Presenteeism exposures and outcomes amongst hospital doctors and nurses: a systematic review

Presenteeism is a contemporary concept which characterizes the behaviour of employees being physically present at work, but with reduced performance [1]. Presenteeism can be categorized into sickness (physical/ mental) and non-sickness presenteeism (due to personal reasons such as work-life conflict, perceived lack of organizational support, stress etc.) [2].

Presenteeism related exposures differ by sector and are common among staff working in jobs with extensive interpersonal interaction [3]. Extended working time due to globalization, downsizing and individual factors such as gaining facetime at work (a strong feature in the Asian environment) due to job insecurity were found to be major contributors to presenteeism behaviour amongst business, manufacturing and public sector employees [4, 5]. Doctors and nurses faced different pressures contributing to presenteeism, such as difficulties finding a substitute due to manpower shortage and strong organizational culture barriers and professional norms against taking sick leave [6, 7].

Robust presenteeism cross-sector correlational studies [8‐10], intervention programs and productivity costing studies have been conducted in the manufacturing and business sectors [11‐14] but not the healthcare sector. Employees in the health care (nurses and doctors) and education (full-time school teachers) sectors as compared to 42 occupations across six industries were more prone to presenteeism [10]. In the UK 86% of general practitioners reported presenteeism, followed by > 50% hospital doctors compared to only 32% of office workers [7].

Presenteeism outcomes commonly investigated include frequency of sickness presenteeism [10, 15], presenteeism-related productivity and labor costs [16], and employee health and related medical costs [12, 17]. Presenteeism not only impairs health but also affects team productivity resulting in significant financial costs. The indirect labour costs and medical expenses associated with presenteeism have been estimated to potentially exceed those of absenteeism [18]. As hospital managers seek ways to reduce labor costs which account for more than half of health care institutional expenses while maintaining quality care standards [19], presenteeism productivity costing and intervention studies may provide useful insights regarding targeted interventions or effective methods to improve work performance.

This systematic review aims to 1) identify instruments measuring presenteeism and its exposures and outcomes; 2) appraise the related workplace theoretical frameworks; and 3) evaluate the association between presenteeism, its exposures and outcomes, and the financial costs of presenteeism as well as interventions designed to alleviate presenteeism amongst hospital doctors and nurses.

Review findings will aid the development of a comprehensive scale to identify modifiable intervention targets in reducing nurse presenteeism, useful for hospital managers in formulating evidence-based human resources policies.

In the initial search, 788 peer-reviewed publications were identified. After removing duplicates, 275 unique publications remained. One hundred and ninety-two publications were screened out based on title and /or abstract leaving 83 publications for full text screening. Of these, 32 were selected for inclusion. Six additional publications were identified by manual search for a total of 38 publications for quality assessment (see Fig. 1).

Of the 38 publications, 61% (N = 22/36) passed the CASP-cohort quality assessment tool, and 100% (N = 2/2) passed the CASP-economic evaluation tool, leaving 24 publications for final inclusion in the systematic review (see Additional file 2).

Presenteeism exposures and outcomes were reported in 17 publications, in which three (18%) used a prospective study design [23‐25], and 14 (82%) a cross sectional study design [4, 7, 26‐36]. All four presenteeism financial costing publications used a cross-sectional study design [18, 37‐39]. Of the three randomized controlled trials on the effectiveness of presenteeism intervention programs [40], two were economic evaluations [41, 42].

Twenty (83%) of the publications included in the systematic review were published after 2010. Twenty-two (92%) drew from Western populations (Europe [4, 23, 24, 27, 28, 30‐33, 36, 38‐42], North America [18, 25, 26, 29, 37], United Kingdom [7]) and only two (8%) from non-western locales (South America [34] and China [35]). Ten (42%) sampled only nurses [18, 23, 25, 27‐29, 34, 41, 42], four (17%) only doctors [4, 30‐32] and ten (42%) a variety of health care professionals [7, 24, 26, 33, 35‐40].

Nine (38%) used a paper-based survey with response rates of 47–86% [4, 7, 18, 23‐26, 29, 39], four (17%) used a web-based survey with response rates of 26–86% [30, 33, 36, 37], two (8%) used a mixture of web and paper survey with response rates approximating 53% [31, 32], and the remaining did not specify the survey method but reported response rates of 49–91% [27, 28, 35, 38, 40‐42].

While all exposure and financial costing studies had clearly stated aims, only 16 (73%) adopted an appropriate sampling framework, recruitment strategy or response rate (anonymized, randomized, and > 50% response rate) (Additional file 2). Sixteen (73%) measured presenteeism exposures and 13 (59%) measured outcomes using valid and reliable tools. Ninenteen (86%) considered confounding factors. Of the prospective studies, only two followed up with subjects appropriately [24, 25]. Data extraction on study characteristics and results of selected publications are listed in Additional file 3.

This systematic review is the first to extensively examine multi-dimensional presenteeism organizational exposures measures, productivity financial costing, intervention studies and related psychosocial frameworks within the hospital-based healthcare workforce context. Most of the reviewed publications were cross-sectional in nature and few reported financial costing, economic evaluation or interventions. The contradictory associations found between presenteeism and common exposures or outcomes across studies limit decisive conclusions for the health care field. Although the concept of “presenteeism” first appeared in late twentieth century [44], there is no agreement on its precise operational definition.

While self-derived single-item measures may be suitable for numerical or categorical answers (e.g. number of medication errors, patient falls, demographics), though often criticized when measuring complex psychometric constructs (e.g. social support, mental conditions) due to low content validity (difficulty in representing a complex theoretical concept), limited sensitivity (more items provide more interval points on scale for discrimination) and restricted reliability evaluation (at least a two-item scale needed in evaluating consistency) [45].

Cross-cultural adaptation studies may also be needed before applying scales developed for a specific population to a different cultural context. Moreover, some commonly investigated exposures/ outcomes (e.g. burnout, psychological stress and general health) were measured by varying adopted scales across studies limiting comparability, as constructs may be conceptualized differently across scales. For example, different conceptualized burnout measures were compared amongst nurses and a two-factor structure (exhaustion and withdrawal) was confirmed to be most favourable. Development of a standardized multi-dimensional presenteeism exposures and outcomes scale may alleviate limitations on comparability for commonly investigated factors of interest. Adopted scales with satisfactory reliability (Cronbach’s alpha > 0.7) in the assessed studies will be considered for our scale development in the next stage.

Most commonly researched exposures and outcomes focus on medical factors, such as stress, burnout, general health, psychological symptoms and conditions, mostly due to the abundance of occupational health studies. The evidence presented here focuses on the impact of work demands and negative work psychosocial emotions (e.g. burnout, stress and dissatisfaction) as compared to work resources and positive work psychosocial emotions (e.g. satisfaction, positive work feelings, meaningfulness). Existing research on presenteeism exposures amongst nurses focuses on the effect of job design on psychosocial emotions and work productivity. The relationship between organizational policies, leadership style and organizational culture on presenteeism have been widely researched in other sectors but not among doctors and nurses [44]. For a more multi-dimensional and comprehensive overview on presenteeism exposures and productivity effects amongst nurses, future research should expand on these potentially impactful but rarely researched exposures.

In this review, presenteeism is measured either by experience, frequency and/or productivity. Operationally some researchers adopted a dichotomized response set to ask whether participants ever experienced presenteeism (yes or no) [21‐23] and thereby limited the utility of the presenteeism data [4, 7, 25, 26]. The Likert scales adopted by others [30‐32] with inherent numerical assumptions limit outcome comparability. Others have used self-reported workplace presenteeism productivity measurement instruments with variable outcome metrics and others still have used presenteeism productivity outcomes which focus on specific disease states rather than overall health-related productivity [44, 46]. Additionally, in most cases a more nuanced analysis of the impact of seasonality, work related factors and stressors was limited.

There is wide variation in presenteeism recall periods amongst selected studies. In a multi-sector productivity audit in the United States, Stewart studied variation in presenteeism recall periods of one, two, and four weeks [47]. The most accurate recall period for health-problem related presenteeism is 2 weeks. Elsewhere researchers used longer recall periods to capture frequency and experience of presenteeism episodes [47]. Variation in recall periods leads to questions about the accuracy of self-reported presenteeism, which has not been considered in most of the studies in this review, a problem which has been highlighted in other reviews [47‐50]. With few objective presenteeism and presenteeism productivity loss measures, the accuracy of self-reported presenteeism and absenteeism is difficult to establish. There are however, well established methods for verifying self-report scale precision, such as using retrospective diary data [51, 52]. Progress on the standardization and validation of presenteeism metrics and its monetary conversion methods has been stagnant since Schultz’s systematic review on employee health and presenteeism [53]. Contradictory and limited comparability on findings across studies may be attributed to variability of selected scales for measuring both presenteeism and its exposures/outcomes constructs.

Methodological limitations in our study include but are not limited to the following. Firstly, meta-analysis was not undertaken for the selected publications due to the heterogeneity of presenteeism outcome measures and limited number of studies. Secondly, limiting searches to only English language publications may have restricted the inclusion of publications written in Asian languages such as Korean, Japanese and Chinese. Thirdly, with the potential measurement error and conceptual differences between presenteeism instruments, comparison of presenteeism association with related exposures and economic costs between studies must be interpreted with caution. Lastly, limited cohort, intervention and economic valuation publications were available, confining the generalizability and heterogeneity of results.

In this systematic review, no conclusive evidence can be drawn on the association between presenteeism and its exposures amongst hospital healthcare workers based on the heterogeneity and limited quality of measurement tools. More evidence is needed to confirm the relationship between presenteeism positive exposures and outcomes (e.g. job satisfaction, social and supervisory support) amongst healthcare employees, and their feasibility as intervention targets. Based on our findings, researchers should consider theoretical frameworks with multi-level interaction which would allow for vertical and horizontal comparisons within and between organizations (e.g. leadership style and organizational culture) and individual exposures or outcomes in the future [59]. The limited number of economic evaluation studies with non-standardized instruments and varying costing methods restrict the estimation and comparison of presenteeism productivity costs amongst healthcare workers across studies. A standardized multi-dimensional presenteeism exposures and productivity instrument should be developed to facilitate cohort studies from both East and West in search of potential cost-effective and cultural-specific work-place intervention targets to reduce healthcare worker presenteeism and maintain a sustainable workforce.