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Exhaustion and Impaired Work Performance in the Workplace

Associations With Presenteeism and Absenteeism

Aboagye, Emmanuel PhD; Björklund, Christina PhD; Gustafsson, Klas PhD; Hagberg, Jan PhD; Aronsson, Gunnar PhD; Marklund, Staffan PhD; Leineweber, Constanze PhD; Bergström, Gunnar PhD

Author Information
Journal of Occupational and Environmental Medicine: November 2019 - Volume 61 - Issue 11 - p e438-e444
doi: 10.1097/JOM.0000000000001701
  • Open


Presenteeism means attending work while ill.1,2 Absenteeism—not attending work because of illness—is a phenomenon closely related to presenteeism and studies have often shown that there is a positive association between them.3,4 The literature on presenteeism and absenteeism describes several factors that determine the decision to go to work (presenteeism), or stay at home (absenteeism) in case of ill health. Work-related or organizational factors that trigger presenteeism may be high workloads and having to catch up with work if absent. Absenteeism may be chosen if there is no immediate pressure to deliver and that colleagues are not negatively affected by this decision.5–7 Personal factors increasing the prevalence of presenteeism could be a strong feeling of identity connected to the job fueled by thoughts of being irreplaceable.8

Particularly in the case of presenteeism, a number of more recent studies indicate that engaging in the behavior is prevalent globally.9 The phenomenon tends to be higher among managers than among crafts and trades workers and higher in the health and education sectors than in industry. In Germany, 57% of teachers engaged in presenteeism10; 56% of Norwegians and Swedes reported presenteeism in the past year11; 56% of UK academic employees reported often going to work ill.12 Although these are only a few examples, the numbers suggest occupational, sectoral, and national high prevalence rates of this behavior.

One aspect of attendance behavior that has been extensively researched is the consequences of presenteeism on self-rated health, physical health, and sickness absence.13 Although attending work can be seen as protective of workers’ health and well-being,14 a large number of studies seem to suggest deleterious health effects of presenteeism. Presenteeism has been associated with poor self-rated health8,15 and future ill health.16,17 There is some evidence that both presenteeism and absenteeism are associated with future physical health and complaints.18–20 It has also been shown that presenteeism led to elevated absenteeism in the future but not the reverse.16,18

A second area where research has concentrated is health outcomes related to psychological well-being, including poor mental health, depression, and exhaustion and attendance consequences of presenteeism. For example, presenteeism has been found to be associated with poor mental well-being.18,21 In a 2-year follow-up study, Conway et al showed that presenteeism was associated with an increased risk of depression, although respondents were not depressed at baseline.22 However, in Lu et al the negative consequences of presenteeism on mental health were no longer found after 3 months.20 According to Demerouti et al, presenteeism and exhaustion could be reciprocal, which suggests that presenteeism leads to exhaustion and vice versa.23 Lu et al24 and Dellve et al25 have concluded that presenteeism had led to exhaustion and burnout, respectively. Although working while ill seems to increase the risk of depression, there is mixed evidence concerning the association between presenteeism and absenteeism and exhaustion.

By far, productivity loss from limitation in work ability and work performance is one of the most studied consequences of presenteeism and absenteeism. Presenteeism may be viewed in a positive light by organizations because at least some productivity occurs. Low rates of sick leave could also suggest a healthy and productive organization.26 However, research shows that coming to work while ill can be detrimental to employees’ work performance.7 Gustafsson and Marklund18 and Dellve et al25 found that two or more days of presenteeism at baseline were a predictor of poor work ability at follow-up. Collins et al also found that presenteeism, but not absenteeism, has implications for work performance at follow-up.21 In turn, studies that have estimated the economic costs of such losses concluded that the negative economic consequences of presenteeism exceed those of absenteeism.27,28

In the present study, we examine the associations between presenteeism and absenteeism with exhaustion and work performance. The contribution of the study is partially to attempt to replicate earlier findings, but also to give a comprehensive picture of these constructs by analyzing their associations simultaneously. Furthermore, we also want to investigate how two different measurements of presenteeism are associated with each other, one general estimation of presenteeism during the previous year versus current presenteeism operationalized as decreased work performance due to poor health during the previous week.

Three research questions were formulated:

  1. What are the levels of exhaustion and impaired work performance in groups with differing frequencies of presenteeism and absenteeism?
  2. Is presenteeism or absenteeism during the previous year associated with current exhaustion?
  3. Is presenteeism or absenteeism during the previous year associated with current impaired work performance?


The study was conducted among employees at a Swedish university in the autumn of 2011. The aim of the survey was to assess and improve the work environment by assessing social and organizational work factors and their impact on the health and work performance of the employees. This was followed by work group discussions and tailored measures to improve the work environment. All staff who had been employed at the university on at least 50% of a full-time position and for a duration of at least 6 months at the time of the assessment were invited to participate (n = 5143). The majority (62%) were academic staff, that is, including researchers and teaching staff.


The invitation to participate in the study was sent out by email and was followed by two reminders for responses to the survey. Participation was voluntary and written informed consent was obtained from all respondents.

Dependent Variables

Exhaustion was measured with the Oldenburg Burnout Inventory.29 The following cutoff points were used: 0 to 17.59 for “no exhaustion,” 17.60 to 21.99 for “moderate exhaustion,” and 22 to 32 for “severe exhaustion”.30 The instrument has been translated into Swedish and their psychometric properties have shown predictive validity.31 The same cutoffs have been used previously.30

Impaired work performance due to ill health was measured by using the question: “During the past 7 days, how much did your health problems affect your performance while you were working?” The respondents were asked to rate how much their health problem affected their performance on a scale from 0 to 10, where 0 indicated “Health problems had no effect on my work” and 10 indicated “Health problems prevented me from working completely.” This instrument has been shown to be reliable and valid.32,33 Furthermore, a dichotomous variable was created as follows: 0 = no health problem in the previous 7 days or no impaired work performance due to health problems reported, and 1 = reporting impaired work performance (1 to 10) on the described item.

Independent Variables

Presenteeism and absenteeism were assessed by means of self-reported questions. Presenteeism was measured by the question: “Has it happened over the previous 12 months, that you have gone to work despite feeling that you really should have taken sick leave due to your state of health?” The respondents were asked to report the number of days of presenteeism. This question is a modification of Aronsson et al's1 measure of frequency of presenteeism in that “times” was replaced with “days” and an open-ended response format was used. Absenteeism was measured by the question: “How many days in the past 12 months have you been absent from work due to illness?” This question is an item of work ability index questionnaire.34,35 Responses to the two single questions on presenteeism and absenteeism were given in number of days. Before the analysis was carried out, sickness presenteeism and absenteeism were categorized into three levels: 1 = “0 days,” 2 = “1 to 7 days,” and 3 = “≥8 days” and used in the main analysis.


The background characteristics of individuals who participated in the 2011 survey were collated. Variables including age (in years), sex coded as (1) female and (2) male, and position (either academic or administrative staff) were also measured. Self-rated health was assessed with a question from the validated 12-Item Short Form Health Survey36,37: “In general, how do you describe your health?” The response options, ranging from 1 to 5, were 1 = “excellent,” 2 = “very good,” 3 = “good,” 4 = “fair,” and 5 = “poor.” The last two categories 4 = “fair” and 5 = “poor” were merged into 4 = “poor” because there were few individuals at this end.

Quantitative job demands and control of work pace were measured using indexes from the validated General Nordic (QPS Nordic) Questionnaire.38 These two scales each have four items and a five-point Likert scale with response categories ranging from “very seldom or never” to “very often or always” is used. An example of an item addressing quantitative job demands is “Do you have too much to do?” A corresponding example for control of work pace is “Can you set your own work pace?” The indexes range from 0 to 100, with higher scores indicating higher demands or control.


Descriptive statistics were used to show the averages, distribution, number of cases, and proportions in the background characteristics as well as for the independent variables exhaustion and work performance. Cross-tabulation was used to investigate the amount of impaired work performance and exhaustion in groups with differing prevalence of presenteeism and absenteeism.

Ordinal logistic regression (the PLUM procedure—Polytomous Universal Model) was used to examine the association between the ordered categories of exhaustion (ie, dependent variable) and presenteeism and absenteeism (ie, independent variables). Work-related characteristics such as job demands, job control, and individual-related characteristics such as sex, age, and self-rated health status were included in the model as confounders. Nagelkerke's R2 was used to estimate the variance in the outcome explained by the independent variables. It should be noted that Nagelkerke's R2 is not similar to R2 in a linear regression model and that R2 from logistic regressions is usually low compared with R2 values from linear regression models.39

A general linear model was used to examine impaired work performance in the previous 7 days based on the number of days of presenteeism and absenteeism (ie, independent variables) the employees reported during the previous 12 months. Interactions between the multiple categorical independent variables (ie, presenteeism and absenteeism) were also tested. Confounders used in the previous model were again included in this model. Crude risk ratios (RR) for reporting any current impaired work performance due to poor health among employees with different amounts of presenteeism and absenteeism during the previous year were also estimated using generalized linear model. All the analyses were performed with SPSS version 25.40 The word “risk” at times was used in a statistical sense and not as a causal explanation of the study results.

Ethics Approval

The study was granted approval by the Regional Ethics Review Board in Stockholm, Sweden (Dnr. 2018/5:2).


A total of 3525 employees responded to the 2011 survey. These included academic staff (n = 2026), with a response rate of 63% and administrative staff (n = 1499), with a response rate of 77%. The total number of participants could vary from one variable to another because of internal missing data. Table 1 shows the descriptive summary of background characteristics for the study sample. Just over 15% of all respondents reported 8 or more days of presenteeism during the previous year. Correspondingly, about 11% of all respondents reported 8 or more days of absenteeism during the previous year. The average for impaired work performance was just over 4 out of 10 (for those with reported health problems) and for exhaustion just below 18 out of 32.

Background Characteristics and Descriptive Summary of Study Sample (n = 3525)

Exhaustion and Impaired Work Performance in Groups With Differing Prevalence of Presenteeism and Absenteeism

Table 2 shows that the proportion of employees with a severe degree of exhaustion increased from 7% among employees with 0 days of presenteeism to almost 38% among employees with 8 days or more of presenteeism. The proportion of employees with no exhaustion was highest among those who reported no presenteeism at all. Concerning absenteeism, 15% reported severe exhaustion among employees with no sickness absence and more than 24% reported severe exhaustion among those with 8 or more days of sickness absence. Furthermore, employees with severe exhaustion reported the highest mean impaired work performance compared with those with no or a moderate degree of exhaustion. As can be seen from Table 2, the amount of impaired work performance became higher in groups with more presenteeism or absenteeism.

Exhaustion and Impaired Work Performance in Groups With Differing Prevalence of Presenteeism and Absenteeism

Association Between Current Exhaustion and Presenteeism and Absenteeism During the Previous Year

The crude and adjusted odds ratios in Table 3 show that presenteeism is significantly associated with exhaustion. In the adjusted model, employees with more than 8 days of presenteeism had 1.7 higher odds of increasing one level in the exhaustion categories than those with zero presenteeism. The association between absenteeism and exhaustion was not statistically significant. Other variables included in the model such as self-rated health, job demands and job control, and sex also showed statistically significant effects. For instance, job control was associated with reduced odds ratio of exhaustion. The ordinal regression model showed overall goodness-of-fit and the test of parallel line was nonsignificant. The Nagelkerke measure of coefficient of variation indicated that the model explains about 39% of the variation in the degree of exhaustion. As the study population comprised people with different professional roles (academic and administrative staff) and who also face different expectations and demands, we also checked for potential interaction between the multiple categorical independent variables (ie, presenteeism and absenteeism) in the results for researchers and the administrative staff. No interactions were found.

The Relationship Between Ordinal Categories of Exhaustion, Presenteeism, and Absenteeism (n = 3525)

Association Between Current Impaired Work Performance and Presenteeism and Absenteeism During the Previous Year

We first calculated crude risk ratios (RRs) for reporting any current impaired work performance due to poor health among employees with different amounts of presenteeism and absenteeism during the previous year. The RR of reporting impaired work performance was 3.74 (95% confidence interval [CI], 3.17 to 4.42) times higher among those with more than 8 days of presenteeism and 2.30 (95% CI, 1.97 to 2.70) times higher among those with one to seven days of presenteeism compared with those with no presenteeism. The corresponding risk ratios for absenteeism were 2.08 (95% CI, 1.81 to 2.39) for those with more than 8 days of absenteeism and 1.46 (95% CI, 1.30 to 1.64) for 1 to 7 days of absenteeism compared with no absenteeism. Severe exhaustion increased the risk of reporting impaired work performance 4.16 times (95% CI, 3.61 to 4.78) and moderate exhaustion 2.37 times (95% CI, 2.05 to 2.75) compared with no exhaustion.

Table 4 shows that presenteeism and absenteeism during the previous year are associated with current work performance. Workers with more than 8 days of presenteeism scored on average 0.82 points higher on impaired work performance than workers with no presenteeism during the previous year when other variables were controlled for. The corresponding estimate for workers with more than 8 days of absenteeism was 0.95 higher when compared with no absenteeism during the previous year. As one might expect, poor health was associated with a higher degree of impaired work performance.

The Association Between Impaired Work Performance and Presenteeism and Absenteeism (n = 1172)


The aim of the present study was to investigate the associations between presenteeism and absenteeism during the previous year with current levels of exhaustion and impaired work performance. Our results showed that the highest proportion of employees with a severe degree of exhaustion was found among those with 8 or more days of presenteeism or absenteeism during the previous year. The results showed that a higher amount of presenteeism, but not absenteeism, during the previous year independently increased the risk of having moderate or severe exhaustion. Presenteeism, absenteeism, and exhaustion were positively associated with impaired work performance even when health status and other confounders were adjusted for. Compared with those with no or a moderate degree of exhaustion, employees with severe exhaustion reported the highest mean impaired work performance.

Presenteeism remained independently associated with exhaustion whereas this result did not hold for absenteeism when health status and work-related and background factors were adjusted for. This may indicate that presenteeism may lead to exhaustion even though the design of this study precludes any far-reaching conclusions. Concerning absenteeism, research findings from other studies are not conclusive, in that short spells of sick leave may provide an opportunity for recuperation,8,23 whereas long-term sick leave seems to have negative effects on health.41

Increased frequencies of presenteeism and absenteeism during the previous year were positively associated with impaired work performance. This association remained even when health and other confounders were adjusted for. It should be noted that the health reasons for reporting impaired work performance included all sorts of conditions which cause poor health. Therefore, the existence of other health problems which are not captured by general health or exhaustion may partially explain the results. Notwithstanding this, even modest amounts of presenteeism and absenteeism were related to impaired work performance and the estimates were approximately of the same magnitude. Our finding was in line with previous research that concluded that impaired work performance is an attendance consequence of presenteeism.7,18

Absenteeism could theoretically have a positive effect on work performance; it offers an opportunity to recover, especially for shorter spells of sick leave and maybe in combination with work adjustments. However, the results from this study do not support this assumption because even a small amount of sick leave independently was associated with an increase in impaired work performance. This finding is in line with other studies that suggest that absenteeism could have negative consequences for individual work performance.21 Presenteeism may have direct consequences for employee work performance. This has led to presenteeism being regarded as being at work but underperforming (therefore leading to productivity losses).42,43 In this study, presenteeism and absenteeism were associated with similar negative effects on work performance.

Concerning the confounders used in model, our findings show that impaired work performance decreased with older age. The estimates were small but statistically significant. This might be explained by the type of work done by the older group of academic or administrative staff or their length of experience. It might also be attributed to the “healthy worker effect,” which implies that the group of academic or administrative staff experiencing health problems and reduced work performance had already left the university.

The subjects of the study were academic and administrative staff in a university setting. More recent large-scale studies indicate that presenteeism is a common work behavior across occupations.9 It is thus likely that this association between exhaustion and presenteeism exists even in other work contexts, and in other occupations. As mental health problems at work, including exhaustion, are common today, these health problems reasonably could lead to both presenteeism and absenteeism. For instance, longitudinal associations were found between presenteeism and burnout among staff nurses.23

In line with earlier research, job control reduced the risk of exhaustion among workers,44,45 whereas job demands increased the risk of exhaustion. The pressure to go to work because of job demands may partially explain the propensity to choose presenteeism before absenteeism.23,46 This may start a reciprocal relation where presenteeism causes exhaustion and exhaustion reduces work performance, which, in turn, encourages more presenteeism to compensate for the impaired work ability, which then causes further exhaustion.23

There are some methodological considerations to discuss. Firstly, presenteeism and absenteeism were measured retrospectively (previous year), whereas impaired work performance was measured with a recall period of 1 week (the week before the survey) and exhaustion referred to the current situation. This prevents us from drawing causal inferences from the results. It is also possible that, for instance, high levels of exhaustion when responding to the survey could have made the respondent more prone to overestimate their presenteeism or absenteeism during the previous year. A second methodological consideration is that work performance levels under certain health condition could differ from person to person, depending both on the individual and the work environment. It is therefore important to note that the performance measurement applied in the present study mirrors within-subject changes. This, for example, means that a high-performing worker who loses productivity because of illness might still be one of the best among peers in terms of global performance.47 Also, as performance is self-rated, it may be influenced by the person's ambitions and personality. One could also argue that work performance impairment may be due to reasons such as work–life imbalance, which have not been covered in this study.


This study sheds light on the phenomena of presenteeism and absenteeism and their associations with exhaustion and impaired work performance. The results indicate that presenteeism to a greater extent than sickness absenteeism was associated with exhaustion. Correlates of impaired work performance were presenteeism and absenteeism during the previous year and exhaustion. From the employer's perspective, the findings that employee health and work performance impairment are related to attendance behavior are important. The results suggest that it is a necessary step to identify beneficial interventions as well as adequate management strategies. In the literature, there is still a lack of knowledge on how to intervene with regard to presenteeism. Interventions that have been suggested to manage presenteeism are (1) physically oriented; (2) psychologically oriented; and (3) organization-oriented interventions. These interventions aimed at reducing presenteeism or productivity loss attributable to presenteeism have come from the health-related, environmental, or occupational medicine literature.48–51 Interventions such as managing stress of employees and work adjustments or support from supervisors and coworkers have been recommended.51


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absenteeism; exhaustion; presenteeism; productivity loss; psychological well-being; work performance

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