STRATEGIES FOR REDUCING PRESENTEEISM AT PRIMARY HEALTH CARE CLINICS IN THE NELSON MANDELA METROPOLE

BY

NOMBULELO J. MAPIKELA

Treatise presented in fulfilment of the requirements for the Degree:

Magister in Business Administration

in the Faculty of Business and Economic Sciences

at the Nelson Mandela Metropolitan University

PROMOTOR: Dr A.WERNER

March 2013

DECLARATION

“I, Nombulelo J. Mapikela, hereby declare that:

• the work in this treatise is my own original work;

• all sources used or referred to have been documented

and recognised; and

• this treatise has not been previously submitted in full or partial

fulfilment of the requirements for an equivalent or higher

qualification at any other recognised educational institution.”

------------------------------------- ---------------------------- NOMBULELO J. MAPIKELA DATE

i

STRATEGIES FOR REDUCING PRESENTEEISM AT PRIMARY HEALTH CARE CLINICS IN THE NELSON MANDELA METROPOLE

BY

NOMBULELO J. MAPIKELA

DEGREE: Magister in Business Administration

FACULTY: Business and Economic Sciences

PROMOTOR: Dr. A. WERNER

ii

ABSTRACT Presenteeism is defined as the loss in productivity when workers are on the job, but

not performing to their best because of health-related issues. As with absenteeism,

presenteeism is considered negative as it results in low levels of productivity and

can, in the long term, have high cost implications. The research problem in this study

was to identify strategies for reducing health-related presenteeism at primary health

care clinics in the Nelson Mandela Metropolitan Municipality.

To achieve this goal, the following actions were taken:

A literature study was conducted to identify the extent of health related presenteeism

at primary health care clinics as well as the management thereof. Strategies that

could be utilised to prevent and reduce health-related presenteeism, ensuring that

there is an ongoing service delivery in the workplace, were identified. The literature

study revealed, amongst others, that those who suffer from emotional and physical

stress have difficulty in performing well on the job. By law, employers have

responsibilities to provide a safe environment. Hence, companies have to conduct an

audit re-examining the health and safety document of the company. In addition,

employers must ensure compliance within the current and developing legislative

context. A balance between professional and personal demands of every employee

should be promoted. In so doing, employees are able to trust their managers to

share whatever problem is encountered. A commitment from the company and good

management of presenteeism will result in a positive effect on productivity and

customer service quality.

A questionnaire was developed and administered to primary health care clinic

personnel in the Nelson Mandela Metropolitan Municipality. The results from this

empirical study revealed that sick or tired employees are less able to work at

optimum levels. These employees have the potential to aggravate their illness,

resulting in prolonged absence, or infecting their colleagues. In the study, chronic

diseases were perceived as prevalent among employees at the health care clinics. It

did not appear as if the management of stress received much attention or that an

iii

audit has been done to determine the state of health of employees. It is therefore

necessary to educate employees about the importance of their wellbeing. Well-

designed jobs and good management can assist in minimising organisational

stressors. Employers need to be convinced that investing in the health of their

employees is in their best interest from a business perspective. In today’s

competitive business world, companies look at maximising both profit and

productivity. Hence, employee health plays a fundamental role in the success of

companies. In the health care environment, the wellness of nurses will lead to more

productive behaviour and better service delivery.

iv

ACKNOWLEDGEMENTS

Any dissertation is never the result of just one person’s work, and my humble

composition is no different. I would be remiss if I did not first acknowledge my Lord

and Saviour, Jesus Christ, without whom my life would not have complete meaning

and purpose.

I am heartily thankful to my supervisor, Dr. Amanda Werner, whose encouragement, guidance and support from the initial to the final stages of this treatise, enabled me

to develop an understanding of the subject. I wish to express my sincere gratitude to the following people for their invaluable

contribution, encouragement and support towards my completing this treatise: The Municipal Director, who gave me the permission to conduct the research in the

municipal area. Managers of the Nelson Mandela Metro Municipality (Wellness

Centre) in Walmer for their enthusiasm for my project. A heartfelt thanks to the

nursing staff of the clinics in the Nelson Mandela Metro Districts that participated in

the study. Last but certainly not least, I would like to thank my friends and family for their

emotional support and encouragement during this period of my study.

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TABLE OF CONTENTS

DECLARATION i ABSTRACT iii ACKNOWLEDGEMENTS v TABLE OF CONTENTS vi LIST OF CHARTS ix LIST OF GRAPHS x LIST OF FIGURES x LIST OF TABLES x LIST OF APPENDICES xi

CHAPTER 1

INTRODUCTION, PROBLEM STATEMENT AND OUTLINE OF RESEARCH PROJECT

1.1 INTRODUCTION 1 1.2 MAIN PROBLEMS 3 1.2.1 Sub problems 3

1.3 PURPOSE AND OBJECTIVE OF THE STUDY 4 1.4 DELIMITATION OF THE STUDY 5 1.4.1 Geographical and organisational delimitation of the study 6

1.4.2 Subject delimitation 6

1.4.3 Target group 6

1.5 KEY ASSUMPTIONS 7 1.6 RESEARCH DESIGN 7 1.6.1 Literature study 7

1.6.2 Empirical study 7

1.6.3 Data collection method 7

1.6.4 Ethics 8

1.7 DEFINITION OF KEY CONCEPTS 8 1.7.1 Absenteeism 8

1.7.2 Presenteeism 8

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1.7.3 Primary health care 8

1.7.4 Strategy 8

1.8 OUTLINE OF THE STUDY 9

CHAPTER 2

PRESENTEEISM: A THEORETICAL OVERVIEW

2.1 INTRODUCTION 10 2.2 PRESENTEEISM DEFINED AND CONTEXTUALISED 11 2.2.1 Presenteeism defined 13

2.2.2 Types of presenteeism 15

2.2.3 Causes of presenteeism 16

2.2.4 Symptoms and consequences 25

2.3 FACTORS CONTRIBUTING TO PRESENTEEISM IN THE WORK PLACE

27

2.3.1 Personal factors contributing to presenteeism 29

2.3.2 Age and gender 29

2.3.3 The dual nature of careers 30

2.3.4 Organisational processes 31

2.3.5 Competition 32

2.3.6 Retrenchment fears 33

2.3.7 Job insecurities 33

2.3.8 Organisational culture 35

2.4 CONSEQUENCES OF PRESENTEEISM 36 2.5 STRATEGIES TO MANAGE PRESENTEEISM 40 2.6 CONCLUSION

50

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CHAPTER 3 RESEARCH DESIGN AND METHODOLOGY

3.1 INTRODUCTION 52 3.2 RESEARCH AND RESEARCH DESIGN 52 3.2.1 Research design 52

3.2.2 Research approach 55

3.3 THE EMPIRICAL STUDY 56 3.3.1 Population and sampling 57

3.3.2 The questionnaire 58

3.3.3 Pilot study 61

3.3.4 Administration of the questionnaire 62

3.3.5 Response rate 62

3.4 CONCLUSION 63

CHAPTER 4

PRESENTATION AND ANALYSIS OF THE RESEARCH RESULTS

4.1 INTRODUCTION 64 4.2 RESPONSE RATE 64 4.3 DEMOGRAPHIC CHARACTERISTICS OF RESPONDENTS 65 4.3.1 Gender 65

4.3.2 Age 66

4.3.3 Home language 67

4.3.4 Highest qualifications 69

4.3.5 Position 70

4.3.6 Years in current job 71

4.3.7 Productivity levels of staff

72

4.4 ANALYSIS OF RESPONSES TO SECTION B - PRESENTEEISM IN THE WORK PLACE

74

4.5 ANALYSIS OF RESPONSES TO SECTION C - STRATEGIES 78 viii

TO MANAGE PRESENTEEISM 4.6 ANALYSIS OF RESPONSES TO SECTION D -

CONSEQUENCES OF PRESENTEEISM 80

4.7 CONCLUSION 81

CHAPTER 5 SUMMARY, FINAL CONCLUSION AND RECOMMENDATIONS

5.1 INTRODUCTION 83

5.2 SUMMARY OF THE STUDY 83

5.3 PROBLEMS AND LIMITATIONS OF THE STUDY 87

5.4 RECOMMENDATIONS 87

5.5 CONCLUSION 90

REFERENCES 91

LIST OF CHARTS

Chart 4.1 Responses with regard to gender 65

Chart 4.2 Responses with regard to age 67

Chart 4.3

Chart 4.4

Responses with regard to home language

Responses with regard to highest qualifications

68

69

Chart 4.5 Responses with regard to position in current job 70

Chart 4.6 Responses with regard to years in the job 72

Chart 4.7 Responses with regard to productivity levels 73

LIST OF GRAPHS

Graph 2.1 The trend in the proportion of deaths due to leading

categories,1997-2007

21

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LIST OF FIGURES

Figure 2.1 Increased health and productivity 16 Figure 2.2 Influences on presenteeism 17

Figure 2.3 Unhealthy business environment results into a business

failure

18

Figure 2.4 Contribution of medical conditions to overall productivity loss 21

Figure 2.5 Psychosocial work environments 23 Figure 2.6 Risks for work-related stress 24 Figure 2.7 A dynamic model of presenteeism and absenteeism 28 Figure 2.8 The hidden costs of presenteeism 38 Figure 2.9 Six pillars of an effective Healthcare and Productivity (H&P)

framework 48

LIST OF TABLES

Table 1.1 Job categories and districts 6 Table 2.1 Estimates of productivity losses for selected medical

conditions

14

Table 2.2 Most costly health conditions 39 Table 3.1 Choosing a suitable research approach 56 Table 3.2 Districts and job categories surveyed 58

Table 4.1 Responses per district 64 Table 4.2 Responses with regard to gender 65 Table 4.3 Responses with regard to age 66 Table 4.4 Responses with regard to home language 68

x

Table 4.5 Responses with regard to highest qualification 69 Table 4.6 Responses with regard to position in current job. 70 Table 4.7 Years in current job 71 Table 4.8 Productivity levels in the work place 73 Table 4.9 Responses to Section B–Presenteeism in the work

place 74

Table 4.10 Responses to Section B reflecting Mean and Standard

Deviation Scores 77

Table 4.11 Responses to Section C reflecting Mean and Standard

Deviation scores 79

Table 4.12 Response to Section D reflecting Mean and Standard

deviation 81

LIST OF APPENDICES

Appendix 1 Covering letter for survey 98 Appendix 2 Survey questionnaire 99

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CHAPTER 1

INTRODUCTION, PROBLEM STATEMENT AND OUTLINE OF RESEARCH PROJECT

1.1 INTRODUCTION

In recent years, there has been a growing interest in research concerning health-

related presenteeism. The concept refers to the phenomenon that people, despite

complaints and ill health that should prompt them to rest and take sick leave, go to

work in any case (Aronsson and Gustafsson, 2005:958). MacGregor, Cunningham

and Caverley (2008:607) revealed that an awareness of sickness presenteeism has

intensified in most organisations. This is evident where employees are not productive

in the workplace due to medical problems. Implied in previous research is that the

prevalence of presenteeism may have escalated as sickness presence is replaced

with sickness absence (Caverley, Cunningham & MacGregor, 2007:306). Most

researchers suggest that presenteeism is a serious problem for organisations.

A reduction in productivity levels is caused by employees who turn up for work when

sick (Demerouti, Le Blanck, Bakker, Schaufeli and Hox, 2008:52). Exhaustion and

presenteeism were found to be reciprocal, suggesting that when employees

experience exhaustion they mobilise compensation strategies. This ultimately

increases their exhaustion. Research studies have focused on the prevalence of

sickness presenteeism in different occupational groups, as well as its effects on

productivity. Demerouti et al. (2008:51) describes presenteeism as being at work

when one should be at home either because of ill health, subsequently working long

hours when one is no longer effective. Hence, Prater and Smith (2011:3) revealed

that a competitive culture coerces managers to pressurise staff to perform,

irrespective of how sick they are feeling.

Although presenteeism is persistent in the workplace, the effects of the condition on

employee health and productivity are less well understood. Evidence is that high

levels of chronic illnesses have a huge impact on productivity as they strike so many

people. These illnesses are known to keep workers away from work thus decrease

their work performance while on the job. The concept of presenteeism speaks to this

issue. MacGregor et al. (2008:607) define presenteeism as times when employees

1

attend work when sickness absence is warranted, thus performing their work under

unfavourable conditions. Aronsson and Gustafsson (2005:958) further describe

presenteeism as denoting attending work even when one feels unhealthy. In his

review, Johns (2009:521) notes that financial constraints and dedication to the job

might compel employees to attend work.

Goetzel (in Puig-Ribera, Mckenna and Gilson, 2008:109) highlights that increasing

chronic health problems are a leading cause of work disability and translate into

significant losses of work productivity. Caverley et al. (2007:305) reveal that

employees in service jobs feel a responsibility towards clients. Hence, they are more

prone to sickness presenteeism than employees in other occupations. Aronsson et

al. (2005:959) share the same sentiments in believing that there is widespread

sickness presenteeism in jobs where work is likely to accumulate during an absence

rather than in jobs that can be completed by replacing workers. Findings from

studies suggest that the cost of lost productivity may be several times greater than

direct medical costs. Furthermore, there is evidence in the literature suggesting that

lost productivity may be due to absence from work, whilst on the other hand, one

may be present but ineffective.

Literature reveals that pressures and the pace of some jobs do result in work strain.

Employees therefore feel inclined to meet demands to achieve the desired level of

performance. Demerouti et al. (2005:51) cite showing up for work, even when too

stressed or sick to be productive, as examples of presenteeism. Workers, however,

believe that losing one day due to illness might put them so far behind that they

could never catch up. On that note, Schaefer (2007:240) defines the word

presenteeism as the practice of workers reporting to work when ill and not operating

to their usual level of productivity. Personal difficulties outside of work can also affect

job performance. These may include pressures from taking care of family members,

financial constraints or marital strains that might distract an employee.

Presenteeism has implications for both the company and an employee. Concerning

sick days, the literature reveals that individual companies set policies and even

negotiate terms in a labour agreement. Munro (2007:22) suggests that organisations

2

should make use of appropriate policies and review these policies to ensure that

their current attendance policy is in line with the needs of the employees. Strategies

to control and reduce presenteeism are a necessity for every organisation to function

optimally. However, studies show that presenteeism, more than the incidents of

absenteeism, accounts for more lost time (Willingham, 2008:11).

D’abate and Eddy (2007:361) reveal that although much of the research on

presenteeism is more from medical literature, research suggests that presenteeism

also includes engaging in personal business while on the job, such as e-mailing

friends, paying personal bills, or making personal appointments. Evidence shows

that presenteeism is as costly to employers as its counterpart absenteeism. Being

present on the job deceives most people, as the assumption is that as long as they

show up that automatically makes them productive. They feel that their presence

contribute to something. They do not consider that coming to work ill or on

medication affects concentration levels. Furthermore, this has an effect on

productivity, which is costly to the company. Despite implications presenteeism might

have on both employee and the employer, there are ways to deal with this issue if

both sides are willing to be accommodating and look after each other.

The above discussion led to the development of the main research problem, which is

stated below.

1.2 THE MAIN STATEMENT

The aim of this research study was to establish strategies that can be used to

effectively control and reduce presenteeism in the work place.

1.2.1 Sub-problems To deal effectively with the main problem stated above, the following sub-problems

were investigated.

Sub-problem 1

• What is presenteeism and the symptoms of presenteeism?

3

Sub-problem 2

• What personal and organisational factors contribute to the prevalence of

presenteeism in the workplace?

Sub-problem 3

• What are the consequences of presenteeism for the individual and the

organisation?

Sub-problem 4

• What strategies can organisations utilise to reduce and control presenteeism?

Sub-problem 5

• What are employees’ perceptions of the prevalence of presenteeism at the

primary health care clinics in the Nelson Mandela Metropole?

Sub-problem 6

• What are employees’ perceptions of the personal and organisational factors

that contribute to presenteeism at the primary health care clinics in the Nelson

Mandela Metropole?

Sub-problem 7

• What are employees’ perceptions of the consequences of presenteeism at the

primary health care clinics in the Nelson Mandela Metropole?

Sub-problem 8

• What strategies are used at primary health care clinics in the Nelson Mandela

Metropole to control and reduce presenteeism?

1.3 PURPOSE AND OBJECTIVES OF THE STUDY

Manufacturing, as well as the service organisations, are facing several challenges

concerning employee attendance in relation to productivity. Presenteeism has an

impact on individuals and organisations, affecting the running of the organisations

and the quality of life and health of employees. The purpose of the study is therefore

4

to investigate strategies that can be utilised to control and reduce presenteeism in

the work place. Existing studies have been concerned with identifying the prevalence

of presenteeism and factors that contribute to it. Aronsson and Gustafsson

(2005:958), however, suggest that there is very limited discussion about the

consequences of presenteeism on individuals. It was also revealed that, unlike

absenteeism, presenteeism is not always apparent.

It is not easy to tell when and how much a medical condition is hindering an

employee’s performance (Hemp, 2004:1). In the literature, it is suggested that

attention should be directed to people who are not working to their full potential due

to health-related reasons. The ultimate aim of the study was to develop an

understanding of the causes of presenteeism, the consequences as well as

management of presenteeism.

The objectives of the study were therefore to:

• Conduct a theoretical study to develop an understanding of presenteeism and

its symptoms, to establish personal and organisational factors contributing to

presenteeism and the strategies organisations can use to manage

presenteeism.

• Assess the prevalence of presenteeism at the primary health care clinics in

the Nelson Mandela Metropole. A survey in the form of a questionnaire was

administered as a data collecting tool. The idea behind this was to probe the

perceptions of clinic staff at the Nelson Mandela primary health care clinics of

the prevalence of presenteeism, personal and organisational factors that

contribute to it as well as the consequences of presenteeism for the individual

and the organisation. Consequently, staff would be asked to suggest

strategies to manage presenteeism.

• Interpret the results of the theoretical and empirical study to put forth

recommendations for the management of presenteeism.

1.4 DELIMITATION OF THE STUDY

The study was restricted to health-related presenteeism at the Nelson Mandela

primary health care clinics.

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1.4.1 Geographical and organisational delimitation The clinics in the Nelson Mandela Metropole are dispersed in three districts: District

A comprises of the Ibhayi and Motherwell clinics. The clinics in Despatch, Park

Centre KwaNobuhle, Joe Slovo, Masakhane and Rosedale all fall under District B.

District C consists of clinics in the Northern areas and include Gelvandale, Helenvale

Westend, Chetty, Booysens Park and Shoda as well as the Linton Grange clinic.

Employees from 54 clinics were included in the study.

1.4.2 Subject delimitation The study focused on the causes and consequences of presenteeism, personal and

organisational factors contributing to it, as well as strategies to reduce it at the

primary health care clinics in the Nelson Mandela Metropole.

1.4.3 Target group All the employees that form part of the teams at the primary health care clinics in the

Nelson Mandela Metropole were part of the population for the study. The survey

included both permanent and temporary personnel and those working on a

contractual basis. In these clinics there were usually four sisters with one of them

being the sister in charge and another the deputy in charge. The table below gives a

presentation of job categories in the districts.

Table 1.1: Job categories and districts

DISTRICTS A B C

CATEGORIES

Supervisor 6 4 6

Deputy Supervisor 3 2 3

Sister 16 11 17

Staff Nurse 4 2 4

Assistant Nurse 6 4 6

Data capturer 2 2 2

TOTAL 37 25 38

6

1.5 KEY ASSUMPTIONS

A key assumption was that the Department of Health was faced with challenges of

sickness presenteeism. It was also assumed that presenteeism can be controlled if

strategies are put in place.

1.6 RESEARCH DESIGN

Firstly, secondary research, in the form of a literature study, was conducted.

Secondly, a quantitative research method was used to collect data to address the

sub-problems. For this purpose, a questionnaire was designed which was

administered to the personnel at the primary health care clinics in the Nelson

Mandela Metropole.

1.6.1 Literature study The study was undertaken to develop a thorough understanding of the concept of

presenteeism and strategies that can be used to control it. The sub-problems

presented earlier in the study were addressed.

1.6.2 Empirical study A quantitative research study, using a survey, was conducted. Questionnaires were

used as tools for collecting data. The information obtained from the participants’

responses was analysed and suggestions were made for managing presenteeism at

the primary health clinics.

1.6.3 Data collection method A comprehensive survey, representative of the population, was completed.

Questionnaires as well as interviews were used to collect data from the population in

the Nelson Mandela Metropolitan clinics. The questionnaire consisted of four

sections, which covered the demographic information, presenteeism in the

workplace, strategies to manage presenteeism and the consequences of it. Data

were analysed and interpreted from the responses.

7

1.6.4 Ethics In an endeavour to obtain high quality standards a questionnaire was submitted to

the Ethics Committee in the Faculty of Business and Economic Sciences at the

Nelson Mandela University (NMMU). Ethics approval was obtained. The

questionnaire was also submitted to the Metro Primary Health Care Office where

approval was granted and signed by the acting Director.

1.7 DEFINITION OF KEY CONCEPTS

The key concepts related to the study are discussed below.

1.7.1 Absenteeism According to Johns (2009:520), absenteeism is defined as not showing up for

scheduled work. Absenteeism is defined as habitual failure to appear, especially for

work or other regular duty (Prater and Smith, 2011:1).

1.7.2 Presenteeism Presenteeism describes the situation when workers are on the job but because

of illness, injury, or other conditions, they are not functioning at peak levels (D’Abate

and Eddy, 2007:361).

1.7.3 Primary health care

Primary health care is a basic level of health care. It includes programmes directed

at the promotion of health. These programmes include early diagnosis of disease or

disability as well as prevention of disease. Primary health care can be provided in an

ambulatory facility to limited numbers of people, often those living in a particular

geographic area. It includes continuing health care, as provided by a family nurse

practitioner at an affordable cost (Brooker, Waugh, van Rooyen, Jordan and Kotze,

2009:52).

1.7.4 Strategy Ireland, Hoskisson & Hitt (2009:4) define strategy as an integrated and coordinated

set of commitments and actions designed to exploit core competences and gain a

competitive advantage. An operational strategy is one of the many types of

strategies that focus on issues of resources, processes and people.

8

1.8 CHAPTER OUTLINE

The study is divided into five chapters.

Chapter 1

Chapter 1 outlines the scope of the study, the problem statement, the purpose of the

study, and the research methodology. Concepts related to the main problem are also

defined.

Chapter 2

In this chapter, an overview of related literature is presented. The focus is on

presenteeism and its symptoms, the consequences, contributing personal and

organisational factors and strategies organisations can use to manage

presenteeism.

Chapter 3

The focus is on the methodology of the study. The methods chosen for the study are

explored, including the tools for the collection and interpretation of data.

Chapter 4

In this chapter, the results are presented and interpreted.

Chapter 5

A summary of the study is presented, final conclusions drawn and recommendations

made.

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CHAPTER 2

PRESENTEEISM: A THEORETICAL OVERVIEW

2.1 INTRODUCTION The focal point of this chapter is on a theoretical presentation of presenteeism, its

symptoms and consequences, the contributing personal and organisational factors

as well as strategies organisations can use to manage presenteeism. The empirical

study focuses on teams working at primary health care clinics in the Nelson Mandela

Metropole. An assumption, as indicated in Chapter 1, was that the Department of

Health was facing the challenge of presenteeism related to ill health. It was also an

assumption that presenteeism is manageable if specific strategies are in place.

Studies currently are more focussed on detecting factors contributing to

presenteeism and little attention is given to how to manage it. Notably, the literature

study revealed that the focal point of most employers was on curtailing absenteeism

levels and the associated costs.

The aim of this study, therefore, is to resolve the main problem cited previously, that

of establishing strategies to be utilised to control and reduce presenteeism in the

work place. As implied in a Medibank report, presenteeism is a concept that

addresses health-related illnesses resulting in productivity losses while the individual

is at work (Medibank, 2007:3). Aronsson et al. (2005:958) suggest that instead of

staying at home to recuperate from their illnesses people come to work. An

indication is that when employees come to work stressed due to an illness, they are

delaying the process of getting better. While they are at work their performance can

deteriorate. Pilette (2005:300) suggests that, as a corrective measure to control

presenteeism, organisations can thus offer supportive and effective methods to keep

employees healthy and productive.

Chapman (2005:2) states that maintaining a healthy and productive workforce

remains a significant challenge for every business. This is due to an increasing

number of people affected by chronic health conditions and an aging workforce.

Consequently, these conditions are likely to have an emotional impact on the people

affected. The rising health care costs and an awareness of productivity losses

10

increase the demand for health promotion programmes in the workplace. As the

report from Medibank suggests, there is an urgent need for employers to address the

health care challenges so that they can create more positive and productive

environments for their employees (Medibank, 2007). This could lead to better

performance and businesses that are more profitable. The impact of presenteeism

will likely continue to grow if precautionary health and workplace measures are not

instituted.

2.2 PRESENTEEISM DEFINED AND CONTEXTUALISED It is evident that many organisations are mostly concerned about absenteeism levels

and its management. Absenteeism is an ongoing challenge for most managers. A

culture of fear and anxiety towards being absent from work resulted in using

resources (time and money) to lessen the prevalence of absenteeism. This has

pushed employees to deprive themselves of physical health, personal productivity

and performance. Subsequently, service delivery as well as staff morale, become

affected and financial losses result. Research reveals that lower absenteeism rates

can be a camouflage for presenteeism (Ontario, 2010:12). Stephens (2010:1), on the

same note, cites that the focal point of presenteeism changes from employees who

absent themselves from work to employees who are present but not as productive as

they could.

Nowak (2011:1) confirms that the estimate is that presenteeism accounts for about

three quarters of the total costs of a company’s expenditure. This estimation

considers direct and indirect medical costs, absenteeism, short and long-term

disability as well as presenteeism. Multiple researchers have attempted to estimate

the costs associated with presenteeism at organisations. For example, Hemp

(2004:3) alleges that the cost of presenteeism could be as high as $150 billion

(R1270 50 billion) per year in the United States alone. Oosthuysen (2007:1) revealed

statistics released by Discovery Health that the cost of absenteeism to South African

businesses is estimated at R12 billion a year. When comparing absenteeism to

presenteeism the report from Medibank reveals that presenteeism is less visible in

the workplace and harder to quantify (Medibank, 2007).

11

The implication is that though not observable, presenteeism has a more damaging

effect than absenteeism. Comparing Australia to South Africa, Oosthuysen reveals

that presenteeism in South Africa costs four times more than absenteeism and it

could be as much as R48 billion a year (Oosthuysen, 2007:1. Employers therefore

can no longer ignore the impact of presenteeism. As suggested in the Medibank

report, by investing in strategies and programmes that support the health and

wellbeing of employees, presenteeism can be minimised, thus improving productivity

in the workplace (Medibank, 2007:3).

Chapman (2005:1) highlighted additional issues that are likely to drive an increased

interest in presenteeism:

• Ageing of the work force;

• Greater awareness of the problem of productivity loss;

• Improvements in the measurement methodology for presenteeism;

• Increased pharmaceutical industry interest and support, and

• Growing competitive pressures in many market sectors.

It is therefore clear that presenteeism is a growing concern for employers and health

professionals. Presenteeism is having potentially disastrous effects on both

employee and organisational health, and thus presenting hidden long-term costs for

employers. Hemp (2004:53) is of the view that employers are beginning to realise

the invisibility of presenteeism, yet it is such a drain on productivity. Most authors

cited in the study (Chapter 1) consider presenteeism as the problem of workers

being on the job but, because of illness or other medical conditions, are not fully

functional. Evidently like most things, if presenteeism is not controlled, it can give

rise to depression or substance abuse. In addition increased disability claims and

higher overall medical costs can result.

Sickness presence, as well as its impact on productivity, could contribute to

increased sickness absence later on because it aggravates the employee’s

condition. Managing presenteeism well not only saves money but also contributes to

the development of a productive workforce.

12

2.2.1 Presenteeism defined In Chapter 1, descriptions by various authors of the concept of presenteeism were

provided. It was indicated that the person who coined the word presenteeism, Cooper

(in Chapman, 2005:1), wanted to name the growing tendency of employees to spend

more time at work even when they are sick and when their continued employment or

jobs were in jeopardy. The same author treats presenteeism as a consequence of a

negative work environment. An indication is that presenteeism is simply the practice of

coming to work when an individual should not, which results in being physically present

at work but functionally absent. This view coincides with that of Middaugh (2006:1)

where presenteeism is described as turning up for work despite being distracted (by

stress or ill health). Noemdoe (2002:31) agrees with the previous authors by describing

presenteeism as when a staff member is distracted by serious personal, work, and

financial concerns and is unable to give full concentration to the job.

Johns (2009:520) indicates a lack of agreement with the definitions provided by most

authors. For instance, an employee may come to work because of financial restraints

and is not prepared to miss work due to illness. Additionally, passion and loyalty to the

job can compel one to attend work despite ill health. The focus as noted in this

definition is not on ill health. Most researchers have often measured presenteeism in

terms of how often an individual attends work while unhealthy as well as measuring the

effects of poor health on job productivity. Hence, Aronsson et al. (2005:959) require

research participants to indicate if they had attended work despite feeling they should

have taken sick leave. An indication is that companies should implement wellness

programmes for their employees aimed at increasing health and productivity (Caverley

et al. 2007:318). Schultz, Chen and Edington (2009:367) show that presenteeism is often measured as the costs associated with reduced work output, errors on the job

and failure to meet company production standards.

From the discussion above, it is evident that the term presenteeism combines the

ideas of the present employee and absenteeism, where the employee is present on the

job but somewhat absent in mind or behaviour (D’Abate and Eddy, 2007:361). The

above definitions further reveal that there is a relationship between health and

13

productivity in the workplace. It is important to note that relations between

presenteeism and a large number of health conditions were examined. These varied

from allergies to irritable bowel syndrome. The cost of presenteeism relative to the total

cost varies by condition.

Table 2.1 below reflects productivity losses due to presenteeism per employee per

year, for employees who have the listed condition over a multi-day or multi-week

period.

Table2.1:Estimates of productivity losses for selected medical conditions

PRODUCTIVITY LOSS

Medical Condition

• Allergy

• Arthritis• Asthma• Any Cancer• Depression • Diabetes • Heart Disease• Hypertension• Migraine/headache• Respiratory Disorders• Back, neck or spinal problems• Eczema or other skin condition

Gross Average LabourProductivity Loss Due toPresenteeism (pa, %)

• 10.95%• 11.2%• 11.0%• 8.5%• 15.3% • 11.4% • 6.8% • 6.9% • 20.5% • 10.9%• 11.4% • 11.0%

Source:Goetzel,2003 (in Econtech:2007) Evidence in a report by Econtech (2007:15) shows that health conditions are common

among all job types and have the potential to affect a company’s financial

performance. Hence, Krohne and Magnussen (2011:1) identified two main research

trends. First and most predominantly, some research tends to view presenteeism as a

negative phenomenon. This negative impact is evident when employees attend work

despite their state of health that justifies taking sick leave. Employee problems thus

can affect the entire work group, hurting morale, shifting the burden of work onto

14

others, and distracting co-workers. The second type focuses on the positive health

aspects presenteeism may have for the individual. D’Abate and Eddy (2007:365) imply

that helping employees find ways to balance their work and personal lives is becoming

increasingly important. Medibank (2007:1), for the purposes of this study, defines

presenteeism as the lost productivity that occurs when employees come to work but

because of illness or other medical conditions, are not fully functioning. This research

hence confines itself to the definition cited in the report given above by Medibank

(2007:3) as it focuses on health being the reason for non-performance and low

productivity at work. Conversely, Chapman (2005:1) reveals that people’s emotional

states are the main drivers of presenteeism that affect employee’s productivity and

harm the organisation. The discussion below focuses on the different types of

presenteeism.

2.2.2 Types of presenteeism

The South African Employment Health Worker’s Survey (SAEHWS)

(SAEHWS,2009) indicates that presenteeism is categorised into three types,

namely:

• Impaired presenteeism: Employees, despite complaints and ill health, go to work and thereby lower their productivity.

• Over-commitment presenteeism: Higher stress and exhaustion levels result in reduced productivity and quality of outputs.

• Disengagement presenteeism: Workplace pressures as well as lack of resources (job and personal) impact on employees’ motivational wellness

and morale.

The diagram below indicates that health and productivity complement each other. It

is clear that ill health affects people psychologically, behaviourally and ultimately

also the organisation.

15

Figure 2.1: Increased Health and Productivity

Chest /back pain, heart disease, GI disorders, headache,

dizziness , weakness , repetitive motion injuries

Anxiety, aggression, irritability, apathy, boredom depression,

loneliness, fatigue moodiness, insomnia

Accidents, drug/alcohol abuse, eating disorders, smoking,

tardiness, “exaggerated” diseases

Absence, work relations, turnover, morale, job satisfaction,

productivity

Medical

Psychological

Behavioural

Organisational

Goetzel: (2003: 11) An indication from the earlier discussion is that high job demands are risk factors for

mental and physical health problems. Consequently, production levels become

affected in the process. Presenteeism is influenced by many factors. Some of the

causes of presenteeism are presented below.

2.2.3 Causes of presenteeism A contributing factor to presenteeism is the approach taken by management to

absenteeism. When policies are imposed, employees might demonstrate an

unwillingness to take time off in cases when they are genuinely sick. The

assumption, according to Demerouti et al. (2008:51), is that high job demands will

evoke pressure to attend work while employees actually feel sick. This can be

viewed as an attempt to avoid lowered performance levels. The diagram below

examines the key influences that appear to contribute to presenteeism in the

workplace. These are organisational pressures and personal motivations.

16

FIGURE 2.2: Influences on presenteeism

PRESENTEEISM

Belief that no one else will do the job

Loyalty to own personal motivation

Obligation and commitment to colleagues, clients and

organisations and

Inability to work to capacity to fulfil the role

Low commitment level to organisation

Workplace pressures

Management style and management of absenteeism e.g. where managers act as role models and attend work

when sick

Return to work interviews, sickness absence and trigger

policies(fear of negative consequences if off e.g.

disciplinary action)

Personal motivation

Work place culture e.g. belief that attending work sets a

good example ,provides strong social networks

Fear of passing on illness to clients and colleagues

Concern about own health deteriorating

Source: Baker-McClearn, Greasley, Dale and Griffith (2010)

It is obvious that company-related factors, such as the organisational plan or the

working conditions and environment, contribute directly to the rate of absenteeism

and presenteeism. Evidently, these factors can have a positive or a negative

influence on the employee’s psychological balance.

17

The table below shows the same sentiments as already discussed. FIGURE 2.3: Unhealthy business environment results in a business failure

Unhealthy and unsafe

workplace

Work related stress

Accidents and injuriesWork-related illnessJob dissatisfaction

Lack of job commitmentBurnout, depressionWorkplace violence

Unhealthy personal health activities(e.g

smoking,drinking,overeating,lack of exercise)

Chronic and non communicable diseases(e.g

coronary artery disease, hypertension,diabetes,cancer

AbsenteeismPresenteeism

Long &Short termDisability

Health insurances

Worker's compensation

claimsUnion

grievancesTurnover

Increased costsDecreased productivity

Decreased Quality of product, or customer service

Fines, imprisonment

Business Failure

Source: Medibank (2007)

The figure above reveals that an unhealthy work environment can result in the failure

of the entire business. Unhealthy behaviours, such as smoking and drinking,

emanate from stressful situations at work. The employee develops a lack of job

commitment and work-related illnesses culminating in not attending or attending

work but not functioning at all. This underperformance in turn is very costly to the

company. According to Baker-McClearn, Greasley, Dale and Griffith (2009:65), it is

apparent that high-pressure environments that do not accommodate absence are

prone to a work place culture that supports presenteeism. Other causes of

presenteeism as presented by Medibank (2007:6) include:

18

• A person’s health status (influence the occurrence of a health condition).

• Sick workers suffering from lower productivity (can spread infection to

colleagues).

• Disease like asthma and allergies can impair workers’ performance.

• Poor work-life balance and high levels of job-related stress.

It is evident from the causes listed above that, a healthy diet, regular exercise, not

smoking and a moderate alcohol intake can decrease the probability of a chronic

health condition. A contamination spread by a single ill worker can impose health

costs on a company. Medibank (2007) report reveals that the cost impact of a

specific worker can be several times higher than the direct cost of absenteeism.

Subsequently, frustration in the job can affect individuals psychologically resulting in

conditions like burnout syndrome or depression (Medibank, 2007:7). Leads were

obtained from various South African and international sources to determine which

health issues are relevant and regarded as having a significant impact on

absenteeism levels in organisations. Although health risks and their relation to

presenteeism were researched in the USA, they are also relevant to South Africa.

It has been indicated that South Africans are affected by health risks such as

alcohol and drug abuse, accidents, smoking, stress, as well as medical conditions

such as cancer. It is therefore logical to presume that in South Africa the same

health risks could influence presenteeism levels in organisation. Hagemann (in

Stassen, 2008:1) highlighted that seven of the 15 top causes of death among South

Africans are largely due to preventable diseases. These include HIV/Aids, heart

disease, stroke, hypertension, diabetes, chronic obstructive pulmonary disease

(COPD) and lung cancer. To illustrate this point, death rates among the South

African workforce were compared according to age distribution. In addition, the

South African National Burden of Disease study conducted in 2000 revealed the

death rates among the workforce aged 25 to 55 were much higher than among the

rest of the population (Stassen, 2008:1). HIV/Aids and non-communicable diseases

were identified as the two main causes of death among this group. Lifestyle

modification can prevent the occurrence or even spread of these diseases.

A report from The Medical Report Council (MRC) revealed that about six million

South Africans suffer from hypertension, four million from diabetes, seven million are

19

smokers and four million have hyperlipidaemia. Chronic diseases of lifestyle are

responsible for 37 percent of deaths in South Africa, second only to 39 percent due

to HIV/AIDS (Stassen, 2008:2). Stassen (2008:2) presents a monetary value

calculated as the annual healthcare claims cost for certain health risk factors.

• Depression risk – R1763

• Elevated cholesterol – R1171

• Stress – R881

• Body mass index (BMI) – R748

• Glucose levels – R558

• Blood pressure – R354

• Alcohol – R329

The indication is that as these risk factors increase over time, for example, blood

pressure levels, the costs of medical claims also increase. The issue of under-

funded and under-resourced health systems in Africa increases the burden of coping

with infectious and chronic diseases. HIV/AIDS will thus have an increasing impact

on businesses. Medibank (2007:7) suggests that presenteeism is more frequent and

therefore more costly than absenteeism when it comes to depression. In the diagram

below, the contribution of medical conditions to overall productivity loss is shown.

The five health conditions with the highest cost are depression, hypertension,

arthritis, migraine and diabetes. These conditions account for about 75 percent of the

costs of presenteeism as estimated (Medibank, 2007:10).

20

FIGURE 2.4: Contribution of medical conditions to overall productivity loss

3%

19%

4%

8%

4%

19%

9%

2%

14%

6%

4%

8%

8%

Eczema and other skinconditionsAllergy

Arthritis

Asthma

Cancer

Depression

Diabetes

Heart Disease

Hypertension

Migraine/ Headache

Respiratory disorders

Back,neck or spinalproblems

Source: Medibank (2007)

GRAPH 2.1: The trend in the proportion of deaths due to leading illness categories between 1997-2007

Source: Bradshaw, Pillay-Van Wyk, Laubscher, Nojilana, Groenewald, Nannan and Metcalf (2010)

21

Figure 2.5 shows a rapid change in the death profile for the period between 1997

and 2007 with a noticeable increase in the proportion of deaths. This is due to

infectious and parasitic causes and respiratory infections accompanied by a decline

in the proportion of deaths due to injuries. Figure 2.4 as well as Figure 2.5 shows

that the imbalances between the demands of the competitive and stressful

workplace environment and work-life are affecting the wellbeing of employees. A

portion of company profits and shareholder fulfilment is hence claimed by these work

imbalances. The chronic diseases of lifestyle come at significant cost to the

individual and the employer, as do HIV/Aids. These chronic diseases include heart

disease, high blood pressure, high cholesterol, cancer, diabetes, lung and nervous

system disorders.

The economic effects of AIDS, on the other hand, will be felt first by individuals and

their families, then move outwards to firms, businesses, and the macro-economy.

D’Abate and Eddy (2007:365) reveal that the disparity among life realms can result

in emotional strain that is detrimental to employees. These life realm clashes can

have detrimental consequences for individuals. The same researcher gives an

indication of these life imbalances. Among them are psychological and physical

health problems, lower life satisfaction, familial problems, substance abuse, and

burnout. These are mostly diseases that could have been prevented by modifying

lifestyles. The implication from the above indicates that in helping employees deal

and cope with these imbalances performance and productivity might be improved.

Figure 2.6 below illustrates the psychosocial and the physical work environment as

causes of ill health. Stevens (2004:2) maintains that psychosocial issues such as

financial troubles, addiction and family problems can stimulate the occurrence of

presenteeism. Leka and Jain (2010:4) define psychosocial hazards as the part of

work scheme, social and environmental contexts which have the potential of

culminating into psychological, social or physical harm. These can impact negatively

on employee productivity.

22

FIGURE 2.5: Psychosocial work environments

Social and Organisational Context Design and Management of work

Indirect

Direct Pathway Experience of Stress

Pathway

(Physical work)Organisational Environment

(Psychosocial)Homework Environment

Harm to employee’s physical psychological and social health

Source: Leka and Jain (2010) The above figure illustrates that organisational and homework environments could

harm employees’ physical, psychological and social health. Leka and Jane (2010:2)

highlighted the existence of a strong association between work-related health

complaints and exposure to psychosocial hazards. Additionally, an interaction

between physical and psychosocial hazards at both individual and organisational

level is also evident as is shown in the above diagram. Many studies have

suggested that a hostile psychosocial environment increases the risk of

psychological and physical illness, as well as absenteeism (Biron, Brun, Ivers &

Cooper, 2007:26). It is therefore important to have an understanding of how

presenteeism is perceived as well as its impact on the workplace. According to the

World Health Organisation (WHO), work-related stress results from peoples’

responses to demands and pressures that are challenging their ability to cope (Leka

and Jane, 2010:4).

Stress at work is one of the biggest challenges facing management today as it

affects job performance. Service delivery among stressed employees is poor; hence,

conflict and disharmony within the work place may result (Cooper and Dewe,

2008:10). Stressed employees display high rates of absenteeism, mistakes on the

23

job, lower productivity as well as low levels of motivation. Prater and Smith (2011:2)

identified health problems emanating from prolonged exposure to stress. Employees

might engage in personal businesses while at work, as, if not at work they face

dismissal or disciplinary action. There is a remarkable change in the workplace due

to globalisation of the economy resulting to a universal use of technology. Prater and

Smith (2011:2) indicated that employees suffering from emotional and physical

stress find it is difficult to perform well on the job. Hence if not managed properly,

stress creates pressure on individuals and families. The table below distinguishes

risks for work- related stress as well as the reactions associated with it.

FIGURE 2.6: Risks for work-related stress

Risk for work related stress

•Job content

•Workload and work pace

•Work schedule

•Control

Stress reactions

•Physiological•Behavioural

•Emotional reactions•Cognitive reactions

Individual characteristics

•Gender•Age

•Education •Competitiveness

Source: Leka and Jain (2010) Figure 2.7 above depicts stress as the result of the lack of fit between the needs and

demands of the individual and those of the environment. Exposure to risk factors at

work may result in stress reactions. These reactions may be emotional, cognitive,

behavioural or physiological in nature. Leka and Jane (2010:8) claim that prolonged

stress reactions may develop into more permanent and fewer reversible health

outcomes. Some of these permanent health outcomes are chronic fatigue, burnout,

musculoskeletal problems or cardiovascular disease. Individual characteristics may

influence one’s ability to cope. Interaction of these characteristics with risk factors at

24

work may intensify or alleviate their effects. For example, if workers are able to deal

with risk factors at work, they will be more experienced and self-confident in

overcoming similar situations in their next encounter. Hence, a healthy and

productive workforce is essential for economic success and population health.

Presenteeism is therefore a complicated problem that is constantly shaped by

individual and organisational factors. Baker-McClearn et al. (2010:311) are of the

opinion that performance and well being are related to the organisational reaction to

presenteeism and absenteeism. It is therefore evident from the above section that

with the average age of the work force increasing, presenteeism may be expected to

increase further in years to come in America (Hooper and Bull, 2009). This may be

due to the potentially higher prevalence of chronic diseases and associated

symptoms within this population. In an attempt to alleviate the symptoms of

presenteeism, employees should manage a better work balance. Additionally, they

should request their employers to establish stress management programmes in the

workplace. Employees are able to show their commitment to work if they know they

are safe in their respective jobs. They take greater pride in their work, and are more

satisfied with and engaged in their jobs.

2.2.4 Symptoms and consequences The literature suggests that presenteeism is driven by several interrelated factors

that are common in today’s workplace (Schultz, Chen and Edington 2009:367).

Evidence shows that stress, employee health and work life balance are among these

factors. Employees are still working long hours to prove their faithfulness to the

organisation as well as securing their jobs. However, when sick, their presence in the

organisation is costly as they are not productive. Research suggests that high

workloads, deadlines, and very little backup support compel individuals to come to

work while ill or injured (Caverely et al., 2007:316). Schultz et al. (2009:367)

complemented this view by citing that factors such as the availability of effective

medication to treat symptoms and work demands may influence the decision to

come to work. Literature hence discloses that service-providing jobs dealing with

people were more prone to sickness presenteeism than other occupations because

of a felt responsibility towards clients (Schultz et al., 2009:367).

D’Abate and Eddy (2007:365) reveal that life realm imbalances can result in time

pressures, conflict, the preoccupation with home, as well as emotional strain. This

25

life realm conflict can further have detrimental consequences for individuals. The

same researchers noted psychological and physical health problems, lower life

satisfaction, familial problems, substance abuse, and burnout as among these life

realm imbalances. Lower job satisfaction, greater turnover intentions and increased

absenteeism, as well as less productivity, are consequences organisations may

experience from such imbalances. An indication is that greater organisational

commitment, trust and loyalty, work effort, and performance may result from the

assistance offered to employees in terms of balancing their work and personal lives.

In a report from Ontario an indication was that factors like work-related accidents,

equipment breakage, absences related to family-work life balance, poor quality of

work, conflicts and interpersonal problems are likely to increase the financial burden

(Ontario, 2010:2).

Presenteeism has both physical and psychological dimensions. Attending work while

feeling incapacitated due to an illness puts healthy employees at risk. Prater and

Smith (2011:1) complemented this view by citing that in chronic condition cases,

employees may have to work in the face of impairment. The impact of the above is

the increase in operational costs and death benefits, recruitment and training costs

due to lost personnel. Evidence is that the reduction of chronic disease is the basis

for both health and labour force productivity improvement. An indication is that

attending work while feeling sick prolongs recovery. Those depriving themselves of a

vacation or those who work very long hours can suffer from stress and depression.

In addition to that, these individuals are not getting the necessary breaks from work.

The distinction presented above results in company costs increasing as employees

are functioning at less than 100 percent for a longer time. Presenteeism can be part

of the cause of a negative workplace culture.

This could lead to low morale and employee resentment. It is therefore evident from

the above section that, as employees become sick, health care costs rises. It is

important for companies and organisations to diagnose their own problems after

which a strategy for managing this important issue must be considered.

26

2.3 FACTORS CONTRIBUTING TO PRESENTEEISM IN THE WORK PLACE Pilette (2005:1) emphasises that in today's work environments, employees are

expected to do much with less organisational support and resources. As a result,

many workers find themselves stressed and unable to perform optimally. Pilette

(2005:1) explains that employee job satisfaction declines if employees are suffering

psychologically and physically. Work-related factors and individual factors surfaced

to be the main predictors of sickness presenteeism in the work place. Biron et al.

(2005:26) reveal that those who have difficulties setting limits when confronted with

excessive demands, tend to show higher rates of presenteeism. Krohne and

Mugnussen (2011:2) indicate that work-related factors could be associated with

control regarding work tasks, relationships at work, and employment conditions.

Individual factors, on the other hand, might be linked to perceived health, financial

incentives, family life, and psychological factors, as well as attitudes from managers

and fellow workers.

Deciding whether to stay home or go to work depends on the understanding the

individual possesses regarding these factors. The same researchers state that a

healthy workplace is one where people are respected and appreciated for their

services. Hence, employees with high levels of job coping and job satisfaction may

decide to go to work, despite health complaints, by choice without being forced.

Johns (2009:521) reveals that from an employee perspective, presenteeism is

perceived to be important in that it might worsen existing medical conditions. It can

further damage the quality of working life and lead to ineffectiveness at work due to

reduced productivity. The implication is that organisational practices and policies

intended to reduce absenteeism could in fact promote presenteeism. On the other

hand, employees can find attendance management policies problematic in managing

chronic illness. This results in employees attending work when unwell to avoid

disciplinary action.

27

The figure below represents a model of presenteeism and absenteeism

FIGURE 2.7: A dynamic model of presenteeism and absenteeism

•Perceptions of presenteeism

Fully engaged

attendance

Health Event•Acute

•Episodic•Chronic

Presenteeism

Absenteeism

Person•Work attitudes

•Stress•Family responsibility

•Family matters

Cumulative Individual

Consequences•Productivity•Downstream

health, Attendance

Source: Johns, 2009 The figure above shows that fully productive regular attendance is interrupted by a

health event. The event can be acute (flu), episodic (migraine), or chronic (the onset

of diabetes). To some extent, the nature of the health event will dictate whether

absenteeism or presenteeism ensues. Johns (2009:532) is of the opinion that

contextual work restrictions determine the choice. This ultimately indicates an

interaction that exists between the person (the exact illness) and the situation (in this

case, occupation). It is evident that both presenteeism and absenteeism contribute to

lower productivity as well as health problems resulting in poor attendance and

concentration on the job. Johns (2009:534) reasons that workplace pressures can be

controlled by providing organisational support. However, it can be expected that

those with positive work attitudes would marginally exhibit presenteeism, as would

workaholics.

It is clear from the discussion that presenteeism affects both the individual and the

organisation. Hence, the impact of health-related presenteeim on the individual

employee as well as the organisation is to be determined.

28

2.3.1 Personal factors contributing to presenteeism Krohne and Mugnussen (2011:2), in their study, distinguish between work-related

demands and person- related demands for presence. In addition, the external factors

that may influence the decision to attend work ill are also recognised. Management

of stress in the workplace is to be treated as a priority for employees to remain at

work, engaged and healthy. Employees’ level of wellness can sustain or erode their

level of engagement. The better the health status of an employee, the more

productive they are. Employers are faced with a workforce that is more diverse.

2.3.2 Age and gender

Central to the analysis of the distribution of insecurity is gender. Women, in many

societies, have had less access to career jobs due to the social inequalities between

men and women. In today’s work environment there has been an improved

participation of women in the service economy (Green, 2009:357). An implication

thereof is that female workers may practise presenteeism more, particularly as they

are more likely to be in caring and teaching occupations. Böckerman and Laukkanen

(2009:1011), in comparing women in permanent full time work, women in fixed term

and part time work, argues that the former have a higher degree of control over their

work. Hence, Böckerman and Laukkanen (2009:1011) reveal that the pressure for

women to work while sick is higher than that of men.

It is therefore evident that the sickness behaviour of women differs from that of men.

Corresponding differences also exist between the sectors of economy. For this

reason, the differences in gender-related attitudes and sector-related work

organisations have an influence on presenteeism (Bockerman and Laukkanen

2009:1010). Given the rising intensity of global competition, the challenge for leaders

today is to create an organisational culture that promotes a performing workforce in a

performance workplace. It is likely that employers with an older workforce experience

the cost burden more acutely as the health status of their employees declines. The

incidence of chronic conditions increases with age, directly influencing the higher

medical costs that older employees incur compared with younger employees.

Emerging research suggests that over 60 percent of working adults between the

ages of 50 to 64 report having at least one chronic disease and that their health care

costs are twice as much as those of younger working adults (Bierla, Huver and

Richard, 2011:104). Additionally, the same researchers argue that older employees

29

seem to work more often while sick. This is due to their weaker potential to be hired,

the fear of losing their present job, while older employees want to appear as being

fully productive.

The moral attitude of older employees compels them to be on duty even if they are

sick. Researchers highlighted that the limited nature of family friendly policies has

often served to reinforce traditional gendered breakdowns of labour. Subsequently,

such gendered policies do little to address the issues and pressures that newer

family structures face. Leka and Jane (2010:32) state that differential negative

consequences concerning health and safety amongst men and women have

demonstrated differential working conditions. Without full time support of the family,

dual-income couples are facing new challenges. The implication is that policies

should be designed to make the work place family friendly. The next section deals

with the nature of dual careers.

2.3.3 The dual nature of careers When both husband and a wife have careers, while maintaining family life together,

they are referred to as a dual- career couples. The dual-career lifestyle has created a

unique set of challenges. Bessinger (2006:15) pointed out that these challenges

relate to socialisation and role expectations, work and family role conflicts. The result

of trying to cope with two careers may be that each individual is less competitive in

terms of his or her own career advancement. Each person has to make

compromises for each other's career, and the net result is often that each ends up

with a little less. A potential source of stress is viewed as the link between work and

home, particularly for dual career couples. It is even worse for those experiencing

financial difficulties or life crises. An unequal division of labour at home often leads to

fatigue on the part of the wife, and conflict for the couple. Balancing careers with

extensive family responsibilities, often including care of elderly parents or in-laws,

should be everyone’s desire (Bessinger, 2006:15). There is a rising concern of the

effects the new forms of work organisation and practices have. This is particularly in

relation to the effect that temporary employment, home working, part time work and

precarious employment may have on the health of workers’ organisations and

communities. A problem associated with the dual-career lifestyle reinforces the need

for programmes that examine role expectations. The above discussion highlights age

and gender as well as the dual nature of careers as some of the personal factors that

contribute to presenteeism. Simpson (2002:38) cites that the dual status of

30

managers, together with associated pressures of insecurity and overload, may well

have a different gendered impact on men, given their earlier advantages. Men may

feel the change more keenly. Long hours and, in particular, presenteeism, may arise

from managerial work. It is possible that these dysfunctions, while affecting men and

women alike, originate in men's feelings of insecurity and uncertainty (Simpson,

2002:39).

2.3.4 Organisational processes Presenteeism is related to the work environment as well as organisational demands.

Organisational processes put pressure on employees to perform optimally. There is

increasing evidence that the way people work, as well as how the workplace is

organised, can contribute to occupational stress (Baker-McClearn et al. 2010:311).

This is aggravated by the fact that, in the current corporate climate, employees are

constantly reminded to do much more with fewer resources. Consequently, this can

lead to serious health problems. Leka and Jane (2010:31) argued that systems like

lean production and flexible work arrangements have had an impact on working

conditions. These new arrangements have reduced feelings of job control, job

security and higher levels of job demands.

Economic pressures, coupled with expanding workloads, often compel managers to

place extraordinary pressures on their staff to perform. What is evident from the

literature is that there are several reasons why employees go to work while they are

actually sick. These may include perceived pressure from colleagues causing them

more work, a point system with incentives for attendance, the fear of promotion

opportunities being at risk and the fear of dismissal (MacGregor et al., 2007:51).

Bierla et al. (2011:98) point out that communal values and perceptions influence

one’s decision to go to work. For instance, an employee might decide to turn up for

work, despite being ill, to save a colleague from an additional workload. The policy of

sick leave adopted by companies has the potential of affecting the employee’s

behaviour and promotes presenteeism (Yang, 2009:341). For example, if employees

do not have enough sick leave days, they have to come to work in a condition that

could keep them from their best performance. Besides this, employees showing up

are costly to companies as their illnesses can infect other staff members. Johns

(2010:521) contends that presenteeism can be viewed as an act of organisational

citizenship and praise gathering. Hence, focusing on productivity loss, as opposed to

31

productivity gain, compared to absenteeism, is unduly restrictive. Research indicates

that without support at an organisational level there is bound to be a commencement

or even an escalation of illness symptoms. This may subsequently reduce capacity

to remain at work in the long-term. Munir, Yarker and Flaslam (2007:1462)

complemented the above view, stating that pressures to attend work while feeling

unwell may also increase symptoms related to stress.

Bergström et al. (2009:630) further interpreted this as indicating that individuals are

more likely to work through illness in occupations that involve caring for others. The

implication of the above is a strong demand on the employee to be at work

throughout despite ill health. Munir et al. (2007:1461) maintain that difficulties in staff

replacement, job demands and organisational norms and workplace cultural barriers

also influence attendance behaviour. Furthermore, the severity of financial loss due

to absence also affects the extent to which a person will attend work while sick.

Aronsson et al. (2005:960) indicate that financial loss due to absence is assumed to

have a more severe impact on the lowly paid. In view of that, their disposition to be

present is higher. Baker-McClearn et al. (2010:311) similarly argue that the right kind

of work can be good for a person but what the working environment entails is less

described. Consequently, consideration is given to how factors in the work

environment affect employee absence and presence (including presenteeism) at

work. Emphasis should be on the fact that sick leave is a benefit to be used when

needed and not to be saved for the purposes of cash on retirement.

2.3.5 COMPETITION Ireland, Hoskisson and Hitt (2009:106) affirm that competition fuels business to be

efficient in almost every way. It forces companies to control their costs, develop new

products and stay at the forefront of technology. Work processes that are efficient

and competitive enough should be guaranteed so that there is survival and growth in

the companies. Hence, work processes have to be sufficiently safe, humane and

financially rewarding to meet employees’ needs. The growing tension in trying to

maintain this balance leaves workers at all levels experiencing significant stress at

work. Prater and Smith (2011:983) argue that managers who desire to create a

competitive culture may not be aware of the underlying pressures compelling

employees to come to work not feeling well.

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Asherson (2008:35) claims that, to remain competitive in these volatile global

markets, companies are seeking greater numerical flexibility. New forms of

employment such as part-time work, temporary and on-call work have emerged.

These forms of employment are often associated with job insecurity, and mostly offer

only low levels of income. Bierla et al. (2011:99) suggest that the existence of a

committed workforce within a team of several employees on fixed term contract,

encourage employees to be present in the workplace. To give evidence of their

commitment and to differentiate themselves from their competitors, employees seem

to control their absence, even if they are ill. Prater and Smith (2011:7) insist that

management‘s failure to acknowledge employees’ fear of job loss may cause

problems as the economy pulls together. Employees who are worried about their

jobs and their financial security are trying to keep up with workplace demands along

with greater personal uncertainty. The above information suggests that in more

severe working conditions that are exaggerated by the employment of more

contingent employees, competition results.

2.3.6 Retrenchment fears Prater and Smith (2011:983) also suggest that employees are more than likely to

conduct personal business while at work for fear of job loss and reprimands.

Researchers suggest that managers are pushing themselves to work even more,

sacrificing potentially their physical and mental health. These employees are working

longer at physically demanding jobs, and those close to retirement fear they cannot

afford to retire. A report from a Disability Management Employer Coalition (DMEC)

suggests that to make ends meet, some employees are taking on two jobs, which

can lead to serious sleep deprivation and other health issues (DMEC, 2009:4). Fear

of redeployment as well as losing a job may cause employees to hide illnesses at the

workplace (Bergstrom et al., 2009:630). As such, employees may not take

appropriate medication, seek support, or make work adjustments due to ill health.

2.3.7 Job insecurities Job insecurity is a consequence of reorganisation, outsourcing, mergers and

acquisitions, as well as redundancies. The inevitable changes can often be highly

disruptive to organisational output and employees’ sense of well-being. Green

(2009:364) further highlights that age, as discussed in paragraph 2.3.2.1, an

individual factor affecting presenteeism, is also likely to be a significant axis along

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which insecurity varies. Older workers will have greater experience but, in an era of

rapid change, may possess obsolete skills. One therefore may expect older workers

to be less secure. Consequently, lower morale, less commitment and

underperformance as well as higher levels of social conflict are escalated by job

insecurity. Research identifies the relationship between the negative health effects of

job insecurity with poorer mental health, burnout, job-induced tension, stress and

depression. Studies, particularly in the public services and health care sectors,

established that job insecurity can be a risk factor for common infections. Therefore,

the threat of job loss may significantly impinge on the psychological contract

between an organisation and the employee and the trust on which this contract is

based. Simpson (1988) highlighted that many managers react to job insecurity and

fear of redundancy by staying at work for long hours in order to demonstrate

dedication to the job. Subsequently, in such cases, employees tend to become poor

organisational citizens and move to a more transactional contract. Such a situation

also brings about a feeling of inequity, which is an additional stress factor, besides

job insecurity itself.

Employees often have concerns about the continued existence of their job, along

with a perceived threat to their position within an organisation or career

opportunities. Nevertheless, employers clearly feel pressure, due to uncertainty in

job markets and the strains of the current economic climate, to go into work even

when ill. The current fragile state of the labour market is contributing to the

increasing rate of presenteeism and its associated costs. Most researchers

(Aronsson et al, 2005:960) highlighted that presenteeism is affected by the ease with

which people can be replaced in the workplace. Specifically, if one feels that s/he is

replaceable, that individual is more prone to attend work while sick. Demanding jobs

are often associated with higher levels of presenteeism. In support of this view,

Demerouti et al. (2009:51) examined job demands and found that they have a

positive relationship with presenteeism.

Research further disclosed that workaholics tend to demonstrate higher levels of

presenteeism. As defined by Schaufeli, Bakker, van der Heijden and Prins

(2009:249), workaholics tend to work excessively and compulsively, and are

internally motivated to work. This might be attributed to job insecurities and

pressures of the job and thus disregarding their wellness. In addition to their high

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levels of presenteeism, Aronsson et al. (2009:960) discovered that workaholics also

displayed the highest burnout and lowest happiness levels compared to groups that

are not workaholics. In addition, policies and procedures that make employees feel

insecure about their financial stability, employment, promotion prospects may create

stress (Baker-McClearn, 2010:313). In addition, tension, low morale and at worst,

employee ill feeling towards the organisation itself may result. This feeling has a

potential of reducing productivity and adversely affecting the organisational climate.

2.3.8 ORGANISATIONAL CULTURE Lathrop (n.d) views presenteeism as often relating to the culture, climate as well as

issues of morale within an organisation. Burton (2009:2) describes organisational

culture as consisting of attitudes, values and beliefs that are demonstrated in the

workplace on a daily basis affecting the mental and physical well-being of

employees. This is evident in daily interactions at work and in employment-specific

events (performance reviews, discipline processes). An implication is that an

organisational culture that exhibits trust has increased employee well-being, job

satisfaction and organisational commitment. In low trust organisations, burnout tends

to be higher, as well as turnover and job dissatisfaction. As a result, mental health

and wellbeing will be affected by culture either positively or negatively.

Hence, an organisation needs to influence and develop its managers to adopt

behaviours that persuade employees to undertake tasks in a positive and

empowering way. On the same note Kirsten (n.d), reveals that, in a survey of 35

large US employers, organisational culture was ranked as the most important factor

affecting employee performance, ahead of health. These employees were asked to

distinguish between factors greatly affecting employee performance as well as health

issues affecting absence and presenteeism at work. Organisational culture that

focuses on health and employee well-being, job satisfaction and organisational

commitment are all enhanced. In addition, a work culture with social support also

enhances employee well-being and can provide a positive environment for

employees who may be experiencing psychological conditions.

An unhealthy culture creates more stress in the workplace, which lowers employee

well-being. Basing company policies on discipline and communicating goals and

tasks is essential. Research reveals that performance management rewards

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constructive behaviours and block disruptive behaviour such as presenteeism

(Saarvala, 2006:7). Management has a role to play in building the conditions to make

employees responsible to find fulfilment