Presenteeism among health care workers: literature review

| Presenteeism is an occupational and psychosocial phenomenon with negative impact on the work environment. In addition to causing losses in productivity losses, it also has implications for the state of health of workers. Therefore, presenteeism is likely to become a serious public health problem. The aim of the present study was to discuss the implications, means for evaluation and impact of presenteeism on the health and work of health care workers. We performed a literature search in database PubMed using keywords presenteeism, absenteeism, nurse presenteeism, physician presenteeism, sickness presenteeism, organization, and working sick. We conclude that adequate assessment, raising the health managers’ awareness about the risks and harms associated with this phenomenon, and developing management tools will contribute to reduce the impact of presenteeism. This seems to be the proper path to make this problem more visible and hinder its growth.


INTRODUCTION
Presenteeism is the term used to designate the situation in which people go to work when in poor physical or mental health conditions. This phenomenon often has negative consequences in terms of productivity, rate of work accidents and the state of health of workers 1-3 . Presenteeism and absenteeism-i.e. absence from work for several reasons-have a close mutual relationship. Both encompass disease conditions with variable personal, biological, environmental, family, financial or functional causes 4,5 . Available evidence indicates that presenteeism increases medical costs, reduces productivity, elevates the rate of work accidents and causes financial losses to organizations. In some countries it represents the main occupational health concern 6,7 .
While studies on this-hard to detect and manageproblem are still scarce, interest is increasing among public and private organizations 8 . The aim of the present study was to analyze presenteeism among health care workers, physicians and nurses in particular, and its implications for the health of this population of workers. We further sought to analyze and emphasize the relevance of validated methods to investigate presenteeism.

METHODS
This is a narrative review by searching for articles in the PubMed database. The review was conducted through the following steps: Searching for articles in the databases and specialized journals, defining inclusion and exclusion criteria, collecting information to be identified in the articles, analyzing and interpreting the selected studies.
The descriptors used were generated from the list of Health Science Descriptors: using keywords such as: presenteeism, absenteeism, nurse presenteeism, physician presenteeism, sickness presenteeism, physician health organizationtion and working sick.
Articles that addressed presenteeism and absenteeism with a broader focus on health professionals were included. Incomplete articles that presented only the summary available for consultation and that did not address absenteeism and presenteeism in health professionals were excluded.

PRESENTEEISM AND ITS CONSEQUENCES
Studies on presenteeism are usually conducted from two main perspectives, one that focuses on its economic consequences for workers assessed by means of measures of productivity loss due to chronic health problems, such as alcoholism, arthritis, allergies, migraine, depression and anxiety. The second perspective emphasizes the effects of going to work when ill on the health of workers 8 .
Workers may choose to work beyond the established hours to make their presence felt or to show commitment to their employer. Reasons to go to work when sick include: avoiding work overload to coworkers or accumulated work, financial issues, not being seen as lazy or unproductive, concerns with dismissal or retaliation, love of one's job, belief that work is healthy, substituting absent coworkers, and being seen as strong and committed, among others 9 .
The European Working Conditions Survey found that 40% of respondents (40,000 people in 34 countries) had worked while they were sick at least one day in the previous 12 months. While in the United Kingdom the overall rate of sickness absence is declining since 2003, this does not mean that the population is becoming healthier, but may indicate that the number of people unable to work due to advanced disease is growing 10 .
Presenteeism might be associated to job burnout, which is characterized by emotional exhaustion, depersonalization and low personal accomplishment and may manifest as low job satisfaction, impaired mental health and poorer quality of care delivery. Workers often manifest symptoms of burnout derived from inadequate recovery from sickness, resulting in vicious circle: the job demands continually grow while workers have less and less energy to cope with such increasing demands, which leads to presenteeism and to the perpetuation of this circle [11][12][13][14] .
Presenteeism is a more complex phenomenon by comparison to absenteeism and may cause direct and indirect financial losses higher than those associated with the latter for conditions such as depression, with up to 80% productivity loss 5,[14][15][16][17][18][19] . A study performed in the United States in 2004 analyzed the ten health problems most frequently related to presenteeism and the corresponding costs. The results indicated that presenteeism was associated with higher medical costs than absenteeism, corresponding to 18 to 60% of such expenses 7 . When delaying medical care for minor health problems, disease might become more complex, leading workers to engage in an alternation of periods of presenteeism and absenteeism. Such behavior increases the rate of presenteeism and consequently also that of absenteeism 10,17 .
The physical and mental health status of workers who go to work when sick is a reason of much concern, since according to the model formulated by O'Donnell, health, productivity and profit are intertwined. As a result, performance improves when workers are physically and emotionally fit 4 , while the opposite condition does not only lead to quantitative losses, but also to poorer quality of services, error and neglect 1 .
Therefore, an accurate understanding of the clinical significance of presenteeism and how it manifests in everyday work routine is essential, since it enables detection and early interventions to hinder its progression over time 5 .

PRESENTEEISM AMONG HEALTH CARE WORKERS
Presenteeism is more likely to occur among workers in jobs with high demands and requiring considerable commitment, as is the case of physicians, nurses, other health care providers and teachers 5 .
The number of available studies on presenteeism among health care workers is scarce and most analyzed nurses only 20 . Having to provide health care under poor physical and psychological conditions may interfere with attention and concentration, with the consequent risk to patients and impairment of the quality of care delivery, as was found in several countries 2,20 . Under such circumstances, reports of problems as e.g. sleep and mental disorders, loss of self-esteem, illness and contradictory feelings are frequent 20 .
As concerns physicians, the prevalence of presenteeism is higher among the older ones, those with high levels of commitment and females 16,21 . Such gender difference derives from the fact that women adduce as reasons "a concern with other people" and "workload", while men "ability" and "money 21 . " Attitudes adopted by health care workers might influence the rates of transmission of diseases to both patients and coworkers. In a study with health care workers who go to work when exhibiting symptoms of acute respiratory illness, 16% of the participants admitted to go to work with fever, 56% with acute respiratory symptoms and 95% even when aware they were putting their patients' health at risk 22 .
In a study performed with a convenience sample of 150 medical residents enrolled in 20 internal medicine residency programs in the United States, 51% of the participants reported to have had gone to work while with flu-like symptoms at least once in the previous year 23 . The authors of another study assessed health care workers with respiratory symptoms using fever as criterion to ban or not contact with patients and subjected workers to mandatory testing for influenza and other respiratory pathogens. Of 449 participants with respiratory symptoms, 41 (9.1%) tested positive for influenza, of whom only 21 had fever, i.e. nearly half of the workers with influenza was afebrile 24 . Under such circumstances, health care workers may contribute to the transmission of influenza at hospitals, namely, a condition with high morbidity and mortality among both patients and health care providers every year 2,25,26 .

INSTRUMENTS TO MEASURE PRESENTEEISM
The number of studies which describe instruments to analyze loss of productivity due to presenteeism or absenteeism is growing 20,27 . Using reliable validated instruments represents a significant step forward in the study of this problem, as well as to develop interventions 18,28,29 .
Forty studies analyzed the quality of 21 instruments to measure presenteeism. The results indicate that only three exhibit strong levels of evidence, to wit, the Endicott Work Productivity Scale (EWPS), the Health and Work Questionnaire (HWQ) and the Stanford Presenteeism Scale (SPS-6) 4,30,31 .
EWPS is a short self-reported questionnaire that affords a high sensitivity measure of productivity. The global score is calculated based on the frequency of behaviors, subjective feelings and attitudes at work along the previous week. The global score was considered to be reliable and valid for a group of outpatients with depression and a sample from the general population. It is easy to administer, short and has adequate sensitivity to assess impacts on performance at work 32 .
HWQ is a 30-item questionnaire that analyzes performance at work in the previous week based on the respondents, supervisors and coworkers' assessment. The instrument comprises six subscales (productivity, concentration/focus, supervisor relationships, non-work satisfaction, work satisfaction and impatience/irritability) and three single items (stress, job control and ability to finish work on time). Lower scores indicate better productivity 33 .
SPS-6 is widely used to investigate characteristics of presenteeism and was validated for use in Portugal and Brazil. The focus of this instrument is on the relationship between presenteeism, productivity and health problems [30][31][32][33][34] . While it exhibits strong internal consistency and structural validity, hypothesis testing and criterion validity are just moderate 34 . This scale comprises 6 items responded on a Likert scale with scores ranging from 1 (strongly disagree) to 5 (strongly agree); the global score ranges from 6 to 30 8,29,34,35 . A self-report questionnaire, respondents are requested to describe their degree of agreement with statements relative to the impact of health on work. The scale measures the ability of respondents to concentrate and perform their tasks when when sick, i.e. finishing work and avoiding distractions. SPS-6 seems to be the most widely used instrument for being easy to administer and efficacious 34 .
The aforementioned questionnaires are easy to administer. For enabling early diagnosis, they foster actions to minimize the adverse effects of presenteeism. Assessment of this phenomenon should not be restricted to estimations of frequency, but must also include its underlying reasons 36 so that strategies to reduce incidence may be fomulated 9 . Several approaches might be adopted in this regard, and that of therapeutic groups has already evidenced efficacy. The authors of a study analyzed 234 medical residents and 813 specialists to investigate the relationship between health, work and suicidal ideation; the therapeutic group approach was associated with reduction of suicidal ideation 22 .

DISCUSSION
Presenteeism is a multidimensional phenomenon with high prevalence among health care workers. Yet, it is difficult to detect, perhaps due to lack of information, even though it impairs performance and possibly leads to distraction and serious errors.
The effects of presenteeism on future health are unknown although it is understood as a cause of potential risk to health 37 . As per the notion of quality of life formulated by the World Health Organization-which associates it to the individuals' perceptions within their culture and values system-presenteeism might be influenced by how each worker rate their own health, which in turn is strongly conditioned by sociocultural factors 5,14 . Aspects such as competitiveness and the idea that health care workers never fall ill were described as contributing to the perpetuation of the neglect of their own health.
Just as success, also error is the result of a chainof events, and any factor that interferes with this chain will also influence the outcomes 2 .

CONCLUSION
This study has concluded that presenteeism and absenteeism are the result of multimorbidities and managers should be made aware of the working risks that stem from these phenomena to propose tools to manage these conditions, minimizing the costs and thus avoiding a public health problem in the future.
Additional studies are needed to understand and assess this phenomenon better and to formulate the earliest possible interventions to thus reduce its impact on health care workers, and consequently also on patients.