‘Choosing’ to work when sick: workplace presenteeism

Abstract

Presenteeism is a concept used to describe the phenomenon of working through illness and injury. This paper is based on interviews and focus groups undertaken at three different work sites in New Zealand: a small private hospital, a large public hospital and a small factory. The research suggests that presenteeism is a prominent phenomenon in the lives of workers at these different sites, but the way in which it is rationalised and the factors that foster presenteeism are quite distinct. Exploring the way in which presenteeism links to economic and social constraints and workplace cultures provides insights into these rationalisations. The powerful forces promoting presenteeism tempers the research community's concern with absenteeism. A presenteeism discourse needs to be more prominently articulated to oppose both the absenteeism discourse, and to moderate the views taken by some postmodernist theorists on choice in relation to health practices in workplace settings.

Introduction

Presenteeism is a concept used ‘to designate the phenomenon of people, despite complaints and ill health that should prompt rest and absence from work, still turning up at their jobs’ (Aronsson, Gustafsson, & Dallner, 2000, p. 503).¹ Studies of professional and office workers suggest that there are links between ‘working through illness’, or ‘presenteeism’ (as opposed to absenteeism) and increased morbidity (Grinyer & Singleton, 2000; McKevitt, Morgan, Dundas, & Holland, 1997). These studies suggest that different workplace arrangements have an impact on the overall degree of morbidity, for example, worker autonomy and control over the work process has been negatively associated with coronary heart disease (Karasek & Theorell, 1990). Other studies suggest that employers and employees focus on different aspects of risk in the workplace, with workers accepting the normality of risk in the work site (Dorman, 1996; Dwyer, 1991; Holmes & Gifford, 1997; Viscusi, 1983).

A Swedish study of 3801 workers found that presenteeism, defined as the respondent reporting that they had attended work on two or more occasions in the preceding year despite feeling that they should take sick leave, was associated with musculo-skeletal pain, fatigue and slight depression (Aronsson et al., 2000). This study also found that those occupational groups that experience high sickness presenteeism also experience high sickness absenteeism. The highest rates of presenteeism were found in the care and welfare and education sectors, including nursing professionals. Sickness presenteeism was also high where there was difficulty in finding replacements.

However, a topic search on Web of Science highlights the difference in emphasis that has been placed on presenteeism compared with absenteeism. When the word absenteeism was entered in July 2003 there were 1262 hits. When the word presenteeism was entered there were 11 hits. This difference can perhaps in part be explained by the relative anonymity of the word presenteeism in the English language, but it can also be suggested that the focus on absenteeism relates to economic concerns about healthy workers. The relative lack of an interest in presenteeism can in part be explained by the way in which occupational health research has “frequently served the interests of employers at the expense of workers: by minimising the scale of work-related illness; limiting the protection of health; ignoring and devaluing workers’ experience of occupational ill health and focusing on individual behaviour in explaining work-related illness” (Daykin, 1999, p. 7).

The lack of focus on presenteeism indicates that the health concerns of workers themselves are under-emphasised. There is literature to support the view that presenteeism needs more attention. Kalia (2002) argues stress-related disability causes as much disability as workplace accidents, and that early recognition of workplace stress was called for. There are a number of factors identified in the literature that would promote presenteeism in spite of stress or other workplace hazards. In a review of certified absence from work, Luz and Green (1997) note that, among other factors, group cohesiveness, job satisfaction and a lack of external demand in market conditions restrain absence from work. To turn this around, these factors can be seen as promoting presenteeism. Daykin notes that “the moral evaluation of sick employees by peers and superiors depends not only upon the biological reality of illness but on preexisting attitudes and patterns of power and control” (Daykin, 1999, p. 2). Where workers are denied relief from distress at work or where absence from work is blocked then “illness or injury will be aggravated” (Bellaby, 1999, p. 21). Bellaby suggests a range of issues that can block work absence, including attitudes of managers and fellow workers. Drawing on ethnographic work at a pottery factory, Bellaby shows that there is variation in working through illness by gender and age. Older men and women ‘reported many more disability days than absences [from work]’ (Bellaby, 1999, p. 105)—implying a higher rate of presenteeism for these groups.

This discussion of presenteeism is situated within the sub-disciplines of sociology of work and sociology of health and illness. Bellaby outlines a number of approaches that link work and health. In particular he combines Marx's theory of alienation with contemporary debates in medical sociology and social anthropology. Bellaby deploys a social model of selection into occupations and work (as opposed to a natural selection model), which implies ‘that there are real choices as to who gets what jobs and survives in them’ (p. 2). The notion of real choices as used by Bellaby does not imply absolute choice. The reference to survival in that quote suggests that for some choices are only made within constraints. Bellaby also refers to other constraints, such as the status of the labour market where employees have less control when jobs are at a premium. Bellaby sums this up by stating that ‘individual choices are apparent not real’ (Bellaby, 1999, p. 27). An underlying premise of Bellaby's analysis is that “employers must exploit labour power to draw profit and employees must conserve it to carry on earning a living” (1999, p. 2). In relation to this, Bellaby draws on the concept of ‘decommodification’ where benefits cover most of the costs of normal earnings. Where decommodification is not present then the ‘market coerces into employment those who have to sell their labour to live’ (Bellaby, 1999, p. 53). As such, Bellaby's work outlines some of the prominent forces that promote workplace presenteeism.

The phenomenon of presenteeism links to issues of workplace identity. Du Gay explores the construction of new work identities in relation to the Foucauldian concept of governmentality. The concept of government in this sense presupposes “the capacity of individuals as agents” (Du Gay, 1996, p. 55). In this sense the promotion of presenteeism can be seen as a technology of self and of identity construction (Du Gay, 1996, p. 138), where workers are embedded within discourses of personal responsibility, responsibility to colleagues and to the organisation within a broader context of prominent discourses about the malingering worker.

The legislative and compensation environments are important contextual factors in relation to presenteeism. Compared to similar countries, New Zealand's yearly workplace fatality record (at 4.9 deaths per 100,000 workers) is approximately 29% higher than Australia's and approximately 53% higher than the United States (Office of the Minister of Labour, 2000). The estimated deaths are based on reports to the Occupational Safety and Health Service of the Department of Labour, but research sponsored by this Service suggests that there is a very high level of under-reporting of deaths (Occupational Safety and Health Service, 2002).

The election of a centre-left government in New Zealand in 1999 has seen a number of developments in the health and safety at work area—most notably an amendment to the Health and Safety in Employment Act that came into force in 2002. Under this amendment employers have to provide opportunities for workers to participate in the management and improvement of safety at work. In addition employees have the right to refuse work that they believe may cause them serious harm. A particularly contentious clause in the amendment related to the requirement that employers monitor the workplace to ensure that workers were not suffering mental stress as a result of workplace hazards (Health and Safety in Employment Amendment Act, 2002).

A central piece of legislation relating to workplace safety in New Zealand is the Accident Compensation Act. New Zealand has, since 1974, had a no-fault response to adverse events that have been associated with injuries. Civil claims for damages arising from personal injury by accident were abolished and so employers could no longer be sued for workplace accidents. The benefits of the scheme are supposed to be provided “as of right without reference to cause and regardless of risk. It is simply one component of the general welfare provision of the country” (Law Commission, 1988, p. x). The Act was meant to overcome the disparities, ambiguities and injustices that occurred under previous legislation, and to prevent costly litigation. In doing so, a social contract was reached where the public gave up its right to sue in order to receive adequate compensation for accidental injury. Due to fiscal constraints and concerns about welfare dependency the New Zealand government introduced the Work Capacity Assessment for those in receipt of ACC in 1997 (Duncan, 1999). There have also been other major changes such as the privatisation and recent re-nationalisation of accident compensation. In addition, assessment criteria have been used by ACC assessors that were developed on the assumption that compensation aggravates morbidity (Dew, 2002; Gorman & Dryson, 1998). This supposed aggravation of symptoms has been labelled compensation neurosis (Bellamy, 1997).

In order to reduce the costs of the scheme ACC has taken steps to shrink the tail of claimants. The tail is defined as claimants receiving weekly compensation who have been on the scheme for more than 12 months (Accident Compensation Corporation, 1998). The introduction of the Work Capacity Assessment process provided a vehicle for ACC to move people off the tail. Performance measures for ACC staff were based on the exit rate of claimants from the scheme that they had achieved (Accident Compensation Corporation, 1998). Unions representing workers have expressed concern that the scheme has been progressively whittled down, with the amount of compensation provided dropping and the obstacles to receiving compensation increasing. These policy moves to restrict compensation and emphasise rehabilitation may come at the expense of fostering presenteeism.

In addition to developments in Health and Safety Legislation and work-related injury compensation, in 1991 a right wing government surfing the wave of the neo-liberal revolution in New Zealand reduced benefits for the unemployed (Peters, 1997). The neo-liberal revolution had been ushered in by the fourth Labour Government elected in 1984, which restructured the economy in order to make New Zealand internationally competitive. A restructured economy required “low wages, minimal regulatory restraints and legal obligations and a ‘natural’ rate of unemployment” (Kelsey, 1995). Restructuring took a particular toll on blue-collar workers, Māori and provincial New Zealanders (Keefe et al., 2002). Many of the manufacturing and agricultural industries adversely affected by the restructuring had high Māori employment rates. Consequently there was an increase in unemployed Māori compared to non-Māori (Te Puni Kōkiri, 1998).

The introduction of the Employment Contracts Act 1991 (ECA) made compulsory unionism illegal, abolished centralised wage bargaining and focused on individual contracts (Maloney & Savage, 1996). Within this environment the power of the unions was vitiated. Workers were warned that they would be “trading off health and safety aspects of their employment to keep their jobs, and felt unable to ask for protective clothing, challenge unsafe conditions or take time off work sick (Kelsey, 1995, p. 202). Watterson (1999) also notes that in workplaces where trade unions are well-organised workplace disease and illness are likely to be better reported.

Although the centre-left government elected in 1999 reasserted many aspects of the welfare state and replaced the ECA with a more benevolent Employment Relations Act, it did not reverse the benefit cuts, and levels of union membership have remained relatively low.

The legislative and bureaucratic context is important in understanding some of the issues related to presenteeism. Workers’ perceptions of their rights and available resources may have important influences on their attitudes towards taking sick leave or seeking compensation for injury. The combination of social pressures and formal rules in the workplace may influence workers in ways that may have long-term detrimental consequences for their health (Dwyer, 1991; Nichols, 1997).

This paper explores some dimensions of the presenteeism issue by comparing a number of work sites. The aim of the research was to explore what aspects of the external social and economic environment and what factors internal to an organisation would promote or inhibit presenteeism. The issue of presenteeism relates to notions of health and choice. As such this research engages with debates about postmodernity and critical realism that have been raised by Fox (1998) and Williams (1999). Taking on board the insights of postmodernist writers, Fox argues that definitions of health are grounded in partial truths that relate to other concerns such as what it is to be a human being or be part of a community. As such, there is a component of choice, where choice can be a refusal or resistance to being defined. Fox relates this refusal and choice to his concept of arche-health. Arche-health is a process of becoming other, and a resistance to coercion. Fox illustrates the role of choice through a discussion of a surgeon's casual response to workplace hazards. Fox argues that the surgeon made active choices about the way he weighed these work hazards, which impinged upon that aspect of his life called ‘health’. Fox argues:

His evaluations of hazards were grounded in complex choices and perceptions, weighings of costs and benefits, and were part of his continual becoming-other: the arche-health of his unfolding life (Fox, 1998, p. 680).

This postmodern position, as articulated by Fox, valorises choice, and sees choice as resisting constraint. Fox argues that “a risk can—in the right circumstances—be an opportunity to become other” (Fox, 1999, p. 217).

The discussion in this paper suggests that choice cannot be taken at face value, but is itself articulated within a system of constraints. This analysis favours a critical realist position where a greater emphasis is placed on the structurally conditioned nature of actions (Bellaby, 1999; Williams, 1999). Fox suggests that choice is available to most workers, although there may be some that face the Hobson variety. This paper suggests that in some instances workers only have a Hobson's choice, but even in relatively privileged positions where choice is strongly articulated—it may also be tightly constrained.

This position supports Du Gay's reading of de Certeau. Du Gay relates the work of de Certeau to his interest in identity at work. The distinction de Certeau makes between strategy and tactics is illuminating here. Strategy constructs a reality “through the interplay of power and knowledge” (Du Gay, 1996, p. 149). Tactics are relational to power, and are “immanent to power” (Du Gay, 1996, p. 165). As Du Gay notes “tactics cannot by anything but ambivalent, being both simultaneously enabled and constrained by circumstance” (Du Gay, 1996, p. 165). The tactics employed by workers in these different settings can be seen in this light.

The research suggests that despite legislative changes to enhance workplace safety, the social and economic factors that promote presenteeism have a powerful influence on workers’ responses to working through illness and injury—even in what appear to be benign environments. Further, it is argued in this paper that a discourse of presenteeism needs to be more prominently articulated to resist the potent discourses of absenteeism and compensation neurosis, and the often related assumptions of workers as malingerers.