by Maria Karanika-Murray, Department of Psychology, Nottingham Trent University

The NTU Psychology blog team are delighted to present this article, from NTU’s Dr. Maria Karanika-Murray, based on The Human Relations Paper of the Year Award-winning paper by Maria and Dr. Caroline Biron (Université Laval). Their award-winning paper tackles the issue of presenteeism (working when we might otherwise be considered too ill to work), which has previously been considered in a relatively simplistic way and this new framework proposes a more nuanced view.

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It’s never nice to feel so unwell that you have to phone in sick from work, and workplace sickness absence can be costly for businesses too. But what about those times you worked even though you didn’t feel well enough? Presenteeism is highly prevalent worldwide in all sectors and groups of the workforce, and extremely costly to individuals and organisations in health, productivity, and financial terms.  Indeed, because it often goes unreported, presenteeism is even more costly than sickness absenteeism. It does not allow individuals to recover and has been linked to longer-term cardiovascular problems and sickness absence even two years later. Unsurprisingly, then, presenteeism has substantial negative effects on a range of outcomes in our working life, mental health, and productivity.

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But other than having a long list of possible determinants and a long list of possible outcomes, we know very little about why and when presenteeism happens or the resources we may need to manage it. The behaviour itself does not give away much that can be of use. If anything, there is new and conflicting research evidence that presenteeism can actually have positive effects in terms of, for example, helping individuals to attend to work demands temporarily or to show collegiality by working even when one is unwell. So, despite the substantial costs and implications of this behaviour, our understanding is atheoretical and impractical.

Therefore, with this conceptual paper, Caroline Biron (Université Laval) and I set out to challenge and question what we know about presenteeism. We aimed to inject a needed understanding of the psychological forces that can explain this behaviour. We set out our starting points and ended up with a potentially useful theoretical framework. Our health-performance framework of presenteeism was published in Human Relations and received the 2020 Paper of the Year.

The principles we set for questioning what we know were: first, all behaviour is teleological; in other words, it has a purpose, serves a function. Presenteeism serves a function for the presentee, however well or ill-defined that may be at the time. Presentees weigh their options and decide on a course of action (or not). In the short term, attending work when sick may help to manage a high workload or support a colleague, especially when a particular set of skills is irreplaceable or work targets are non-negotiable. However, the long-term consequences are often overlooked, but it is these long-term impacts that may not help the individual to recover, leading to future sickness absenteeism and burnout, reduced well-being and productivity.

Second, the functions of presenteeism behaviour are implied in its definition: working whilst sick. It is about engaging in work or attending to work tasks under compromised health. It is about attempting to balance health and performance demands. In other words, we defined presenteeism as “goal-directed and purposeful attendance behaviour aimed at facilitating adaptation to work in the face of compromised health”. Ill-health and work do not necessarily preclude each other. But attending to conflicting demands can be tricky. And it is achieving a balance between performance demands against the limitations imposed by the health condition (which will be different for different individuals) is the what is adaptive and therefore useful about presenteeism behaviour. Presenteeism helps us to adapt to conflicting health and work demands.

Third, in addition to overlooking its adaptive potential, labelling presenteeism or any behaviour as inherently positive or inherently negative risks grouping all presentees into one homogeneous group, which completely ignores individual differences and their health or work circumstances.  People vary in their drives, needs, and of course behaviours, and in the circumstances that give rise to different behaviours in different situations. So a more person-centred approach that seeks to understand individual behaviour in its context is more appropriate, accurate, and practical. Furthermore, it allows us to identify the resources that can help to achieve a balance between any given health and performance demands.

We then placed health constraints and performance demands on two axes, which gave rise to four quadrants or health-performance configurations or types of presenteeism.

Figure 1. The Health-Performance Framework of Presenteeism

In our paper we describe dysfunctional presenteeism as “presenteeism behaviour that is harmful for health and performance” and is “an unsustainable choice with a high potential to lead to sickness absenteeism”. Work tasks are not adjusted to the limitations of the health condition with the result that both are impaired, possibly with a delayed effect. This group of presentees is more likely to experience a downward spiral of depleted resources, ill-health and performance declines.

Meanwhile, overachieving presenteeism implies that “the presentee is able to maintain a high level of performance, but at the expense of their recovery from ill-health”. Overcommitment to work when health limitations also limit performance can allow for little adjustment and respite for recovery, leading to burnout and cardiovascular issues. A re-tuning of one’s focus on health and resources to engage with work, if this is the choice, whilst not impairing health further, is important especially as some of the substantial health effects of overachieving presenteeism are delayed.  

Functional presenteeism is about “engaging with work and attending to performance demands during ill-health but without further taxing the presentee’s health”. It is about optimal adjustment to both health constraints and performance demands. Here, work is balanced so as not to impair heath.  A positive and supportive psychosocial working environment is essential to achieve this balance which is idiosyncratic to the individual.

Therapeutic presenteeism “implies a greater emphasis on health and a lesser focus on performance demands”. This taps into the beneficial, even therapeutic effects of work, the routine that it provides, and the social support aspect that can support recovery from ill-health, mental or physical. But it can lead to impaired performance, especially in the longer term as an accumulated effect. Better balance can be achieved if work tasks are adjusted to the health condition, for example more cognitive tasks if physical health is impaired, so that the therapeutic benefits of work can be effective and performance is protected.

The health-performance framework of presenteeism (via FSA ULaval channel)

We thus sketched four types of presenteeism defined in terms of the weight the presentee places on health or performance. The quadrants are not fixed so presentees may move from one type to another as they apply work resources, flexibly adjust these resource to their needs as their health condition or even work demands change. In practical terms, the aim is to identify high-risk presentees and the resources needed to move them towards functional presenteeism.

This framework has helped us to articulate some of the benefits of presenteeism, place some of the ‘conflicting’ research findings in context, and identify clear needs for future useable research. We hope to also temper some of the extremes in the media around sickness presenteeism by helping to explain why we work while sick, when it’s okay to do so, and how we can support presentees to maintain their health and their performance. Our current research builds on this work by focusing on the individual and work resources that can help to foster functional presenteeism (Social Science and Health Research Council of Canada, Lead: C. Biron, 2018-2021).

About the Author

Maria is part of the Centre for Public and Psychosocial Health and the Work, Wellbeing, and Performance Research Group at NTU. You can follow the @WorkPsychNTU on Twitter.