Seek advice If you feel you are being treated unfairly, and your manager is taking a punitive approach, then talk to your union, if you are a member

5. Prioritise your health and well-being Pushing yourself to burnout level is likely to mean more time off in the longer term

Is there a climate of fear about sick leave among nurses in the NHS?

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‘There have been big drives in recent years to bring down sickness absence in the NHS,’ explains Ms Sunley.

Many employers use the Bradford Scale – an HR tool that calculates intermittent sickness absence days, length of absences and patterns.

Such tools are in common use in and outside the NHS – they collect data on absence and trigger formal sickness management policies. So, for example, if someone calls in sick more than three times in a six-month period, or more than four times in 12 months, a formal meeting with a manager may be triggered.

‘Taking a more holistic view will mean that managers look at individual staff’s needs, rather than falling back on the “triggers” system’

Kathryn Grayling, assistant director of engagement, NHS Employers

Although NHS policies allow for exceptions, such as work-related accidents and illness, anecdotally nurses have reported that exceptional circumstances are disregarded and in any case proving work-related causes of sickness absence can be difficult.

’Organisations need parameters – but it’s the indiscriminate use of triggers that causes issues,’ says Ms Sunley. ‘This is especially true when you’re talking about a work-related injury or health condition, or an issue to do with infection control, but can also be complicated when dealing with mental health difficulties that arise from stress at work.

‘And sometimes nurses are simply following workplace policies: for example to take 48 hours off after sickness or diarrhoea.’

Stages of sickness absence management in the NHS

Sickness absence policies vary according to employer. For those on NHS contracts, entitlements to sick pay are given in section 14 of the NHS Terms and Conditions of Service Handbook.

Until the seventh calendar day of sickness, nurses will need to self-certify, explains the RCN. Employers may have their own self-certification form, but if not, these can be downloaded from HM Revenue and Customs or use form SP2 from the GP surgery. A fit note is required from an appropriate healthcare practitioner for all periods of sickness absence that exceed seven days (including non-working days).

If a period of sickness exceeds seven days, it will probably trigger the organisation’s sickness policy and a ‘stage 1’ meeting will be called, advises the RCN. This should be seen as an opportunity to discuss any problems and is not usually anything to worry about. If you are off work for a longer period or if there are repeated periods of sickness while on stage 1, then stage 2 of the policy may be triggered. Employers may involve the HR and occupational health departments (where they exist) at that stage.

If off sick for a long period or repeated sickness, another meeting may be called.

The RCN says: ‘It is very important you do not go alone to these meetings, contact us for further advice. At this stage the employer has to consider all options available to them. These can include redeployment but also potentially dismissal and/or ill health retirement’

At all stages, nurses should read and follow their employer’s sickness policy.

Cause for optimism – moves to a more holistic approach to staff well-being

It is fair to say not all approaches to absenteeism are punitive. NHS Employers assistant director of engagement Kathryn Grayling is working with trusts in north-west England to move towards ‘a more holistic, person-centred’ approach to sickness absence, due to be implemented from 2023.

‘There is an acceptance now that current policies have not worked to bring down the higher sickness absence rates in regions like the north west and midlands,’ she explains. ‘We have been able to show that presenteeism is actually more detrimental to productivity in the workforce than a 5% sickness absence rate.

‘Taking a more holistic view will mean that managers look at individual staff’s needs, rather than falling back on the “triggers” system – but also that health and well-being policies target the whole workforce rather than just the 5% who are off sick.’

Managers should have an informal chat with employees to let them know they are approaching a ‘trigger’; to discuss reasons for absence and what support could be put in place to help, according to NHS Employers guidance. Conversations with managers about the reasons for sickness absence are confidential.

Adequate nurse numbers would foster good employer-employee practice

Ultimately, Professor Ball says the real solution to presenteeism is not a quick fix.

‘It is not so much about getting nurses to understand it is unacceptable to come to work when sick – but recognising this is a system issue,’ she says. ‘We have to tackle the underlying problems which stem from working conditions and staffing.

‘If there are enough nurses to provide care, then everyone feels able to look after each other and live according to those high values of good employer and employee practice. But how many managers feel able to actively say to their staff “if you’re not feeling right, don’t come in”?’

Further information