New Nurses and Midwives Face Higher Long-Term Sickness Absence from Day One

A newly published Danish register study has found that newly qualified nurses and midwives who begin their careers in hospitals experience higher rates of long-term sickness absence and are more frequently diagnosed with back disorders than equally educated graduates of the same age who enter other sectors. The finding is striking because the differences appear within the very first years of employment, long before the cumulative physical toll of decades of shift work, patient lifting and night rotations could plausibly explain them. The research, conducted by Louise Schubert Paaske, a PhD student in health economics at the Danish Centre for Health Economics (DaCHE) at the University of Southern Denmark, together with colleagues at DaCHE and the National Research Centre for the Working Environment (NFA), was published in Communications Health under the title Health trajectories of early career hospital nurses and midwives compared to other graduates in Denmark.

What sets this study apart from much of the existing literature on occupational health in nursing is its starting point. Most previous investigations have examined nurses and midwives later in their working lives, when patterns of ill health, sector switching and early retirement are already well established. That approach carries a serious methodological risk: employees who have been harmed by their working conditions may already have moved into other sectors or left the labour market altogether by the time researchers look at the data, leaving behind a selectively healthier workforce. By following newly qualified graduates from their very first job and for six years thereafter, the Danish team was able to capture health trajectories at the earliest possible stage, before such selective attrition could distort the picture.

The study drew on nationwide Danish registers, a resource that allows researchers to track entire populations across employment, healthcare and social administrative systems with minimal loss to follow-up. The researchers identified people who completed a bachelor’s degree and entered employment no later than 180 days after graduation between 2010 and 2015. Using a target trial emulation framework, a design borrowed from epidemiology that mimics the logic of a randomised trial using observational data, they compared hospital-based nurses and midwives with newly qualified graduates of the same educational level who began working in 36 other sectors. The final analysis included 8,752 people, each followed for six years from their first job.

To make the comparison as fair as possible, the groups were matched on a wide range of background characteristics. These included age, gender, ethnicity, marital status, number of children, municipality of residence, the timing of their first job and their use of healthcare services before entering employment. Matching on pre-employment healthcare use is particularly important, because it reduces the chance that the hospital group simply started out with worse health than the comparison group. Even so, the researchers acknowledge that they cannot rule out all differences between people who choose different professions and workplaces, a limitation inherent to any observational design that compares self-selected occupational groups.

The headline results are quantitative and unambiguous. During the first four years of employment, hospital-based nurses and midwives had a higher annual likelihood of both long-term sick leave and diagnosed back disorders than their counterparts in other sectors. The difference reached up to 2.8 percentage points per year for long-term sickness absence and up to 0.6 percentage points for diagnosed back disorders. While these figures may appear modest at the level of an individual year, they accumulate across a workforce and across a career. After around four years, the gaps between the groups narrowed, but, as the researchers emphasise, this convergence does not necessarily mean that the health of those remaining in hospitals was improving.

The reason for that caution lies in one of the study’s most revealing supplementary analyses. Around 13 per cent of the hospital-based nurses and midwives left hospital work altogether during the six-year follow-up period. When the researchers examined the health trajectories of these leavers, they found that long-term sickness absence and recorded mental health problems increased in the period leading up to their departure from hospital work and declined again afterwards. In other words, part of the apparent narrowing of the health gap after a few years may reflect a healthy worker effect in reverse: employees whose health is deteriorating gradually exit hospital employment, so the remaining workforce appears healthier on average even if no individual has recovered. Paaske noted that when the differences become smaller after a few years, one cannot simply conclude that the health of those working in hospitals is improving, because employees with health problems may be gradually leaving hospital work. This also implies that studies restricted to people who remain in hospital work may present an overly positive picture of how health develops in the profession.

The researchers are careful to point out that their analysis describes developments before and after leaving hospital work but cannot establish that leaving in itself causes better health. The design is observational, and the observed improvements after departure could reflect recovery, changed working conditions, or other factors that the registers cannot capture. What the analysis does establish is a temporal pattern, rising ill health before exit and improvement after, that is consistent with the hypothesis that working conditions in hospitals contribute to the health problems of early career nurses and midwives, while stopping short of proving it.

One result initially appears to point in the opposite direction. Hospital-based nurses and midwives were less likely than the comparison group to have recorded use of healthcare services and treatment related to mental health conditions, including talking therapy with a general practitioner, medication, psychological treatment and psychiatric treatment. The researchers urge strong caution in interpreting this finding. Because the study is based on register data, the researchers do not measure participants’ mental well-being directly; they can only observe whether a person has a recorded diagnosis or has received certain types of treatment. Psychological strain that has not resulted in contact with the healthcare system, or that has not yet produced a diagnosis, remains invisible in the data. Paaske stressed that the lower use of treatment and healthcare services should not be interpreted as evidence that hospital-based nurses and midwives have better mental health, and that the higher level of sickness absence may, among other things, reflect psychological strain that has not yet resulted in a recorded diagnosis or treatment. The finding therefore speaks to recorded healthcare use rather than to actual mental well-being.

The technical limitations of register-based research frame the scope of the conclusions. Registers can only provide information about health conditions that are actually recorded, which means undiagnosed disorders, untreated strain and health behaviours are outside the analytical window. Moreover, the results concern the first six years of employment for the specific groups included in the study and cannot automatically be generalised to all nurses and midwives working in hospitals, whether in Denmark or elsewhere. The study was funded by Helsefonden and Lån & Spar Fonden, and its method of research was data and statistical analysis of national registers, with people as the subject of research.

Despite these caveats, the study carries a clear message for health system policy at a time when many countries struggle to retain nursing and midwifery staff. Because the newly qualified employees are at the beginning of their working lives, even a modest increase in long-term sickness absence and early departure from hospital work could have consequences over an entire career, both for the individuals concerned and for workforce planning in hospitals. The researchers suggest that the first years after graduation are an important period to focus on if hospitals are to retain more nurses and midwives, although the results do not in themselves identify which specific conditions in hospitals need to change. By following employees from the very start of their working lives and continuing to follow them after they leave hospital work, the study offers a perspective on the relationship between work and health that studies of later-career employees cannot provide, and it signals that the earliest years of a nursing or midwifery career may be decisive for both health and retention.

Subject of Research: Long-term sickness absence and health trajectories of early career hospital nurses and midwives in Denmark

Article Title: Newly qualified nurses and midwives have higher rates of long-term sickness absence

Article References: Newly qualified nurses and midwives have higher rates of long-term sickness absence. (n.d.). Original publication

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Keywords: nurses, midwives, long-term sickness absence, back disorders, occupational health, register data, Denmark, early career, workforce retention, mental health, hospital work, health economics