Presenteeism: An overview

Introduction

Presenteeism as a concept is increasing in importance in the work environment. It occurs when workers go to work when ill and are unable to perform effectively due to their ill health. Due to this loss in productivity, it has been estimated that presenteeism costs organisations more than sickness absence, and as such should be monitored to a greater extent. It impacts on workers’ health, wellbeing and resilience, as well as organisational health. These issues are discussed as are the implications for workplace policies and practices to manage presenteeism.

Presenteeism and workplace policies and good practice

The concept

While presenteeism is influenced by the overall health and wellbeing of employees, there are many work and non-work factors that may cause employees to go to work when ill and when they are not able to produce and perform to the best of their ability. As a rule, individuals who are experiencing ill health should refrain from reporting to work until they are fully recovered. However, for some individuals, depending on their illness, they may either agree with their employer on reduced work hours, less strenuous activities or both, to facilitate return to work after long-term sickness absence. Work generally is good for physical and mental health and overall wellbeing and conversely a lack of work can lead to poorer physical and mental health and overall wellbeing^[1]. In this respect, individuals who may have mostly recovered from an illness, but are not 100% fit could engage in certain activities at work^[2], and thereby assist further with their full recovery. It must be recognised though that a ‘controlled’ return to work for workers with support from their organisations when on the way to recovery from ill health, would generate different results from those individuals who may feel that they should go to work when they are ill due to the pressures of the work environment.

Presenteeism is a concept that gained attention since the early 2000’s but there is still no generally accepted definition of presenteeism^[3]. Johns (2009)^[4][3] in a review of the concept to date noted that the slightly different interpretations of the term tended to fall into two groups. The first, the European definition, focuses on the management and epidemiology or occupational health aspects of the term and its impact on job insecurity, i.e., workers going to work to ensure that they are ‘seen’ to reduce their chances of being made redundant, with possible consequences of stress and ill health. This is tempered against the North American focus that defines presenteeism as the measurable loss of productivity due to attending work with health problems^[5]. This approach assesses the impact of ill health, such as experiencing a migraine, on productivity^[4]. Johns notes that many of the terms lack scientific integrity such as stating that presenteeism is the opposite of absenteeism and proposed that more research is required to assess the underlying causes of the concept. Ruhle et al. (2020)^[5] identified next to these two definitions, a third line of research on presenteeism broadening the scope of presenteeism. The definition goes beyond “coming to work while ill” to include the concept of ‘being physically present but functionally absent’. Such dysfunctional presence at work may be due to reasons that are unrelated to health5. The authors emphasise that all three approaches contribute to an understanding of the concept but that a common definition is needed in order to develop reliable measurement methods and to compare research results. They propose that ‘research on presenteeism should recognise the basic understanding of presenteeism as behaviour of working in the state of ill-health’  encompassing all kinds of health conditions, including mental disorders. Moreover, research on presenteeism should be neutral and not consider the behaviour in itself as positive or negative^[5].

The causes

As presenteeism involves going to work when ill, it could involve any aspect of ill health. In general, the most common health reasons why people work while unwell, are similar to those that lead to sickness absence, namely musculoskeletal disorders, gastrointestinal symptoms and common mental health problems^[6]. Individuals who suffer from emotional, thyroid or blood pressure concerns are more likely to stay at home to deal with their conditions, while back pain could cause workers to equally choose going on sick leave (absenteeism) or coming to work but not able to work efficiently (presenteeism) to cope with these conditions^[7]. Further, higher stress levels are more likely to increase a pattern of presenteeism among individuals^[7].

Financial pressure and job insecurity are among the most common reasons why people go to work despite being ill. However, it is possible that job insecurity points to other underlying factors related to presenteeism, such as a poor work environment and work climate^[8]. A Swedish study based on a nationally representative sample has shown that sickness absence and presenteeism are influenced by a poor work environment, with poor health and high stress levels further strengthening this relationship^[9]. Further, the two concepts positively affect each other, as individuals who are experiencing ill health will manage this illness by alternating between sickness absence and presenteeism, contributing to a further decline in their health^[9]. This could lead to future long-term sickness absence, due to poor health^[10], allowing for presenteeism to be considered a ‘predictor’ of sickness absence^[11]. Therefore, organisations in seeking to manage one of those issues (either absenteeism or presenteeism) should work to manage the other at the same time.

There are several factors that influence presenteeism and absenteeism behaviours and these include^[12]:

• The nature of the health problem itself,
• The objective and perceived characteristics of work,
• Organisational policies and procedures,
• Wider cultural and socio-economic context,
• Managers’ relationships with employees and their effectiveness in implementing organisational policy.

For example, if managers and supervisors adjust organisational policies and procedures, to allow flexible working; this allows the employees to adjust work patterns so they could have a more manageable workload and better manage their ill health^[13] [8] and they may not ‘feel’ compelled to report to work. Such an approach would realise better outcomes over the long-term. 

Some of the other factors that contribute to a ‘presenteeism culture’ in the organisation are low replaceability, low control, conflicting demands, lack of work resources, time pressure, high psychological demands, supervisory status, social support, job insecurity and having a family life that is more demanding than work^[12], but not wishing to acknowledge that they have these challenges and thereby reducing work-life balance. In this respect, employees may go to work without addressing some of the challenges that may arise in their home life, thereby selecting ‘work’ over ‘home’, and creating work-life imbalance. It has been found also that parents would go to work when ill to ‘save’ paid sickness absence and vacation leave to care for their children when they in turn fell ill^[14]. In addition, individuals with higher performance-based self-esteem (i.e., those whose self-esteem is directly linked to their performance) have been found to go to work when ill^[15]. Another factor involves how an organisation’s sick pay provision is allocated, although this may depend on the size of the organisation and the type of work in which the employee is engaged, which have all shown to impact on the return to work practices of employees^[16]. Organisational practices, such as a culture of workaholism^[17] has been found also to increase presenteeism, as has work-life imbalance due to work interfering with life as workers feel pressured into going to work when ill^[18], and thereby not taking care of their health, reducing their ability to deal with both work and home.

Research shows that home-based telework is positively related to presenteeism^[19]. Telework removes barriers such as travelling to work and provides more flexibility to adjust working conditions and schedules. Also, teleworkers do not risk infecting their colleagues in case of a contagious illness. During the COVID-19 pandemic home-based teleworking rapidly increased. A German study^[20]based on qualitative data from 505 workers showed that many reasons for deciding for or against presenteeism remained unchanged during the pandemic. However, the findings do suggest an increase in ‘virtual presenteeism’ (not travelling to work but working from home while being ill)^[20]. In that respect, COVID-19 has changed attitudes towards presenteeism and changed people's views on the acceptability of being sick at work, as people are more aware of the threat of infection in the workplace.

Prevalence

Due to the increase in the volume of research that is being generated about presenteeism, some information is available on its prevalence and the characteristics of the workers more likely to come to work when they are sick. However, when interpreting the results, it is important to bear in mind that studies are not always comparable as they are based on different measurement methods and definitions e.g. timeframe, number of presenteeism days, seriousness of the illness, etc.^[5].  In the United Kingdom, 80% of a group of 1279 doctors had worked while ill^[21] over the previous year of the survey. In Sweden out of 3096 employees from various professions/jobs 70% had worked while ill^[22] over the past 12 months, whilst in Denmark a similar result (73%) was found from 11, 270 employees from various professions/jobs who were questioned about their leave patterns over the previous year^[23]. Other research shows that 60% of 6309 employees in organisations across the United Kingdom and Europe reported working while ill18. In addition, a survey of 510 employees of varied professions/jobs from a health insurance company in the United Kingdom showing that when 18% of employees reported sickness absences, a higher rate was found (45%) for employees reporting coming to work when ill^[24]. Further, those who go to work when ill are more likely to be women and to have a higher level of education, as a study of 2191 participants from various occupational groups in the United States of America (USA) has shown^[25].

Information from the European Working Conditions Telephone Survey (EWCTS) 2021^[26] shows that 28% of the respondents in the EU indicate that they often or always have worked when they were sick. Women were more likely to work when sick than men, 31% compared to 26%.^[27] The presenteeism rate differs according to the place of work. Home-based working teleworkers report most often that they continue their work when they are ill (see figure 1)^[27].

Figure 1: Presenteeism by place of work, EU27 (%)

Source: Eurofound^[27]

Presenteeism varies also among different employment statuses, occupations, and industries. It was most prevalent among the self-employed, particularly those with employees (43%), and the solo self-employed (38%). Sectors with the highest rates of presenteeism included agriculture (38%), health (34%), financial services (31%), and education (31%), while it was less common in the industry (23%) and transportation (24%) sectors. Occupations where presenteeism was most widespread were agricultural workers (45%), managers (35%), and professionals (32%), while clerical and blue-collar workers exhibited below-average levels of presenteeism^[27].

These sectoral and occupational influences in relation to presenteeism are also reflected in the disparities observed among the four COVID-related groups. The highest percentage of individuals reporting that they worked while sick was in the frontline workers group (34%), whereas the lowest percentage was among on-location production workers (24%)^[27].

The data from the EWCTS 2021 also show that economic pressure is a reason for presenteeism. During the pandemic, there was a higher percentage of single parents (mostly women) who reported having worked while ill (36%), followed by workers in households with two adults and children (31%)^[27].

The consequences and benefits

Presenteeism impacts on both employee and employer. For example, when pressure is put on employees to go to work, this may lower their burnout^[28]. Workers with high job demands may feel compelled to go to work to ensure that the work gets done, but some of the other consequences include exhaustion and depersonalisation^[28], depression^[29], and depending on the nature of the job, may lead to other health and safety risks to the colleagues of the worker due to him/her being less alert and therefore more accident-prone; thereby adversely affecting both parties by presenting her/himself at work^[30].

It must be stressed that going to work when not fully fit does not necessarily lead to presenteeism (i.e. not doing the work as expected). In fact, research has shown that a ‘controlled’ return to work could benefit, both the organisation and the employee, when the employee returns to work while recovering from an illness. A study by Howard et al. (2009)^[25] assessed two groups of workers suffering from chronic pain conditions. One group was classified by the authors as ‘presentees’: i.e., those who worked more than 20% of the time post-injury and for more than three months post-injury; or were working at the time of admissions to the treatment. The other group was called ‘absentees’: i.e., those who did not meet the previously listed criteria.

The assessment found that: those workers who were ‘presenting’ themselves at work (i.e., those classified as presentees)

• were more likely to complete the prescribed functional restorative treatment programme;
• to return to work either on full-duty or full-time;
• to retain their work one year post treatment, and
• not to have a decrease in job demand from pre-injury to post-treatment.

These results suggest that employees and employers benefit if the ill or injured employee stay at work post-injury rather than going on short-term or long-term disability, however, the working conditions must be adjusted to their current abilities^[25]. This assessment supports the belief that if employees receive the support from the organisation as part of a staged return to work, then they are more likely to return to work full time after stress related sickness absence and should be one of the return to work strategies to cope with musculoskeletal disorders. The study suggests one of the ways that could be used to encourage employees to work with organisations in managing their ill health and thereby reduce the potential of employees leaving the job due to an acute or short-term health problem. When the workplace is supportive and provides adequate resources to aid adaptation, presenteeism can be a sustainable choice for maintaining performance under impaired health^[31]. 

The cost (estimated) and good practice

Costs and impact of presenteeism

Due to the nature of presenteeism, official records do not include individuals who go to work when ill; hence it is difficult to obtain accurate values of its cost to organisations and society. However, more instruments are being developed to measure presenteeism by assessing the effect of ill health on productivity loss^[32]. Despite this, it is argued that a ‘best method’ of measuring presenteeism is yet to be developed or established^[33]. Some workplace associations have estimated the cost of presenteeism by examining sickness absence figures, by using international research that shows that in general presenteeism costs could be at least three times higher than absenteeism, with one of these studies suggesting that presenteeism costs were 1.8 times higher when compared to the costs for absenteeism^[32].

Overall, it is difficult to gain an accurate estimate of how much presenteeism costs an organisation. Despite this, when a worker chooses to go to work when not fully recovered from an illness or is not able to function at his/her optimum, this could have a negative influence on her/his productivity, thereby, incurring a cost to the organisation. On the other hand, organisations also avoid costs, such as costs associated with the unplanned absence e.g. replacement^[5]. More research is required therefore to determine the extent to which such behaviours impact on organisations to allow the development of an evidence-base to positively address this issue. In recent years more research has become available that emphasises the possible positive effects of presenteeism^[5]. In terms of productivity, attending work might be better for the organisation than no attendance. For the individual worker, under the right circumstances, staying at work might be therapeutical^[31]. Presenteeism does not automatically lead to adverse outcomes but from doing so without proper management or adjustments to the work tasks, organisation, or equipment, to ensure that it promotes the individual's health rather than harms it. Thus, the focus should not be on preventing presenteeism as such, but on ensuring that attending work is a suitable course of action considering both the health condition and the nature of the work^[5].

Workplace policies and good practice

Due to the evidence presented above, the rational for a comprehensive approach to addressing presenteeism^[34] seems to warrant pursuing, rather than one that is based solely on the medical model^[12][34], i.e., only focusing on physical symptoms. It is especially important to know an individual’s beliefs about his/her illness in order to determine how best to manage it^[12]. Interventions are increasingly available and are being recommended also to address presenteeism at both the organisational and the individual levels.

The risk assessment process should be used to identify any psychosocial risks that could affect workers’ health. Employers in the European Union (EU) are required to evaluate the risks to the safety and health of workers and to put in place any appropriate action to prevent or control those risks, as outlined in the Occupational Safety and Health (OSH) Framework Directive 89/391/EEC^[35]. Presenteeism is a risk factor and would fall under this process,

Some of the useful recommendations that should be considered at the onset when managing risk factors, which may lead to presenteeism practices, are^{[12] [28][32][36]} :

• Provide line manager training in policies and practices to those who supervise others.
• Monitor absence and support health and wellbeing as these will improve productivity and reduce sickness absence levels.
• Develop an organisational culture that clearly states that employees should take sick leave when ill.

When workers are part of a supportive culture in which they know that time away from work is acceptable, then they are more likely to ‘detach’ from work to allow sufficient recovery from the work environment. The benefit of detaching from work has been recommended to improve on health and wellbeing^[37].

Another solution that may assist in managing presenteeism is to develop checklists or indices that supervisors and managers could use to focus on the specific characteristics of the work environment to assess those that could be changed, inclusive of^[38]:

At the organisational level:

• Are ‘light duties’ really available, such as those that do not require excessive or strenuous input?
• If available, are they appropriately used? In that the employee can choose when these can be done, rather than having set times to do certain tasks?
• How much control can the worker have over the pace and intensity of work?
• Are other workers available to take on the work if pressure builds up?
• What is the extent of peer pressure to work ‘as normal’?
• Can workers engage in meaningful dialogue with supervisors about what they can and cannot do?
• What impact would work absence have on job security and job promotion opportunities?
• Are health professionals available to tailor workplace exercise programmes?
• Have supervisors and managers been trained to consider presenteeism, its impact, and what they can do to support sick workers?
• What is the attitude of management to workers taking time off work?

At the individual level:

• What is the attitude of the worker to taking time off work, and especially when s/he is suffering from ill health?
• What external pressures are there on the worker to go to work when sick?
• Has the worker experienced episodes of ‘burnout’ and depression in the past? This may indicate that the worker may choose to present at work, rather than managing their ill health through sickness absence.

One of the ways to deal with presenteeism is to use workplace health promotion programmes to address the health risks that could lead to an increase in presenteeism behaviours amongst workers^[33]. It is useful to implement such interventions as when risk factors change: i.e. improve; this has a positive effect on presenteeism^[39]. Other strategies that could work comprise the following^[40]:

1. Including presenteeism questions into Health Risk Assessment (HRA) instruments to allow a more valid assessment of the problem. This allows an understanding of the issue and gains information for any future methods to target and evaluate the issue.
   A presenteeism question could entail, ‘Over the past 12 months did you work when you were sick?’ Yes or no responses would suffice.
2. Constructing and providing individual self-care guides to each worker based on his/her symptoms and chronic conditions that were identified in the HRA. This identifies the workers at risk and ensures that the appropriate prevention strategies are in place to reduce presenteeism-related productivity losses.
   The self-care guide could provide any of the following: information and advice on the specific illness of the worker, give techniques that the worker could use in coping with the illness and allow the worker space to record his/her medical history.
3. Using the presenteeism-related data from the HRA to design appropriate interventions for any work (sub)-groups within the organisation. As with the individual guides, these allow the identification of symptoms and conditions that could then be targeted accordingly to the respective groups.

These data could list the types of illness that employees may experience, but choose to work through them.

1. Including presenteeism issues in health communication actions. This increases the awareness among workers of the most typical conditions that affect productivity and provides information on the different ways that this could be minimised.
   Any communication should mention also that employees who go to work when ill may take longer to fully recover and may experience other health issues as a consequence.
2. Including typical presenteeism conditions in information on medical self-care and training. This facilitates learning for workers on the prevalence of the condition and ways to prevent it from occurring.
   For example, workers may come to work when they have the flu, but information could be given to them suggesting that resting at home with appropriate fluids and medication would result in faster recovery than if they go to work and try to ‘work’ through the illness.
3. Providing targeted intervention strategies for the most costly conditions. These strategies could consist of educating or providing the worker with information on solutions that are available to alleviate symptoms and onsite occupational health services support.
4. By acknowledging that some measure of presenteeism might be beneficial to both employees and organisations, so long as it is well managed. This requires building a culture of trust where workers are strongly committed to the organisation and will meet their responsibility towards their colleagues^[5].
5. Creating an organisational culture that ensures workers take regular breaks, regular vacation leave and also sick absence when staying at home is the appropriate way for a full recovery.
6. Including measurements of pre and post presenteeism as part of program evaluation. A consistent evaluation of presenteeism at baseline and regular intervals allows any potential programme effects to be more accurately determined.

The interventions listed above would contribute to a healthy organisation, which in turn could assist in managing presenteeism. However, it has been noted that presenteeism could still occur with employees who operate within a supportive organisation, as they may report for work in support of the organisation and to not let it down^[35].

Conclusions

As shown, there are strong links between presenteeism and sickness absence, with organisational policies being one of the influencing factors that impact directly on employees alternating their absenteeism with presenteeism to manage their ill health. While employees note that they ‘choose’ to go to work while being unfit for work^[18], such choices would be reduced or eliminated if they knew that the required support from the organisations and their managers/supervisors was available in managing not only their workload, but their health and wellbeing.

The measurement of presenteeism remains an issue with a number of diverse instruments in use that may not provide a full realisation of the costs or consequences involved in the behaviour4 ^[41] and that may generate different estimated costs^[41]  or struggle to establish its overall impact. The continuing research for suitable instruments would improve and build on the tools that organisations could use to measure, assess and evaluate and thereby implement suitable interventions for this risk factor.