Perceived social support and presenteeism among healthcare workers in China: the mediating role of organizational commitment

The concept of presenteeism has long attracted the interest of researchers. Presenteeism was first defined, in 1892, as attendance at work but with suboptimal performance [1‐4]. Later, presenteeism came to include sickness presenteeism, a construct usually related to health problems [1, 5, 6]. More recently, the concept of presenteeism was extended to include negative conditions caused by physical and other events that reduce productivity in enterprises and organizations [1‐4, 7, 8]. The enormous impact of presenteeism is difficult to measure. Recent studies reported that presenteeism was responsible for 3 and 1.8 times the financial burdens of medical illness and absenteeism, respectively [2, 3, 5].

Most research on presenteeism has focused on its predictors; mechanisms to address presenteeism have rarely been investigated. Johns divided the determinants of presenteeism into context (including social support, work interference, and work enhancement) and personal perspective (including work–life balance, job stress, and health) [1]; however, only social support interventions targeting presenteeism were reported to be effective in previous studies [1, 2, 7‐9]. In some studies, social support was categorized as supervisor support (including supervisor attention to each worker through coaching, directing, helping fulfill workers job responsibilities, and performance evaluations) and coworker support (i.e., coworker willingness to assist others in completing work-related, service-based duties) [10‐12]. These supports effectively address presenteeism because strong support enhances job satisfaction, performance, and productivity, and reduces presenteeism in organizations [7, 13, 14]. However, few subsequent empirical studies investigated potential interventions.

Social support should be enhanced in order to reduce workplace presenteeism. With respect to the relation between social support and presenteeism, only job stress, the most significant determinant of presenteeism [15], was examined as a mediator [7]. Additionally, organizational commitment—defined as the relative strength of an individual’s identification with and involvement in a particular organization [16]—significantly mediates the relationship between job stress and presenteeism [4]. No further mediator was identified in previous studies of social support and presenteeism. Interestingly, these two studies indicate that organizational commitment to the study of social support and presenteeism has a more direct influence on presenteeism than on work stress. Self-determination theory posits that people can be motivated by self-initiatives through both rewards and strengthening self-identification of value in organizations [17]. Social support as a kind of intrinsic motivation affects the internal self-worth of strong employees and strengthens organizational commitment [18], thus relieving presenteeism. To effectively address presenteeism, we analyzed organizational commitment as a specific mediator in our study.

China is a policy-driven country, and the social effects of policies are much greater than in other countries [19‐21]. In China, the primary concerns of medical reform are controlling medical costs and improving healthcare quality [20, 22]. Healthcare workers are required to provide an increasing number of healthcare services at a high level of quality. However, Chinese healthcare workers have been victims in numerous incidents of violence and face stricter qualification requirements and longer training periods as compared with other occupations. Occupational stress has resulted in poor physical and psychological well-being among healthcare workers [23‐25]. Therefore, they have been unable to meet strategic requirements, which has limited healthcare efficiency in China [26‐29]. In this study of the effectiveness of social support interventions for presenteeism, we investigated organizational commitment among Chinese healthcare workers (Fig. 1).

Coworker support had a significant inverse effect on presenteeism and slightly increased organizational commitment, while supervisor support was more effective in improving organizational commitment.

Our model can be explained by social exchange theory, which describes how people gain positive affect, trust, and kinship from outside. Blua maintained that social exchange occurs when one individual is attracted to another because the association is likely to be rewarding in some way, and because the interest in expected social rewards draws them to the other individual at work [37, 38]. When workers are satisfied, they develop feelings toward the organization, supervisor, and coworker, which are referred to as supervisor support and coworker support [39]. When workers feel such support, their trust in the organization is enhanced, which then manifests as organizational commitment. As part of the exchange, workers choose to behave better, and anti-productive behavior is reduced. In this way, we confirm the finding that organizational commitment can reduce presenteeism in the previous study.

The most valuable findings of this study are that coworker support adversely affects presenteeism, while supervisor support has no significant effect on presenteeism. Supervisor support has a stronger effect than coworker support on organizational commitment, because of differences between the roles of coworkers and supervisors. Regarding supervisor support, Mintzberg’s The Nature of Managerial Work holds that managers have 10 roles, including functioning as corporate spokespersons, information disseminators, and resource distributors [40]. Thus, managers represent the entire organization. A manager’s support of an employee means that the organization affirms the employee’s competencies and value in the organization, which can enhance his or her loyalty to the organization and sense of belonging, as well as the sense of organizational commitment [10, 16]. According to the theory of self-efficacy (i.e., whether a person can complete a job depends on a self-assessment of his/her own abilities) [41], promotion of organizational commitment ensures that employees feel they are important to the organization, which in turn stimulates initiative and reduces presenteeism and anti-productive behavior. Therefore, organizational commitment fully mediates the relationship between supervisor support and presenteeism.

With respect to coworker support, the job demand–resources model (JD-R) posits that the characteristics of any job can be divided into job demands and job resources. Job resources stimulate employee initiative to complete work goals (Jari 2008). Some researchers found that when the workload was large, coworker support as a job resource resulted in the sharing of tasks among employees, which relieved physical and psychological burdens and reduced presenteeism [42, 43]. Others noted that coworker support was linked to motivation and organizational commitment [43]. In the organization, relationships between colleagues are more relaxing and equal than those with supervisors. Employees can share their feelings with colleagues and benefit from their understanding [44]. The sympathy and understanding of colleagues can strengthen organizational commitment by making employees feel concern from the organization, thereby reducing anti-productive behavior [43]. The present results were consistent in part with those of previous studies [2, 3, 45, 46], which concluded that social support was important in promoting productivity, i.e., high social support was associated with greater productivity and less presenteeism [45‐47]. The present study adds the valuable finding that supervisor support and coworker support have different mechanisms in relation to presenteeism. As noted in a previous study which found that organizational commitment was a more appropriate mediator in the relationship between social support and presenteeism. In future practice, enhanced supervisor support and coworker support for healthcare workers could be essential in reducing presenteeism [1]. In addition, increasing the sense of commitment among medical staff is important.

In subgroup analysis, the results for women, workers with less education and workers with senior jobs differed from those for the overall population. First, supervisor support has a direct positive effect on presenteeism among female employees but not among the overall population, because women are more perceptual while men are more reasonable [48]. Women care more about others, and medical institutions are expected to establish a multi-dimensional system to motivate female workers.

Second, supervisor support had a significant effect on presenteeism only among workers with less education. In addition, coworker support was not associated with organizational commitment or presenteeism in this subgroup. The JD-R suggests that supervisor support is more effective than coworker support at providing the resources needed for the repetitive work usually performed by less-educated employees [2, 3, 49]. Therefore, to improve social support at differing levels of job complexity, training in interpersonal relationship should be encouraged among Chinese public hospitals.

Among senior employees, supervisor support was not significantly associated with organizational commitment, and coworker support had no direct effect on presenteeism. This can also be explained by the JD-R model. Most senior workers are supervisors. They represent the entire organization, are more likely to give rather than receive support [49]. Supervisors value financial and human resources, as well as any opportunities to increase their social status. Thus, hospitals could encourage them by using these mechanisms.

Organizational commitment partially mediates the relationship between coworker support and presenteeism and fully mediates the relationship between supervisor support and presenteeism. This study examined organizational commitment as a mediating role was better than job stress [2]. In the present study, coworker and supervisor support explained 27% of the variability in organizational commitment, and coworker support, supervisor support, and organizational commitment explained 22% of the variability in presenteeism. A future study should focus more on the mediating effects of organizational commitment between job stress and presenteeism.

The present findings have potential theoretical and practical utility. First, the concept of presenteeism described by Hall concerned the relationship between presenteeism and health problems and considered health-related factors as the only indicators of presenteeism [27, 50, 51]. In the present study, we defined presenteeism as a behavior leading to productivity loss and found that presenteeism was related to health problems and psychological determinants such as organizational commitment, as indicated by the social exchange theory [1, 4, 24]. This finding may alter the conceptualization of presenteeism in future studies. Second, this study contributes to the reform of healthcare policy. Successful implementation of the Healthy China 2030 strategy requires that the well-being of healthcare workers be given top priority in a policy-driven country [28, 52]. More attention to job stress and presenteeism of healthcare workers would reduce productivity loss by providing appropriate support from leaders and colleagues. Furthermore, our findings indicate that supervisor and coworker support can enhance worker commitment to an organization and reduce productivity loss. Previous studies investigated several methods of increasing worker performance and reducing presenteeism, including improving the health conditions of workers [1, 2, 4, 8]. Future studies should examine methods of improving supervisor and coworker support.

This study has four limitations. First, the participants were mostly employees of Chinese class A tertiary hospitals, which limits the generalizability and accuracy of our conclusions. Second, our model examined only some of the determinants of organizational commitment. Third, this was a cross-sectional study; thus, our findings regarding presenteeism require confirmation in a cohort study. Fourth, the number of hospitals and research areas should be expanded in the future study and different types of Chinese hospitals would be useful.

Chinese healthcare workers are becoming more important to policy-makers hoping to achieve the Healthy China 2030 goals. However, healthcare workers are exposed to considerable job stress and lack sufficient social support. This study found that to promote medical reform in China and cope with these challenges in Chinese hospitals, appropriate supervisor support and coworker support are critical in limiting presenteeism and sustaining high organizational commitment among healthcare workers.