Nurses experience with presenteeism and the potential consequences on patient safety: a qualitative study among nurses at out-of-hours emergency primary care facilities

Resilience in healthcare

Resilience in healthcare (RiH) is a patient safety perspective, which includes the actions and adjustments individuals and organisations make in order to maintain the healthcare systems’ regular operation in the face of disturbances (eg, reduced staffing, increased patient flow, lack of resources), and moreover, the ability to anticipate potential disturbances, adapt their work and to make sense of the situation.8

OOH facilities are complex, unpredictable and rapidly changing environments.9 RiH can contribute to an increased understanding of how OOH nurses respond to and cope with disturbances in everyday work when they engage in presenteeism and, further, how their reactions influence patient safety.

Aim and research question

This study aimed to explore nurses’ experience with presenteeism and how they found that working in less than-good health affects patient safety. More specifically, the study sought to gain new insight and knowledge on OOH emergency primary care nurses’ experience of presenteeism in their work environment and their outlook on the impact they recognised the phenomenon to have on patient safety when caring for acute patients.

The following research question guided the study:

How do nurses experience presenteeism, and how do they perceive its potential consequences on patient safety when caring for acutely ill and injured patients in a Norwegian out-of-hours emergency primary care setting?

Epistemological underpinnings

Heidegger’s phenomenology inspired the study process, as its purpose was to grasp the phenomenon (presenteeism) from a nurse’s viewpoint within an OOH setting while still acknowledging the researcher’s role and influence.12 The study was further influenced by Gadamers’ hermeneutic philosophy (the hermeneutic circle), appreciating that this concept is valuable and closely related to content analysis: taking a mass of data, pulling it apart, and putting it together again as a new understanding.13 Adopting these frameworks of phenomenology and hermeneutic philosophy allows us to gain knowledge from the experiences of others.14 The philosophical underpinnings of this study were, in other words, closely intertwined with the problem under study and inspired the data analysis.

The study had a deductive approach. The study aimed to explore a population’s (OOH nurses) experience of a phenomenon (presenteeism) by providing them with the definition of the phenomenon and then gathering their experience and perceptions related to it.12

Context

In Norway, primary healthcare services are provided to all citizens by municipalities through the Municipal Health and Care Act of 2011.15 These services include round-the-clock care for patients with urgent or acute illnesses or injuries and are mainly provided by OOH clinics when general practitioners’ (GPs) offices are closed. The organisational structure of OOH services varies slightly across the country as municipalities have discretion within specific regulations. Typically, groups of GPs, both small and large, rotate the responsibility of caring for the patient population of all group members.16 As of 2022, there were 168 OOH clinics in Norway.17 The OOH clinics provide medical assistance to patients of all ages and a wide range of diagnoses.7

Recruitment

This study was conducted at three OOH emergency primary care facilities in southwest Norway (one medium-sized and two smaller facilities). These facilities were recruited through email correspondence with the head nurses. All included facilities offered telenursing and walk-in services and were staffed with physicians and registered nurses (RNs). Participants were recruited using convenient sampling and snowball sampling.18 19 The head nurses distributed a formal request for voluntary participation to staff groups containing the researcher’s contact details. In addition to the initial recruitment strategy, personal contacts and, by then, already recruited nurses were engaged in the final recruiting process. The participants were introduced to the details of the study through an information letter sent by email after expressing a desire to participate. Participation was entirely voluntary; no incentives were offered, and participants were informed that they could withdraw from the study at any time without facing negative consequences.

Participants

Ten RNs working in OOH clinics were included in the study. To be eligible for participation, individuals had to meet the following criteria: (1) meet the requirements as an RN, (2) engage in direct patient care at one of the selected OOH clinics and (3) be employed at the clinic for a minimum period of 2 years. All recruited nurses were women between the ages of 25 and 49 (table 1).

Data collection

Ten semistructured individual interviews were conducted during the spring of 2022. Each interview lasted an average of 45 min and was conducted by the first author (AM). The interviewer had broad experience as an OOH nurse and, therefore, needed to be continuously reflexive towards her research role and potential bias while conducting the interviews.18 An interview guide consisting of open-ended questions was applied. The guide covered the aspects related to participants’ experience with absenteeism and presenteeism within their workplace and their experience and perception of the consequences presenteeism had or could have on patient safety while treating acutely ill or injured patients. AM verified answers throughout the interviews and the participants were allowed to give supplement information at the end of each interview.20 MKG, who has a different research and clinical background, participated in the interview guide development and oversaw interview transcripts to limit potential bias relating to the interviewers’ role. The interview guide was piloted on one RN who met the inclusion criteria to assess its applicability. All interviews were recorded, stored encrypted, and later transcribed and anonymised.

Data analysis

The first author (AM) initiated a step-by-step analysis using Graneheim and Lundmans21 approach to qualitative content analysis. First, all transcripts were read to gain familiarity and obtain a sense of the whole. Second, the data was re-read to retrieve content meaning units relevant to the research question.21 The content meaning units were organised in a Word table. The third step involved condensing words and sentences to catch the essence of the quotes. The significant meanings were labelled with codes, and codes with uniform meanings related to the research question were then sorted into categories.21 All the data were shared and discussed with the coauthor (MKG), and the final categories and themes were generated in collaboration (see table 2 for an example of the analysis process).

Patient and public involvement

No patients or members of the public were involved in the planning, the design or the conduction of the research.

Strong work ethics influence the decision to attend work when unwell

The interviews revealed that most nurses were unfamiliar with the term presenteeism, or sick presence, as translated into Norwegian. A clear definition of the phenomenon used in the study was provided early in the interview.

There was a mutual agreement among the nurses that the threshold to call in sick was high, and most of the nurses admitted that they had attended work in less-than-optimal health on one or more occasions. Before the COVID-19 pandemic, coming to work with a cold and fever was reported as frequent. They perceived conditions qualifying for sick leave as physical illnesses, such as severe migraines and contagious conditions, such as gastroenteritis. For some nurses, mental issues were less justifiable for absence.

People should stay home if they are sick, but at the same time, you can understand if it is a life situation or something mentally challenging [that is the cause of illness]. It is difficult to justify staying at home. (Participant 5)

It was evident from the interviews that absenteeism levels varied between the clinics. Those nurses who observed low sick leave rates associated them with a positive work environment, a strong work ethic and effective leadership. Regarding presenteeism, nurses felt a moral obligation to their colleagues, influencing their decision to come to work even when ill. They expressed guilt as their absence could lead to understaffing and increased workload for their colleagues. This was especially prominent during holidays when staffing levels were already low, and it threatened the nurses’ annual leave.

I felt, and I believe others did too—we just had to step it up [avoiding sick absences and covering unexpected vacant shifts]. (Participant 1)

In addition to a common understanding of a high level of persistence before calling in sick, one nurse stated that nurses refrained from accepting notes of sick leave from their GPs as this was regarded as embarrassing. The nurses also described a culture of taking medication to treat pain and fever to go to work.

That’s the way it is in the healthcare system. We chuck down painkillers and go to work. You have to be pretty unwell before you call in sick. (Participant 8)

However, most nurses described a positive and supportive work culture. For some nurses, the fellowship was a weighed factor for coming to work. They claimed that staying at work while having mental issues positively affected their health.

We have an open culture. You can always talk to people. You can cry if you need to. You feel cared for, and I believe that this is the reason why sick leave rates are low. (Participant 4)

The interviews revealed that the leadership significantly impacted the nurses’ decision to attend work or not. The nurses demonstrated an allegiance to their leaders and a craving for recognition. The leaders’ attitudes towards the nurses when they reported sickness were crucial. Some participants believed that a few nurses might hesitate to call in sick if their workplace policies require them to report their absence directly to the head nurse rather than their colleagues. In some instances, going to work was more practical than taking time off.

A leader’s attitude means a lot. I have experienced that a former leader of mine sighed heavily on the phone once when I called in sick. That doesn’t make it easy calling in those times you can’t go to work, but then you have those leaders who help you express your feelings, and despite not feeling your best, you come to work and try. (Participant 8)

Work environment factors have a negative impact on nurse health

The nurses recognise working in an OOH facility as demanding. In contrast to many other healthcare settings, the OOH nurses stated that they had to make independent professional nursing assessments over the telephone and initiate responses according to the urgency of need. The interviews identified this as the cause of high job stress. When asked about the most common reasons for presenteeism in their workplace, many nurses answered colds, migraines and pregnancies. However, one nurse answered:

A lot of it is due to mental exertion. Taking all those calls is straining, and you are constantly assessing and prioritising. The work pressure is high, and you’re juggling quite a few patients at once. (Participant 4)

There was a common perception among the nurses that COVID-19 had exceedingly added to the work stress. The extreme restrictions applied by the government led to staffing challenges, and the nurses experienced high volumes of work for an extensive length of time. The nurses experienced that the work was overwhelming and expressed feelings of fatigue. These findings were most prominent among the nurses from the larger OOH. They described symptoms of presenteeism such as problems concentrating, impaired ability to focus and reduced memory.

I have developed memory problems. If I don’t do things at once, then I forget them. I put a note in my pocket, which stays there [throughout the day] because I forget it. (Participant 1)

Among the various sources of stress, the study found that insufficient staffing levels were the most challenging for the nurses. In addition to taking on more hours voluntarily, nurses were forced to work mandatory overtime.

We were constantly afraid of being forced to take a shift. We hid in the corridors. Nobody answered their phones, so they had to use the nurses that were already present. They may already have worked full time, had worked all week, and were forced to work the weekend before a new full week. (Participant 3)

The staffing shortages also increased the nurses’ reluctance to announce their absence when feeling unwell.

Another identified aspect was the connection between presenteeism and the payment system. In addition to a basic salary, Norwegian RNs receive extra pay for working on public holidays. One participant expressed that being a nurse was a low-wage occupation and would go to great lengths to avoid sick leave on well-paid shifts. Well into the pandemic, Norwegian nurses were offered an additional bonus for taking on more hours, increasing wages by up to 300% under certain circumstances. Some nurses expressed concern that these financial rewards fostered presenteeism. Nurses already showing signs of exhaustion proceeded to take on more hours due to the extraordinarily high pay.

You get so much more money than a regular shift that you feel you have to get to work, even if you have to pull yourself by the hair. (Participant 10)

Nurses’ awareness of the consequences of presenteeism on the quality of care and patient safety

When engaging in presenteeism, nurses described adverse effects such as higher levels of stress and attitude issues like lack of empathy and being unpolite to patients. Some claimed that their reduced health had a negative impact on their communication skills and that they sometimes had problems following patient conversations. Several nurses admitted they only completed necessary tasks when sick, would do them the most straightforward way, or sometimes skipped them altogether. An impaired ability to focus could hinder the nurses in detecting early signs of patient deterioration. However, most nurses denied knowing of any occasions where their deficient nurse performance significantly impacted patients. Only one nurse stated:

Personally, I have experienced receiving a formal complaint, thinking that the event occurred on a day where I shouldn’t have been at work. (Participant 7)

The nurses acknowledged that presenteeism could cause adverse events and impact patient safety. Examples such as giving the wrong medication or administrating the drug incorrectly were presented. Naturally, amid a pandemic, attention was also drawn to nurses contributing to disease transmission. Furthermore, the nurses highlighted the danger of not detecting signs of deterioration due to a lack of concentration on details. One of the nurses described the possibility of missing concealed injuries due to a poor patient examination. Some nurses suggested that working in less-than-optimal health may risk conducting inadequate assessments over the telephone, failing to recognise the seriousness of the patient’s condition, and not initiating the right level of care.

It’s first and foremost assessing and prioritising. If you do something wrong here, this will delay patient care and cause the situation to become a lot worse than it needed to be. (Participant 4)

Although they displayed considerable knowledge of the ramifications of presenteeism, most nurses perceived the danger as insignificant.

Potentially yes, but I believe the risk is small [of adverse events]. In that case, a lot of unfortunate factors would have to strike at the same time. (Participant 8)

A few of the nurses narrated examples of adverse events in which, in one case, a medical error resulted in the patient being hospitalised. In this case, it appeared that presenteeism may have influenced the outcome. However, as far as the participant knew, this was not concluded. One of the nurses with additional administrative tasks stated:

I have possibly never considered a potential link between presenteeism and complaints. It will probably be in the back of my mind now whether or not the nurse was in shape to be at work. (Participant 8)

Nurses make use of coping strategies when engaging in presenteeism

The participants presented several strategies for addressing presenteeism. Foremost, the majority of the nurses emphasised the importance of informing colleagues of the situation. Alongside this, nurses would hand over responsibilities, avoid being team leaders, and, if possible, choose other tasks not involving physical patient contact if suffering from contagious conditions. When participants were aware of a colleague’s presenteeism, they would, if possible, refrain from asking that nurse for assistance. Furthermore, nurses were likely more adherent to triage tools such as the Norwegian Index of Emergency Medical Dispatch when conducting patient assessments over the telephone. When treating acute patients at the OOH facility, the participants said they would physically lay the procedure before them.

If I feel tired or weary at work and I’m caring for an acute sick patient, I at least quickly find the protocol, for example, anaphylaxis [a potentially life-threatening allergic reaction]. On a good day, I’ll remember how many milligrams of stuff [medication], but on a day like that, I would rather find the protocol and have it in black and white in front of me before doing anything. (Participant 5)

The most surprising finding was that all nurses were confident that regardless of the cause of their presenteeism, their health issues would not impact patient safety while treating acutely ill or injured patients. They justified this by expressing the effects excitement and increased adrenaline levels had on the body.

I think I just get a little bit more worked up. You get sharpened and focused. My critical care brain just turns on in a different way than when dealing with a pearl up the nose. (Participant 1)

Presentism among emergency care nurses

While not quantified, the findings still suggest a high incidence of presenteeism among the OOH nurses. These results are supported by the existing body of knowledge of nurse presentism in other contexts.22 Moreover, a study by Aronsson et al23 found that nurses engaged in emergency patient care exhibited higher presenteeism levels than other occupations.

According to the data collected in this study, OOH nurses link their presenteeism to guilt towards their colleagues, showing concern that their sick absence would most likely lead to a shortage of staff and an increased workload for the remaining nurses. These findings are consistent with previous research, such as a similar study conducted by Fiorini et al,24 who also identified attitudes towards coworkers as a reason for engaging in presenteeism in a geriatric setting. This demeanour is closely related to staffing issues in healthcare services worldwide25 and the growing concern about a potential global shortage of nurses in the future.26 What is more, insufficient nurse staffing levels have been associated with adversities such as nurse burn-out,27 increased levels of healthcare-associated infections in patients,28 and missed care,29 and are, overall, considered a possible threat to patient safety.30 This demonstrates the dual negative effect presenteeism may have on patient safety: nurses being faced with the decision of whether to go to work in suboptimal health and risk adverse events such as medication errors, impaired teamwork, poorer quality of care, inadequate documentation and acting as a vector of disease6 31–34 or to take sick leave and potentially contribute to understaffing. Research suggests a link between stress, responsibility and presenteeism.35 However, more research is needed.

Work-related presenteeism

Similar to previous research, the nurses described migraines, health ailments associated with pregnancy, common colds and mental health issues as common antecedents to presenteeism.23 33

Additionally, this study identified a correlation between a stressful work environment and impaired health. The nurses exhibited signs resembling work-related stress, such as memory problems, fatigue and mental exertion. These issues were particularly prevalent during the COVID-19 pandemic. This is supported by D’emeh et al.36 The relationship between work stress and impaired health among nurses has been well established.37–39 Our findings are consistent with the model of presenteeism in nursing proposed by Rainbow et al,40 which suggests that work conditions are closely related to the health of nursing staff.

Furthermore, research suggests that work-stress-related presenteeism adversely affects patient care and safety due to an increased risk of errors, as nurses are more prone to make poor decisions.3 41 Moreover, previous research has linked presenteeism to additional health problems for nurses.4 33 42 For example, in an American cross-sectional survey, nurses reported that prolonged sick attendance could worsen their health, induced by exhaustion, lack of time for self-care and recovery, and feeling ineffective.33 Interestingly, this contrasts with the findings in this study, where some of the nurses expressed a positive experience of taking part in work despite facing personal mental tension. This is, however, in line with a newly conducted study which claims that presenteeism has a positive side that is underexplored.43 The authors state that working through an illness can positively affect nurses’ health and well-being and that abstaining from work is not always recommended.43 It can be discussed if promoting presenteeism for nurses’ well-being may conflict with patient safety in an unpredictable, high-paced work environment such as an OOH clinic. This discussion is highly significant but beyond the scope of this article.

Work ethics

The included OOH nurses in this study expressed a standard high threshold for sick absence and a high level of work ethics among the included nurses (eg, feelings of obligation towards colleagues and respect for leaders). Although most organisations value employees with strong work ethics, the findings suggest that this attitude promotes nurses to attend work despite not being well—a finding supported by previous literature.37 44 45 Moreover, presenteeism is regarded as a demonstration of high morale.44 However, this ‘positive’ outlook on presenteeism contrasts with nurses’ requirements of ethical behaviour. According to the ICN Code of Ethics for Nurses,46 nurses are obliged to ‘maintain fitness to practice (having the skills, knowledge, health and character) so as not to comprise their ability to provide quality, safe care’. These obligations are also stated in the Norwegian Healthcare Personnel Act,47 indicating a conflict between ethics, work morals, law and presenteeism culture. Research has shown that organisations with a culture that tolerates absenteeism tend to experience higher levels of absenteeism and lower levels of presenteeism.48 In their study, Fiorini et al24 found that work culture could facilitate presenteeism. The nurses experienced positive reinforcement to attend work despite being unwell due to their cordial relationships with their peers or negative peer pressure to attend work to align with the majority. This emphasises the importance of workplace culture when addressing absenteeism and presenteeism.

Limitations of the study

One potential limitation of this study is the small sample size obtained from a restricted area of the country, which may not represent the diversity of the overall population. Nevertheless, the participants had in-depth experience in presenteeism in OOH settings, providing high informational power. According to Malterud et al’s51 information power model, ‘the more information the sample holds, relevant for the actual study, the lower the number of participants is needed’. Furthermore, it has been argued that small samples ‘facilitate the researcher’s close association with the respondents’ and may enhance the ‘validity of fine-grained, in-depth inquiry’.52

The unique organisational structure of OOH in Norway may limit the applicability of the study’s findings to other organisational structures. Additionally, the motives and outcomes of presenteeism may vary across organisations, as factors such as personality, staff attitudes and work-time arrangements may influence why nurses engage in presenteeism. As a result, the findings may not be directly transferable. However, a detailed description of the study context and sampling is provided to increase external validity, enabling readers to determine whether the findings are relevant for other settings.18