More recently, the concept of presenteeism has been expanded to reflect the behaviour of coming into work when sick, whether or not productivity loss ensues. This behavioural definition is based on a worker’s report that they came into work while feeling unwell or when they really should have stayed at home, or simply from a sick worker not taking any sick leave. This behavioural view of presenteeism has greater clinical currency than the more narrow economic definition, given the evidence that presenteeism is far from a benign concept in terms of health and functional outcomes.
Table 1. Definitions of presenteeism
Economic
- Reduced productivity at work due to health problems32
- Reduced productivity at work due to health problems or other events that distract one from full productivity (eg. office politics)33,34
Behavioural
- Attending work, as opposed to being absent35
- Working elevated hours, thus putting in ‘face time’ even when unfit36,37
- Being unhealthy but exhibiting no sickness absenteeism2
- Going to work despite feeling unhealthy14
- Going to work despite feeling unhealthy and experiencing other events that might normally compel absence (eg. child care problems)38
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Why does presenteeism matter?
Working when sick is a consequence of ill health but can itself be a risk for adverse health events. These include cardiovascular disease,2 poorer self rated health,3–5 and future sickness absence.4 Importantly, the economic cost of presenteeism exceeds that of absenteeism for many disorders.6 This is especially the case for depression, where lost productive time from presenteeism accounted for 80% of total lost productive time costs.7 Thus, presenteeism is not just an issue between a worker and their employer, but should be of concern in health settings in general, and primary care in particular, given the role of the general practitioner in managing work attendance via sick leave certificates.
How will presenteeism ‘present’ in general practice?
Any employed patient attending for management of a health condition, who does not request sick leave certification, is a potential candidate for presenteeism. Presenteeism is especially likely among patients who have not been taking time off work and are not seeking a sick leave certificate, but can also be apparent in people who have had a series of short term work absences, as presenteeism on either side of an absence is known to occur.
Who is at greater risk of presenteeism?
Presenteeism has been related to health, personal, work and occupational characteristics. In terms of health conditions, depression has been highlighted as having a greater association with presenteeism than other health conditions, possibly related to issues of recognition or willingness of the individual to disclose their condition to their employer for the purposes of taking planned sick leave.8 Presenteeism has been reported as more common among older workers, women,9 and those with conscientious personalities.10 Presenteeism propensity will also be influenced by how a person perceives their health, with sociocultural influences on illness perceptions playing a role.11 Work features that increase the likelihood of presenteeism include job insecurity, no access to paid sick leave, limited job opportunities and temporary employment.12,13
Physicians and healthcare professionals – a special case?
Occupations more at risk of presenteeism include those with strong attendance demands such as physicians, nurses, allied health professionals, and welfare and teaching occupations.14 This may arise from characteristics inherent in these job types, such as a greater sense of responsibility to their clients and patients.14 Responsibility to co-workers may also prompt presenteeism; a survey of UK doctors found more than 80% reported presenteeism with many citing their reluctance to burden their colleagues as the reason for continuing to work when ill.11 A sense of being irreplaceable,15,16 or subject to high workloads, numerous, immovable deadlines, and little to no backup support,17,18 are common among highly skilled healthcare professionals.17 Presenteeism among physicians, especially residents and GPs, has been highlighted as having special risks of adverse consequences for themselves, their colleagues, and their patients,19,20 with implications for workforce management.21
Working through illness – the pros and cons
Managing work attendance in the short term can be aided by a consideration of the possible positive and negative consequences of the decision: keep working while ill, or take some time off. A summary of these possible consequences for presenteeism versus absenteeism is presented in Table 2. Depression is a good example to illustrate these benefits and harms, given a majority of people with depression are able to keep working and thus at increased exposure to the consequences of presenteeism.22 In terms of cons, depression is associated with performance deficits across all types of job demands, may create tensions in jobs that rely on team work,23 and increases the risk of job loss.24 Psychosocial work stressors such as bullying, unfairness, or unreasonable demands with low control, are themselves risk factors for depression.25 A planned absence from an environment that may have contributed to poor health can be preferable to continued exposure to a stressor. As noted, an employee with depression may also be reluctant to disclose a mental health issue to their employer for the purposes of seeking time off work and, as such, may not see sick leave as an option. On the positive side, for many individuals with depression, work is a source of structure and routine and continued work attendance could be health promoting in and of itself.26 Continued attendance at work, even with some loss of productivity, is also likely to aid job retention. Related to this, a person’s capacity to consider and manage aspects of self care is a critical consideration. If an individual has flexibility in their job, and can make temporary adjustments to their workload or call on additional resources, a short term absence may be the preferred option. If, on the other hand, the individual does not have this flexibility, and will face increased work load and backlog upon their return, the incentive to continue working while ill may be stronger.
Table 2. Presenteeism versus absenteeism: the potential positive and negative consequences
| | Potential negative consequences | Potential positive consequences |
|---|
| Presenteeism |
- Lost productivity
- Reduced work team cohesion
- Accidents
- Job insecurity/turnover
- Worsening health
- Longer recovery time
|
- Income/keep job
- Some productivity
- Structured routine
- Social support
- Improved health
|
| Absenteeism |
- Lost productivity
- Loss of income
- Job insecurity/turnover
- Loss of social support
- Isolation
- Long term absence
|
- Time to seek treatment
- Shortened recovery time
- Improved health
- Retain job
- Removal from stressors
- Work team cohesion
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So how to balance these competing demands? Specific interventions around graded sickness absence offer promise. Graded or partial sickness absence is a flexible use of sick leave that allows partial work attendance while health problems are treated or modifications to the work environment are made. This occurs before a long term sickness absence and is designed to reduce the risk of moving from short-to-longer term sick leave.27 This flexible approach to attendance is embodied in the ‘fit note’ system from the United Kingdom for managing return to work from extended sick leave28–30 (Table 3). Such an approach acknowledges that meaningful work can be an important part of the rehabilitation process. Further, programs involving ‘work hardening’ recognise the importance of maintaining contact with work throughout the recovery process following a physical injury or illness.
Table 3. Description and benefits of the ‘fit notes’ used in the UK since April 201029,30
Fit notes:
- Are used by GPs to provide advice about an employee’s fitness for work
- Replace sick notes and focus on what someone can do rather than what they can’t
- Require and encourage communication between GPs, employers and employees
- Focus on a return to work where appropriate
A review of the use of fit notes revealed they have:30
- Changed how GPs, employers and employees think about work and health
- Improved GPs’ discussions with patients and the advice they provide
- Made GPs more likely to recommend a return to work
- Encouraged employers to support employees to return to work
- Helped employees challenge negative assumptions about their capacity when sick
- Encouraged employees to discuss staying in/returning to work with their employer
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When to work and when to take time off?
So what are the considerations for a GP when advising a worker on how to best manage illness while managing their work responsibilities? Clinical guidelines for decisions over the short term do not yet exist, but there are some simple questions based on evidence to date on predictors and consequences of presenteeism, that can be asked to help weigh up the positive and negative consequences. Ultimately, as noted by Bird,31 the management of sick leave is between an employee and their employer and the employer has the final say in whether they will accept a medical certificate for sickness absence. Nonetheless, the GP can play an important role in helping their patient think through the pros and cons of presenteeism. Some questions that could be helpful in these discussions can be found in Table 4.
Table 4. Questions for consideration when managing short term work attendance decisions
Patient’s health complaint and health status
- Does the patient have an infectious or non-infectious condition?
- What is their medical history and overall health status?
Extent of work capacity
- Is health currently impacting on work performance?
If so, how?
- Does the patient have a history of repeated sickness absences or long term sick leave?
Patient’s job and work environment
- What is the patient’s occupation and what type of work do they do?
- Do they currently have sick leave – paid or unpaid? Is their job temporary or insecure in any way?
- Is the patient currently in a position to be absent or does the nature of their work have strong attendance demands? Has the patient considered contingency plans to manage work load in their absence or while working at reduced capacity?
- What is the risk of injury or accidents arising from work performance problems such as poor concentration, difficulty making decisions, or reduced physical capacity?
- Does the patient consider that work is contributing to their ill health, for example through job stress? Does the patient consider that work is important for their broader wellbeing?
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Summary
Certain patients will be at risk of presenteeism, even when absence may be clinically advisable, due to the pressures of the job or the propensity of the individual. Continuing to work when unwell is especially prevalent among the helping professions, such as in healthcare settings. Presenteeism behaviour can have both positive and negative consequences for the patient’s own health, their job performance and tenure and their workplace, and these should be weighed up when helping patients to manage their work responsibilities. For many chronic diseases, the ‘hidden’ cost of presenteeism exceeds the visible costs of absenteeism. Presenteeism may need to be the subject of direct inquiry by the physician and suggested strategies for managing this phenomenon in day-to-day practice have been outlined.
Competing interests: None.
Provenance and peer review: Commissioned; peer reviewed.