Presenteeism: A hidden phenomenon with many shades of gray

Traditionally, industrial and occupational medicine practitioners have been focusing on sickness absenteeism, and the absence of workers from the workplace due to illness, incapacity, or other reasons.[1]

In recent years, the other end of the spectrum, sickness presenteeism, is increasingly recognized as a hidden burden affecting individual well-being and work output.[2] While there are many definitions of presenteeism, a simple one is “continuing to work during illness.”[3] There are estimates that it can cut down a worker’s productivity by one-third or more.[4] The economic implications are greater than sickness absenteeism. While absenteeism is apparent and can be counted and quantified, presenteeism is a hidden phenomenon. This poses a challenge to research as well as to economic analysis.

However, some researchers are trying to overcome these challenges. This is by way determining the prevalence of presenteeism, the impact on work output, and exploring ways to cope with it in cost-effective ways. The work being preliminary, there are many research gaps, the most important being the differential impact of various illnesses on work output.[4] This diversity will also depend, in addition to the type of illness, to the job requirements of the worker. For instance, depression may not affect a manual worker’s output, but musculoskeletal disorders will do so. To explore the effect of sickness on the job, one may have to put oneself in the worker’s shoes.

The initial research on presenteeism was skewed. It emphasized on the negative consequences of presenteeism. A recent approach favors a neutral ground on the presumption that the context is important to decide whether it is beneficial or harmful.[5] Such an approach considers that presenteeism has both positive and negative predictors and outcomes for individuals and industries. It puts forth a Health-Performance Framework of Presenteeism (HPFP), endeavoring to balance health limitations and performance demands.

This approach explores the diverse profiles of presenteeism based on similar health problems, physical, mental, and social as well as their performance, and variations in attendance and job stressors among the subgroups. A study by Biron et al.[5] using this approach, identified four profiles of presenteeism. Those reporting good health and high work output were classified as functional presentees. The group which had poor health and poor work output was categorized as dysfunctional presentees. Those with high performance in spite of poor health were classified as overachieving presentees. Lastly, those with average scores on health as well as work output were categorized as average presentees comprising the bulk. And lastly, those with good health but poor work output were labeled as therapeutic presenteeism. The investigators did not find any difference in absenteeism across the various presenteeism profiles. This underscores the difficulties of quantifying the impact of presenteeism as workers with similar days of presenteeism had different work outputs.

Another confounding factor is the work environment. Dysfunctional presentees experienced more exposure to job stressors. One has to keep in mind that the work environment can impact both presenteeism and job output. The HPFP concept considers these dynamics, taking a worker-centric approach to tease out presenteeism from the total count of presenteeism days. This has relevance for industrial psychologists, intervention research, and practice.

Presenteeism can have a positive perspective and can be functional in certain situations when appropriate support at the workplace, and resources are made available. However, there are also concerns that short-term increase in output may aggravate the long-term adverse effect on health leading to sickness absenteeism in the future.[6]

Cultural context is crucial. In many Asian cultures, it is common practice for employees to stay back in the workplace even after work, if their boss is still in the office.[7] This does not increase the output but can lead to fatigue and stress jeopardizing work-life balance.

And lastly, a phenomenon of “presenteeism” which is perhaps seen only in India and eludes classification! The National Medical Commission (NMC) had noted that several medical colleges are run by postgraduates as senior faculty are largely absent from work to attend to their private practice.[8] The NMC had noted that doctors visit the institutions, sign the attendance register, and leave for their private practice.

In response, NMC has mandated the full-time presence of faculty during working hours. To ensure this, biometric digital attendance linked with Aadhar and face recognition twice a day has been implemented. This may not be full proof either. It leaves a large “window of opportunity” between the two biometric attendances for a faculty to go and practice after login in the morning and pay a quick visit in the evening to logout. Do we classify such a phenomenon as “absenteeism-presenteeism?” The faculty is physically absent, but digitally present. This increases the work of the honest faculty who do not indulge in private practice during working hours and can be demoralizing for them.

Authors’ contributions

AB is responsible for the concept, drafting, revising and final approval of the manuscript.