Revisiting presenteeism to broaden its conceptualization: A qualitative study

Abstract

BACKGROUND:

Presenteeism is generally viewed as a symptom of organizational or individual dysfunction and is rarely considered as a behavioral response to positive triggering factors. Our study examines this issue in small enterprises (SEs), which are an unexplored environment in terms of presenteeism.

OBJECTIVE:

Through in-depth analysis, this study aims to understand the positive and negative factors that impact presenteeism in the context of small and medium enterprises (SMEs), with a particular focus on SEs.

METHODS:

We adopt a qualitative methodological approach in which we conducted 17 semi-structured interviews with employees and owner-managers of SEs with between 20 and 49 employees.

RESULTS:

Our thematic analysis shows that presenteeism can be explained by factors related to pressure to attend work, by individuals’ constraints and commitment, by organizational and individual characteristics and by a congenial work environment. Presenteeism can also be a type of “therapy” which helps individuals to avoid focusing on being sick and enables them to stay active and avoid social isolation.

CONCLUSIONS:

Our study differs from earlier research by providing a more in-depth analysis of the positive and negative factors that trigger presenteeism. This article will help to expand the current theoretical knowledge about presenteeism and encourage a more holistic interpretation of the phenomenon.

Keywords

Conceptualization psychosocial risks positive factors motivational factors small enterprises (SEs)

1 Introduction

Presenteeism is defined as the act of showing up at work although sick [1]. It is a poorly understood [2 –4] and relatively unfamiliar concept outside academic spheres [5]. The phenomenon has only recently been attracting attention as one of the main factors that affect organizational performance [2]. Compared to absenteeism [2, 3], research on presenteeism is “markedly atheoretical” [3, 6]. The issue requires further theoretical and empirical development [2, 7] and a deepening of existing knowledge to understand the mechanisms—organizational and individual—that lead to the practice of presenteeism.

Table 1
Definition of presenteeism

Definitions of presenteeism Authors

“Presentees not working at full capacity” Collins et al. [12]

Going to work despite illness (Europeans stream)

“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” [1, 9] Aronsson et Gustafsson (2005, p 958) [1] Hansen et Andersen (2008, p 957) [9]

“The phenomenon of people, despite complaints and ill health that should prompt rest and absence from work, still turning up at their jobs” [13 –15] Bergström et al. (2009, p629) [13] Westerlund et al. (2009, p1099) [14]

“Ill and still work” [6 , 17] Demerouti et al. (2009, p51) [15]

Johns (2010, p 519) [6]

Halbesleben et al. (2014, p177) [16]

Johansen et al. (2014, p1) [17]

Loss of productivity due to attending work with health problem or other health conditions (American stream)

“Workers are physically present but function at less than productivity because of illness or other health conditions” [18, 20] Turpin et al. (2004, p1123) [18] Prochaska et al. (2011, p 736) [19]

“loss of productivity due to attending work with health problem or other health conditions” [21, 19] Cancelliere et al. (2011, p1) [20] Tang et al. (2011, p337) [21].

“Where employees are working less productively due to health or medical problem” [10] Hutting et al. (2013, p1) [22].

“loss of productivity due to attending work with health problems” [22]. Caverly et al. (2007, p305) [10]

Definitions of presenteeism	Authors
“Presentees not working at full capacity”	Collins et al. [12]
Going to work despite illness (Europeans stream)
“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” [1, 9]	Aronsson et Gustafsson (2005, p 958) [1] Hansen et Andersen (2008, p 957) [9]
“The phenomenon of people, despite complaints and ill health that should prompt rest and absence from work, still turning up at their jobs” [13 –15]	Bergström et al. (2009, p629) [13] Westerlund et al. (2009, p1099) [14]
“Ill and still work” [6 , 17]	Demerouti et al. (2009, p51) [15]
	Johns (2010, p 519) [6]
	Halbesleben et al. (2014, p177) [16]
	Johansen et al. (2014, p1) [17]
Loss of productivity due to attending work with health problem or other health conditions (American stream)
“Workers are physically present but function at less than productivity because of illness or other health conditions” [18, 20]	Turpin et al. (2004, p1123) [18] Prochaska et al. (2011, p 736) [19]
“loss of productivity due to attending work with health problem or other health conditions” [21, 19]	Cancelliere et al. (2011, p1) [20] Tang et al. (2011, p337) [21].
“Where employees are working less productively due to health or medical problem” [10]	Hutting et al. (2013, p1) [22].
“loss of productivity due to attending work with health problems” [22].	Caverly et al. (2007, p305) [10]

Conceptualization of presenteeism is not uniform [8], as demonstrated in table (1). Johns [6] explained two key streams of interest to define presenteeism. The first stream of research (European scholars) focus on the act of attending work while ill, the occurrence of presenteeism and its antecedents (eg., [1, 9]). However, the second stream of research, specifically North American research, defines presenteeism as a loss of productivity due to attending work with health problem or other health conditions. American researchers are more concerned with the productivity consequences of presenteeism, related to various illnesses while disregarding the causes of working while ill [10]. The different approach to define presenteeism may induce confusion on how to measure and prevent presenteeism [8].

While it remains tricky to define presenteeism, most researchers agree that presenteeism is: “going to work despite illness” [1]. Werapitiya et al. [11] reviewed forty articles (40) to verify how researchers define presenteeism. Twenty-three (23) articles of forty defined presenteeism as being at work despite illness.

Showing up for work when one is ill, implies indirectly that presenteeism is a negative behavior. Karanika-Murray and Biron [3] note that presenteeism is often considered to be “negative and costly behaviour”. It is often understood as an indicator of dysfunction [3 , 24] and is only analyzed in terms of organizational and individual shortcomings, health-related problems which indirectly leads to productivity loss [8]. The positive effects of presenteeism is still sparse in the presenteeism literature [8].

In this vein, presenteeism has been explained as being caused by organizational pressure factors [7, 25] such as having a heavy workload [9 , 26], staff shortages, problems with staff filling in for each other when off sick [1 , 27], attendance policies [6, 28], job insecurity [10], pressure from supervisors and colleagues [27] and workplace downsizing [6]. Also, in many organizations, absenteeism can be a gage of performance. As being absent may have an impact on promotion prospects, this can discourage employees from taking sick leave, thereby increasing the likelihood of them working while sick [29]. Most of the research suggests that presenteeism has a significant negative impact on productivity [30 –32] and on health. It is often associated with burnout [15], musculoskeletal disorders [33], depression [34], the risk of cardiovascular disease [35] and deterioration of overall health [13].

This negative approach, which Cooper et al. [5] call the “bad presenteeism phenomenon”, is over-represented in the literature. Zhou et al. [25] contend that presenteeism does not automatically suggest that the environment of a person’s workplace is negative. To understand presenteeism as a positive behavioral response, these authors call for its corresponding theoretical base to be revisited or, at the very least, for the current approach to the phenomenon to be changed.

Karanika-Murray and Johns [7] and Karanika-Murray and Biron [3] show that presenteeism as a positive phenomenon is gaining popularity, but it is still at the very early stage of development. Chia and Chu [23] argue that the perception of presenteeism as a negative phenomenon needs to be nuanced. Indeed, presenteeism is rarely presented as a positive behavioral choice prompted by affective-motivational factors [3 , 36–38]. Most studies fail to consider the influence of work-related attitudes and motivation on this behavior [7]. Johns [6] warns of ‘definition creep’ beyond health and disagrees attributing motives or including consequences to the definition of presenteeism.

Despite the widespread emphasis on presenteeism as an invisible behavior and the fact that it is time-consuming and costly, it is more often studied in large organizations and public-sector institutions, particularly in the health and education sectors [39, 40]. Few studies have investigated the causes of presenteeism in small and medium-sized enterprises (SMEs) [41, 42]. The presenteeism literature rarely distinguishes SMEs from larger firms [42]. Indeed, SMEs are characterized by a younger and less-educated staff working under precarious contracts [43] where employee wages are lower, regular schedules are rarer, periods in work are sometimes alternated with unemployment, and seniority and unionization are relatively rare [44]. Johns [6] reports that presenteeism is particularly high among individuals who work in teams and is more common among those with low levels of job security.

Knani et al. [42] demonstrate that presenteeism depends on company size. SMEs tend to be workplaces where employees follow a culture of presenteeism, notably because absenteeism has an amplifying effect on work activities. Indeed, what might be considered as small problems in larger organizations (e.g. absence) can have significant impacts for SMEs in a way that is similar to the “butterfly effect” (chaos theory) [45]. Large businesses are better at handling the problem of absence and have more resources to hire reserve staff [42]. Also, because of their small size and the contiguity between employees, the risk of contagion from illness is increased by the absence of monitoring and occupational health practices in SMEs. Several studies have confirmed that SME employees are more at risk of occupational injuries [46, 47] and are the most disadvantaged in terms of representation and support for their health [37]. Presenteeism itself is also contagious because proximity between employees can contribute to a culture of presenteeism in the workplace. Johns [6] describes “presenteeism culture” in a similar way to his description of “absenteeism culture”: in SMEs, strong emotional and physical interconnection between employees can influence self-perception of sickness [7] and increase presenteeism [42].

In summary, this study aims to understand, through more in-depth analysis, the positive and negative factors that cause presenteeism in the context of SMEs, with a particular emphasis on small enterprises (SEs). D’Amboise and Maldowney [48] are of the view that the small size of SEs makes it easier to identify and understand this baffling phenomenon. Research into SEs provides the opportunity to “concretely bring to the attention of observers the kind of workplace issues that are invisible or difficult to grasp and interpret in larger organizations” [40].

Our research questions are:

Why do employees’ practice presenteeism?

What motivates employees to go to work despite being ill (investigate positive and negative factors)?

How do the work conditions in SMEs impact the practice of presenteeism?

2 Methodology

Qualitative methodology has the primary broad goal of providing a rich and detailed picture of target phenomena. The depth and richness of the method enables the generation of new knowledge [49] and in-depth understanding of phenomena, their evolution, and their significance [50, p. 82]. As well as being descriptive and exploratory, qualitative research is a “powerful” tool for narrowing the gap between theory and practice. Qualitative analysis was therefore a valuable method for us to use to better understand why some employees decide to go to work when they are ill and to identify the positive predictive factors that influence their decisions about doing so, particularly in the SE context.

2.1 Study sample

Our sample is composed of employees and owner-managers of SEs (organizations with between 20 and 49 employees) across a variety of sectors. To avoid bias, we used stratified random sampling to identity potential participants. The participants were not selected based on a desire to prove a specific research objective. Emails were sent to potential participants explaining the purpose of the research and what their participation would entail. We assured them that their participation was voluntary and that they would be free to end it at any time. We also stressed that declining to participate or deciding to withdraw would not incur any penalties. We assured participants that their identity would be protected, and confidentiality agreements were signed.

After establishing the sample, we conducted 17 semi-structured interviews with employees and managers. Most studies suggest that between 5 and 50 participants are sufficient for qualitative research [43]; the sample size used in qualitative research is often smaller than that used in quantitative research, because the purpose of qualitative research is directed toward providing in-depth understanding and meaning rather than generalizing findings [51].

We fixed our sample size when we reached data saturation, which happens when “there is enough information to replicate the study [52] and when the ability to obtain additional new information has been attained” [53].

Table 2 below provides an overview of each enterprise’s sector of activity, its size and some of the respondents’ characteristics, notably their professional experience.

Table 2
Sectors of activity of SEs studied and characteristics of participants

Sector Total number of employees, including the owner-manager Men Women Participants Work experience

Food services 21 employees Managers Cooks 2 19 yrs (Mgr.)^*

5 yrs (Empl.)^**

Medical device production 36 employees Owner-Managers Executive Assistants 2 10 yrs (Mgr.)

6 yrs (Empl.)

Broadcasting 42 employees Managers Secretary 2 8 yrs (Mgr.)

32 yrs (Empl.)

Technology and innovation 31 employees Owner-Managers Accountant 2 11 yrs (Mgr.)

3 yrs (Empl.)

Environmental consultancy 25 employees Owner-Managers 2 9 yrs (Mgr.)

9 yrs (Mgr.)

Construction 22 employees Owner-Manager 1 4 yrs

Social services 40 employees Owner-Manager 4 Agents 6 9 yrs (Mgr.)

1 Secretary 6 yrs (Empl. 1)

3 yrs (Empl. 2)

5 yrs (Empl. 3)

2 yrs (Empl. 4)

7 yrs (Empl. 5)

^*Mgr: Manager; ^**Emp: Employee.

2.2 Data collection process

The university’s ethics committee approved the research protocol. Before conducting interviews, a pretest was carried out to prove the content and appropriateness f the interview guide and to ensure that the research questions were clearly understandable. The guide covered topics such as the culture of the workplace, the characteristics of the SEs, perceptions of presenteeism, triggers (organizational or individual) of presenteeism, and measures to prevent the practice.

Data were collected from the semi-structured interviews, which were conducted in the participants’ workplaces. The interviews, which were all conducted by the first author, were recorded, and lasted between 60 and 80 minutes. The consent of the participants was obtained before the interviews were recorded. No additional interviews were conducted once saturation had been reached (when data collection no longer offers any new or relevant data).

2.3 Coding and data analyses

Our interviews were transcribed verbatim for coding and data analysis. Data coding was carried out following the model of Miles and Huberman [54]. This model makes it possible to systematically analyze the data collected and reduce the complexity of the qualitative data obtained, and it can therefore serve as the starting point for the data analysis process [54, 55]. Miles and Huberman [54] break the process down into three steps: (1) condensation of the data (reduction and coding), (2) presentation of the data, and (3) validation of the data and formulation of conclusions.

The interview transcripts were read and reread several times to ensure that the information they contained had been fully and correctly understood. We then selected paragraphs as our basic coding unit. By identifying and highlighting significant content in the transcripts, we were able to reduce the volume of data to be analyzed and identify paragraphs of meaning. This allowed us to eliminate any passages unrelated to our research topic, which Miles and Huberman (1991) [54] call “trash”. A list of codes by paragraphs of meaning was then drawn up with reference to the content of the interview transcripts. Because of the exploratory nature of the study, emerging coding categories were identified as free kernels to contribute to the creation of new knowledge. We began the coding process by matching the main themes with the corresponding passages from the interview transcripts. Our interview analysis can thus be seen to be the result of thematic choices guided by our most important research questions.

To ensure the authenticity of our results, we chose thematic content analysis as the preferred approach for this study [54, 55]. Repeated readings of the identified passages allowed us to group the most frequently recurring themes together. Subsequent vertical (intra-interview) analysis helped to clarify the interviewees’ perceptions of all the issues identified in the interview guide (with each theme mentioned by interviewees being considered separately). We then carried out horizontal analysis (inter-interview) to identify the different ways in which themes in the interview guide were approached by the different interviewees. This analysis also enabled us to identify the most frequently occurring themes and sub-themes in the interviews. The main purpose of this data analysis was to use the raw data so obtained to establish categories that could later be used in our theoretical model. To reduce to a minimum any risk of bias in our interpretation, all the authors ensured that the findings fit with the collected data and not with our own positions. From the formulation of the questions to the subsequent treatment, the codification and data analyses were conducted and discussed by all the authors, and the results are presented without any judgment.

3 Results

Before examining the positive and negative factors that trigger presenteeism, we needed to better understand how our interviewees felt about the phenomenon. Two different viewpoints stood out in our analysis: (1) presenteeism is a common practice in SEs, and (2) presenteeism is a behavioral response which employees choose to engage in.

3.1 Presenteeism in small enterprises: A common practice that is willingly followed

3.1.1 Presenteeism in SEs: A common practice

As our semi-structured interviews clearly revealed, presenteeism is a given for many employees. Our results show that presenteeism is now considered normal behavior and is becoming widespread in this type of workplace:

“I’m not a good example because, you know, I think I might have taken 10 sick days in 32 years, and that’s probably generous, (. . .), and frankly, I don’t find it unreasonable, quite the opposite, it’s perfectly normal for someone who wants to earn her living.”

It is also justifiable behavior for owner-managers as responsibility for running the enterprise lies largely with them. The SME “is a mega person, in contrast to a big business megastructure” [56, p 22]. In a similar vein, one of the managers we interviewed noted that any absence by him was quite unsettling for his employees as he was the “only captain on board”. This is consistent with the findings of Torrès [56], who stresses that “the enterprise’s extreme dependence on its boss often makes the boss indispensable, indeed irreplaceable”. Thus, for one manager, going to work even when unwell is acceptable behavior, especially in the eyes of his employees, because he is the owner and must manage the daily operation of his enterprise:

“Somewhere along the line, your employees recognize that you are the leader of the business, its owner, so it’s normal that you do more hours, it’s normal that you work even if you’re sick... finally, it’s my business and I have to oversee its survival and its growth.”

3.1.2 Presenteeism: The employee’s own choice

In some circumstances, presenteeism is an individual behavioral choice. The voluntary aspect of presenteeism depends on the individual employee’s health condition. When the condition is severe, going to work is not an option. When it is minor, presenteeism is a matter of choice and is motivated by different factors such as a sense of personal accomplishment or simply loving one’s job and was conceptualized as a balancing act between health constraints and performance demands.

“When my health problem isn’t debilitating or serious like the flu [(. . .] I’ll come into work without batting an eyelid.”

Moreover, choosing to go to work when sick is an individual decision that employees take when they believe their condition is not contagious and will not worsen their own health. When they choose presenteeism in these circumstances, they judge their illness to be minor and non-contagious rather than incapacitating and contagious. In this situation, going to work when unwell is almost automatic:

“If someone calls me and says they have the flu, I really don’t want them to come in, because they’ll be contagious, and I don’t want everyone coming down with it, too. If I have the flu, I know that same bug could spread as well, so it’s better if I stay at home.”

In summary, our results show that the decision to go to work when sick is driven by the judgment of the employees concerned about their ability to work, their assessment of their own health and their personal motivations (love their work, sense of achievement and of professionalism):

“It’s an obligation I place on myself. I know nobody is demanding I come in if I really am sick. It’s just something I make myself do for the sake of my professionalism.”

3.2 Factors that contribute to presenteeism

Our research shows that presenteeism is not driven only by negative factors (organizational and individual pressures and constraints, e.g., deadlines, peak periods, assessment of the consequences of being absent, financial precarity, no sick leave). It is also driven by positive motivating factors, particularly: (1) the employee’s personal values, (2) the opportunity to avoid focusing on being sick and being socially isolated, (3) a sense of personal accomplishment, (4) the employee’s professional commitment, (5) a congenial working environment, and (6) workplace adaptations to accommodate health issues. This means that negative contributing factors arising from the pressure to go to work coexist with positive motivating factors and together explain the presenteeism decision-making process.

3.3 Negative contributing factors

3.3.1 Individual factors

Assessment of the consequences of being absent. Some of our interviewees judged that their absence was expensive and reported that this was a factor in their presenteeism. Their absence can impact their pay, their work, and their potential job advancement:

“My absence will have personal and organizational costs. I prefer to come to work even when sick, to keep my job.”

In addition, employees engage in presenteeism to avoid overloading their colleagues, especially when it is difficult for a colleague to fill in for them, and they therefore go to work when ill:

“My absence disrupts the pace of work and it increases the workload of my colleagues. I do not want to overload them, since nobody can replace me.”

Also, workers with difficult financial circumstances are more likely to engage in presenteeism. This is particularly the case for those at the lower end of an organization’s hierarchy and those who are part-time employees:

“My financial situation is difficult. I have to keep my job at all costs, even going to work when sick”.

3.3.2 Organizational factors

Deadlines and peak periods. Presenteeism increases at times of high pressure, and many workers go to work when they are sick because they have deadlines to meet and no one can do their work in their absence. Employers rarely send sick employees’ home when there is a need to meet deadlines, but at less-pressured times presenteeism can decrease and absenteeism may well increase:

“I have contracts with customers, and it is very important to meet the deadlines, otherwise the customer may change supplier. We often come to work when sick to honor our contracts.”

Employees who have less access to paid sick leave and those who have exhausted their available sick leave are also more likely to engage in presenteeism:

“I have a chronic illness, and I have used up all my personal days off, that’s why I do presenteeism.”

3.4 Positive contributing factors

3.4.1 Personal values

Strongly held personal values. Most interviewees reported that engaging in presenteeism was strongly aligned with their personal values. These individual norms and values play an important role in their decision to go to work when sick. Most interviewees agreed that presenteeism is a choice which is driven by their own convictions and values, whether those characteristics are found within their organization. Our results demonstrate the importance of personal attitudes, standards, and values in the decision to go to work despite being unwell. These standards and values are individual in nature and not necessarily shared by the organization or by society more broadly.

“I don’t feel any pressure from my employer to come to work when sick, quite the opposite. It’s really a pressure I put on myself, it’s my values that dictate my behavior.” “I make my own decisions, very much on the level of values, it’s my own personal value system, not the value system of the organization.”

Following family values. Interestingly, our results revealed the role of deep-seated family values in the occurrence of presenteeism. For some of those interviewed, presenteeism seemed to be a natural extension of the “ideology” of their personal circle, especially of their parents. Interviewees, both employees and employers, reported that they had been exposed to the culture of presenteeism very early in their lives and that presenteeism behavior was not exceptional in their own family setting. Presenteeism had somehow become a “value in itself” or an “element of family culture” that was passed on from one generation to the next. The desire to set an example can also be an explanatory factor in presenteeism. Our results show that family dynamics is one of the personal characteristics that contributes to presenteeism.

“I needed to be really sick, not just sort of sick, for my parents to say I should stay home, and now I follow them.”

“Certainly, it’s partly my parents’ doing that I come to work when sick, it’s a family trait, I guess!”

Work as an important element in the individual’s life. For most of those interviewed, working gave meaning to their lives, created a sense of balance and well-being, helped them develop a social network, gave them a sense of belonging, and contributed to their social involvement. For others, notably those with mental health issues, working improved their self-esteem and general quality of life. These motives weighed heavily on the decision of several interviewees to go to work when they were unwell. Being absent deprived them of the benefits they derived from working. Then, the level of presenteeism is directly influenced by employees’ sense of work.

“It’s funny but coming to work when sick makes me better! My work makes me well again, and it makes me feel useful.”

3.4.2 Presenteeism as therapy in a favorable context

Distraction from illness. Our results show that SE employees dealing with mental health issues are more inclined to engage in presenteeism. This is largely due to the social climate and emotional closeness experienced by employees in small organizations. Many people with mental health problems find understanding, mutual help, and friendly relations in their workplace, often without judgment or stigmatization. Being part of their work group gives them an opportunity to talk about and, above all, a way of being distracted from their health problems. The relational interactions in their regular contact with their colleagues can be effective in helping unwell individuals to avoid focusing on being sick. Such employees feel supported psychologically and therefore choose presenteeism. Work becomes a haven and a safe place for negotiating difficult times, especially those related to mental health.

“Sure, when it’s an issue of physical health, presenteeism is maybe a bit more negative, but on the mental health level, it makes me forget that I’m sick. So, if I really want to take care of myself, I know I’m better off going to work.”

Breaking out of isolation, remaining active. Going to work enables employees to stay active and keep up their connections with colleagues. For employees who are unwell, going to work despite their health problems does not necessarily have adverse effects on their health, especially their mental health, because the workplace is seen as an environment for social exchange and communication, and notably as a place for social interaction. For most of our interviewees, working was a way to escape isolation and stay active, so they had no hesitation in going to work when sick:

“My illness is primarily related to my mental health, so for me it’s more fun to come to work; I come, really, looking for the social contact that being here gives me. Human contact is what prompts me to come to work when sick. It’s precisely coming in and laughing with the others, working together on our projects, that’s what’s so great for my health.”

Interviewees also stressed that they did not like staying home, and so were much more motivated to return to work despite their health problems. This is consistent with the findings of Giæver et al. [57] which showed that some doctors preferred to go to work while sick, as staying at home did not necessarily help to improve their health.

Feeling of pride. Several of our interviewees saw their work as a source of pride, self-fulfillment, and professional achievement. For them, going to work despite their health problems showed they had stamina and perseverance and encouraged their sense of self-worth, particularly because overcoming those problems gave them a feeling of personal accomplishment:

“Turning up at work, it’s really for the psychological boost it gives me, not for the money, I’m doing okay, money-wise. I don’t need it. I really come because of the positive social aspect and above all for the satisfaction, the pride in knowing I am fulfilling myself. I’m meeting challenges, I’m managing to do things well despite my health problems.”

Attachment to the enterprise. Employees’ commitment to their work often stems from it having a positive workplace culture and a congenial environment. SEs stand out as places of work where employees are fulfilled at the personal level. Because they are small, these businesses seem to encourage a sense of usefulness and the desire to be actively involved in the organization and contribute to its daily operation, particularly when the enterprise is a family business. Most of the interviewees had a sense of satisfaction and close connection with their enterprise, which made them want to do their work well. This attachment reveals a three-way symbiosis between employees, their work, and the enterprise they work for. Their commitment is reflected in positive behavior such as presenteeism, which they believe protects the enterprise from any negative impact from them being absent. In this respect, presenteeism can be a positive gesture by satisfied and committed employees. Our result shows the close link between employees’ presenteeism and commitment to an enterprise.

Commitment to clients. Some employees adopt presenteeism behavior out of respect for commitments that they or their enterprise have made to clients. Wanting to avoid any delay in delivering or providing goods or services was one reason given by interviewees to justify their presenteeism. These interviewees (both employees and managers) explained that, as their organization had managed to carve out a place for itself in the market, they felt it important to help to contribute to and strengthen its position there, hence their personal decision to practice presenteeism. In fact, in this study, SE managers, especially men, display presenteeism behavior as a way of asserting their professional identity.

“I often turned up sick and everything, but that wasn’t for the enterprise or for my colleagues. It was really for my clients!”

3.4.3 Congenial work climate

Team spirit in the workplace. Almost all the interviewees viewed their SEs as “human” enterprises, with a value system that reflected their own values and convictions. Others emphasized the sense of being part of a big family, a feeling which is specific to SE workplaces. For them, SEs foster harmonious relations and clear internal communication. It could be said that presenteeism is the symbol of a symbiosis between the employee and the enterprise, reflecting an “obligation” that employees feel toward their colleagues. This intra-group loyalty places a certain amount of pressure on employees, as they feel indebted to an organization which offers them so much in terms of their social and personal relations. Several interviews felt it would be “disloyal” to leave their colleagues in the lurch and destabilize the team. In fact, good relations among employees motivate individuals to go to work despite being sick. Presenteeism therefore becomes a gesture of empathy and a fair return for the people (colleagues or manager) they feel close to.

“I think we really have great teamwork here, so it’s precisely when one of us isn’t well and has said so, that we all rally round and help. And we have our slogan: ‘Our strength lies in the team’. So, we really work hard, immensely hard at teamwork.”

Physical and affective closeness among employees. The small size of SEs promotes regular contact among employees. In these workplaces, everyone knows everyone else and interacts with them every day; this leads naturally to a climate of mutual help, of looking out for one another and to a friendly work atmosphere. A type of emotional closeness develops within the entire group, including the manager, and this closeness encourages presenteeism by instilling a sense of obligation to the group, to the team. So, although there can be downsides to organizations being small, the closeness that SEs create among colleagues can also help to reduce tension in the workplace:

“It’s this closeness we all have together: we’re really just a single close-knit unit that functions as one for the good of all, the organization and the clients. This closeness makes us feel responsible to each other at work.”

Finally, presenteeism becomes the behavior of choice when an organization is prepared and able to adapt to the needs of its employees and support their rehabilitation after being sick. This occurs primarily through workplace group support and adaptation:

“I think that being a small team, and having an informal and very flexible structure, helps a lot. Getting back into the swing of things is much easier. When you’re in a big business, I’m not sure you get this same kind of support. Here, we’re very close, even with the manager. We’re all friends, and this helps us get back into our work rhythm bit by bit.”

A family-like relationship. The strong interpersonal ties developed with colleagues increase the tendency for presenteeism. In SEs, workplace relations are more like family connections or friendships than hierarchical relationships with authority figures. Our interviewees stressed that they felt truly bonded with others in their work environment. They saw the SE as a “family unit” or “community of workers” where the classical employer-employee hierarchical opposition was simply not experienced. For several, the goodwill they found in their SE workplace reinforced their positive perception of the organization and, as a result, indirectly encouraged them to practice presenteeism:

“The atmosphere is always very positive and we’re always there for each other, helping each other, we’re one big family here! You can’t find that in a big business.”

Managers’ openness to workplace adaptations. Adaptations to make it easier for employees to return to work were one motivating factor of presenteeism identified by some of the interviewees. When employers suggested adapting a workstation or adopting a flexible work schedule to ease them back into their job, employees felt encouraged to return to their workplace despite their health problems. As they saw it, such workplace adaptations created a good balance between the needs of the workplace and their reduced ability as employees, thus helping to foster better performance and a sense of well-being at work for the employees concerned. In sum, adaptation at work and the reorganization of the tasks of employees who have not yet fully recovered help to improve their work performance.

“My boss offers me a lot of flexibility and latitude, and this gradually helps me to get back into my work routine.”

Table 3 presents all the results from this section.

Table 3
Contributing factors to presenteeism in small enterprises (SEs)

Positive contributing factors

Individual factor

Personal values

•Strongly held personal values

•Family values serve as a model to be followed

•Professionalism in work seen as an important value

Feeling of perseverance and personal accomplishment

•Feeling of pride

Presenteeism as therapy

•Opportunity to avoid focusing on being sick

•Opportunity to avoid workplace social isolation and remain active

Commitment to the job

•Attachment to the enterprise

•Commitment to clients

Organizational factor

Congenial work climate

•Team spirit in the workplace

•Physical and affective closeness among employees

•Family-like relationship in the workplace

Support provided by SE manager

•Openness to workplace adaptations

Negative contributing factors

Individual factor

Assessment of the consequences of absence

•Overloading colleagues

•No replacement

Financial precarity

Organizational factor

No sick leave

Pressure factors

•Deadlines

•Peak period

4 Discussion

There is a need to understand the factors that encourage the practice of presenteeism. Through our in-depth analysis of the positive and negative factors that trigger presenteeism, our study highlights the importance of broadening our understanding of presenteeism in order to balance the predominantly negative view of it and deepen our understanding of the phenomenon.

Drivers of presenteeism include the pressure to attend work and individual constraints (deadlines, peak periods, assessment of the consequences of being absent, financial precarity, no sick leave). Our research extends the current knowledge of presenteeism and contributes to a better understanding of the factors that underly this practice. Although presenteeism can be costly and negative, this article has highlighted its potential positive effects—especially for employees with mental health problems. Indeed, presenteeism can be the result of a demanding but stimulating work environment. The practice of going to work when ill decreases when employees have a lack of challenging and sufficient work.

This study shows that presenteeism is a positive behavior which is explained by motivating factors, particularly (1) the employee’s personal values, (2) the opportunity to avoid dwelling on being sick and being socially isolated, (3) a sense of personal accomplishment, (4) the employee’s professional commitment, (5) a congenial working environment, and (6) workplace adaptations to accommodate health issues.

Our results reveal that characteristics of SEs, such as the social support they provide and the physical and affective proximity between employees and managers, help employees to cope with their health problems and make the experience less unpleasant. Our interviewees (both employees and managers) put particular emphasis on the fact that SMEs are “human”. This is because the small size of SEs encourages cooperation, small-group activities, and strong interpersonal relations. Indeed, one advantage of SEs is their low level of bureaucracy, characterized by informal family-like interactions, proximity and emotional bonding among employees, and their regular contact with owner-managers, which all increase employees’ commitment to the organization. When an enterprise meets its employees’ social needs and their need to belong to a group, and enables them to apply their work skills, it contributes to their employees having a positive attitude.

Affective and positive experiences in the workplace and having a positive attitude to work, (such as employees having commitment, feeling they are fairly treated by colleagues and managers, feeling positive about work and feeling supported) leads to the practice of presenteeism as a way of demonstrating engagement and satisfaction. A recent study of more than 6,000 academic employees in UK universities found that engagement was one of the strongest predictors of presenteeism [37]. Our research shows that presenteeism is a personal choice which depends on the severity of the health condition and cultural and familial values. Attitudinal-motivational processes, such as having a positive attitude toward work and motivation, increase presenteeism, a finding which is consistent with previous studies [1 , 59].

In addition, when employees respond appropriately to job demands, they preserve their self-respect and self-efficacy, despite their health problems. Feelings of self-efficacy have been identified as an important predictor of continuing to work during periods of illness. Karanika-Murray and Biron [3] use the term “functional presenteeism”, or maintaining productivity despite being ill, which is dependent on the “accessibility of work resources to reach balance between performance and health capacities in tandem”.

Presenteeism is also conditioned by employees’ perception of their work environment and the meaning they attach to it. if they consider work to be fundamental to their identity, self-fulfillment, and inclusion, then presenteeism is voluntary and a way to maintain these work-related benefits. This is consistent with the results of de Vries et al. [58] who found that their respondents identified their work as a fundamental value that could motivate them to continue working, even when experiencing musculoskeletal pain. Employees for whom work has important value will therefore choose to go to work despite being ill.

The therapeutic role of presenteeism adds another dimension to our understanding. Indeed, individuals with mental health problem, such as depression, burnout, or emotional distress, are more likely to engage in presenteeism. If employees feel that their workplace is a place for recovery and healing, presenteeism becomes a way for them to avoid focusing on their illness and to counter social isolation. Work becomes a generator of social contacts and a buffer against feelings of loneliness.

Going to work despite health problems improves individuals’ mental well-being. Presenteeism can be a type of therapy for employees who suffer from mental health issues, and work becomes “beneficial” for their mental health. Being with colleagues is better than being alone with their mental health problems. Sanderson and Cocker. [60] showed that the rate of presenteeism in employees who suffer from depression is twice as high as in employees who do not. Further research on the therapeutic effects associated with presenteeism could be extremely valuable. Also, it is important to draw a distinction between mental and physical illness because they are perceived differently in the workplace and lead to different reporting behaviors.

4.1 Limitations and implications for future research

Our study explored the predictive factors that influence presenteeism in SEs. However, our results cannot be generalized to all SMEs or large enterprises. SMEs are not a monolithic group of enterprises; they are highly diverse workplace environments.

SMEs should not be considered in opposition to large enterprises. Many studies which compare small and large enterprises contain numerous caveats, so any comparison can be “dangerous” [56]. It is worth mentioning that some of the salutary aspects of SEs described in this study can obviously also be found in large organizations. In addition, our qualitative results are initial, and needs to be explored in other contexts to more understand presenteeism.

In summary, this study clarifies the conditions under which employees choose presenteeism instead of absenteeism¸ and provides insights into the reasons why they engage in presenteeism. Our research presents a mixed view of the positive and negative factors. Although presenteeism is often viewed negatively, we demonstrate that it can be a positive behavior with a positive impact. It is therefore important to consider the evolution of the conceptualization of presenteeism to advance empirical understanding of presenteeism and balance the current negative perspective.

In this vein, work to develop conceptual clarity could help researchers to better understand presenteeism and its dynamic factors and nature. This research helps to fill some theoretical gaps and paves the way for future research to revisit presenteeism and broaden its conceptualization.

Presenteeism is mostly the outcome of attending work despite illness. However, decision to attend work ill is not only based on simple health condition. Presenteeism can be categorized into sickness presenteeism (physical/mental health) and non-sickness presenteeism, explained by non-illness-related factors. In other words, presenteeism may be due to triggers that are unrelated to health. Such consideration does expand the meaning and definition of presenteeism,

In fact, our research suggests that definition of presenteeism needs to be broader to contain illness-related reasons (sickness presenteeism or health related presenteeism) and non-illness-related reasons (non-sickness presenteeism). For illness-related reasons we propose that researchers retain the fundamental understanding of presenteeism, as behaviour of working despite illness, and to consider severity and duration of illness (episodic or chronic) and the type of illness (mental or/and physical). In fact, not every health problem necessarily causes productivity losses or affects workability of the employee. For non-illness-related reasons, we should consider organizational, and individual factors, which opens the way to consider the positive and negative facets of presenteeism. This conceptualisation of presenteeism makes a similarity to the definition of absenteeism, in which researchers make a difference between health-related absence (sickness absenteeism) and absence due to other causes (non-illness reasons).

Also, it is worth to mention that the current conceptualization of presenteeism, as going to work despite illness, hide the possible positive effects of presenteeism that are often overlooked. To better understand the phenomenon, it will be important to consider the presenteeism’s dark side (negative and costly behavior) along with its therapeutic side, in certain cases of mental sickness. However, it should be recognized that while presenteeism has a positive impact, maintaining performance can be short-lived and, in the long term, presenteeism can lead to longer periods of absenteeism and deteriorate health.

Presenteeism can be beneficial for health, can satisfy short-term operational imperatives, and can improve the recovery process, notably for individuals with mental health problems. However, the long-term risks of being unwilling to disengage from work can be harmful and well-being may deteriorate over time. So, even positive presenteeism needs to be carefully managed and organizations must take a long-term view of the consequences of presenteeism. Establishing an organizational culture that encourages workers to take adequate time off to recover from being ill seems essential, even for employees who practice functional presenteeism.

More research is needed to separate the factors from the effects of presenteeism. We identified positive and negative factors that can explain presenteeism, but future research could explore the long-term effects of functional presenteeism on performance and global health.

Finally, although there is growing theoretical knowledge about the issue of presenteeism, there are still no preventive strategies keeping pace with these advances. A broader approach would make it easier to identify presenteeism behavior and to better understand it in different workplace contexts. After all, presenteeism is an issue for all organizations and therefore needs more attention and action strategies.

5 Conflict of interest

None to report.

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Sector	Total number of employees, including the owner-manager	Men	Women	Participants	Work experience
Food services	21 employees	Managers Cooks		2	19 yrs (Mgr.)^*
					5 yrs (Empl.)^**
Medical device production	36 employees	Owner-Managers	Executive Assistants	2	10 yrs (Mgr.)
					6 yrs (Empl.)
Broadcasting	42 employees	Managers	Secretary	2	8 yrs (Mgr.)
					32 yrs (Empl.)
Technology and innovation	31 employees	Owner-Managers	Accountant	2	11 yrs (Mgr.)
					3 yrs (Empl.)
Environmental consultancy	25 employees		Owner-Managers	2	9 yrs (Mgr.)
					9 yrs (Mgr.)
Construction	22 employees	Owner-Manager		1	4 yrs
Social services	40 employees	Owner-Manager	4 Agents	6	9 yrs (Mgr.)
			1 Secretary		6 yrs (Empl. 1)
					3 yrs (Empl. 2)
					5 yrs (Empl. 3)
					2 yrs (Empl. 4)
					7 yrs (Empl. 5)