Sick and tired at work

Presenteeism: sick and tired at work

Donna J. Middaugh

“Wow! You look like death warmed over! What are you doing at work?” “Why didn’t you call in sick?” “Hey, didn’t you work last night?” “What are you doing here today?” We frequently ask these questions of co-workers and receive answers such as, “I have to save my sick time for when my child or my elderly parent is ill,” or “We were really short, so I needed to work.” Statements such as these are made each and every day on nursing units throughout the country. While we might hear similar comments in the corporate world, they don’t have the same significance as knowing that the sick or tired nurse is in charge of patient lives.

These declarations are examples of presenteeism. The concept of presenteeism has been identified for decades, but it is relatively new in the health and productivity literature. Presenteeism is the opposite of absenteeism. It isn’t an ideology or doctrine. It is simply the practice of coming to work when an individual should not, which results in being physically present at work but functionally absent. Presenteeism may be defined as, “The feeling that one must show up for work even if one is too sick, stressed, or distracted to be productive; the feeling that one needs to work extra hours even if one has no extra work to do” (, 1995).

Lowe (2004) equated presenteeism to two different employee behaviors. First, presenteeism can describe employees going to work sick or tired. These employees remain on the job but are not as productive as usual due to stress, depression, illness, headaches, or other disorders. Second, presenteeism can occur when employees put in excessive work hours as an expression of commitment or a way of coping with job insecurity. Even beyond the fact of physical presence at work, these employees are not functioning at their peak capacity. This puts them, their co-workers, patients, and families at risk not only for contagion of their illness, but for effects of their reduced attention span and increased potential for errors.

Scope of the Problem

We all probably assume that when people are at work, they are productive. The literature indicates that this is a flawed assumption. The Center for Law and Social Policy reported that lost productivity was significantly greater from days being at work while sick (72%) compared to missed work days due to illness (28%) (Levin-Epstein, 2005). Of the total $250 billion annual cost for lost productivity alone, approximately $180 billion is due to presenteeism (Levin-Epstein, 2005). A major study conducted by Cornell University reported that presenteeism could account for as little as 18% to as much as 61% of the total cost of worker illness (Goetzel et al., 2004).

The cost of absenteeism is easy to calculate: 100% of the worker’s productivity is lost each day that the worker is not on the job. However, the cost of presenteeism and its accompanying loss of productivity is not easily measured. Burton and colleagues (1999) reported that most attempts to quantify productivity losses with presenteeism have focused on employee surveys. Employees are asked retrospectively to estimate their decrease in performance that may be due to a health problem. For example, these questionnaires may ask employees to rate the sedating effects they experience at work while using antihistamines for allergies or colds. The productivity of employees suffering from chronic disorders may be more difficult to measure. Workers with low back pain can have limitations on lifting, standing, or sitting. Carpal tunnel may slow computer work. Some illnesses or allergies may inhibit the quality of communication on the job. Employee conditions may create the need to repeat a task, or cause them to work more slowly (Burton et al., 1999).

A report in Risk & Insurance indicated that the root causes of presenteeism are not always medical. They frequently include issues of child care, financial worries, addiction, divorce, or family problems (Stevens, 2004). recently reported that many women are one sick child away from losing their jobs (Goodman, 2005). Most difficult of all to measure may be the productivity effects of employees who are experiencing depression. It is unclear how much depression in the workplace is due to an existing mental health condition or caused by stressful working conditions. However, the World Health Organization predicted mental illness will be one of the leading world health problems (Lowe, 2004). The National Institutes of Health identified depression alone as costing employers $44 billion a year in lost productivity (Ruez, 2004).

When we add the money spent for medical care, impaired performance, and disability, presenteeism is not just a human resources problem. It is a major financial business issue, especially in the health care arena. We really have two different concerns: how employees’ health affects their work, and how their work affects their health. Both of these perspectives must be explored. The mantra for American work life often has been to work harder and longer to get ahead. Recent news reports have identified the stress of work as a cause of decreased productivity and potential errors. Laws and regulations limiting the number of hours nurses and medical residents can work have been enacted in many states. Even moderate sleep deprivation can cause mood disruptions, slowed responses and reflexes, and poor communication (Lynch, 2002).

Impact for Nurses

Let’s put this into perspective for nurses. A study of 21,000 nurses found that their health declined more over a 4-year period than would be expected than if they were smokers or led sedentary lives (Lynch, 2002). After adjusting for factors such as participants’ age, body mass, smoking, exercise, education, and chronic disease, researchers found this group of nurses ranked considerably lower in physical functioning, vitality, and mental health than did those employees working in medium-strain or low-strain jobs. Despite what the nurses did individually, their demanding jobs affected their health (Lynch, 2002).

The current and impending nursing shortage is contributing to burnout among nurses. The average staff nurse today is older, and is faced with both greater workloads and increased patient acuity. This, combined with caring for aging parents and other family issues, leaves little time to care for their own well-being.

Presenteeism by those with contagious illnesses is a considerable problem, especially with nurses. Coming to work sick not only endangers co-workers, but also patients and their families. A recent news story reported that hospitals infect people at a rate of nearly 2 million per year (Ostrovsky, 2005). The Centers for Disease Control and Prevention reported that hospital-acquired infections kill more than 90,000 Americans each year (Breen, 2006). On top of this, only 38% of health care workers in the United States received a flu shot in past years. Health care workers below the age of 50 were 33% less likely to be vaccinated than were their peers between the ages of 54 and 64 (Brown, 2006).


Presenteeism is a symptom that must be diagnosed and treated, whether it indicates a problem within individual employees or within the workplace environment. Managers can identify the scope of the problem by discovering the frequency of presenteeism among their staff. In this age of a worsening nursing shortage, it might be problematic to say we should not work people harder or longer. However, presenteeism is often a reaction to overwork and stress at work. Creating an environment that supports a balance between work and life is not done easily in health care.

Managers can strive to make the issue of presenteeism a visible one with employees. They can survey employees for their perception of the cause of their presenteeism. It is important to determine if employees are feeling pressure to work longer hours and more overtime, or to discover their reasons for not taking sick leave.

Managers can employ these 10 realistic strategies to identify and reduce the negative effects of presenteeism on their units:

1. Conduct anonymous job satisfaction and stress surveys of staff. Allow the employees to include details of specific stressors or dissatisfiers and also offer suggestions for improvement. Gain familiarity with the real concerns of your nurses.

2. All approaches must be integrated into your Employee Assistance Program (EAP). Target and direct employees to utilize the confidential EAP services for counseling or support.

3. Disability specialists can assist employees with chronic, disabling injuries to modify their work techniques.

4. Employee wellness programs must include a disease management specialist to provide techniques to individuals experiencing a chronic medical condition.

5. Schedule group and individual chat times, and encourage employees to voice their concerns and receive support and group problem solving.

6. Confer with other managers, and review human resource policies and benefits that support work/life balance.

7. Review opportunities to offer flex-time, “mothers’ hours,” or shared scheduling. Greater flexibility does increase job satisfaction and reduce turnover.

8. Remind employees of the option to utilize the Family Medical Leave Act (FMLA).

9. Explore community resources to meet needs for sick child care, elder day care, estate planning, or family law counseling. Employee assistance programs should provide free counseling and a list of referrals to assist employees with solutions to their life concerns. This will reduce time spent worrying about these things while at work.

10. Offer frequent lifestyle programs on relaxation and meditation techniques for stress reduction in short 15-30 minute sessions on your units. Ironically, the health care arena lags far behind corporate America in recognizing the relationship between health and productivity in the workplace. It is time for health care employers to acknowledge that poor worker health affects not only productivity, but employee satisfaction, patient satisfaction, and quality of care. How long can we continue to promote the health and well-being of our patients, yet neglect our own employees?


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Goetzel, R. Z., Long, S.R., Ozminkowski, R.J., Hawkins, K., Wang, S., & Lynch, W. (2004). Health, absence, disability, and presenteeism: Cost estimates of certain physical and mental health conditions affecting U.S. employers. Journal of Occupational and Environmental Medicine, 46(4), 398-412.

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Levin-Epstein, J. (2005). Presenteeism and paid sick days. Center for Law and Social Policy, 1-4.

Lowe, G. (2004, January 20, 2006). Here in body, absent in productivity presenteeism hurts! Retrieved February 6, 2006, from http:/!gslpresenteeism.html

Lynch, W.D. (2002). Health affects work, and work affects health. Retrieved February 6, 2006, from http://www.managedhealth

Ostrovsky, D. (2005). Proposed bill takes on MD hospitals that make people sick. Retrieved February 6, 2006, from

Ruez, P. (2004). Quality and bottom line can suffer at the hands of the working sick. Retrieved February 2, 2006, from http://www. up.jsp?id=133407

Stevens, M. (2004, March). Present dangers: Presenteeism is the next area of focus as companies seek to maximize their investment in human capital by improving productivity and promoting employee health and wellness- disability. Risk & Insurance, pp. 40-42. (1995). Presenteeism. Retrieved January 20, 2006, from

Donna J. Middaugh, PhD, RN, is the Coordinator for the Nursing Administration Masters Specialty, University of Arkansas for Medical Sciences, College of Nursing, Little Rock, AR; and a MEDSURG Nursing Editorial Board Member.

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