Last summer, the US Democratic Party presidential nominee left a 9/11 memorial service in New York City after feeling overcome by the day's heat. She subsequently shared that she had been diagnosed with pneumonia before attending the event. Online commentary varied, but some postings offered shared experiences of “going to work sick” and “powering through it.” There were many statements about the importance of the memorial event and how this significance influenced the candidate's decision to attend. Others theorized that gender-based comparisons of illness are often more harshly applied to women and that calling out “sick” from the event would likely have been viewed as a sign of frailty. Related conversations, postings, and media analyses were interesting and triggered curiosity about the phenomenon of going to work while sick. Certainly, many people might argue that going to work when ill is a high-frequency event that is often required, depending on the type of employment, position within the organization, and substitutability of the sick employee.
Sickness absenteeism and sickness presenteeism contribute to lost workplace productivity. It is common to discuss sickness and productivity in terms of lost revenue and other adverse economic outcomes. The economic burden of presenteeism can be greater than the expenses of absenteeism, and these costs are often the focus of related studies.1 Sick leave or sick callouts are typically viewed as negative events rather than as health-promoting occurrences. It is this vantage point that contributes to a negative view of sick absenteeism, despite arguably legitimate concerns about contagious illness in the workplace and risks of worsening of chronic illnesses with repeated occasions of sickness presenteeism rather than recuperation at home.
One study of particular interest examined a variety of likely factors related to sickness presenteeism, defined as electing to go to work despite recognizing personal illness.2 These influential conditions were connected to employment, personal circumstances, and attitudes toward sickness.2 The study was conducted in Denmark and included a large, random sample (N = 12 935) drawn from the Danish workforce, including men and women between the ages of 19 and 64 years. Data were collected by questionnaire, and the response rate was 68%. Findings revealed that sickness presentation and sickness absenteeism were equally prevalent. Of those respondents who did have episodes of sickness presentation (n = 8227) 73% had presented at work while sick 2 to 3 times, whereas many (n = 901) attended work more than 5 times while sick.2
The researchers hypothesized that sickness presenteeism was influenced by factors within 3 categories: work-related factors, personal circumstances, and attitudes.2(p957) Their intent was to develop an understanding of whether or not currently held beliefs about potential sickness presenteeism causative factors were valid and then to offer recommendations for future research. Work-related factors included job responsibilities and inadequate substitution/coverage options when an employee elected to take an absent day for illness.2 This concern is commonly reported by nurses and other providers when describing the work backlog that occurs when sick time is used. Anecdotally, many health care professionals share that finding coverage for patient care, appointments, weekend shifts, off-shifts, and other related responsibilities is an onerous task and often one that cannot be successfully addressed.
Work task control was included in the work-related factors category and described as the employees' discretionary influence over their work responsibilities.2 When employees are able to schedule their work tasks, it is easier to present to work when feeling ill because assignments can be shuffled and responsibilities can be deferred to allow for a lower level of productivity during periods of illness. This category also included team dynamics and colleague relationships. The premise was that when employees work in cooperative, mutually dependent work settings, they are more likely to come to work when feeling ill because there is support.
An alternative view informed by nurses' anecdotes is that there is considerable pressure to present to work despite sickness due to inadequate resources. In these instances, nurses and other health providers may feel that they are abandoning their shift colleagues and contributing to unsafe levels of staffing, particularly when illness strikes on days and shifts that are difficult to cover with overtime or schedule changes. A final characteristic included within the work task category was job security.2 The researchers postulated that when employees fear job loss or other retaliatory response, they are more likely to demonstrate sickness presenteeism.
The personal circumstances category included non–work-related influences, including whether or not paid sick time was available.2 The researchers asserted that some employees may find their home circumstances more stressful than their working conditions and thus prefer to attend work in a sickness state rather than staying in the home environment.2 A strong commitment to work or an inability to decline requests or say no was also included in this category. Attitudes included the decision-making influences and beliefs operationalized during the decision-making process of recognizing sickness and committing to either absenteeism or sickness presenteeism.
The study examined the dependent variable, sickness presenteeism, in relation to the independent variables, the aforementioned categories of possible predictors and health status. Ordered logistic regression models provided the statistical analyses.2 The strongest predictor of sickness presentation was pressure related to time.2 Variables connected to relationships with colleagues and employment conditions also influenced sickness presenteeism decisions. Work-related factors offered the greatest contribution to sickness presenteeism, but personal circumstance factors were close. Attitudinal factors had little effect on decisions to work while ill. Study findings were limited in several respects including the reliance on self-reporting. It is also possible that the findings are not generalizable to other cultures; however, it seems reasonable to consider that these results are likely applicable to similarly well-developed countries with technological and industrialized infrastructures.
Holistic care providers should consider the phenomenon of sickness presenteeism and offer guidance to clients, colleagues, and organizational leaders as to how to address this frequently occurring event. Discussion as to associated risks and practical strategies for illness risk mitigation are also valuable and may be useful, particularly when related to infectious illness as opposed to chronic illness. Both categories of sickness, chronic and acute, deserve attention when considering opportunities to reasonably address sickness presenteeism.
Chronic illnesses, including but not limited to diabetes, back pain, depression, anxiety, heart disease, and anxiety, are associated with both absenteeism and sickness presenteeism.3 Care providers have a role to play in providing input into attendance management policies with respect to balancing organizational needs for consistency, productivity, and expense management against individual health care needs and employee retention. Employees with chronic illnesses that affect work attendance are often in untenable circumstances, given scare replacement resources and time-sensitive job demands. These employees may or may not choose to disclose their illnesses, and it is unknown whether disclosure supports or jeopardizes employment.3
It is feasible that when employees feel pressure to present to work when ill, they are at greater risk for stress-related symptoms.3 It may also be the case that sickness presenteeism negatively affects the employee's potential to remain in the work position for the long term.3 These questions require further investigation but, at a minimum, should be explored with patients who are employed and are juggling the competing demands of employment and personal health promotion and protection. Providers may find it useful to recommend to employment professionals that they consider exploring the prevalence of chronic illnesses in the workplace and offer resources and policies specifically designed to assist employees in decision making related to sickness presenteeism and absenteeism. Recommending proactive discussions about chronic illness management, including responsible use of the Family and Medical Leave Act (FMLA) provisions, may be another useful intervention.4
Acute illnesses should be addressed via primary prevention interventions that reduce risk such as immunizations, good handwashing, and clean work environments. Encouraging influenza and pneumonia immunizations and emphasizing the importance of staying home from work when ill are important components of workplace illness prevention programs. Providers should consider the environmental context within which sickness presenteeism occurs. Professionals, including those who work in health care settings, need to consider whether sickness presenteeism places coworkers, colleagues, patients, and families at risk. Sickness presenteeism is particularly concerning when the affected environment includes particularly frail and vulnerable people, including seniors, infants, children, and others with compromised immune responses.
Holistic health care providers need to consider their role in illness presenteeism. They need to appropriately role model good health behaviors and avoid sickness presenteeism, particularly during acute illness events. Administrators of clinics, offices, and other health settings need to consider proactive and responsible systems to respond to inevitable and justifiable absenteeism. It may be that teams should explore whether or not the work culture promotes illness machismo that encourages inappropriate sickness presenteeism. Practitioners need to have candid, proactive conversations with colleagues and patients about the importance of attentive self-care and care of others demonstrated by staying home when acutely ill. Nurses and colleagues also need to work to make it safe to appropriately elect absenteeism so that those who do need to stay home can do so without guilt, fear, or worry.