Employees who come into work when feeling ill will not be able to perform to the best of their ability, which has a knock-on effect on productivity. What can occupational health do to help manage this situation? Jane Downey investigates.
Presenteeism is a term that has received regular coverage in the press but there is little specific advice on how to manage it. Research does, however, offer insights into the causes of the problem and recommendations about how it can be managed, which includes an important role for occupational health practitioners.
The Centre for Mental Health defines presenteeism as "reduced productivity when employees come to work and are not fully engaged or perform at lower levels as a result of ill health". It also calculates that presenteeism due to mental ill health now costs the UK economy £15.1 billion, compared with £8.4 billion for sickness absence.
According to Lowe (2002), presenteeism is characterised by two different employee behaviours. The first is when employees come to work sick or tired and are not as effective due to stress, depression, headaches or a chronic physical disorder. The second is the behaviour of employees who work excessively long hours as a result of over-commitment or job insecurity.
Research carried out by mental health charity Mind in 2009 showed that the recession had a negative effect on employees' mental health, with four men out of 10 feeling worried or in low mood, while middle-aged men were seven times more likely than women to have suicidal thoughts.
As men are less likely to seek help from their GP for such problems, it is likely that many will be attending work with untreated symptoms.
A Chartered Institute of Personnel and Development (CIPD) "Employee outlook" report in 2011 demonstrated that employees are not receiving adequate support from employers. Only 25% of the 2,000 employees surveyed stated that their organisations encouraged them to speak openly about their mental health problems and only four in 10 said that they would be confident to admit that they had a problem. The survey showed that most people with poor mental health continue to work, but may struggle with concentration, making decisions and providing effective customer service.
In addition, research carried out by Mind in 2011, regarding employee disclosure of mental health problems, showed that 22% of employees who admitted to having a mental health disorder regretted it, as they believed that this resulted in them being sacked or forced out of their job.
Business in the Community, a corporate responsibility group, in collaboration with the Centre for Mental Health, offers advice in the "Workwell" document on the causes and management of presenteeism due to mental health conditions.
This article looks at the findings and recommendations of research carried out on general chronic conditions and their relationship with presenteeism. However, when considering how to manage presenteeism, organisations should be aware that physical conditions often have a psychological overlay, as highlighted by Black (2008).
When considering how to manage presenteeism, organisations should be aware that physical conditions often have a psychological overlay."
The two issues discussed above, struggling to work when not well and fearing the outcome of disclosure, were echoed in research carried out by Munir et al (2007; 2008) on employees with chronic conditions. A quantitative study (Munir et al; 2007) aimed to assess the psychosocial factors associated both with psychological- and health-related stress for employees who had suffered from one of six chronic illnesses: musculoskeletal pain; arthritis and rheumatism; depression and anxiety; asthma; heart disease; and diabetes. The study involved more than 1,000 UK employees across three sectors: local government, transport and manufacturing.
The research demonstrated that low psychological wellbeing and high health-related distress are associated with high presenteeism, as well as poorer management of illness symptoms at work and low workplace support. Additionally, health-related distress is associated with disclosure of illness and long-term sickness absence.
Both frequent short spells and longer periods of presenteeism result from employees with chronic illness being unable to take time off when necessary to manage their condition, according to the research. In some cases, it could be due to difficulties in covering absence, but more often it is due to strict attendance management policies based on the "trigger points system" used in all of the organisations surveyed.
Trigger points systems, where management action is triggered when a certain level of absence has been reached, penalise employees for raised incidences of short-term absence.
Further research by Munir et al (2008) investigated how stakeholders within organisations in both public and private sectors viewed the effectiveness of their attendance management policies on chronically ill employees. Seventeen types of chronic illnesses in the "International Classification of Diseases" were covered. A mixed-method approach was employed using two studies.
First, a survey compared the levels of absenteeism and presenteeism reported by employees with and without a chronic illness. It was predicted that absence and presenteeism would be higher among those with a chronic illness.
Second, interviews were carried out with key stakeholders such as line managers, HR, occupational health, health and safety, and trade union officials. The aim was to explore their perception of chronic illness and how it is managed within the organisation, together with their views on presenteeism, sickness absence and the factors that, they perceived, hindered or facilitated effective absence management.
The findings indicated that employees with chronic illnesses were found to have significantly higher certified and non-certified absence and also significantly higher presenteeism. Managers were not aware of the prevalence of chronic illness or its impact on productivity although, on average, 15% to 20% of working-age adults will have a chronic illness and, of those, 5% will be work related.
Regarding the efficacy of the attendance policy, those interviewed felt that it was useful to have employees with minor ailments to be at work while monitoring them. However, they also believed that the attendance of those with chronic illness could exacerbate symptoms because they were attending work in order to avoid disciplinary action due to a trigger points system. This could result in long-term absence. Ironically, once they were on long-term absence, a rehabilitation plan would be set up to support return to work. The problem was compounded by the fact that only 50% of employees with chronic conditions had disclosed their illness due to fear of stigma, loss of employment or due to distrust in their manager.
The research recommends that organisations devise flexible attendance management policies that do not penalise employees for taking occasional short-term absence in order to manage their condition. This would prevent a deterioration leading to long-term absence. Employers should emphasise job retention rather than purely preventing absence of any sort. The researchers advised managers to work closely with OH advisers, who can provide disability management advice and give early support. This requires the employee's disclosure and consent, putting the onus on managers to allay fears of employees.
Research shows that much can be done to reduce levels of presenteeism and manage the wellbeing of employees with chronic illness."
This theme of lack of trust between employer and employee was echoed in a qualitative study (Wynne-Jones et al, 2011) involving a group of 18 employees with musculoskeletal pain and 20 managers in two large public sector organisations in South Wales. The study investigated the beliefs and attitudes of managers and employees with musculoskeletal pain regarding presenteeism, sickness absence and return to work. The aim was to identify areas of conflict and agreement. Both employees and managers believed that there was a strong culture of presenteeism in both organisations but they disagreed on how to manage this.
Employees felt that contact from managers when absence was legitimate was intrusive. And, while managers gave support to those they perceived to be genuinely ill, they believed that a number of individuals were "working the system" and not reporting absences appropriately.
The study concluded that it was important to provide a culture that respected the rights and responsibilities of both employers and employees, and that devises and implements strategies for improving communication, trust and cooperation.
Working toward wellbeing
The principle of developing a working culture that enables employees to experience optimum wellbeing at work is a major theme in influential reports such as Dame Carol Black's "Working for a healthier tomorrow" (2008). This was built on the research of Waddell and Burton (2006), which asked "Is work good for you?" and led to National Institute for Health and Clinical Excellence (NICE) guidelines on promoting mental wellbeing at work and managing long-term sickness absence and incapacity for work.
Juniper (2011) states that organisations often confuse wellbeing with health promotion activities and may be disappointed when their investment, for example in healthy eating or gym membership, does not yield the results in increased productivity and reduced sickness absence that they had anticipated. Juniper (2011) also argues that organisations need to define what they mean by "wellbeing". Waddell and Burton considered it a subjective state that is influenced by the social, physical, emotional and developmental influences around a person.
Juniper (2011) also states that employees' perceptions of how the working environment and practices affect them should be considered before changes are made. She discusses the case of an NHS trust that found nurse absence levels were not influenced by health promotional activities and investigated the underlying causes, finding that they related to certain working patterns and practices. This emphasises the importance of assessing employees' perceptions of what negatively and positively influences wellbeing and then assessing what changes can be made. It needs a systematic process that requires analysis and planning and may possibly require the input from areas other than OH and HR, such as facilities or IT, which conventionally may not be associated with employee health and wellbeing.
There are advantages for organisations in assisting employees with problems caused by issues outside the workplace. Frone (2000) states that personal factors can cross over into the work domain and increase presenteeism and sickness absence. Employee assistance programmes can be beneficial as they provide access for employees to confidential counselling for work and non-work-related matters, including advice on financial and legal matters, which are common causes of non-work-related stress.
Role of occupational health
Research shows that much can be done to reduce levels of presenteeism and manage the wellbeing of employees with chronic illness, and that increased attendance does not necessarily equate with increased productivity. Organisations often manage this poorly because managers are unaware of the extent of the problem and have neither the knowledge nor expertise to manage it effectively. This is an opportunity for OH practitioners to raise their profile and offer advice, as well as educate and, where appropriate, train managers on how to implement most of the major research recommendations discussed in this report.
It is up to each organisation to decide how they can best utilise this advice, which may often require creative thinking and collaborative working, with OH input a key component of success."
OH can advise managers on adjustments for employees and ensure that they receive the necessary support as early as possible. OH can advise HR and managers on appropriate attendance/absence management policies and ensure they are in line with the overall wellbeing strategy.
OH practitioners can also train managers to handle initial conversations with employees who they feel may be struggling with a condition, or to manage a return-to-work interview. Following a systematic analysis, OH can work collaboratively with other areas within the organisation, such as facilities or IT, to address underlying causes.
Employees play a crucial role in this process, not only because it is vital to gain their perception of the problem, but also because effective self-management is a key ingredient of success. However, for this to work, employees must disclose their conditions either to OH or managers. Organisations must "provide a culture that respects the rights and responsibilities of both employees and employers and implements strategies for improving communication, trust and cooperation". (Wynne-Jones, 2011), One way to achieve this is to ensure that "wellbeing" and "diversity" policies are enshrined in the business ethos and not dry, lifeless tomes gathering dust on a shelf.
Research is invaluable for best practice as it not only highlights weaknesses but can also recommend possible solutions. It is up to each organisation to decide how they can best utilise this advice, which may often require creative thinking and collaborative working, with OH input a key component of success. Occupational health practitioners should embrace these opportunities and make a real difference in the way envisaged by Dame Carol Black (2008).
Jane Downey MSc (Org Psychiatry and Psychology), RGN, SCPHN (OH) is a wellbeing and occupational health consultant at Wellbeingworks4business.
Black C (2008). "Working for a healthier tomorrow". A review of the health of Britain's working-age population. London: the Stationery Office.
CIPD Employee Outlook December 2009.
Cooper C, Drewe D (2008). "Well-being - absenteeism, presenteeism, costs and challenges". Occupational Medicine 58; pp.522-524.
Frone MR (2000). "Work-family conflict and employee psychiatric disorders: the national co-morbidity survey". Journal of Applied Psychiatry 85(6): pp.888-895.
Juniper B (2011). "Defining employee wellbeing" and "Making the most of it" Occupational Health. (Oct and Nov).
Lowe G (2002). "Here in body, absent in productivity: presenteeism hurts output, quality of work-life and employee health". Canadian HR Reporter, December.
Mind and YouGov (2009). "Men and mental health - get it off your chest".
Munir F, Yarker J, Haslam C, Long H, Leka S, Griffiths A, Cox C (2007). "Work factors related to psychological and health related distress among employees with chronic illnesses". Journal of Occupational Rehabilitation 17: pp.259-277.
Munir F, Yarker J, Haslam C (2008). "Sickness absence management: encouraging attendance or 'risk-taking' presenteeism in employees with chronic illness?" Disability and Rehabilitation 30(19): pp.1,461-1,472.
National Institute of Clinical Excellence (2009). "Promoting mental wellbeing at work". Clinical practice guideline. London: Department of Health.
National Institute of Clinical Excellence (2009). "Managing long-term sickness absence and incapacity for work". Clinical practice guideline. London: Department of Health.
Waddell G, Burton AK (2006). "Is work good for your health and wellbeing?" Department for Work and Pensions.
Wynne-Jones G, Buck R, Porteous C (2011). "What happens to work if you are unwell? Beliefs and attitudes of managers and employees with musculoskeletal pain in a public sector setting". Journal of Occupational Rehabilitation 21(1): pp.31-42.