REVISIONES

 

Nursing presenteeism. Patient safety implications. Possibilities of control and reduction

Presentismo en Enfermería. Implicaciones en seguridad del paciente. Posibilidades de control y reducción

 

 

Reyes Revuelta, Juan Francisco*

*Nurse. Hospital Clínico Universitario Virgen de la Victoria. SAS. Nurse teacher at E.U.E. Diputación Provincial de Málaga. University of Málaga. Spain. E-mail: reyesrevuelta@hotmail.com

 

 

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ABSTRACT

We begin to find studies and research oriented towards the idea that poorer health and welfare of health care workers may have important implications for quality of care and safety that patients receive. The emerging phenomenon of perfect attendant, referred to those employees who despite being sick or injury that would force them to absent, report to work, serves as an example to try to explain this reality.
Objectives: Try to answer the following questions: Is nursing a perfect attendant profession? Why nurses do not call in sick? What implication does have this behaviour for Patient Safety? What chances have nursing supervisors and managers of health institutions to control and reduce perfect attendance in their organizations?
Methodology: A review of the available scientific evidence literature in Castilian and English between 1995 and 2011 was conducted in order to try to answer the following questions: Database used were Medline, Pubmed, Scopus, Cuiden, CSIC- ISOC y PsycINFO. Search was completed with references and intuitive search in Google. We found 57 items of which 48 were selected.
Results: The nursing profession, with care-and-welfare and education sector at the primary level is one of the professional groups with significantly higher rates of perfect attendance compared to other professions. A large number of variables, both organizational and individual have been described as perfect attendance predictors, i.e. facilitate and increase the likelihood that sick nurses go to work. After reviewing scientific literature no empirical study that relates the variables perfect attendance and occurrence of adverse events in clinical practice was found. We found a greater number of items that provide their attention to the role than doctors and other health professionals play in disease transmission to patients and to other colleagues when they decide to work despite being sick being carriers of infectious diseases. In a generic way a response to the phenomenon of perfect attendance in healthcare companies would be that they should tend to be salutogenic organizations, generating all the devices so that the conditions of work, their organization and their environment are healthy.
Conclusions: There is still a small number of researches focused on perfect attendance in the field of health institutions. Experts in occupational health, health management or quality or care should include this new phenomenon in their agendas, designing research to try to find better scientific evidence.

Key words: Preseenteeism; Patient Safety; Occupational Health; Nursing supervision.

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RESUMEN

Cada vez empezamos a encontrar estudios e investigaciones que orientan hacia la idea de que una peor salud y bienestar de los trabajadores sanitarios puede tener importantes repercusiones para la calidad de los cuidados y la seguridad que los pacientes reciben. El fenómeno emergente del presentismo, referido a aquellos empleados que a pesar de encontrarse enfermos o con alguna lesión que los obligarían a ausentarse, se presentan a trabajar, nos sirve como ejemplo para tratar de explicar esta realidad.
Objetivos: Tratar de responder a las siguientes preguntas: ¿Es enfermería una profesión presentista?, ¿Por qué las enfermeras no cogen la baja por enfermedad?, ¿Qué implicaciones tiene este fenómeno para la Seguridad del Paciente?, ¿Qué posibilidades tienen supervisores de enfermería y gestores de instituciones sanitarias de controlar y reducir el presentismo en sus organizaciones?
Metodología: Se ha realizado una revisión bibliográfica de la evidencia científica disponible en castellano e inglés entre los años 1995 y 2011. Las bases de datos utilizadas han sido Medline, Pubmed, Scopus, Cuiden, CSIC- ISOC y PsycINFO. Esta revisión se completó con búsqueda referencial y búsqueda intuitiva en Google. Encontramos 57 artículos de los que se seleccionaron finalmente 48.
Resultados: La profesión de enfermería, junto con las cuidadoras y la enseñanza a nivel primario son uno de los grupos profesionales con tasas significativamente más altas de presentismo en comparación con otras profesiones. Un gran número de variables, tanto organizacionales como individuales han sido descritas como predictores del presentismo, es decir, facilitan y aumentan la probabilidad de que una enfermera acuda enferma a trabajar.
Conclusión: Existe aún un número escaso de investigaciones centradas en el presentismo en el ámbito de instituciones sanitarias. Expertos en salud laboral, gestión sanitaria o en calidad asistencial deberían incluir este nuevo fenómeno en sus agendas de trabajo, diseñando investigaciones para conseguir encontrar una mejor evidencia científica.

Palabras clave: Presentismo; Seguridad del Paciente; Salud Laboral; Supervisión de Enfermería.

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Introduction

The term "presenteeism" is a neologism to describe a phenomenon opposite absenteeism, employees despite being sick or with some injury that would force them to take time off and sick leave are reporting to work^(1,2). It is an emergent phenomenon, recently study, analysis and description. The interest has begun to increase in some experts who consider that in real terms it is more harmful and bigger the cost originated via presenteeism than absenteeism path^{(3,4,5,6,7,8)}. In 2004 the prestigious Harvard Business Review reported that in the United States the estimated annual losses from presenteeism were over 150 billion US $ per year. In real terms cost would exceed the caused by sick works to stay home⁽⁹⁾. The term presenteeism does not refer to a concept still used in some labour laws which rewards employees who are absent less in their jobs or who don't use permissions that correspond to them (e.g. Argentina, Chile and Paraguay). This clarification is not to be confused with loss of time in non-productive activities at work (such as going for coffee, pause to smoke a cigar, make personal calls phone) or to pretend to be sick to avoid performing some tasks in job.

Most of the medical problems that result in presenteeism are of a relatively benign nature. After all, more serious diseases often force workers to stay home for periods of an extensive time. So research on presenteeism focused on diseases such as seasonal allergies, asthma, migraines and other kind of headaches, back pain, arthritis, respiratory infections, gastrointestinal disorders and depression. As we see all diseases with a high prevalence, impacting the health, but some workers and employers don't take it as something that affects job performance and therefore productivity labour.

This behaviour, to go to work while sick, to some people it may seem noble and admirable example of professionalism, but it can have dire consequences for health worker as to the quality of care provided and security to the patient.

This article aims to review the scientific literature on preseenteeism in healthcare workers, specifically in nursing group and try to answer four fundamental questions:

Is nursing a presentist profession?

Why nurses do not call in sick?

What implication does have this behavior for Patient Safety?

What chances have nursing supervisors and managers of health institutions to control and reduce presenteeism in their organizations?

 

Methodology

There has been a literature review in order to find evidence of scientific information's available on presenteeism in general and specifically in the nursing profession, as well as strategies to control and manage this phenomenon in healthcare organizations.

Search strategy:

Databases consulted were as follows:

-Medline

-Pubmed Scopus

-Cuiden

-CSIC- ISOC

-PsycINFO.

Descriptors used in the search databases in English were:

-"presenteeism",

-"sickness presenteeism",

-"nursing presenteeism",

-"sickness presence",

-"nursing performance",

-"nursing attendance"

-"Sickness attendance".

Descriptors used in the search databases in Castilian were:

-"presentismo"

-"presentismo & enfermería"

Inclusion and exclusion criteria.

-Articles with high relevance were selected covering 1995 to 2001. The last search was conducted on November 6th, 2012.

-Articles related to presenteeism were excluded in its meaning award to employees who are absent less in their Jobs or not using the permissions that apply to them. Also excluded articles in its meaning wasting time on unproductive activities at work.

After the protocolized search a total of 57 articles were identified. After reading the title and abstract, we have selected 48 articles meeting the inclusion criteria. After the analysis of the complete article we selected 32 items and we added 16 items by referential and intuitive searching on Google.

 

Results

1.Is nursing a presentist profession?

Studies over the past decade have agreed on point to the nursing profession, with carers and primary level teachers as one of the professional groups with significantly higher rates of presenteeism compared to other professions. In a large study, based on surveys conducted among more than 3300 Swedish workers in 2000, nurses were the professional group most likely to engage in presenteeism. Namely 4 times longer than other professional groups, O.R. 4.26 (IC 95% 2,05-8,86)⁽¹⁾. In another study conducted in the state of Tenessee (United States) between 2007 and 2008, the prevalence of presenteeism found in a sample of 112 nurses was 50%⁽¹⁰⁾. Recently in 2009, in a study conducted in New Zealand, 47% of the 68 nurses surveyed anonymously stated that they showed up for work with infectious disease symptoms⁽¹¹⁾. Unfortunately we did not find in the literature reviewed any paper posted on presenteeism among Spanish nursers.

2.Why nurses do not call in sick?

We know therefore that nurses work when ill, but for what reason? A large number of variables , institutional , economic and individual have been described as correlates of presenteeism, i.e., facilitate and increase the likelihood to go to work sick . The nursing profession is characterized by several of these correlates:

High job demands. Job demands include physical, cognitive and social features leading to prolonged physical and psychological effort. In nurse profession we can find low control over tasks, high workload, lack of time or resources, need to be physically present at work, need to respond quickly to complex, numerous and different information, situations of uncertainty, dealing with patients and families, time pressure. Demerouti et al. reasoned that those works who work under pressure would be more inclined to presenteeism precisely to maintain high levels of performance⁽¹²⁾.

Teamwork. Grynger and Singleton noted the influence of teamwork and peer pressure with the decision to go to work sick. High levels of cooperation into performance of the tasks have been associated with high levels of presenteeism⁽¹³⁾. In a qualitative study conducted in Australian nurses, they identified as the main reason for presenteeism the strong sense of responsability to the team. Absenteeism was perceived by nurses as negative and detrimetan to their peers. This perception was based on a context of low templates and high work demands⁽¹⁴⁾.

Attendance control. Grynger and Singleton in a quialitative stydy illustrated how strictly attendance control could cointribuite to presenteeism. Especially worrisome were those dynamics in which a worker was cited for an interview after a certain number of episodes of absenteeism leading to disciplinary action. Such control stimulated presenteeism⁽¹³⁾.

Job insecurity. On one hand, downsizing (the intentional reduction in workforce size for supposedly strategic reason) stimulate absenteeism due to perceived injustice, breaking the psychological contract and stress-related illness⁽¹⁵⁾. On the other hand one might also think that absenteeism would be reduced, as a defensive strategy, by the fear of losing the job, increased workload or changes in organizational structure would increase competition among workers making visible their commitment⁽¹⁶⁾. Implicitly or explicitly the idea is that some portion of the reduction in absenteeism engaged presenteeism.

Non-payment of sick days. Lovell cites a lack of paid sick leave as a particular stimulus for presenteeism especially among workers whith greater financial difficulties⁽¹⁷⁾

Difficulty or lack of replacement. Several investigations have examined the impact of presenteeism in the difficulty or lack of replacement, defined as the extent to which work missed due to absenteeism has to be made up upon return to work. These studies illustrate that workers are more inclined to attend the job despite being sick if they see that the work can piling up^(1,18). This condition may result from lean staffing, high specialization or a lack of multi-skilled workers. MacKevitt et al. found that UK specialist's physicians working in Hospitals response given the lack of replacement as the major reason for not using sick leave⁽¹⁹⁾. Following downsizing among Canada workers Caverley et al. found that the lack of replacemente it was most common reason cited for presenteeism⁽²⁰⁾.

Female. The scenario is that women are more inclined than men to presenteeism . Aronsson and Gustafsson found that women were more inclined than men to report presenteeism^(1,18). On one hand, women were over-represented in sectors with high presenteeism, on the other hand, migraine and depression, two of the diseases most associated with presenteeism, are more prevalent in women than in men.

Presenteeism culture. Jobs that involve care, support, and education at the primary level are more aimed to presenteeism, suggesting a culture created in part to the loyalty to vulnerable users such as children and patients. The philosophy that has traditionally surrounded the nurse identity as subordinate and the apparent absence of a culture of self-care contributes in part to explain the phenomenon of presenteeism⁽²¹⁾.

3.What implications dos have this behaviour for patient safety?

The revised literature has not found any empirical study linking both variables. Some authors have suggested the relationship may have presenteeism with the occurrence of adverse events in clinical practice^(22,23.24). Presenteeism can manifest in poor quality work, leads to deterioration of the quality of products and services and can be of a more severe mistakes happens. It can also manifest in poor time management, lack of concentration, poor teamwork, generally resulting in a low output per hour worked⁽²⁵⁾.

Adverse events rarely occur by a single mistake these are usually the sum of latent errors or root causes of system. Active error is the term used to refer to errors made by the professionals directly related to the patients. These are usually easy to identify (pressing a wrong button, inject the wrong medicine...) and almost always involve someone located on the first line of care and its effects are felt almost immediately. Fall into this category: forgetfulness, distractions, and lapses, errors of assessment and breach of established standards. Among the various active errors factors are physiological factors including fatigue, lack of sleep, use o certain drugs or suffering from a chronic or acute illness. Thus it is reasonable to think that a presentist nurse is more likely to commit an active error.

We find in the literature a large number of articles that pay attention to the role that physicians and other healthcare professionals play in the disease transmissions to patients and their peers when they decide go to work despite being sick, being carriers of infectious diseases (e.g. influenza, gastroenteritis)^{(24,27,28,29)}. As an example of the dangerous domino effect and its consequences, review papers describing the epidemic Norvovirus at the Hospital in New Zealand in August 2008, in which over a period of 4 weeks more than 38 workers and more than 143 patients were affected, affecting over 2300 missed shifts. The fact that there were more affected workers than patients made him think they were carriers and reservoirs of the virus and patients could contract the disease by the interrelation with presentist healthcare works.

4.What chance has nursing supervisors and managers of healthcare institutions to control and reduce presenteeism in their organizations?

Is therefore necessary that the clinical risk management and active error prevention happens to control this new phenomenon linked to the state of health of workers.

In a generic way, as stated by the Chilean researcher Aldo Vera, we could guess that a response to the phenomenon of presenteeism would be companies should strive to be salutogenic organizations, generating all devices for healthy working conditions, healthy organizations and healthy environment⁽³⁰⁾. In a more concrete form some of the recommendations for nursing supervisors or managers in healthcare companies about managing and reducing presenteeism would be the following:

1. Focus on presenteeism and not only absenteeism^(22,23), Supervisors who solely focus on absenteeism may be at risk of underestimating the impact that presentist workers have on their organization.

2. Become familiar with the concept^{(22, 31)}. Being a new phenomenon, magnitude and impact on organizations is still in a very early stage. It means many supervisors and managers have not focused attention on this variable with serious implications for the quality, safety of patients and the health and welfare of nurses.

3. Monitor the problems and conditions of physical and mental health affecting nurses and its impact in job performance, measuring prevalence of a number of common diseases including allergy, migraine, respiratory infections, asthma, gastrointestinal disorders, arthritis, stress and depression⁽³¹⁾.

4. Conduct research among nurses to quantify presenteeism, identify its causes and consequences. It is sometimes difficult to detect, to do this you can use a self-administered questionnaires with proven reliability and validity such as the Work Limitations Questionnaire (WQL), the Standford Presenteeism Scale (SPS), the Work Performance Questionnaire (HPQ), the Work Impairment Questionnaire (WPAI)^{(32, 33)}. Despite bias memory inherent in any such self-administered questionnaire, tools can provide valuable information. The HPQ has been developed by the World Health Organizations to asses indirect costs of health in the workplace and has a Castilian version called "Cuestionario sobre salud y desempeño" (CSD)⁽⁷⁾.

5. Carry out vaccination campaigns at work particularly in the case of infectious diseases. Promote hand washing and mask use^{(23, 24)}.

6. Promote the work of Occupational health services, which feature professionals whose functions include health surveillance, primary prevention and early detection of disease and the design and development of programs to promote behaviours and healthy habits among the working population⁽³⁵⁾.

7. Implement aid and assistance to employees with health problems, particularly depression, stress and others substantially affect job performance⁽³⁶⁾.

8. Asses the organizational climate⁽³⁶⁾. The phenomenon of presenteeism can be expressed and measured by signs such as:

-Co-workers who ask for help more often

-Co-workers who take breaks more frequently.

-Co-workers who are not able to complete their tasks on time.

-Complaints in the team of the poor performance of one of her workmates.

-Verbalisations on difficulties and job dissatisfaction.

-Increase in complaints from patients or relatives.

9. Using job satisfaction questionnaire provides additional information on interpretation organizational causes behind phenomenon of presenteeism⁽³¹⁾.

10. Establish clear policies regarding work attendance and discourage attending work while ill, particularly in the case of infectious diseases^{(23, 27, 33)}.

11. Examine the explicit or implicit message that sometimes can be sent to nurses in areas such as overestimating the presence of the employee at work, instructions for late, strictly control of work attendance, etc.^{(13, 22, 23, 33)}.

12. Encourage nurses to communicate their health problems or diseases without fear of reprisal^(13,23,33).

13. Provides employees with full pay when absent due to disease⁽¹⁷⁾.

14. Establish adequate nurse staffing ratios and ensure immediate replacement in case of co-worker sick leave⁽³⁵⁾.

15. Deepen leadership through a commitment to health employees and the quality of care⁽³⁵⁾.

16. Make health and welfare of the employee a corporate objective that is measurable⁽³⁰⁾.

 

Conclusion

Low performance of a presentist nurse can be the origin of active errors committed in the process of care. There is little researching focused on presenteeism in the field of healthcare institutions. Occupational health experts and healthcare quality managers should include this new phenomenon in its agenda, designing investigations where both variables, presenteeism and safety patient, are empirically related to finding better evidence.

It is appropriate that nursing supervisors and healthcare managers exceed model focused only on absenteeism. Firstly it is recommended that you become familiar with the concept of presenteeism and its harmful effects and to devise strategies and lines of action aimed at its reduction. This means not only lower levels of presenteeism but also absenteeism, healthier working population, workers more productive, with higher levees of job satisfaction and safeties hospital for users.

In the current economic crisis it's necessary to indicate that some political decisions have a direct influence on presenteeism. One example is suppression of a full complement for sick leave for workers of public health services in some regions of Spain. Another example is the latest labour market reform approved in Spain that facilitates firing conditions contributing to increased insecurity for workers. A final example is the increased budget cuts leading to smaller number of replacement nurses and increased workload, two variables considered correlates of presenteeism. Public administration should therefore explore possible consequences of policy action on phenomena such as presenteeism. A greater awareness of this problem would allow politicians to take well-informed decisions for the health of workers, the labour productivity and patient safety.

 

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