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The hidden costs of working when sick

Mariella Miraglia and Gail Kinman review the evidence on presenteeism.

03 July 2017

Back in 2010 Gary Johns traced the development of interest in presenteeism and highlighted the many ways in which it has been defined. Overall, two themes emerge: first, presenteeism is seen as the practice of attending work in spite of illness or injury; second, it is used to describe the productivity loss resulting from employees working while unwell and unable to perform to their full capacity. This perspective tends to be used in the field of occupational medicine, where attempts are made to quantify the productivity loss of presenteeism related to illness in general, or to specific medical conditions, such as coronary heart disease, arthritis and depression. Although it is vital to raise awareness of the financial costs of presenteeism, the validity of defining the concept in this way is questionable, as it confounds the cause (i.e. the behaviour of working when sick) with the effect (i.e. impaired productivity). This does not allow researchers to identify the underlying reasons why people work while sick and the wider implications of this phenomenon.

Notions of the 'ideal worker' as one who shows their dedication and commitment by continuing to work while sick are being challenged, as knowledge of the incidence and costs of presenteeism has increased. Most of the research has been conducted in North America and Australia, but UK researchers for the Sainsbury Centre for Mental Health have estimated that employee presenteeism is between 1.8 to 10 times more frequent than absenteeism. Working while unwell is thought to cost the UK economy almost twice as much as absenteeism (not being at work when unwell); indeed, a recent study calculated that presenteeism from mental ill health alone costs UK employers more than £15 million per annum.

There is also evidence that working while sick might be becoming more common. A 2015 survey of 600 UK businesses conducted by the Chartered Institute of Personnel and Development indicated that more than one employer in three reported an increased incidence of presenteeism among their staff in the previous year.  

Why do people work while sick?

A wide range of contextual and individual difference factors has been found to contribute to workplace presenteeism (see 'Main causes of presenteeism'). Miraglia and Johns (2016) recently investigated the main drivers of presenteeism by synthesising the findings of 61 studies, with a total of 175,965 employees from several countries. Support for a dual-process model was found, whereby presenteeism was predicted by positive as well as negative factors. The first pathway is via health impairment and stress, where people work during sickness due to pressure of work and a lack of job and personal resources. The second pathway is attitudinal/motivational, where people who are deeply committed to their job may be more inclined to 'go to the extra mile' and continue to work when unwell.

Factors such as high work intensity, job insecurity and lack of support from supervisors and colleagues have been found to encourage presenteeism. The most important constraints on absenteeism, however, appear to be strict attendance management policies, such as limited entitlement to uncertified absence days, a lack of entitlement to sick pay, or threats of disciplinary action. Organisations often use a 'trigger point' system, where employees are penalised after a threshold level of absence is reached. Consequently, individuals may continue to work while unwell to avoid being punished by their employers, especially if their jobs are insecure, they are experiencing financial difficulties, or there are fewer options for alternative employment.

The roots of presenteeism also lie in job design. Arnold Bakker's Job Demands–Resources (JD–R) model stipulates that job resources can offset the negative impact of job demand. Demands such as heavy workload, time pressure and understaffing may induce people to work excessively long hours – even if they are sick – in order to deal with a high volume of work and meet tight deadlines. The risk of presenteeism may also be exacerbated if employees have fewer resources to draw upon. Drawing on Hobfoll's conservation of resources model, employees who are taxed by high demands at work may use all their available resources, including continuing to work when ill, to avoid any further resource loss and maintain productivity. As we'll discuss later, attempting to comply with excessive demands in this way is likely to exacerbate strain and illness, increasing the risk of further presenteeism and the likelihood of sickness absence over the longer term.

On a positive note, job resources may help prevent presenteeism. Workplace support has been found to reduce it; supervisors and colleagues may encourage individuals to take time off sick when required, and their work may be reallocated among the team or temporary staff may be recruited to provide cover. Another job resource that can discourage presenteeism is control. There is some evidence that individuals who feel more in control of their job typically feel less pressure to work while sick, but findings are inconsistent. Job control encompasses a wide range of factors, and it is likely that some aspects may be more protective than others. For example, schedule flexibility (the ability to control where and when you work) may enable people to work from home when they feel too sick to physically attend work. The role played by adjustment latitude – the opportunity people have to reduce or adjust their efforts at work – has also been highlighted. High adjustment latitude may reduce the likelihood of presenteeism, as employees who are feeling below par may be able to choose the work tasks they feel better able to fulfil, reduce their cognitive effort, decrease their pace of work, or take more breaks.

As working conditions and job characteristics vary according to occupational group, it is perhaps unsurprising that the factors that predict presenteeism are likely to differ. A mixed-methods study of UK prison officers conducted by Kinman and colleagues (2014, 2016) found that more than eight out of ten participants felt pressurised to work while sick. A combination of job demands, low control, poor support from managers and interpersonal conflict were the strongest predictors of presenteeism. The qualitative data highlighted a range of other factors that encouraged officers to work during illness such as an 'anti-sickness' culture, management pressure, job insecurity, staff shortages, fear of letting colleagues down and a strong sense of duty. Fear of referral to external absence management providers and the likely penalties was also a strong driver of presenteeism.  

A tendency to work while sick also seems particularly common within health and social care workers. A 1997 study of UK doctors led by McKevitt found that more than 80 per cent of participants had continued to work through illness. This strong attendance pressure felt by members of the so-called 'helping' professions is likely to arise from a combination of factors. Health and social care employees typically have a high workload, work long antisocial hours, often under challenging conditions, and are at a higher than average risk of job-related stress and burnout. They also tend to work within cultures that emphasise the meaningfulness of the role and inculcate a strong sense of responsibility for the welfare of vulnerable people. All these factors are likely to encourage employees to continue to work while sick. Working cultures that encourage employees to neglect their self-care and consider sickness to be a sign of weakness and a burden for colleagues will also encourage presenteeism. The risks for the wellbeing of service users from such attitudes and behaviour, as well as the long-term health of professionals themselves, are clear.  

What is the impact of presenteeism?

Working during contagious illness can obviously threaten the health of co-workers and members of the public. In the short term, however, continuing to attend work while sick may be desirable for organisations; the individual is still 'on the job' and able to perform according to the limitations of their medical condition. When illness is neither overly debilitating nor contagious, there is some evidence that the benefits of going to work for employees might outweigh the costs. This view is supported by a study of over 2000 individuals affected by chronic occupational musculoskeletal disorders conducted by Howard and colleagues (2009). Employees who were designated 'presentees' were more likely to complete a functional restorative treatment programme and return to work full-time than those who took more sick leave. Working while sick might also be seen as an example of organisational citizenship behaviour and a sign of commitment and loyalty to the organisation.

Although working while sick may have some benefits, at least in the short term, a review of the literature shows that it can be damaging for employees and organisations. First, presenteeism can be a major threat to long-term wellbeing. There is evidence that working while sick is a risk factor for future adverse health events, including cardiovascular disease and mental health problems such as anxiety and depression. In turn, this increases the risk of subsequent absenteeism as recovery will be threatened and health decline accelerated. A 2009 study of nurses in the Netherlands led by Evangelia Demerouti examined how working while sick can increase the risk of burnout over time. Burnout is a chronic syndrome in response to excessive work stressors that is characterised by emotional exhaustion, together with feelings of depersonalisation and reduced personal accomplishment. A reciprocal relationship was found between presenteeism and emotional exhaustion, indicating that working while sick increases emotional exhaustion that, in turn, increases the likelihood of presenteeism. Working while sick was also found to intensify feelings of detachment from the job role, possibly in an attempt to recover from the emotional demands of the job.

The implications of working while sick for the health and safety of others have been examined. There is evidence that people who are working under par tend to make more slips and lapses of judgement. Studies of healthcare workers have associated presenteeism with an increased risk of patient falls and medication errors. Such risks are well illustrated by a 2015 study of UK pharmacists conducted by Niven and Ciborowska.  Employees who worked while sick tended to make errors more frequently, such as giving a patient the wrong medication or prescribing the wrong dosage. They also reported higher levels of depression and anxiety than those who took time off sick. The authors maintained that working while unwell requires more effort to meet the required standard of performance, as employees need to increase concentration to overcome the distracting symptoms of illness, such as pain. As this requires cognitive effort, the capacity to monitor and respond promptly to environmental demands is constrained, therefore increasing the likelihood of errors and accidents.

What can be done to address presenteeism?

Few organisations take any steps to discourage employees from coming into work when sick. Although it was generally acknowledged that presenteeism had increased and was a cause for concern, 56 per cent of respondents to the CIPD's absence management survey admitted taking no action to reduce it. Of particular concern was the finding that just under half indicated that operational demands tended to take precedence over the health and wellbeing of their employees. As presenteeism is complex and multi-determined, interventions at multiple levels will be required. To begin with, organisations should take steps to identify the incidence of presenteeism and assess its impact on the health and productivity of the workforce. This will raise awareness of the need to intervene.

Although most companies have systems in place to record and manage employee absence, it is considerably more challenging to measure presenteeism. Working while unwell may be invisible; not always disclosed by employees and difficult to detect by even the most sensitive managers and colleagues. Moreover, at what point does somebody become a presentee? People frequently feel 'off colour', but not sick enough to take time off. As perceptions of health are highly subjective in nature, relying on self-reports of presenteeism and judgements of its impact on job performance would seem inevitable, but the risk of confounding factors, such as negative affectivity and health anxiety, should be acknowledged. Staff wellbeing surveys could ask employees whether they have worked while sick over a specified period and, if so, to estimate the number of days they have done so. Alternatively, employees to recall any health problems that occurred over the past year and then indicate whether they took time off sick or continued to work. In this way, organisations could keep records of health and resulting attendance behaviours (i.e. absenteeism and presenteeism). Whether demographic factors or characteristics of the job predict presenteeism could also be examined. These methods could also be supplemented by measures of productivity loss related to presenteeism, such as the Stanford Presenteeism Scale (Koopman et al., 2002), that captures the impact of health problems on outcomes such as completing work (e.g. the ability to complete difficult tasks) and avoiding distraction (e.g. feeling hopeless about completing tasks due to health problems).

A further challenge for organisations is to set up specific policies to manage presenteeism. Reducing unnecessary absenteeism without increasing negative presenteeism will be difficult to achieve – especially in a culture that expects and rewards long working hours. Given the findings of the CIPD survey, it would seem appropriate to raise awareness among managers that the long-term risks of presenteeism to productivity are likely to outweigh any immediate gain. The robust research findings showing that presenteeism can negatively affect the wellbeing of colleagues and service users, as well as the health and productivity of individuals, should also be disseminated. The recognition that an 'ideal' employee takes sufficient time off sick to recover, rather than struggling to work through illness. This would discourage the emergence of an 'anti-sickness' organisational culture that reinforces, or even celebrates, working while unwell. Training is also required to help managers notice the signs and signals of presenteeism and develop the sensitivity and empathy needed to support their staff through illness. Managers should also act as role models for sickness behaviour and take sufficient time to recovery from periods of sickness. Increasing opportunities for flexible and remote working may also reduce the incidence of presenteeism, as people may be able to work from home for part of the day, or during times that better accommodate their limitations.

As we've discussed, presenteeism may stem from job design and working conditions. Thus, well-designed jobs should be the first line of defence against working while sick via the careful management of job demands, such as workload, time pressure and overtime work, and the provision of appropriate support when people are absent. Moreover, opportunities to increase job resources such as job control that can protect the wellbeing of individuals in the face of work-related stressors and strains should be maximised. As presenteeism is as much linked to health as absenteeism, organisations could introduce workplace wellness and health programmes to reduce work-related stress and illness. These programmes can inspire healthier lifestyle practices, offer health assessments to monitor the wellbeing of staff and provide assistance programmes, such as counselling services. By assuring a healthy workforce, these programmes should reduce the costs of absenteeism as well as presenteeism.

Finally, it should be acknowledged that presenteeism is not always undesirable and damaging. For some chronic disorders, such as depression, attending work while feeling unwell may be a 'sustainable' behavioural choice and help people to reintegrate themselves back into the workplace. The main challenge for psychologists and human resource professionals is to understand when presenteeism should be encouraged and when it should be avoided. A careful assessment of a wide range of factors is required when making such decisions, such as the type of illness, the phase of recovery, the employee's readiness to return to work, the requirements of the job role, the organisation's willingness to adjust work activities according to the employee's needs and work capability and the availability of support.

Box: Why do people work while sick?

  • Stress
  • Lack of support from colleagues/interpersonal conflict
  • Job insecurity
  • Lack of support from supervisors
  • Strict absence policies and sanctions
  • Low job control
  • Anti-sickness culture/norms; discrimination
  • Management pressure
  • Lack of sick pay
  • Short staffing; lack of cover
  • Financial difficulties
  • Fear of burdening colleagues
  • Low perceived employability
  • Feeling responsible, irreplaceable and indispensable
  • High job demands, particularly heavy workload and high time pressure
  • Strong sense of duty and responsibility
  • Long working hours culture
  • Enjoyment of work; high commitment and engagement
  • Understaffing/downsizing
  • Demographics: women, high educational level

 - Mariella Miraglia is at Norwich Business School, University of East Anglia [email protected]

- Gail Kinman is at the University of Bedfordshire [email protected]


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