Editorial do Journal OCCUPATIONAL MEDICINE discute tema atual
Presenteeism—the case for action
The sickness absence rate in the UK is currently at the highest level since 2010, with an estimated 149.3 working days lost due to illness or injury [1]. Given the scale of the COVID-19 pandemic this increase is unsurprising, but presenteeism (i.e. working while sick) is also commonplace. A research report recently published by the Chartered Institute for Personnel and Development [2] found that, of the 804 organizations sampled, 65% had observed presenteeism among office-based employees and 81% among those working at home. In line with growing evidence for the damaging effects of presenteeism, the report indicates that more organizations are taking steps to discourage it. Of some concern, however, is the finding that nearly half (47%) of organizations who participated in the research are failing to take any action. Guidance to help occupational health practitioners work with organizations to reduce dysfunctional presenteeism during the COVID-19 pandemic was provided by Kinman and Grant [3,4], but the risk has clearly not abated.
Many factors influence sickness absence behaviours that include characteristics of the individual (e.g. a poor sick record and financial concerns), the organization (e.g. workload pressures, short staffing and lack of support) and the job itself (e.g. where people have a strong sense of duty and responsibility for the welfare of others) [3]. Although working while not fully recovered from illness can be therapeutic [5], presenteeism is increasingly acknowledged as a high-risk behaviour that may delay recovery from illness, increase future sickness absence, reduce productivity and increase the risk of errors, accidents and injuries to the employee, their co-workers and the public [3]. It is therefore crucial for organizations to monitor dysfunctional presenteeism in their organization, identify the causes and put interventions in place to support employees and discourage such behaviour.
While most organizations have systems in place to monitor sickness absence, managing presenteeism is more challenging. Supervisor evaluations of an employee’s health status and performance-related outcomes can be used, but self-evaluations of fitness for work are crucial [3]. Self-report measures of presenteeism are considered valid and have been found to predict subsequent health problems, future sickness absence and impaired job performance over time [3,5]. Questions on presenteeism (i.e. the number of days worked while sick over a particular time scale) can identify the prevalence across an organization and highlight any risks associated with demographics (e.g. age and ethnicity), the job (e.g. role and experience) and working patterns (e.g. working hours or location). Work-related stress, mental health disorders and chronic health conditions such as musculoskeletal problems are particularly common reasons for people engaging in presenteeism [3]. People often alternate sickness absence with sickness presenteeism to manage a long-term health condition, to accommodate crises of peaks in work demands or to avoid disciplinary sanctions associated with sickness absence policies [3,6]. Obtaining information on sickness absence behaviours at the employee level can help identify patterns and inform supportive interventions, but anonymity should not be compromised.
Incorporating questions on presenteeism into employee engagement surveys can also help organizations monitor sickness presenteeism over time. This method can also enable links to be made with relevant issues such as perceptions of the organizational culture and climate, any stigmatization of illness, access to support and any measured outcomes such as stress, mental health, job satisfaction and turnover intentions. The ability to identify the specific reasons why employees have worked while unwell is also helpful. People often return to work while not fully fit as part of a negotiated and supported rehabilitation process. Nonetheless, structural factors, such as competitive workplace cultures, organizations that lionize (or even reward) presenteeism, heavy workloads, tight deadlines and job insecurity, are commonly cited as reasons for presenteeism [7–9]. Individual orientations to work, such as over-commitment, feelings of irreplaceability, guilt or fear of letting people down and a sense of duty, are also frequently implicated [7–9]. Asking employees who have worked while sick why they did so can therefore help target organizational and individual-level interventions to encourage a ‘healthier’ approach to sickness absence.
Sick leave is costly for organizations and the disadvantages of people working while unwell may be overlooked, especially during times of financial pressure and uncertainty. Nonetheless, recognition of the costs of dysfunctional presenteeism should provide impetus for action. Organizations have a duty of care to protect the health and well-being of employees and there is also a clear moral, social and business case for doing so. Attempts have been made to calculate the monetary costs of presenteeism stemming from reduced work output and quality and an increased incidence of errors and injuries [9]. Several validated measures are available for organizations wishing to make a business case for intervention by estimating the productivity losses associated with working while sick. A single-item measure of the effects of sickness or injury on performance may be a useful additional to longer employee surveys [10], but the six-item Stanford Presenteeism Scale [11] is most commonly used to estimate the effects of an employees’ primary health condition on their productivity. The Work Limitations Questionnaire [12] may be particularly relevant for occupational health practitioners, as it identifies health-related impairments relating to four areas: the management of time, physical, mental-interpersonal and output demands.
The findings of the Chartered Institute of Personnel and Development survey [2] show that the most frequent steps taken by organizations to discourage presenteeism are managers asking people who are unwell to take time off, providing guidance for employees on expectations regarding sick leave, leaders role-modelling not working while ill and providing line managers with guidance in spotting the warning signs. The findings revealed that only just over 1 organization in 10 (11%) who are taking steps to reduce presenteeism consider this to be a priority and very few (9%) are considering introducing mechanisms to monitor it.
In light of the recent statistics highlighted above and the growing awareness of the risks of sickness presenteeism, proactive management is clearly needed. Most importantly, the real costs of working while sick should be realized and a business case built to address the issue. A careful review of sickness absence management policies and practices will help ensure that any new or existing initiatives to reduce absence do not inadvertently encourage presenteeism. Regular assessment of the prevalence and causes of presenteeism is required to target interventions and establish any trends among the workforce. To build commitment to action plans, employees should be consulted about their experiences of sickness presenteeism and involved in decisions about how it should be managed.
As work pressure is a common cause of presenteeism, monitoring workload and working hours will help ensure that employees are not overloaded and cover should be available for sickness absence. Presenteeism appears to be a growing problem among remote workers [3], but signs of sickness can be difficult to identify when communication is online. Occupational health has a role to play in helping develop guidance for line managers to ensure remote workers take time off when needed and do not return to work too soon. Regardless of their location, identifying and reducing barriers to accessing occupational health will also help support employees who have been off sick back to work and ensure reasonable adjustments are made and progress is monitored. Finally, it should be recognized
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