THE EXPERIENCE OF PRESENTEEISM: ACUTE CARE NURSES WORKING IN NORTHERN HEALTH by Lynn Carol MacDonald BSc. Physical Therapy, Dalhousie University, 1991 THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS IN DISABILITY MANAGEMENT THE UNIVERSITY OF NORTHERN BRITISH COLUMBIA June 2010 ©Lynn C. MacDonald, 2010 1*1 Library and Archives Canada Bibliotheque et Archives Canada Published Heritage Branch Direction du Patrimoine de I'edition 395 Wellington Street Ottawa ON K1A 0N4 Canada 395, rue Wellington Ottawa ON K1A 0N4 Canada Your file Votre riterence ISBN: 978-0-494-75146-6 Our file Notre r6f6rence ISBN: 978-0-494-75146-6 NOTICE: AVIS: The author has granted a nonexclusive license allowing Library and Archives Canada to reproduce, publish, archive, preserve, conserve, communicate to the public by telecommunication or on the Internet, loan, distribute and sell theses worldwide, for commercial or noncommercial purposes, in microform, paper, electronic and/or any other formats. L'auteur a accorde une licence non exclusive permettant a la Bibliotheque et Archives Canada de reproduce, publier, archiver, sauvegarder, conserver, transmettre au public par telecommunication ou par Nnternet, prefer, distribuer et vendre des theses partout dans Ie monde, a des fins commerciales ou autres, sur support microforme, papier, electronique et/ou autres formats. The author retains copyright ownership and moral rights in this thesis. Neither the thesis nor substantial extracts from it may be printed or otherwise reproduced without the author's permission. L'auteur conserve la propriete du droit d'auteur et des droits moraux qui protege cette these. Ni la these ni des extraits substantiels de celle-ci ne doivent etre imprimes ou autrement reproduits sans son autorisation. In compliance with the Canadian Privacy Act some supporting forms may have been removed from this thesis. Conformement a la loi canadienne sur la protection de la vie privee, quelques formulaires secondaires ont ete enleves de cette these. While these forms may be included in the document page count, their removal does not represent any loss of content from the thesis. Bien que ces formulaires aient inclus dans la pagination, il n'y aura aucun contenu manquant. 1+1 Canada Presenteeism in Nursing ii Abstract This study involved a phenomenological research design whereby participants described their experiences of attending work when they should have stayed home, a phenomenon referred to as presenteeism. The study also explored possible contexts, situations, and/or factors influencing this experience. Data was gathered using face to face open-ended standardized interviews with 10 participants who had experienced presenteeism. Qualitative analysis resulted in 10 themes. Acute care nurses working in Northern Health attended work when they felt they should have stayed home. The experience was felt physically and mentally, thereby creating a distraction in the provision of safe and adequate patient care. Both internal and external factors were noted, all and/or some of which influenced the decision of whether or not nurses attended work. Furthermore, all factors were interrelated, adding to the dilemma of making a sound decision that was in the best interest of the nurse, the patient, and the workplace environment. Presenteeism in Nursin TABLE OF CONTENTS Abstract Table of Contents List of Tables List of Appendices Acknowledgements Chapter 1 The Experience of Presenteeism: Acute Care Nurses Working in Northern Health Introduction Chapter 2 Literature Review Chapter 3 Research Methods Chapter 4 Data Analysis Results Discussion Chapter 5 Conclusion Recommendations Future Research References Appendices Presenteeism in Nursing List of Tables Table 1 Selected Examples of Significant Statements of Persons with Presenteeism and their Related Formulated Meanings Table 2 Examples of Theme Clusters (1 to 6) and their Formulated Meanings Table 2 (continued) Examples of Theme Clusters (7 to 10) and their Formulated Meanings Presenteeism in Nursing v List of Appendices Appendix A Interview Protocol 84 Appendix B Research Information Package 85 Appendix C Informed Consent 88 Appendix D Transcriber's Agreement 89 Appendix E External Auditor's Agreement 90 Appendix F Table 1 91 Appendix G Table 2 92 Appendix H UNBC Ethics Approval Letter 94 Appendix I NH Ethics Approval Letter 95 Presenteeism in Nursing vi Acknowledgements I would like to thank the following individuals for their endless support and belief in me: • Dr. Henry Harder for his guidance, expertise, assistance, patience, and for being so readily available every time I needed help; • My research committee members (Dr. Josee Lavoie and Dr. Lela Zimmer) for their guidance (always available when I needed them), expertise, and devotion to my study; • My external examiner, Dr. Greg Halseth for his time and interest in my study; • Kathy Yeulet for her time, her continuous encouragement, and words of wisdom; • Diane Miller for assisting with recruitment of my research participants • Northern Health and UNBC's Research Committees for supporting and approving this study; • The participants for their involvement, their time, and their valuable insights; • My colleagues at Workplace Health and Safety, especially Terri and Janet, for their many words of encouragement and their formatting assistance; • Frank Talarico for his patience and encouragement; • My transcriber and external auditor for their prompt assistance; • Kara Taylor and Barry Wong for their assistance pre and post the oral defence; • Kelsey, Craig, and Benji for understanding that mommy was busy (all the time); and • Curtis for standing by my side throughout this entire journey. Presenteeism in Nursing 1 Chapter 1 Introduction Statement of the Problem Every day, and within all industry sectors across the world, it is believed that hundreds of people attend work when they feel they should have stayed home. On-the-job productivity and performance are affected, a phenomenon known as presenteeism. Unlike absenteeism, presenteeism occurs when workers are actually on the job but not fully functioning. "The fact is, when people don't feel good, they simply don't perform at their best" (Hemp, 2004). Most employers can easily keep track of time away from work, yet are not as well equipped in keeping track of those who experience presenteeism. For most organizations, the latter remains a hidden and unaccounted cost. The nursing population has become an area of focus for researchers, especially considering the high prevalence of presenteeism in members of occupational groups whose everyday tasks involve providing care and welfare services to other human beings or those who teach or instruct others (Aronsson, Gustafsson, & Dallner, 2000). This notion is strongly supported by the Human Service Organizations (HSO) theory whereby tasks involving caring or helping one another generate a greater disposition to work when feeling or being sick (Hasernfeld, 1983). Given any day, nurses attend work suffering from aches and pains, colds, depression, child care issues, and other common conditions that are likely to affect productivity (Stout, Salas, & Fowles, 1997). The possible scenario of a nurse attempting to call in sick, only to be told that there is no one else to work in their place, is a reality experienced in today's health care organizations. This phenomenon is of interest within the nursing population, especially when this profession Presenteeism in Nursing 2 is being continually plagued by staffing shortages, high turnover, workload issues, and low job satisfaction. Nurses who attend work despite feeling that he or she should have stayed home experience presenteeism. Since the 1990's, health care institutions have undergone constant change (Lavoie-Tremblay, Bourbonnais, Viens, Vezina, Durand, & Rochette, 2005). "In hospital departments that are more fractured and difficult than previous decades, nurses are asked to do things better, quicker, and with fewer people" (Pilette, 2005, p. 300). Work hours and schedules are known stressors in the health care industry, both of which can negatively affect one's health (Sparks, Cooper, Fried, & Shirom, 1997). "Health care workers need healthy workplaces, yet the common cry in Canada is that we have too few people working too hard. Staffing shortages and workload problems have led to stress, burnout, and early retirement" (Health Council of Canada, 2005, p. 44). Nowadays, healthcare workers seem to be expected to show up for work when staying home would be best, either for mental or physical reasons. Workers who show up for work sick, injured, tired, or stressed pose a danger to work productivity. Unlike being absent, these employees are in the workplace and do impact the productivity of those who are present and feeling well. In other words, the phenomenon can pose a "catching" effect, thereby spreading the illness among colleagues. Furthermore, there is concern that presenteeism could lead to future absenteeism. In addition to occupational groups and work environments, presenteeism is more prevalent in those who suffer from depression (Druss, Schlesinger, & Allen, 2001; Greenberg, Stiglin, Finkelstein, & Berndt, 1993; Stewart, Ricci, Chee, Hahn, & Morganstein, 2003), as well as being associated with certain chronic conditions such as Presenteeism in Nursing 3 arthritis, neck/back pain, and certain respiratory conditions. In a cross-sectional study involving over 28,000 active workers in the U.S. (not health care specific), Stewart, Ricci, Chee, Morganstein, and Lipton (2003) conclude that lost productivity due to common pain conditions such as arthritis, back, and other musculoskeletal injuries account for approximately $61.2 billion annually. They further conclude that the lost productivity time (over 76%) was explained by reduced health-related performance while at work (presenteeism) as opposed to absenteeism. "Historically, health care organizations have neither viewed nurses' health as something to manage and measure beyond absences, disabilities, and worker's compensation, nor had the tools to quantify presenteeism and depression" (Pilette, 2005, p. 301). Presenteeism in the nursing population, especially those who work in hectic acute care environments and those who may be prone to depression, is a potential concern that should be explored. Woody Allen once stated that 80% of one's success in life can be achieved by simply showing up (Hemp, 2004). Now more than ever, this saying needs revisiting. Calling in sick could be more beneficial than originally thought. Focus Area Being a long time employee of Northern Health (NH), I was interested in studying the experiences of presenteeism in my fellow nursing colleagues. Personally, I admit to having attended work despite feeling that I should have stayed home. I continue to have working colleagues (both in NH and elsewhere) that attend work when they should otherwise stay home. It has been my experience that organizations are not aware of the magnitude of this phenomenon, and if they were, not cognizant of how to tackle it. Presenteeism in Nursing 4 NH takes pride in its newly developed Strategic Plan (2009-2015), with a mission statement reading as follows: "Through the efforts of our dedicated staff and physicians, in partnership with communities and organizations, we provide exceptional health services for Northerners" (Northern Health Strategic Plan - 2009-2015, 2009). The strategic plan's slogan is, "The Northern way of caring", which effectively portrays and communicates a vision of caring for oneself and others, in a true spirit of collaboration and optimal wellness. In my current role of Regional Manager, Prevention Services, Workplace Health and Safety, I had a vested interest in proactively addressing the risks/hazards that may negatively affect one's health and work productivity. The creation and sustainability of a healthy workplace is an important step in the retention of health care's most valuable asset: its employees. I was interested in further exploring the experiences of those who attended work despite feeling that they should have otherwise stayed home, presumably due to various workplace stressors that may possibly be minimized, and/or prevented. I considered this personal and academic interest to be closely aligned with NH's Strategic Plan. NH is one of the five health care regions of British Columbia's (BC's) health care systems, funded and governed by the BC Provincial Ministry of Health. As the geographically largest health authority, accounting for 65% of the province, NH presents with its unique challenges, one of which is recruitment and retention of its employees. In essence, NH is considered rural and remote to all of its neighbouring Health Authorities (HA's). As one might imagine, the need for developing a competitive advantage over the other HA's is great, thereby urgently calling for a sustained health and wellness recipe for Presenteeism in Nursing 5 its employees. Consistent with the rest of Canada's health care system, NH has, and continues to experience organizational restructuring, the result of which can pose additional stressors in the workplace. Nowadays, as perhaps never before, health care environments can be hectic places to work. Of significant interest is the ongoing state of flux in various departments within an acute care hospital. Traditionally, the areas designated as highly acute and/or traumarelated can be places of extreme activity. This study initially focused on the emergency and intensive care departments, being the area's best representative of the most highly acute and/or trauma-related departments within NH's largest acute care hospital, the Prince George Regional Hospital, now called the University Hospital of Northern British Columbia (UHNBC). Within three weeks of attempting to recruit participants, the surgical departments of UHNBC were added as an attempt to increase participation. The surgical departments are also areas of high patient acuity. The largest acute care hospital was chosen as the area with the largest sample size of potential participants. Purpose Statement The purpose of this study was to examine the experience of presenteeism in acute care nurses within the largest acute care hospital in NH, and to explore the contexts, situations, and/or factors that may influence this experience. The target population was acute care nurses working in the emergency, intensive care, or surgical departments of the UHNBC. Interestingly, the need for creating healthier workplaces within this working population has been widely recognized (Canadian Nursing Advisory Committee Report, 2002). Given that nurses represent the largest occupational group in the industry, it is Presenteeism in Nursing 6 anticipated, with much confidence, that any enhancements within this profession's quality of work life will be experienced by others who share a similar work environment. This study consisted of in-depth face to face interviews with 10 participants. The central focus of this study was on the qualitative data gathered in the interviews, leading to a common understanding of the experiences of the participants as measured by a selfassessment of their state of health. Significance of the Study The current payroll system in NH tracks and measures sick time hours (Now Solutions, 2009). There is currently no measure of presenteeism and/or awareness that this phenomenon exists in the NH workforce. This study has emerged out of the researcher's personal experiences and her passion for the topic. When I first became interested in studying presenteeism, I came across one article that examined the phenomenon of presenteeism in nursing (Pilette, 2005), in addition to another article (Aronsson et al., 2000) which identified certain occupational groups and risk factors such as understaffing and downsizing to be associated with presenteeism. The first study examined nurses in the United States, while the latter study involved a group of employed persons in Sweden. I am interested in exploring presenteeism in Northern Health, the results of which may help to further focus on presenteeism within the British Columbia health care system and hopefully the larger Canadian system. Research Questions From a qualitative perspective, I was interested to know the participants' experiences with presenteeism and what contexts, situations, and/or factors (if any) influence this experience. As for defining presenteeism, I described this as a phenomenon Presenteeism in Nursing 7 whereby a worker attends work despite feeling that he or she should have stayed home. This study explored the following research questions: (a) what is the experience of presenteeism in acute care nurses working at UHNBC; and (b) what contexts, situations, and/or factors (if any) influence this experience? My Research Experience I have been fortunate to publish an article on presenteeism entitled, "Presenteeism: What Employees Need to Know" (MacDonald & Harder, 2008). My work experiences have introduced me to various research opportunities, primarily within various health and safety program and project planning initiatives. This thesis was my first formal research opportunity. Philosophical Assumptions and Limitations of the Study This study used a phenomenological research design with an ontological philosophical stance "toward the nature of reality" (Creswell, 2007, p. 16), essentially reporting of multiple realities whereby the person and the world are "one". Within an ontological assumption, Creswell (2007, p. 17) notes that the researcher "uses quotes and themes in words of participants and provides evidence of different perspectives". As noted in Creswell (2007, p. 62) "participants in the study need to be carefully chosen to be individuals who have all experienced the phenomenon in question, so that the researcher, in the end, can forge a common understanding." The researcher assumed that acute care nurses working in NH, and specifically in the emergency, intensive care, and surgical departments of the UHNBC had experienced the phenomenon of presenteeism. The researcher also assumed that the phenomenon of presenteeism was unknown despite having experienced it herself. Presenteeism in Nursing 8 Limitations of this study included the participant group. Results of this study apply to acute care nurses at the UHNBC only, independent of other health care workers working at this location and in the areas studied. A second limitation was the small sample size. Albeit suitable for the design used, it could be difficult to generalize the findings to all acute care nurses in NH. Finally, the last limitation pertained to qualitative research methodology in itself. Qualitatively, this study focused on the quality and texture of the experience, without being able to identify any cause-effect relationships. A final limitation was the limited experience of the researcher. Key Terms Merriam-Webster OnLine (2009) defines "acute care" as "providing or concerned with short-term medical care especially for serious acute disease or trauma". For the purpose of this study, acute care referred to all hospitals in NH, exclusive of diagnostic clinics and treatment centers. During the participant recruitment phase, I was asked if the study only involved registered nurses (RN's) or if it was open to Licensed Practical Nurses (LPN's). I then realized I hadn't clearly defined the "nurse" population that I was targeting. The initial recruitment had targeted RN's working in those areas; however LPN's were also interested as they would read hard copies of the pamphlets and research package available on their units. I allowed all participants who had experienced the phenomenon, regardless of their designation as RN or LPN. In the end, I interviewed nine RN's and one LPN. Presenteeism in Nursing 9 Chapter 2 Literature Review Introduction Presenteeism is a phenomenon describing employees who attend work despite feeling that he or she should have stayed home. Unlike absenteeism, whereby employees are sick and staying at home, presenteeism occurs when workers are actually on the job but not fully functioning. "When people show up for work sick, injured, stressed or burned-out there is a drain on productivity. This is the problem of presenteeism" (Thorpe Benefits, 2002). Most commonly, the term presenteeism has been coined with losses in work productivity in those experiencing illness or injury. Through a slightly different lens, it is also suggested that presenteeism represents those who put in more hours as a result of job insecurity. Researchers are becoming interested in studying this phenomenon, primarily due to its significant costs, the possibilities of leading to absenteeism, the possibility of human errors associated with being at work ill, and the fact that this phenomenon tends to be overlooked when employers are looking to maximize their human capital (Health and Productivity Management Center, 2006). Of particular interest is the incidence of presenteeism in those professions whose everyday tasks involve caring for others, a task that is most common in the health care industry. This literature review will first attempt to better understand the types and definitions of presenteeism, followed by a review of its prevalence within certain occupational groups, health risks, medical conditions, and organizational factors. This will provide a suitable segue into possible solutions aimed at either preventing and/or Presenteeism in Nursing 10 reducing its impact. The literature search has been primarily conducted via Ovid SP (Wolters Kluwer Health, 2009) and included the following key words: (a) presenteeism; (b) presenteeism + health care; (c) presenteeism + nurses; (d) presenteeism + work productivity; (e) presenteeism + interventions. Presenteeism: Expanding the Definition "As with all new endeavours, no single authoritative definition of presenteeism is in common use" (Chapman, 2005, p. 1). That being said, the literature defines presenteeism within two different employee behavioural patterns. On the one hand, and according to Professor Gary Cooper who first coined the term presenteeism, presenteeism involves those who work excessive hours either as an expression of work commitment and/or as a way of coping with job insecurity. Secondly, presenteeism refers to those who attend work sick or injured. According to CCH Incorporated (2003, p. 163), "presenteeism is a new term used by human resource professionals to describe circumstances in which employees come to work even though they are ill, posing potential problems of contagion and lower productivity". Levin-Epstein (2005, p. 1) presents a similar definition, "presenteeism is defined as lost productivity that occurs when employees come to work but perform below par due to any kind of illness". Within both perspectives, the presenteeism phenomenon can further extend to those attending work a) as a possible coping strategy in escaping certain personal stressors, including one's medical state, b) in response to co-worker empathy in minimizing the work burden (e.g. staffing shortages), and c) in response to financial pressures. Coupled with the above definitions, presenteeism is a term that requires immediate attention, especially in organizations who embrace health and productivity. Presenteeism in Nursing 11 A Costly Phenomenon Until very recently, absenteeism was known and thought to be the largest drain on work productivity. In other words, employees who are absent from work are clearly not active contributors of productive work. Ever increasingly, organizations (including the health care sector) are being challenged to offer exceptional customer service to continually demanding clients. Despite the type or nature of the industry, this level of customer service requires dedicated and committed employees. For this reason, organizations have adopted programs such as Attendance Support/Management Programs with hopes of identifying acceptable levels of absenteeism, while developing effective strategies necessary for corrective action in addressing unacceptable attendance levels. Although the intent of these programs is applauded, could it be that encouraging attendance might eventually lead to presenteeism? Since the start of the 21 s century, researchers are now beginning to focus on a phenomenon known as presenteeism. Researchers are suggesting that the costs of sickness absenteeism will slowly decrease at the cost of higher presenteeism (Aronsson, & Gustafsson, 2005). The cost of absenteeism is obvious - 100% of the absent worker's productivity is lost. For presenteeism (on-the-job-productivity), the costs are hidden. Goetzel, Long, Ozminkowski, Hawkins, Wang, and Lynch (2004) examined a database of 375,000 employees and 10 health related conditions mostly affecting workers. Results confirmed that for most conditions, the costs of presenteeism far outweigh the costs of any other employer health care costs including absenteeism, hypertension, heart disease, depression, and arthritis. Various studies sponsored by the Employers Health Coalition of Tampa, Florida have revealed that lost productivity from presenteeism is 7.5 times Presenteeism in Nursing 12 greater than lost productivity from absenteeism (Thorpe Benefits, 2002). Furthermore, certain conditions such as depression, allergies, heart disease, hypertension, migraine headaches, and neck or back pain are known to increase this ratio by 15 to 1. In situations where employees attend work when sick, it is believed that recovery is possibly compromised and delayed compared to those who stay home and convalesce appropriately. In a 2001 study of work-life balance in Canada, Linda Duxbury and Chris Higgins found high work-life conflict often caused people to go to work when unwell (Duxbury & Higgins, 2001). More than four out of five employees reported going to work, despite experiencing high work-family conflict. A recent report by Desjardins Financial Security confirms the following: (a) Approximately two-thirds of Canadian workers (62%) make work a priority when suffering from mental and physical problems, (b) 44% report that money is the main source of stress for needing to go to work, and (c) 59% of employees sacrifice their personal health as well as family and friendships for going to work (National Union of Public and General Employees, 2007). "Presenteeism, the feeling that you must show up for work even if you are too sick to be there, is a major factor in employee stress and distraction" (Beauchesne, 2006). Until recently, the health care dollar was divided into the following five main costs: (a) medical, (b) pharmacy, (c) disability, (d) absenteeism, and (e) workers' compensation (Schwerha, 2006). It is becoming obvious that an integral piece of this dollar is missing, a cost known as performance at work. This latter piece is necessary in allowing employers to accurately explore the consequences of poor health. A recent article by Schultz, Chen, and Edington (2009) concludes that health conditions do affect Presenteeism in Nursing 13 losses in work productivity and that presenteeism represents a major component in total costs born by the employer, regardless of not yet being able to determine an exact cost at this time. Prevalence in Certain Occupational Groups Studies exploring the prevalence of presenteeism have focused on different occupational groups. McKevitt, Morgan, Dundas, and Holland (1997) have found low incidences of sickness absenteeism among medical doctors and accountants/consultants, therefore increasing the likelihood of such occupational groups working when feeling ill. The most common reason for working in such situations was that no one else was available to do the job. Furthermore, McKevitt et al. (1997) have found strong cultural barriers related to workplace culture and work ethics whereby an absence imposes a further burden on colleagues among hospital physicians. This places them in a position of working despite complaints of ill health. In a study involving public-sector employees (Grinyer & Singleton, 2000), researchers identified two reasons why employees will show up for work despite being unwell. First, employees feel a sense of responsibility when working in a team environment and second, employees were subject to a sick leave monitoring system which would warrant their need to explain their reason for illness. Aronsson et al. (2000) conclude that presenteeism is more commonly found among middle age workers. The same study was inconclusive for patterns relating to education, full-time versus part-time work, and individuals with children at home. Bockerman and Laukkanen (2010) identify sickness presenteeism (those going to work despite being ill) to be more sensitive and prevalent in working-time arrangements such as permanent fulltime status, shift work, working excessively long hours, and those who experience a Presenteeism in Nursing 14 mismatch between desired and actual hours worked. The same study also concludes that regular overtime decreases sickness absenteeism. Of major importance is the high prevalence of presenteeism in members of occupational groups whose everyday tasks involve providing care and welfare services to other human beings or those who teach or instruct others (Aronsson et al., 2000). Specifically, these professions include nursing, midwifery, nursing home aides, compulsory school teachers, and early education or preschool teachers. Interestingly, both the health and education sectors have experienced significant cutbacks and major organizational restructuring since the 1990's. The same study confirms highest rates of presenteeism with those experiencing the lowest monthly income and those with the higher rates of sickness absenteeism. Prevalence in Nursing Presenteeism in nursing is becoming a popular area of research for health care organizations. Hospital environments are becoming places of extreme stress and chaos. "In hospital environments that are more fractured and difficult than previous decades, nurses are asked to do things better, quicker, and with fewer people" (Pilette, 2005, p. 300). By having to balance work with personal/family issues, it is believed that nurses have very little time to care for themselves, taking a toll on their health and productivity. Nurses are often at work when they possibly should not be. Most nurses hesitate to take sick leave as they are very aware of the added burden on their colleagues (Grinyer & Singleton, 2000). At the heart of this profession's work demands are three factors responsible for presenteeism: (a) stress, (b) employee health, and (c) work-life balance. A 4 year longitudinal study involving 21,000 nurses in high-demand, low-control jobs Presenteeism in Nursing 15 resulted in the health of these nurses to deteriorate more than if they had smoked or lived sedentary lives (Lynch, 2003). The same study concludes that the high demanding jobs of nurses affects their health. In 2016, it is expected that Canada will be short 113,000 registered nurses, the bulk of those being in acute care environments (Canadian Nurses Association, 2002). It is anticipated that the health care industry will be unable to successfully meet its social policy mandate, including delivery of the six major principles of the Canada Health Act (i.e., public administration, universality, accessibility, portability, comprehensiveness, and accountability) without investing into its workforce (Health Canada, 2004). Prevalence within Certain Health Risks Presenteeism has been linked to various health risk factors. Compelling evidence is available via a systematic review of 113 studies which confirms that certain health risks, as measured by a Health Risk Appraisal (HRA), identify physical activity and body weight to be associated with presenteeism (Schultz & Edington, 2007). The same review concludes allergies and arthritis to be associated with presenteeism. Burton, Chen, Conti, Schultz, Pransky, and Edington (2005) examine twelve health risk factors in relation to self-reported work productivity. These risk factors are divided in three categories: (a) lifestyle or behavioural (smoking, alcohol), (b) health or biological (blood pressure, weight, height), and (c) perceptual or psychological (satisfaction with life or work, health perception). Conclusions are significant in that changes in self-reported health risk factors are associated with changes in self-reported on-the-job-productivity, as measured by the Work Limitation Questionnaire (WLQ). In other words, as the number of self-reported health risk factors increased, so did the percentage of employees Presenteeism in Nursing 16 reporting on-the-job work limitations. Boles, Pelletier, and Lynch (2004) demonstrate a similar linear relationship between the amount of risk factors and the loss of on-the-jobproductivity. Additionally, this same study classifies diabetes to be significantly related to absenteeism and stress to be related to presenteeism. Munir et al. (2007) conclude that low psychological well-being and high healthrelated distress result in high presenteeism, poorer management of illness symptoms while at work, and increases in work limitations. This correlation may identify a potentially vicious circle whereby those employees who suffer from various illnesses and who attempt to function effectively at work are presumably unable to succeed. It may be necessary for employers to offer strategies aimed at managing these illness in overcoming health-related limitations while at work. Bunn, Stave, Downs, Alvir, and Dirani (2006) observe the possible relationship of presenteeism on current, former and non-smokers. Results are significant in that current smokers experienced the highest rate of absenteeism and presenteeism compared with former and non-smokers. Prevalence within Certain Medical Conditions Presenteeism is more prevalent in those who suffer from depression (Burton et al., 2004; Druss et al., 2001; Greenberg et al., 1993; Stewart et al., 2003). Depression is closely followed by obesity, migraine headaches, musculoskeletal ailments (low back pain, arthritis), and respiratory conditions (asthma, colds, flu) (Marlowe, 2002). Of these, allergies, arthritis/joint pain or stiffness, and back or neck disorders are believed to have a significant impact on presenteeism, especially with those classified as a chronic condition (Collins et al., 2005). The latter study concludes that the costs associated with presenteeism far exceed the combined costs of absenteeism and required medical Presenteeism in Nursing 17 treatment. Recently, Parker, Wilson, Vandenberg, DeJoy, and Orpinas (2009) conclude that employees suffering from comorbid mental health symptoms and physical health conditions are significantly less productive compared with those suffering from either of the above and/or those from any other health status group. Depression impedes concentration and memory, contributes to irritable behaviours and attitudes, and slows reaction time, all of which deplete one's mental and physical energy. This, in turn, affects the quality and quantity of one's work performance. Lerner and Henke (2008) conclude that those suffering from depression experience more unemployment, work absenteeism, and at-work performance limitations that those without depression, rendering this medical condition as having multidimensional work impacts. This is worrisome in a profession such as nursing whereby there exists a zero tolerance for any medical errors. In other words, staying focused is critical to the profession's clinical best practice standards. A recent study identifies presenteeism to be associated with severe depression symptoms, psychologically demanding work, poorer general health, and less job control (Lerner et al, 2010). The literature is compelling in identifying presenteeism, due to a mental disorder, as the major component of decreasing employee productivity (Dewa & Lin, 2000; Goetzel et al, 2004; Greenberg et al, 1993; Kessler, Akiskal, Ames, Birnbaum, Greenberg, Hirschfeld, et al, 2006; Kessler & Frank, 1997; Kessler, Greenberg, Mickelson, Meneades, & Wand, 2001; Lim, Sanderson, & Andrews, 2000; Sanderson, Tilse, Nicholson, Oldenburg, & Graves, 2007; Stewart et al, 2003; The Sainsbury Center for Mental Health, 2007; Wang et al, 2004). Wynne-Jones, Buck, Varnava, Phillips and Mian (2009) also conclude that mental health, as opposed to physical health, has the Presenteeism in Nursing 18 greatest influence on one's ability to work. The same study identifies that poor health has a greater impact on work performance than absenteeism. In studying workers who were recipients of occupational health services, Lee and Jung (2008) found a strong correlation between presenteeism and the health conditions/problems of those workers. Measurement of Presenteeism Attempting to measure and understand presenteeism is evolving into an immediate priority within the field of workplace health and productivity. According to Lerner and Henke (2008), parameters that would lend themselves well to presenteeism (e.g., work effort, task performance, and individual worker productivity) are challenging to measure due to the changing nature of work, including a shift from manufacturing (production-based) to technology (knowledge-based) tasks. The literature does in fact identify six self-report productivity instruments known to be the Endicott Work Productivity Scale, Health and Labour Questionnaire, Health and Work Questionnaire, Health and Work Performance Questionnaire, Work Limitations Questionnaire (WLQ), and the Work Productivity and Activity Impairment (WPAI) Questionnaire (Prasad, Wahlqvist, Shikiar, & Shih, 2004). Of those, the WPAI has been the most extensively used by employers. Another popular and widely used instrument is the Stanford Presenteeism Scale (SPS). This latter tool differs in that it measures both knowledge-based and production-based jobs. It is known to result in high degrees of reliability and validity with user-friendly application for employers who seek a single scale measure encompassing a diverse group of employees (Turpin et al., 2004). Application of the WLQ demonstrates that productivity losses are not usually associated with demographics or job type but more commonly linked with perceived health status Presenteeism in Nursing 19 and the existence of a particular health condition (Ozminkowski, Goetzel, Chang, & Long, 2004). Prevalence Associated with Certain Organizational Factors Workforce productivity is severely dependent on the strength and sustainability of an organization's overall business performance, which, in turn, is severely dependent on the health of its workforce. A study investigating the impact of corporate environmental factors on job performance using a self-reported measure of presenteeism via the Health Risk Appraisal (HRA) identifies presenteeism to be associated with poor working conditions, ineffective management/leadership, and work-life imbalance (Musich, Baaner, Spooner, & Edington, 2006). In studying the association of organizational risks with presenteeism, Burton et al., (2005) conclude that perception-related risk factors such as job and life dissatisfaction, including stress, contribute significantly to decreased onthe-job-productivity. Stevens (2005) matches similar findings of interpersonal conflict, negative perceptions of the work environment, and job dissatisfaction as significant contributors of presenteeism. Caverley et al. (2007) conclude that certain work factors such as job insecurity, lack of supervisory support, and job dissatisfaction are strong determinants of presenteeism. The same study supports presenteeism as a much stronger predictor of workplace health compared to absenteeism. Karlsson, Bjorklund, and Jensen (2010) identify several psychosocial work factors such high work demands, low job control, and less role compatibility to be related to presenteeism. The same study concludes work commitment (employee being less committed) and a negative social climate to be related to future productivity losses (presenteeism) and to absenteeism. Presenteeism in Nursing 20 The evidence of unhealthy work environments is studied by Landeweerd and Baumans (1994) which identify a direct relationship between work organization characteristics and injury/illness among health care workers. Specifically, these authors identify the main organizational factors associated with poor health outcomes to be workload pressures, a lack of participation in decision-making, a lack of control over work, a lack of communication and feedback, unfavorable relationships in the workplace, poor social support and/or difficulties with management style, and unsupportive leadership. Shain and Suurvali (2001) further identify that the psychosocial work environment, the way work is organized, and the management culture within the work environment have the most impact on increased employee stress and negative health outcomes. As such, interventions should perhaps be targeted towards the organizational environment, including a shift in management thinking (and culture) that values and supports a 'taking care of your staff approach, coupled with an in-dept look at how work is organized. There exists a proposition in the literature that the rise in presenteeism could also be occurring as a result of a substitution of presenteeism for absenteeism. As noted previously, Cary Cooper (Professor of Organizational Psychology and Health at Manchester University in England) coins presenteeism to describe overwork and job insecurity resulting from the corporate downsizing and restructuring events of the 1990's. He further describes presenteeism as a sort of first cousin to absenteeism. Essentially, it is a symptom of the high magnitude of pressure in today's workplaces. The growing interest in measuring and understanding presenteeism has partly evolved due to the increasing hours employees spend at work, constant work restructuring, and the continual and Presenteeism in Nursing 21 looming unmeasured impacts of negative health experienced by workers (Organisation for Economic Co-operation and Development, 2007). Lewis and Cooper (1999) suggest that employees may be spending more time in the workplace (when they are ill) due to workload demands and job insecurity. Quinion (1996) concludes that employees will work excessive hours or remain the evenings, even when there is no work left to do, for fear of losing their jobs. Even worse, employees may be fearful of staying away from work, essentially representing a commitment to one's work (Lewis & Cooper, 1999; Simpson, 1998). In a study exploring the possible impact of sickness presenteeism on future sickness absenteeism, the authors conclude that several episodes of sickness presenteeism may lead to future sickness absenteeism (Bergstrom, Bodin, Hagberg, Aronsson, & Josephson, 2009). Within the nursing profession, chronic understaffing, limited and/or reduced time off for education and training, on-call scheduling involving mandatory overtime, and work assignments outside of one's specialty area continue to jeopardize one's personal health. An alarming 45% of Canada's nursing population report being dissatisfied with their jobs, in addition to perceiving the working conditions to be deteriorating (Canadian Health Services Research Foundation, 2006). Lowe (2004) cites that a healthy organization is one "whose culture, climate and practices create an environment that promotes employee health and safety as well as organizational effectiveness". Is this possible within acute health care environments, and to some extent, involving the nursing profession? Solutions to Presenteeism: Awareness as a First Step Presenteeism in Nursing 22 "Renewed attention to the health, safety and wellness needs of employees is essential if our economy and productivity are to continue growing and thriving" (Hymel et al., 2004, p. 518). Ever increasingly, employers need to closely examine and attempt to understand the impact of employee health on workforce productivity. The Health and Productivity Management Center (2006) concludes that only 14% of employers are actively studying presenteeism. Without a doubt, presenteeism is directly related to certain health and organizational risk factors, including a strong relationship to depression and other chronic conditions, and predominately found in professions that involve a caring component such as nursing. Presenteeism, as we now understand it, is a measure of work productivity and specifically "the loss in productivity that occurs when workers are on the job, but not performing at their best" (Stevens, 2004). Clearly, a crucial link must be made, matching employee health to sustained productivity. How is this done? The first step in preventing and/or reducing presenteeism is becoming aware of the problem. This responsibility falls on the part of the employees, unions, managers/supervisors, human resources, and all other stakeholders whose interests lie within health-related productivity. First and foremost, employees must adopt a selfresponsibility model of being proactive in their own health. Pelletier, Boles, & Lynch (2004) conclude that individuals who reduce one health risk factor improved their presenteeism by 9% and reduce their absenteeism by 2%. These percentages are independent of age and gender. In order to decrease health risk factors, employees must be aware of what factors they possess. This is where the introduction of Health Risk Assessments (HRA) can assist both employees and employers in better understanding the Presenteeism in Nursing 23 magnitude and severity of their individual health status as it relates to occupational demands, thereby arriving at prevention/intervention strategies aimed at improving one's overall health and productivity. Ozminkowski et al. (2004) support the introduction and sustainability of health promotion and disease management programs as a necessary measure in improving overall perceived health status with hopes of decreasing the number of health-related risk factors. Additionally, there exists compelling evidence in the integration of health services, especially for those suffering from depression (Sullivan, 2005). Relating to depression alone, the literature supports huge benefits in productivity with minimal interventions such as early screening, treatment, and education (Hemp, 2004; Goetzel et al., 2004). According to these authors, 80% of depressed workers are able to successfully remain or return to work upon receiving proper diagnosis and treatment, the latter involving a worksite-based program known as Employee Assistance Program (EAP) coupled with a behavioural therapy component. Engaging the services of EAPs have proven beneficial in the management of depression as well as reducing the consumption of costly mental health and medical benefits (Citrin, Crook, & Winn, 2004; Moran, 2004). Kahn (2008) concludes that depression is a workplace condition that is common, yet readily treatable, provided it is diagnosed accurately and quickly. Specific treatment and focused care is both cost effective for the employer and extremely beneficial for the employee. In assessing the relationship between compliance with antidepressant therapy and employer-related costs, Birnbaum et al. (2010) conclude that absenteeism is significantly reduced with use of antidepressants. Also reduced are the debilitating effects of depression which allow workers to return to work. However, due to Presenteeism in Nursing 24 the recovery process now occurring in the workplace, this may negatively affect productivity. Of equal merit is the need for organizations to gain an awareness of their workplace climate, keeping in mind the various health-related risks that can be heightened (made worse) by the workplace environment. Unfortunately, many workplaces (and especially today's acute care hospitals) have become hectic and stressful environments whereby the concept of a "healthy" work-life balance is a thing of the past. Of particular interest is the downsizing (reduction in personnel) of organizations, coupled with low replaceability of absent staff. The evidence suggests that employees working in such organizations are more reluctant to take leave, thereby increasing the likelihood of attending work while ill (Aronsson et al., 2000). Musich et al. (2006) conclude that interventions in health management and workplace environments are directly associated with positive gains in work productivity. Although many employers now are concerned about workforce health, their efforts to address this problem have tended to focus on medical costs without considering the impact of health on workforce productivity (Loeppke, Taitel, Haufle, Parry, Kessler, & Jinnett, 2009). Additionally, many employers have chosen several interventions that have shifted the costs to employees, the result of which has delayed medical care due to barriers in access (Fronstin & Collins, 2008). Changing an organization's way of doing business, such as altering the mission, vision, and values represents a move towards the culture (fabric) of that organization. Albeit not an easy task, Bachmann (2000) identifies increased productivity levels, thereby lending a competitive advantage for organizations interested in positively affecting their bottom line. Corbett (2001) remarks the following: Presenteeism in Nursing 25 "the common thread for leaders in both sectors of our economy is to realize the need to have a work culture that recognizes the whole person, as it is through the professionalism and competency of the people who do the work that strategic growth happens". According to Corbett, there are four strategic longer term drivers that can be expected as positive change in creating healthy workplaces. These are: (a) becoming and sustaining an employer of choice; (b) establishing corporate social responsibility; (c) creating and maintaining value; and (d) minimizing liability impacts for both the employee and the organization. Realizing the vastness and uniqueness of all workplaces, how can employers ensure appropriate health and productivity management plans for all workers, whom by virtue of being human, present with their own uniqueness and individuality? Solutions to Presenteeism: Health and Productivity Management Although healthier workplaces are rarely created in one day, the investments made to one's workplace are well worth it, especially if they are well planned and implemented. By and large, employers are committed in doing "the right thing" for their employees. Upon studying 10 employers (unfortunately none of these health care), Loeppke et al. (2009) conclude that a strong link exists between poor health and reduced work productivity costs, in comparison to medical and pharmacy costs alone. On average, health-related productivity costs are 2.3 times greater than medical and pharmacy costs combined. The authors also identify certain chronic conditions (e.g., depression, obesity, arthritis, back/neck pain) to be the main drivers of productivity loss. An emerging concept within today's industries is Health and Productivity Management (HPM). Essentially, this practice involves a measure of health-related lost Presenteeism in Nursing 26 productivity, with an overall purpose of assessing the business implications of a "full cost" strategy in managing health. According to the Health and Productivity Management Center (2006), HPM is "a concept that directs corporate investment into interventions that improve employee health and business performance. It can also be described as the integrated management of health risks, chronic illness, and disability to reduce employees' total health-related costs, including direct medical expenditures, unnecessary absence from work, and lost performance at work - also known as "presenteeism". Within a business equation, HPM links productivity to economic growth and profit. In other words, "better management of worker health and related productivity outcomes may create a competitive business advantage" (Sullivan, 2004). Organizations must demonstrate the business case that supports HPM by identifying three kinds of healthrelated data: (a) data on direct costs of medical treatment, (b) data on loss time or absence, and (c) data on lost performance at work (presenteeism). Loeppke et al. (2009) conclude that integrating health and productivity data can be of significant value to employers in successfully developing workplace investment strategies. In other words, "it is important for all employers - whether small, medium or large - to look beyond health care benefits as a cost to be managed and rather to the benefits of good health as an investment to be leveraged" (Loeppke et al., 2009). Collectively, these employers are joining forces in developing a continuum of comprehensive health care management services available to their workforce. Loeppke et al. (2007) conclude that health conditions known to impact medical and pharmacy costs alone (cancer and diabetes) are different than those known to affect health and productivity costs (depression, anxiety, and allergies). As such, it is imperative for employers to assess the broader health related Presenteeism in Nursing 27 costs specific to their organizations, upon which a comprehensive and integrated approach is implemented. HPM considers an organization's workforce as human capital, an entity that should be managed and focused with the same level of commitment and interest as financial capital (Health and Productivity Management Center, 2006). According to Berger, Murray, Xu, and Pauly (2001), an employee's productivity is dependent upon characteristics intrinsic to the employee and the organization itself. Characteristics intrinsic to the employee include such components as education, health and well-being, employee outlook and attitude, while characteristics intrinsic to the organization include management effectiveness, employee training programs, and effective use of capital assets. The authors demonstrate an interdependence involving both the employee and the organization, with a mutual goal of maximizing workforce productivity. In such mutual arrangements, organizations invest in their employees, who, in turn, positively influence the overall cultural climate of the organization. These arrangements result in employers who are committed in knowing their employees. In other words, employers make a conscious and genuine effort in personally and professionally knowing who works for them. "Employee wellness, a concept relating to one's physical, mental, emotional and spiritual state, is the stage or moment in time when employees are actively and fully engaged within their work sites" (MacDonald & Harder, 2008, p. 16). This statement is supported by Lowe (2004) who maintains that sustained organizational success is dependent on employee health and well-being. Solutions to Presenteeism in Health Care Presenteeism in Nursing 28 Unfortunately, the health care industry is still shy of adopting HPM practices. The literature identifies presenteeism to be a relatively new concept in health care and especially in health and productivity research (Middaugh, 2007). According to Middaugh (2007, p. 173), "Managers can strive to make the issue of presenteeism a visible one with employees. They can survey employees for their perception of the cause of their presenteeism. It is important to determine if employees are feeling pressure to work longer hours and more overtime, or to discover their reasons for not taking sick leave". The time is ripe for doing just this. Presenteeism in Nursing 29 Chapter 3 Research Methods Overall Approach/Research Orientation/Rationale The nature of the phenomenon being studied is a complex, specific, lived human experience. As such, this study consisted of a phenomenological design, with the purpose of describing the common experiences of those who had been exposed to the phenomenon of presenteeism. Researchers applying phenomenology are interested in the lived experiences of the people involved (Greene, 1997; Holloway, 1997; Kruger, 1988; Kvale, 1996; Maypole & Davies, 2001; Robinson & Reed, 1998). Phenomenology allows for an in-depth exploration and analysis of first-hand experiences of presenteeism as described by the participants. Creswell (2007, p. 58) notes that "the inquirer then collects data from the persons who have experienced the phenomenon, and then develops a composite description of the essence of the experience of all of the individuals". Moustakas (1994) coins this description to be what and how the phenomenon is experienced. The approach used in this study was a transcendental or psychological phenomenology (Moustakas, 1994), whereby the researcher focused on the descriptions of the experiences as opposed to her interpretations (hermeneutic phenomenology). Within this approach, the researcher employed a concept known as epoche (bracketing), ensuring that personal experiences are removed, thereby allowing a fresh perspective (newness) of the phenomenon being studied (Moustakas, 1994). This was undertaken as the first step in the qualitative data analysis process. The researcher set aside all Presenteeism in Nursing 30 preconceived experiences in order to best understand the experiences of those interviewed. The rationale for using a qualitative phenomenological design included wanting to identify the common experiences of presenteeism in acute care nurses working in NH, and to develop a deeper, in-depth understanding about the features of presenteeism within this population. Although abundant in the literature, the phenomenon of presenteeism has not been studied in great detail within heath care environments, and especially within the Canadian health care system. Participants and Sites Participants were selected via a purposeful sampling method whereby "there is an assumption that there is an even distribution of characteristics within the population" (Statistics Canada, 2009). Statistics Canada (2009) also notes that these methods "can be useful when descriptive comments about the sample itself are desired". Of the 16 types of purposeful sampling methods (Patton 1990), this study utilized a criterion sampling method, whereby a criterion was set and all the cases involved in the study met the criterion (Patton, 1990). This method of sampling is very strong in quality assurance. In his discussion on phenomenological designs, Creswell (2007, p. 128) notes that "criterion sampling works well when all individuals studied represent people who have experienced the phenomenon". The criterion for participation was acute care nurses working in the emergency, intensive care, or surgical departments of the University Hospital of Northern British Columbia (UHNBC), in the city of Prince George, British Columbia, who have experienced the phenomenon of presenteeism. In other words, those nurses who have Presenteeism in Nursing 31 attended work despite feeling that he or she should have stayed home. The UHNBC was chosen due to its size, being the largest hospital in NH, and therefore able to choose participants from the largest staffing numbers. The emergency, intensive care, and surgical departments were chosen as they are hectic and, at times, chaotic environments for nurses working in those areas. Access and Permissions Following ethics approval (Appendix H and I), the researcher connected with a UHNBC resource (Administrative Assistant), and provided an electronic copy of the research information package (Appendix B), attached in an email to potential participants. In the initial recruitment phase, the UHNBC resource e-mailed all acute care nurses of the emergency and intensive care departments. The research package included the researcher's contact information, upon which the interested participants would contact the researcher directly. Hard copy research packages, pamphlets, and posters were also provided to the UHNBC resource that, in turn, facilitated the distribution to these nurses via the clinical practice leaders. The researcher ensured hard copy packages were readily available on each unit by liaising with the UHNBC contact on a regular basis. The email was re-sent to the initial distribution list 12 days post initial contact. On day 17 of participant recruitment, surgical north and south nurses were added as potential participants and contacted via the same process above. The decision to add the surgical departments was due to the researcher having access to a larger number of potential participants. This resulted in a number of participants coming forward as interested in this research opportunity, likely as a result of more publicity within the hospital. In the end, I Presenteeism in Nursing 32 had numerous participants expressing interest, however stopped interview at the point of saturation which was at 10 interviews. Data Gathering Methods In-depth face to face interviews with 10 participants were conducted and used as the primary data collection technique within this study. Bogdan and Biklen (1982) support the notion of using open-ended questions, the result of which allow for individual variations. Of the three types of qualitative interviewing which are informal/conversational interviews, semi-structured interviews, and standardized openended interviews (Patton, 1990), the researcher utilized the latter. Interviews were held in a convenient agreed upon location at the UHNBC. All interviews were conducted face to face. Initially, the researcher conducted two interviews and received feedback from her research committee. At that time, it was highlighted that the researcher needed to be more interactive with the participants. These two initial participants were invited to add to their transcripts which they did. Each interview varied in time, ranging from 15 minutes to 55 minutes. The shorter interviews (a few of them) did manage to capture the experiences of the participants and the factors influencing that experience. The same level of probing was used during all 10 interviews. For the shorter interviews, participants were explicit in their responses, yet not very talkative. At mid point during the participant recruitment phase, the researcher contacted her supervisor on exploring the possibility of conducting telephone interviews. It was decided to not pursue this avenue until absolutely necessary. The researcher received many phone calls from interested participants who wondered about the possibility of Presenteeism in Nursing 33 conducting the interviews over the phone. When asked why, it became obvious that the participants felt it would be more convenient to participate by phone, especially as they did not have time to be interviewed during work hours (some don't even take breaks), and they did not want to remain at work either prior to, or after working a 12 hour shifts. When asked about the researcher conducting these interviews at the participants' homes, this invitation was denied. The data was recorded via the use of a digital voice recorder. Each interview was coded as Participant 1, 2, 3... 10. Although I prepared and intended to take notes during the interviews, I found myself so engaged in individual conversations that I felt it was more of a hindrance than a help. Also, the participants were very engaged and very explicit in their responses, which allowed me the opportunity to capture the relevant data on the voice recorder. Actual wording and the order of the questions varied slightly, however the questions were kept to a consistent process. In other words, all main and probing questions were asked of all participants (Appendix A). The recordings were then uploaded via a MP3 file on the researcher's computer, using the exact coding that was used on the digital voice recorder. These were again coded as Participant 1, 2, 3... 10. The recordings were then transcribed verbatim by an external transcriber who signed a transcriber's agreement (Appendix D). These transcripts were transcribed by use of the digital voice recorder as opposed to the MP3 file. The MP3 file was only used and accessed by the researcher who was able to listen to the recordings in preparation for the data analysis. Validity/Reliability - Trustworthiness Presenteeism in Nursing 34 Interpretive validity was addressed by a team of external auditors (members of this research committee) who each reviewed and coded the three richest transcripts. In addition, an additional external auditor (non-committee member) was recruited to review and code the same three richest transcripts. The external auditor signed the external auditor's agreement (Appendix E) prior to undertaking the review. These three richest transcripts were then compared to the researcher's coding system, ensuring consistency in the coding and interpretation of the data. Verification was achieved by adhering to the phenomenological method, bracketing past experiences, keeping the participants focused on the questions, using an adequate participant sample, and interviewing up to the point of saturation of data. Polkinghorne (1989) recommends an adequate sample size to be between 5 to 25 participants which was adhered to. Ethical Considerations Consistent with current practice, this research proposal was submitted for consideration and approved by the University of Northern British Columbia's Research Ethics Board (Appendix H) and NH's Research Review Committee (Appendix I). Informed consent was collected from all participants prior to each face to face interview (Appendix C). For the two participants that were interviewed twice, consent was obtained prior to the second interview and recorded on the initial signed consent. Data was not shared among the participants or with anyone outside my thesis committee. The four basic principles of ethics in health services research (autonomy, non-maleficence, beneficence, and justice) were adhered to at all times (Mathers, Howe, & Hunn, 2002, p. 5). In addition, this study observed the four ethical rules of veracity, privacy, confidentiality, and fidelity (Mathers et al., 2002, p. 8). Presenteeism in Nursing 35 According to Richards and Schwartz (2002), there are four potential risks inherent to qualitative health services research, including the scenario where participants are health care professionals themselves coupled with a researcher who is also a health care provider. These four risks are: (a) anxiety and distress, (b) exploitation, (c) misrepresentation, and (d) identification of participants in published documents. In the case of this study, the association between presenteeism and depression, including other chronic medical conditions, has the potential to provoke anxiety and distress which cannot be predicted accurately. This could have resulted in raising participant expectations on receiving therapeutic/follow-up care from the researcher. In the case of exploitation, power imbalances have been argued as inevitable circumstances in research relationships (Hammersley & Atkinson, 1993), exaggerated when the researcher is also a health care professional (Etherington, 2001). The latter can occur due to participants feeling pressured to participate as a sense of duty to their colleagues and/or the interview taking the form of a therapeutic encounter, especially in the presence of qualitative open-ended questions whereby participants may start disclosing more information than originally intended at the time of the consent. In the case of a researcher being employed by the organization in which participants are recruited from, this can place the researcher in a potential conflict of interest. In minimizing potential harm to both above risks, the professional background of the researcher, including her role within the organization, was made clear to the participants at the beginning of each interview. At that time, the participants were informed that this study was not intended to be therapeutic in nature, nor would it affect them in any way, regardless of their level of participation. The researcher also notified Presenteeism in Nursing 36 the participants that her role within the organization was independent of her role as a researcher. Should any of the participants had expressed signs of anxiety and/or distress, the researcher would have referred the participants for follow-up care by their medical physicians. This was not applicable as none of the participants expressed anxiety and/or distress. Misrepresentation, or the feeling that one's narrative views have been taken out of context and/or not accurately represented within the data analysis process, was addressed by the team of external auditors involved in reviewing transcripts (see above). Finally, anonymity and confidentially of all participants was maintained, ensuring that participants are not identified in any possible published data. Presenteeism in Nursing 37 Chapter 4 Data Analysis The research data was analysed via the following steps (Moustakas, 1994): (a) horizonalization, (b) clusters of meaning, (c) textural description, (d) structural description, and (e) structure or essence. Within horizonalization, the researcher begins sorting through the data by highlighting significant statements, quotes, or sentences that "provide an understanding of how the participants experienced the phenomenon" (Creswell, 2007, p. 61). The statements are then arranged into common themes, which develop clusters of meaning. The themes and statements are then arranged to write a textural description or "meaning units" of what the participants experienced, followed by a structural description of the contexts, situations, and/or factors influencing their presenteeism experience. Finally, the researcher writes a common description, derived largely from the textural and structural descriptions. This common or composite description represents the structure or essence of the experience. One week post data collection, I started the analysis by describing my own experience of the phenomenon, attempting to set aside any preconceived findings. This important step, known as bracketing, allowed me to take a fresh perspective and to focus solely on the phenomenon experienced by the participants in the study (Moustakas, 1994). Within the bracketing step, I interviewed myself, using the digital voice recorder and interview questionnaire that was used with the participants. I then transcribed the transcript, ensuring I would have a written copy for easy access during the entire data analysis process. On numerous occasions, I found myself referring back to my transcript, Presenteeism in Nursing 38 an important step that further allowed me to be as objective as possible in the data analysis. I then began listening to each data recording, repeating this step until I was very familiar with each recording. I then read and re-read each transcript, again familiarizing myself with the data but also trying to capture/hear repeated words, similar statements, and/or sentences. I then listened to each recording, this time coinciding with the transcribed copy, noting repeated words, similar statements, and/or sentences that related back to my research questions. Following this step, I began listing all significant statements for each participant, eventually creating a list of 241 verbatim significant statements. At this stage, I started color coding (grouping) each verbatim significant statement into clusters of meanings/themes that were evolving. I initially had 19 clusters of meanings/themes, which allowed me to color code every verbatim significant statement or parts thereof. In other words, it was common to have a verbatim significant statement include two colors, sometimes three. With each color representing a potential theme (note that I still had 19 initial themes at this stage), I attempted to classify each statement by their corresponding color. In other words, I created a table for each color and started grouping the verbatim statements under each color, essentially extracting formulated meanings (many still remaining verbatim statements, yet shortened) corresponding to each color coded significant statement. This important step identified various duplicate clusters of meanings/themes that were evolving. Further breakdown of duplicates resulted in 10 themes. From the above information, I then proceeded to write a textural description of "what" the participants experienced, including verbatim examples. The same step was Presenteeism in Nursing 39 undertaken for writing of a structural description of "how" the phenomenon was experienced by those in the study. Finally, I was able to write a brief description (the essence) of what all participants experienced related to the presenteeism phenomenon. Results From 10 transcripts, a total of 241 verbatim significant statements were extracted. Table 1 identifies a few selected examples of significant statements and their formulated meanings. Presenteeism in Nursing Table 1 Selected Examples of Significant Statements of Persons with Presenteeism and their Related Formulated Meanings Significant Statements Formulated Meanings I was just feeling gross and my brain wasn't working that great and probably wasn't the safest thing to be there. Brain and mind are not working that great. I didn't feel safe, I didn't feel I was safe, I didn't feel my patients were safe and that was a really bad feeling I didn't feel safe and I didn't feel my patients were safe. I remember I came in the assignment was everything I was dreading, if not worse and um, they I looked I, I felt absolutely ghastly it was a ghastly day. I don't specifically remember the day but I remember feeling like I wasn't thinking well A dreadful assignment A ghastly day Not remembering the day, not thinking well That day I came in and I remember thinking I'm, I might not make it today and I didn't make it I went home sick and I was off for a couple three months I remember thinking, 'I might not make it today, and I didn't. Well, with my experience I have called in sick before and you feel so guilty about not coming in. Then you sit at home and you're like "Well am I really that sick or could I probably have made it, I probably could have been fine" so then you just feel harder on yourself so that's why I kind of doubt yourself so you go into work Feeling bad and guilty about not coming in I was in pain and being disabled at the time temporarily trying to keep up and its a fast moving job Trying to keep up with the fast pace while being temporarily disabled You're on your feet all day it's like you need a reliable, reliable legs I didn't have them No reliable legs when you need them I was actually called into the office my next set and warned that uh I was abusing my sick time privileges to extend my vacation which totally wasn't true Warnings of sick time abuse Being hard on myself Am I really sick? Grouping the formulated meanings into clusters allowed 10 themes to emerge. Table 2 identifies examples of all 10 theme clusters and their formulated meanings. 40 Presenteeism in Nursing Table 2 Examples of Theme Clusters (1 to 6) and their Formulated Meanings Theme Clusters and Meanings Theme Clusters and Meanings Theme 1 Demanding Workloads Everybody has double or triple their regular assignments Everybody is over their patient quota The workload is just ridiculous and how people are getting injured or getting sick or getting unhealthy and yet they're still pushing the patients on Unable to find someone to cover for breaks Theme 4 Cracking Down on Sick Time We are allowed one sick day a month There is manager harassment We look bad if we are over There is a lot of pressure Being watched Probing into nurses' personal lives Theme 2 Caring for Oneself Okay, I can't do this I felt I shouldn't be at work I remember thinking I might not make and I didn't We don't do ourselves a favour by working that way I remember the day when I finally gave it up Think of yourself too It was a learning experience. There is a reason we call in sick Theme 3 Morale Does Suffer It just makes it bad You are like a service and that's it We were pretty disgusted It is not nice at all Definitely doesn't help the morale, that is for sure No support from anybody Theme 5 Obligated to Come to Work Didn't want to let my team mates down Feeling bad and guilty about not coming in Worried what other people will say I called but chickened out Worrying about what people will do without you A conscience burden thing I can't do that to my coworkers Theme 6 Noticing you are Unwell, Yet Please Stay - Please don't go home - Not feasible with one less body - You look so tired - Don't worry, we're here with you - Go have a nap - We can't let you go home - Do the best that you can do - Just don't leave us 41 Presenteeism in Nursing 42 Table 2 (continued) Examples of Theme Clusters (7 to 10) and their Formulated Meanings Theme Clusters and Meanings Theme Clusters and Meanings Theme 7 Hoping for Safe and Adequate Patient Care Brain and mind are not working that great Not doing everything for the patient Not mentally there Can't give the gold standard of care that these people need Your best is not very good anymore A fine balancing act Theme 9 Working Short Staffed Without Anyone to Call In Working short staffed is a standing issue Always hard to get anyone to come in Never staffed sufficiently Immediately envision my coworkers working short Critically short Only one or two casuals to call in for one area Theme 8 Surviving the Dreaded 12 Hour Shift, Especially at Night A nightmare Physically and mentally exhausted Distracted and stressful because of the pain Back pain was killing me Functioning without being efficient Tired and unorganized A miserable shift Trying to keep up with the fast pace while being temporarily disabled Theme 10 Solutions to Presenteeism There are just not enough people (not enough younger nurses) Not attracting younger nurses Running the units on the number of beds that are budgeted for Get staffing in the middle of the night A call out list for night shifts Bond and stand together Change lines Theme I: Demanding workloads. Working at one's complete maximum was a consistent message evolving from the participants. In one unit in particular, the patient to nurse ratios had recently changed. Within the last three to four months, nurses could be expected to double or triple their assignments, thus meaning that one nurse could look after two or three patients each on ventilators at one time, "everybody has doubled and tripled their assignments (interview #1)." This usually resulted in either a lack of, or shorter breaks. Eating at the bedside was fairly common, "I mean there's so many occasions in the twelve hour shift we don't get breaks, you cannot get a break. I, we have Presenteeism in Nursing 43 eaten right at the bed side table (interview #3)." The workloads can be difficult for a healthy nurse to look after, not to mention an unhealthy one. This scenario can present a vicious cycle whereby nurses are either coming to work ill or injured and expected to deal with current workloads, or those who attend work feeling well, and then are at risk of becoming ill or injured. "It's just ridiculous the workload and how people are getting injured or getting sick (interview #5)," "I bet you most, like soft tissue accidents or pokes etc., all happen when people are tired and really shouldn't be at work because you're just trying to get through the day (interview #6)." Demanding workloads are stressful and dreaded, especially more so when one is unwell, "I remember, I came in and the assignment was everything I was dreading, if not worse. I felt absolutely ghastly (interview #8)." One nurse remarked: I am supposed to be able to do absolutely everything I can do within my power to get that patient the best care possible and when doubled up and I'm spread between two patients and by end of my shift you look at my charting and there is nothing on my sheet because I've not sat to chart, there is no time... I wonder what I have done you know that what I should have done, what I didn't get done. Well, number one, if someone was to take a look at the chart and they would think I did nothing the entire shift. It's, it's very frustrating and you end up cutting corners and, and doing minimal just to be able to (pause) just to be able to get the minimum done (interview #3). Theme 2: Caring for oneself. Once at work, and depending on how the day is progressing, some do make it through the shift and some don't. Overall, there appears to be a level of awareness for self-care and one's ability (or not) to survive the day. That being said, practicing self-care is not as widely adopted as it possibly should. The following responses highlighted the nurses' awareness of their own limitations: "I was completely incapable of doing my job after that (interview #4)," "I do remember one time.. .1 had got a migraine headache and I remember.. .1 couldn't see though and actually Presenteeism in Nursing 44 the nursing supervisor and drove me home (interview #5)," "I hurt myself even more and ended up going home (interview #4)," "I came in and I remember thinking I'm, I might not make it today and I didn't make it. I went home sick (interview #8)," "sometimes when you're in the middle of stuff you don't really realize what you're doing to yourself and you're not helping yourself (interview #8)." Nurses do believe that "when you're sick, you're sick (interview #9)." Yet, most are unable to follow that next logical step of staying home. When asked about the experience, one nurse remarked, "It was kind of a learning experience you know, there's a reason we call in sick, I think maybe in the end I kind of got under foot more than it helped (interview #7)." Another commented, "If I had been alert, I think I would have been better if I'd actually stayed home and taken care of myself (interview #8)." One nurse described her current experience as "this time I recognized what was happening and my self-care has been much better.. .I'm much better at saying no, I'm not going to do this or no, I'm not coming in (interview #8)." One nurse stated, "We've all got to the point where we don't come in on our days off or we try not to come in on our days off (interview #3)." Theme 3: Morale does suffer. For some participants, the responses related to morale and overall workplace environment were primarily shared in relation to sick and overtime use. Responses such as "it just makes it bad (interview #1)," it's just not nice (interview #1)," "kind of hurtful (interview #1)," "definitely doesn't help the morale for sure (interview #1)," "you're a number (interview #2)," "you are like a service, that's it (interview #2)," "really discouraging (interview #1)," and "there isn't that caring (interview #2)" were noted. For some, the lack of support was noted: "[the patient] three Presenteeism in Nursing 45 times threatened staff and I did not get any support from anybody (interview #4)." I don't have any autonomy even as charge nurse you see you need more staff, you see they're not coping they still want you to just suck it up and do it you know. Or they pull your staff or they give you more patients than what you have and you can't say no anymore, you can't refuse a patient (interview #5). One nurse mentioned, "for a hospital we don't really take, you know, hospitals are not taking care and I'm not sure that I, that the system knows how to take care of the people working in it (interview #8)." Furthermore, "they don't make it easy, they don't make it easy (interview #8)." Theme 4: Cracking down on sick time. For those who attempted to call in sick, the following statements reflected their experiences, "I have attempted to call in sick and most times I mean they try, you know they try to diffuse the situations where they.. .try and talk you out of it (interview #2)," "there is a lot of pressure, there's lots of outside pressure (interview #2)," "I've called and staffing will say, oh God you know we've already had two calls (interview #7)." In contrast, one nurse shared, "when the department is good like they don't really, if you call in sick it's, it's fine.. .will always say well no don't come in (interview #8)." Unfortunately, I didn't ask this participant on elaborating further on "when the department is good". Several responses indicated that sick time is being reviewed, to the point of reaching allowable targets of approximately one sick day per month. One nurse remarked, "I'm not sure 4% of what but we are allowed one sick day a month. You would be over and it would look bad (interview #1)." Others commented, "all the hospitals they target at 3% sick time which I really, really feel is quite unrealistic for what we are doing and what we are dealing with in this day and age with everything becoming virulent (interview #2)," "they graph it they look for if it is weekends, if it's nights, and then Presenteeism in Nursing 46 that's brought to your attention that you have patterns at times etc. etc., like it's, it's, it's very interesting (interview #2)." A 'fit of pattern' was mentioned whereby: If you just worked overtime last set, then you know you call in sick for your first set of days then they say that you meet this pattern even though it's really not really a pattern at all. You just might be sick that day so that sometimes influences as well as you don't want to be that person (interview #1). One nurse shared, "there's been a lot of probing for into people's personal, personal issues and, and people's sick time and why it's happening (interview #10)." In contrast, one nurse stated, "When you do call in sick, it's good, like you don't get any pressure to come in (interview #5)." Also, some highlighted that abuse of sick time is still a reality, "I'm starting to see that sick calls where I'm working are very much abused (interview #7)," "if we could just bond together and stand together but the problem is that there are people who abuse the system, there are, I've seen it (interview #6)." The same nurse remarked, "I'm irritated when my coworkers phone in and I know they are not ill and I don't want to be that (interview #6)." Theme 5: Obligated to come to work. When asked why they attended work, nurses expressed feeling obligated to be at work, "it gets to the point where if I don't show up then their night is going to be awful, hell run to the bones so I'm going to go in (interview #7)." Nurses experience guilt, loyalty to coworkers/the team (and ultimately their patients), peer pressure, fear of repercussions, constant doubting of their own ill feelings, and fear of exposing their illness onto others. Peer pressure, pure and simple. I think that this place is political. I think that people really judge your actions..., it's a culture where if you slack, if you're perceived as a slacker, then you really get given a hard time (interview #6). The following reflected common experiences of all participants, "I just didn't want to stay at home and let my team mates down so I decided I could try and struggle it out at Presenteeism in Nursing 47 work (interview #1)," "I'm hurt but I'm going to go and show up and help out and be a team player (interview #5)," "the biggest thing I think is guilt, feeling bad for calling in (Interview #2)," "we do care about who we work with because we spend a lot of time with them, you feel really bad for them so you, you drag yourself in (interview #2)," "then you just feel harder on yourself so that's why you kind of doubt yourself so you go into work (interview # 1 ) , " "I'm responsible, they're counting on me to show up and do it (interview #8)," "when you come then you sort of are almost made to feel, what are you doing here (interview #10)?" One nurse admitted to calling in and this is what she had to say, "I phoned here and then I chickened out and hung up the phone. It's like I can't even tell you I almost did it (interview #6)." Some leave the decision to others: I got sick with a bad, bad head cold but I stayed home cause I phoned my boss. I left it up to [my boss], that's how guilty I felt cause I phoned [my boss] and said these are my symptoms. What do you want me to do cause I will come in if you want, I will come in but I don't really want to but what do you want (interview #3)? Coming to work when ill or injured is a common practice, "Even people who give me heck for coming in I see them doing the same thing (interview #5)," "I see everybody doing it. It is catching (interview #5)." Furthermore, a few participants noted that they do attend work (perhaps more than they should) for other reasons, "if I don't take those calls I don't get hours so then my seniority decreases so then I.. ..can't further myself (interview #6)," "on a normal situation right now I'm working full time and then also working part time so I'm exhausted but that's my own doing (interview #7)," "I like a little overtime in my bank (interview #8)." Theme 6: Noticing you are unwell, yet please stay. "People are all so happy just to have a warm body (interview #2)." When asked if coworkers commented, all participants Presenteeism in Nursing 48 noted that coworkers will comment when one attends work when feeling unwell. Comments range from "you look so tired (interview #6)," "you look like crap (interview #1)", "you look like hell (interview #3)," "you look worse than the patient (interview #3)," "what are you doing here (interview #10)," "we know you're tough (interview #7)," "don't worry, we're here with you (interview #6)," to "maybe if you go lay down for a bit you can feel better (interview #10)." On numerous occasions, it was mentioned that coworkers comment because they care about each other. Coworkers are noted to be kind, compassionate, and positive in their comments. Some will offer medication (Tylenol, Advil) for that staff member to get through the shift. With all caring comments, there appears to be an undertone that communicates the following: "Oh it's okay, we'll help you out, we got your back, you can have a nap on your break. All that stuff is really geared towards just don't leave us (interview #6)." One nurse stated, "They're looking at you going please don't go home, like please don't go home, we can't do this at all (interview #1)." One nurse shared, "colleagues feel sorry for you cause you look like hell so they will try and send you home but .. .we're never staffed sufficiently to be able to even pick up another staff load (interview #3)." In contrast, one nurse remarked being uncomfortable in the presence of sick coworkers: I think if you're sick you should stay at home and if you come to work, then I guess just shouldn't share your information with others to make them sick and worry.. .you start thinking.. .it's so hard to do your work. I think they should keep their stress home and they shouldn't come (interview #9). One nurse called it a "you're damned if you do and you're damned if you don't (interview #10)" situation. In other words, colleagues want you there, yet they don't want you exposing their illnesses onto themselves. Another nurse called it "kind of a catch Presenteeism in Nursing 49 22.. .I'm mad that you're there too cause now I'm going to get that too on my days off. I'm probably going to spend it sick (interview #2)." Theme 7: Hoping for safe and adequate patient care. Providing safe and adequate patient care is the most important goal for all acute care nurses, and the highest on their priority list. "I was worried number one about the patients (interview # 5)," "Patient safety is the most important for the nurse. When you're sick, then their safety is compromised and you can't give proper care (interview #9)." This goal appears to surpass one's own personal safety and health care needs, "I decided to come in because I based my decision on the fact that I can still give safe patient care that is sort of my guideline, even if it's not really good for me to do (interview #6)." Awareness that patient care may suffer or be compromised due to one's physical or mental state is high. In other words, nurses do recognize when they are either not performing to professional standards and/or to what the patient care needs are, "You're not doing everything that should be done for that patient (interview #2)," "the patients really aren't getting the best critical care they can (interview #2)," and "we're doing professional responsibility forms (interview #5)." They are also aware of efficiency levels, noting that "they're just functioning and they're not that efficient, like you're not really efficient (interview #6)," "you just don't get the things you should be doing done (interview #3)," "you feel like you're almost stupid (interview #6)," and "you're not really physically and mentally at your full potential (interview #2)." Fear of making mistakes is common. Regardless of one's best attempts, this may not be enough, "your best is not very good anymore (interview #6)." Mentally, critical thinking suffers, "My brain wasn't working that great and probably wasn't the safest thing to be there - you Presenteeism in Nursing 50 know because my mind isn't working as well and you know you're not as good at critical thinking (interview #1)," "part of it is your brain is running slower (interview #6)." One nurse remarked, "When we can't do the job that we feel we should have done, that's when we start paying the price (interview #3)." Theme 8: Surviving the dreaded 12 hour shift, especially at night. The following statement provides a visual image of what one participant experienced at night, "Once you get to about 3 o'clock in the morning, it's horrible; it's kind of like you're climbing up the side of the mountain with your bare hands (interview #6)." The dreaded shift is described accordingly: "A nightmare (interview #2)", "ghastly (interview #8)", "extremely chaotic (interview #7)", "a miserable shift (interview #7)." The experience is felt physically and mentally. Examples of physical symptoms include "burning in my lower back (interview #5)," "walking with a limp (interview #3)," "in pain and disabled at the time (interview #7)," "physically sick and nauseous (interview #10)," "no reliable legs when you need them (interview #3)," "back pain was killing me (interview #5)", and "I just immediately felt my back go (interview #4)." One nurse commented on her evening whereby "you're trying to find somebody to watch your vented patient while you are spending you know, 50% of your time in the bathroom with diarrhoea or whatever it may be throwing up, in a bathroom that everyone is using (interview #10)." For some, the physical experience is described as "an out there feeling like I wasn't almost in my body (interview #8)," "doing this on automatic (interview #8)." The same participant shared, "I broke down in tears (interview #8)," and "I was really embarrassed (interview #8). One nurse commented that "by the end of the shift you're so worn out that you no longer care at that point (interview #6)." Presenteeism in Nursing 51 Mentally, the symptoms range from being "unable to deal with it anymore (interview #1)," "functioning without being efficient (interview #6)," to the point of being worn at the end of the shift to the point of no longer caring. One nurse noted that a previous compassionate ability was no longer present. Overall, there appeared to be a drain on one's mental capabilities, noted earlier in Theme 7: Hoping for safe and adequate patient care. Survival is a common element and expressed accordingly, "You just keep thinking to yourself one more shift, just one more shift. You know, you look for the light at the end of the tunnel so you can get through the shift (interview #3)". Overall, there is a sense that nurses push themselves to the point of being incapacitated. "Mentally and physically we run ourselves so to the end that you, whether you're sick mentally or physically, you've just had enough and you just can't deal with it anymore (interview #1)." That being said, those interviewed managed to show up for work on their next shift, with some not even realizing that they are sick, "I had to keep coming back to work the next day because I'm not sick or anything, I am just mentally messed up (interview #4)." Survival is also seen to bring about a certain level of pride that nurses hold dear to their hearts. The tough and proud nurse is, at times, hesitant in admitting that something is wrong or that he/she will possibly not make it, "I didn't think it was too much of a problem (interview #5)," "I showed up to work on crutches (interview #7)," "I didn't really want to admit to anybody that this was not copeable, that I couldn't cope with it and I thought I covered very well (interview #8)," "we're tough we don't need to debrief (interview #8)," "I took some Tylenol and brought my warm blanket and just you know, just did it (interview #5)." Presenteeism in Nursing 52 Overall, the experience is memorable and perhaps one of the toughest days of one's working life, "It's extremely busy, they can't replace me to go to work and that's what I did and it was one of the toughest shifts I remember (interview #8)." Theme 9: Working short staffed without anyone to call in. Working short staffed in acute care areas is a common occurrence. A few comments were noted: "we are not always replaced (interview #2)," "working short staffed is a standing issue (interview #2)," "we are never staffed sufficiently (interview #3)," "we are needing to work overtime due to low staffing levels (interview #3)." The lack of casuals to call in, especially at the last minute, was a consistent scenario: "we only have the one or two casuals which we are using for vacations (interview #2)," Obviously when you're close, too close to call in sick it gets too close to your shift and you're worried about if they are going to be short staffed, they can't find anybody, not enough time so.. .1 came to work (interview #9). Nurses will attend work and hesitate to call in sick as they "immediately envision coworkers working short (interview #4)." One nurse remarked, "I have a ton of sick time and would not hesitate to call in if we had the proper staffing levels (interview #4)." If the nurse is uncertain if he/she will manage once at work, the responses suggested that they would feel better to show up, perhaps be sent home or return home, than initially calling in sick. However, this introduces this scenario, "I can't go home now if I go home now then they're really screwed because they can't phone anybody in (interview #4)." Low staffing levels present an added sense of responsibility for those who should likely stay home, "It's just a shame that we don't have enough staff so that we, so that we don't feel so guilty, so that we don't feel so responsible (interview #5)." Another nurse noted, "I can remember one shift specifically where I woke up and I thought, I really don't want to Presenteeism in Nursing 53 go to work I, I don't think I can do it anymore and, but it's 6 in the morning (interview #6)." One nurse remarked the need to work on their days off, "we are so short, so many people are coming on their days off and nobody is taking a break (interview #3)." Coupled with current staffing levels and lack of casuals is a rising patient acuity, "It's not as though you're just nursing healthy people who have had surgery; these people you're dealing with and their families are in extreme stressful situations and, you got to have it to be able to help them (interview #3)." Theme 10: Solutions to presenteeism. It is important to note several solutions to presenteeism shared by some participants. With the exception of a few personal strategies also noted in Theme 2: Caring for oneself all solutions were discussed within an organizational and systems-based context. In other words, participants offered possible solutions that would only be possible by engaging the organization (Northern Health) to make system-wide changes. Some examples of these possible solutions: "in our culture, I think one thing to help that situation would be to get staffing in the middle of the night, some call out list (interview #6)," "implement a system.. .like a call out list or somebody who is on call (interview #3)," "if we could just bond together and stand together but the problem is that there are people who abuse the system (interview #3)," "it's just not enough people.. .we aren't attracting the younger nurses (interview #2)," and "it would be nice to work in an environment where you didn't have to worry about them not managing without me (interview #4)." One participant shared a possible solution of "closing the unit and improving our staffing numbers (interview #3)." When asked about clarifying this statement, the participant advised that closing the unit means "a closed unit in that not anyone can admit to it (interview #3)," which further signified that patients would Presenteeism in Nursing 54 require a specialist (internist) for admission to that unit. Personal strategies noted included such comments as "I need to go to an area that has more control and that I can control a little bit (interview #5)," "I meditate you know and my self-talk is much better (interview #8)," "you need to take care of yourself (interview #8)," and "I had to change something in my work environment and I changed the personalities I was working with and that, and that made a real difference (interview #8)." These 10 themes were integrated into a textural description (what was experienced) and structural description (how it was experienced) of presenteeism in acute care nursing. Both descriptions were reduced to the "essence" of the phenomenon whereby "all individuals experience it" (Moustakas, 1994). The following paragraphs include both descriptions and the essence of the presenteeism experience. Textural Description. Nurses attending work experience a variety of physical symptoms ranging from a considerable amount of pain, tiredness, low energy, nausea, to the point of being incapable of walking. The shift is considered a nightmare, whereby the environment is chaotic, ghastly, a mad house, and too busy to even care for each other. Mentally, the mind and brain are not working well. Critical thinking is on the slower side, whereby nurses worry about making mistakes and notice their inefficiencies. They report being there in body, however not mentally there. Some call it an out-there feeling or being on automatic. Nurses experience comments by their coworkers. These range from you look tired to what are you doing here? With all comments, there lies an undertone which really says, 'We know you are unwell, however we need you and please don't leave us'. This internal Presenteeism in Nursing 55 dilemma is made worse by nurses experiencing a loyalty to their coworkers, guilt, doubting their own ill feelings, peer pressure, a sense of pride, and fear of exposing their illness onto others. By already working double or triple their assignments and often being short staffed, those who stay or return home cannot be replaced due to lack of casuals, especially during last minute sick calls. Breaks are often taken at the bedside, if they are taken at all. Structural Description. Physical and mental symptoms consistently worsen as the shift progresses, with a sense of being done and no longer caring by the end of that shift. Nurses may require medication in order to survive the shift. The 12 hour shift, and especially night shifts, are exhausting, to the point of some trying to stay awake. Nurses are often unable to sleep during the day which adds to the physical and mental exhaustion. Mentally and physically, they are not really sure how they are getting through the shift. When deciding whether to stay at work or return home, nurses worry about how their coworkers will manage without them. In an attempt not to lose a working nurse, coworkers will offer care and support in the form of allowing longer and more frequent breaks, naps, medication, making positive comments about how appreciative they are that the nurse is staying at work. Overall, the increasing acuity of patient care, coupled with the lack of control over workloads, sick time coverage, and sick time targets negatively affects the workplace climate. Some recognize and agree that taking care of oneself is crucial. There is a sense that the healthcare system is not recognizing, nor does it know how to take care of those who work within it. As a tough breed, nurses are also a proud bunch and do try and cover Presenteeism in Nursing 56 up in an attempt to hide any indication that something is wrong or that one is unable to cope. Nurses will often put 'their all in'; however do later pay the price in being so conscientious. Essence. Acute care nurses attend work when they feel they should have stayed home. The experience is felt physically and mentally, thereby creating a distraction in the provision of safe and adequate patient care. Both internal and external factors are noted, all and/or some of which influence the decision of whether or not nurses attended work. Furthermore, all factors are interrelated, adding to the dilemma of making a sound decision that in the best interest of the nurse, the patient, and the workplace environment. The experience does affect one's work performance, and in the end can lengthen the safe recovery of the ill or injured nurse. Discussion The phenomenological design resulted in 10 narrative transcripts which provided an exhaustive description of the presenteeism experience among acute care nurses working in the UHNBC. Furthermore, the design identified common contexts, situations, and/or factors that influenced this experience. Although recognizing their inability to possibly function well when at work, nurses are hesitant to call in sick, and in the rare event that they do, attend work experiencing an array of physical and mental symptoms. Internal and external factors (represented by the 10 themes) influence the nurses' decision to attend work. The experience does affect one's work performance, and in the end can lengthen the safe recovery of the ill or injured nurse. The majority of participants attended work when suffering from physical ailments. These ranged from low back pain (most common), leg pain, to a fractured ankle Presenteeism in Nursing 57 not yet diagnosed that later required surgery. Two nurses suffered from chest colds (with allergies), while another suffered from depression. One nurse did suffer from a mental disorder initially (stayed at work) which then ended up in a low back pain injury. When discussing the possibility of not attending work and/or returning home, two participants noted that a migraine headache would either prevent them from attending work and/or require them to return home. When asked what was it like to be at work that day, the following terms and expressions were noted which help signify the nurses' awareness of their inability or lessened ability to perform as they should: "not that efficient (interview #6)," "inefficient (interview #2)," "just functioning (interview #6)," "feeling almost stupid (interview #6)," "not at full potential (interview #2)," "best is not very good anymore (interview #6)," "brain is slower (interview #6)," "critical thinking is a little bit on the slower side (interview #1)." Collectively, these responses communicate a possible impact to one's work productivity. This would support Burton et al. (2004) where they concluded that an employee's medical health, and in particular certain chronic medical conditions such as depression, migraine headaches, allergies, low back pain, have a direct and negative impact on productivity while on the job. The literature was quite compelling in identifying presenteeism to be more prevalent in those who suffer from depression (Burton et al., 2004; Druss et al., 2001; Greenberg et al., 1993; Stewart et al., 2003). Interestingly, only one participant in this study suffered from depression. The literature review noted an approximate two-thirds of Canadian workers (62%) make work a priority when suffering from mental and physical problems (National Union of Public and General Employees, 2007). The findings of this study are unable to reproduce accurate Presenteeism in Nursing 58 percentages, however have noted consistency in those suffering from mental and physical problems. "Presenteeism, the feeling that you must show up for work even if you are too sick to be there, is a major factor in employee stress and distraction" (Beauchesne, 2006). This statement is supported by the findings, especially as nurses expressed the stressful environments due to high workloads and the distraction due to symptoms of pain and discomfort. In a study involving public-sector employees, Grinyer and Singleton (2000) identified two reasons why employees will show up for work despite being unwell. First, employees feel a sense of responsibility when working in a team environment and second, employees were subject to a sick leave monitoring system which would warrant their need to explain their reason for illness. This study does support the above. Bockerman and Laukkanen (2010) identified sickness presenteeism (those going to work despite being ill) to be more sensitive and prevalent in working-time arrangements such as permanent full-time status, shift work, working excessively long hours, and those who experience a mismatch between desired and actual hours worked. All participants studied worked shift work, with some working extended hours (i.e. longer than a 12 hour shift), some working additional shifts over and beyond those booked (either in the form of voluntary or involuntary overtime) and one participant working more than one full time equivalent (FTE). Of the 10 subjects interviewed, seven participants held permanent full-time positions. In such situations, could presenteeism be occurring as a form of protest against the working-time arrangements noted above? Such a conclusion could not be drawn, yet worth noting as a possibility. The same study also concluded that regular overtime decreases sickness absenteeism. Could this mean that Presenteeism in Nursing 59 working regular overtime increases presenteeism, thereby causing a potentially vicious circle of working more and being less productive? According to Middaugh (2007), "It is important to determine if employees are feeling pressure to work longer hours and more overtime, or to discover their reasons for not taking sick leave". This might be worth pursuing within a root cause analysis exercise. Most nurses hesitate to take sick leave as they are very aware of the added burden on their colleagues (Grinyer & Singleton, 2000). This finding was apparent in all participants interviewed, especially in the absence of available casuals to call in, demanding workloads, and the nurse's loyalty to their coworkers/work teams. This was again echoed, especially in reference to low staffing levels and the lack of casuals. In contrast, two participants noted the following, "well everything is kind of at a standstill right now, there's not too many full time positions opening up.. .cut backs (interview #7)," "before Christmas I think some of the younger nurses were let go on some surgical floors, which is ridiculous (interview #2)." The latter comments may lend support to Aronsson et al. (2000) whereby the authors concluded that employees working in organizations that undergo downsizing (reduction in personnel), coupled with low replaceability of absent staff, are more reluctant to take leave, thereby increasing the likelihood of attending work while ill. The literature identified presenteeism due to a mental disorder as the major component of decreasing employee productivity. Wynne-Jones, Buck, Varnava, Phillips and Mian (2009) concluded that mental health, as opposed to physical health, has the greatest influence on one's ability to work. The following response from one participant helps to support the above, especially since this participant initially suffered from a Presenteeism in Nursing 60 physical ailment whereby attending work was still possibility, up to the point of experiencing mental health issues: I would like to really go towards mental health if I could actually. Can I comment on something like that because I have a very negative experience with mental health sort of contributes to. It was a very upsetting situation. I was completely incapable of doing my job after that (interview #4). This study did identify various comments related to one's work environment. It was noted that morale does suffer and that nurses do perceive the workplace environment to be a possible factor: No matter how much focus you have, if you're over tired and you're sleep deprived and you're sick, mistakes still can be made.. .and if it's a cultural thing that's at fault, then that needs to change.. .it's like a corporate culture because everybody acts the same way (interview #6). The same participant remarked a culture of negativity: Everybody acts that way and sometimes it's really hard to not like to stop that culture of negativity and say, wait a second we need to take care of each other because everybody else is not, everybody else will try to get us to come in as much as we can work for the least amount of money as we can, work with way too many patients that we can't take care of (interview #6). Stevens (2005) did find similar findings of negative perceptions of the work environment as contributors to presenteeism. He also matched interpersonal conflict and job dissatisfaction as equal contributors. The results of this study don't allow such conclusions to be drawn, however do note the negative perceptions of one's work environment, which could either contribute to, or result from, presenteeism. Regarding interpersonal conflict and previously noted, one nurse shared her experience of changing "the personalities I was working with and that made a real difference cause sometimes the personalities that you work with create stress as well (interview #8)." Shain and Suurvali (2001) identified that the psychosocial work environment, the way work is Presenteeism in Nursing 61 organized, and the management culture within the work environment have the most impact on increased employee stress and negative health outcomes. Such conclusions were not explicit, however they are important to note, especially in reference to Theme 3: Morale does suffer. Caverley et al. (2007) conclude that certain work factors such as job insecurity is strong determinant of presenteeism. It is unlikely that job insecurity is a factor in acute care nurses working in Northern Health. In some departments, it is not uncommon to have shifts that are left unfilled due to the lack of available nurses. Also within Theme 3: Morale does suffer, it was noted that the majority of responses related to morale were evoked when participants were invited to share final comments. It is unknown why such was the case, other than a possibility that upon completion of the formal interview questionnaire, (a) participants felt more comfortable in openly sharing their overall experiences, (b) the interview questionnaire failed to ask a specific question on morale, and/or (c) the participants' initial responses elicited further thoughts on the workplace environment. Consistent among five participants, it was noted that attending work when ill or injured extended their illness/injury. In all of these, the approximate time loss was in excess of three months after having attended work. This would lend support to the Bergstrom, Bodin, Hagberg, Aronsson, and Josephson (2009) study whereby the authors concluded that several episodes of sickness presenteeism could lead to future sickness absenteeism. The literature identified work-life imbalance (Musich, Baaner, Spooner, & Edington, 2006) and job dissatisfaction (Caverley et al., 2007) as contributors of presenteeism. Regarding work-life balance, one nurse did note that "on a normal situation Presenteeism in Nursing 62 right now I'm working full time and then also working part time so I'm exhausted but that's my own doing (interview #7)." The narratives did identify some participants as having busy lives outside work, with some working extended hours and additional shifts. For some, personal commitments did impact their ability to sleep during the day, especially upon working night shift. However, conclusions could not be drawn identifying work-life balance as a contributor of presenteeism. As for job dissatisfaction, the narratives were not that explicit on deriving this as a contributor of presenteeism. One nurse stated, "I'm a good nurse, I enjoy nursing, so why don't I want to go to work (interview #8)?" Finally, participants shared several personal and system-wide (Northern Health wide) solutions to presenteeism. While some solutions could possibly be implemented easily and promptly, most will require ongoing discussions (some being currently underway), while others may take years to implement. Within the scope of this study, it is important to note that those working in the health care system (especially in direct patient care) are often the most knowledgeable in finding solutions that will benefit themselves, their peers, and the larger system as a whole. As such, the solutions noted are worthy of consideration The literature discusses a Health and Productivity Management (HPM) solution whereby organizations invest in their employees, who, in turn, positively influence the cultural climate of the organization (Health and Productivity Management Center, 2006). The comments: "hospitals are not taking care and I'm not sure that I, that the system knows how to take care of the people working in it (interview #8)" and "if it's a cultural thing that's at fault then that needs to change ... it's like a corporate culture because Presenteeism in Nursing 63 everybody acts the same way (interview #3)" appear well aligned and in support of a Health and Productivity Management solution. This would also support Corbett (2001) in his plea for healthy workplaces, "the common thread for leaders in both sectors of our economy is to realize the need to have a work culture that recognizes the whole person, as it is through the professionalism and competency of the people who do the work that strategic growth happens." A work culture that recognizes the whole person will recognize the need to better know and take care of their employees. Presenteeism in Nursing 64 Chapter 5 Conclusion The purpose of this study was to examine the experience of presenteeism in acute care nurses within the largest acute care hospital in NH, and to explore the contexts, situations, and/or factors that may influence this experience. The phenomenological design and analysis of transcribed interviews was an appropriate methodology in meeting the purpose of this study. The essence of the presenteeism experience spoke for itself in all transcriptions. Acute care nurses attended work when they felt they should have stayed home. The experience was felt physically and mentally, the result of which created a distraction in the provision of safe and adequate patient care. Both internal and external factors were noted (represented by the 10 themes), all and/or some of which influenced the decision of whether or not nurses attended work. Furthermore, all factors were interrelated, thereby adding to the dilemma of making a sound decision that is in the best interest of the nurse, the patient, and the workplace environment. It was interesting to note that within the 10 themes, not one of them was more prominent than the other. Moreover, every participant appeared to experience a component of each of the 10 themes, adding to the interrelatedness of all factors. Key Findings Despite working a day or night shift, acute care nurses experiencing presenteeism reported physical pain, tiredness, low energy, nausea, exhaustion, all of which created a distraction in the provision of safe and adequate care patient care. Mentally, nurses were preoccupied by recognizing that they were not at their best, and by worrying how their coworkers would manage if they returned home. The shift was a nightmare, the Presenteeism in Nursing 65 environment was chaotic and stressful, yet the units were expected to continue admitting patients regardless of current workload and staffing numbers. Coworkers noticed and made comments, demonstrating their care for each other. All comments were geared towards their appreciation that the nurse was at work and would remain at work. In some situations, the tough and proud nurse tried to cover up and hide any indication that something was wrong or that he/she was unable to cope. Recognizing selfcare was considered important, yet not widely practiced among the participants. Interestingly, the negative experiences were not enough to stop the phenomenon of presenteeism. Everybody did it. It was also noted that some nurses voluntarily attended work for other reasons, perhaps indicating a component of personal investment. Despite being in the practice of caring for sick individuals, nurses struggle with being able to care of themselves. Internal factors noted were loyalty to coworkers/work teams, guilt, doubting their own ill feelings, peer pressure, pressure from colleagues to stay at work, fear of exposing their illnesses onto others, fear of repercussions from coworkers, pride, and worry that patient care is being compromised as a result of inefficiencies and making mistakes. External factors consisted of demanding workloads, low staffing issues, lack of casuals to call in (especially at the last minute), management of sick and overtime use, a negative perception of the workplace environment (morale), and the nurse's personal life outside work. These factors represented the key findings of the study (the 10 themes). At the center of these factors is a nurse who has a professional obligation to be at work caring for sick individuals, when they themselves should not be there. Recommendations Presenteeism in Nursing 66 Gaining awareness of, and understanding presenteeism. As a first step, the healthcare industry, and in particular the UHNBC, is likely interested in better understanding the presenteeism phenomenon, including gaining awareness that this does exist, followed by an assessment of its impact within the organization. As noted, there is a strong focus and awareness on absenteeism, with very little and possibly no awareness, recognition, and knowledge of the presenteeism phenomenon. Coupled with this interest is the employer's due diligence in better understanding the occupational risk factors that can jeopardize one's health. Both objectives would benefit from a Northern Health-wide educational program on presenteeism within the workplace. This would set the stage for the organization to begin their journey of acknowledging that presenteeism exists in the workplace, followed by a commitment to address it. Better knowing your employees. Northern Health is currently involved in employee engagement initiatives, including ongoing employee engagement surveys. It may be beneficial to incorporate an assessment of the workplace environment/climate, adding such components as employee motivation, job satisfaction, and other factors related to self-perception of one's working environment. Better yet, it may timely for Northern Health to consider adopting an organizational cultural survey, the result of which can assess the working conditions and experiences of those who work within it. Measuring presenteeism. You can't manage what you can't measure. Measures of presenteeism (and onthe-job productivity) are not common in most industries, let alone healthcare. It may be Presenteeism in Nursing 67 helpful for Northern Health to begin exploring certain measures of presenteeism, with a focus on asking employees how their health is affecting their ability to do their jobs. Such a question can be addressed via the Stanford Presenteeism Scale, whereby the tool utilizes six psychometric factors that measure health and productivity. Assessing employee health. "Employers are faced with a health crisis, not a healthcare crisis" (Sullivan 2004). It may also be beneficial for Northern Health to engage in health risk assessments, the result of which may help identify certain risk factors that employees (and employers) can proactively manage in their strive towards optimal health and wellness. The business case for health and productivity management (HPM). The participants did offer a few possible solutions that may, either in a shorter or longer term timeline, impact the experience of presenteeism in acute care nurses. The literature identifies HPM as a strategy that targets corporate investment into interventions aimed at improving employee health and productivity. In such organizations, human capital is considered within the same or higher priority sequence as financial capital. If Northern Health considers its employees as its main and most valuable asset, it is time to begin demonstrating the business case that supports HPM. This would warrant the collection of data that is likely not yet being collected: (a) data on direct costs of medical treatment, (b) data on loss time or absence, and (c) data on lost performance at work (presenteeism). Shifting the paradigm. It is now an opportune time to shift the paradigm from the "cost of health care" to the "value of health care". Practically, organizations must shift from treating disease to Presenteeism in Nursing 68 managing health status. It is becoming more and more obvious that the current way of doing business in most healthcare industries (especially in Canada) is not sustainable. Furthermore, it is not possible to continue treating sick individuals with sick caregivers. The healthcare industry needs to, first and foremost, manage the health status of its employees. The saying, "pay now or pay later" may be familiar to some of us. Today's health care organizations are being faced with significant budgetary shortfalls. The topic of money is a sensitive one, especially when discussed within a deficit equation. Loeppke et al. (2009) are able to shed light on this: "it is important for all employers - whether small, medium or large - to look beyond health care benefits as a cost to be managed and rather to the benefits of good health as an investment to be leveraged". Future Research As a segue to this study, it might be beneficial to further explore the link between nurse (employee) safety and patient safety. It was interesting to note the participant responses related to providing safe and adequate patient care. How safe or unsafe was that care? It was noted that presenteeism is catching, and that everybody does it. Is this consistent within and across disciplines and departments? A deeper understanding of this catching effect may be helpful, including an analysis of why they are doing it? It would be interesting to further explore the themes, attempting to better understand if one is more prominent than the other. Within all 10 themes, the workplace environment is a common denominator. In other words, nurses experience presenteeism in the workplace environment, and presumably influenced by the many factors within that environment. As such, it is perhaps accurate to assume that the workplace environment Presenteeism in Nursing 69 plays an important role in the nurse's decision to attend work or not. Would addressing the workplace environment (and likely the larger systemic issues) be the most prominent and best place to start? This may encourage the organization to proactively address the presenteeism phenomenon within a systemic approach as opposed to a person approach. This would require a new thinking that considers the person (the employee) as a consequence of attending work when ill or injured rather than a cause. Finally, several participants noted that night shifts were unpopular, yet a reality in the healthcare industry. Sleep is affected, interfering with many daily activities (child care, family time), and for some, adding to the anguish of working the last shift within their set. Does sleep (and the lack thereof) contribute to one's overall health status? If so, to what extent? Concluding Remarks I am hoping that this study has provided the necessary awareness and recognition that presenteeism is experienced by acute care nurses at the UHNBC, and that several factors influence the decision of nurses attending work or not. Nurses are caring professionals who care, first and foremost, for their patients. This nurse to patient relationship is special, unique, and needs to be preserved. From my persepctive, this study has identified the need and opportunity for healthcare organizations to care for those who provide care to others. 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K., Pronk, N. P., Simon, G. E., et al. (2004). Effects of major depression on moment-in-time work performance. The American Journal of Psychiatry, 767(10), 1885-1891. Wolters Kluwer Health. (2009). Ovid SP. Retrieved May 5, 2009, from http://ovidsp.ovid.com/ Presenteeism in Nursing 83 Wynne-Jones, G., Buck, R., Varnava, A., Phillips, C , & Main, C. J. (2009). Impacts on work absebce and performance: what really matters. Occupational Medicine, 59(8), 556-562. Presenteeism in Nursing 84 Appendix A The Experience of Presenteeism: Acute Care Nurses Working in Northern Health INTERVIEW PROTOCOL INTERVIEW QUESTIONS 1. Tell me about a time when you attended work despite the feeling that you should have stayed home. Probing Questions: • • • • • What really made you decide to go to work that day? What was it like to be at work that day? How did your day go? How did you feel on that day? Tell me more about that feeling. 2. How would you describe your experience, including circumstances, situations, and factors that best reflect your experience of attending work that day? Probing Question: • • • • What was happening at the time of your experience? Did others at work comment? Did you attempt to call in sick? Did your employer or anyone else try to send you home? NOTES Presenteeism in Nursing 85 Appendix B The Experience of Presenteeism: Acute Care Nurses Working in Northern Health RESEARCH INFORMATION SHEET Researcher's name: Lynn MacDonald The Researcher is an employee of Northern Health, working as a physiotherapist in the capacity of Regional Manager, Prevention Services, Workplace Health and Safety. The researcher is in pursuit of a Masters of Arts in Disability Management, which is independent of her role in Northern Health. Supervisor's name: Dr Henry G Harder, R.Psych. Professor and Chair, Health Sciences Programs Chair, Research Ethics Board Scientific Director, BCEOHRN, www.bceohrn.ca University of Northern British Columbia 3333 University Way Prince George, British Columbia, Canada V2N 4Z9 tel (250) 960-6506 fax (250) 960-5744 email harderh(g>unbc. ca website http://web.unbc.ca/~harderh/ Title of project: The Experience of Presenteeism: Acute Care Nurses Working in Northern Health (NH) Type of project: Thesis Purposes of research: a) to examine the experience of presenteeism in acute care nurses at Prince George Regional Hospital (NH's largest hospital) and b) to explore contexts, situations, and/or factors possibly affecting or influencing this experience. Participants will be asked to: Participate in a face to face recorded interview for approximately 60 minutes regarding their experience with presenteeism. Interviews will be held in a convenient agreed upon location in the Prince George area, preferably at the University Hospital of Northern British Columbia (UHNBC). Location will be in the Workplace Health and Safety office (across from the hospital cafeteria). Should this location not be suitable for some participants, provisions will be made for an alternate location. Potential risks: The following 2 minimal risks have been identified as possible harm to participants: (a) anxiety and distress, and (b) exploitation (and possible conflict of interest). In minimizing potential harm to both above risks, the professional background of the researcher, including her role within the organization, will be made clear to the participants Presenteeism in Nursing 86 at the beginning of each interview. The researcher will also notify the participants that her role within the organization is independent of her role as a researcher. For those either expressing or showing signs of anxiety and distress, the researcher will refer the participants for follow-up care by their medical physicians. Potential benefits: This study will provide a better understanding of presenteeism within this population, as well as explore common contexts, situations, and/or factors that influence this experience, the result of which could lead researchers in prevention and/or reduction of the phenomenon. Health care employees and employers could benefit in first gaining an awareness of the phenomenon, followed by possible strategies in prevention and/or reduction of its organizational impact. How are participants chosen: All emergency and intensive care nurses working in Prince George Regional Hospital will be invited to participate either by: a) an e-mail from PGRH's administrative assistant which will provide an electronic copy of the research information package, b) obtaining a research information package via the administrative assistant, and/or c) obtaining a research information package available on each unit (via a posted envelope). The criteria for participation will be those nurses who have experienced presenteeism. Following 3 weeks attempted contact, and if I have failed to recruit 10 participants, I will connect with the administrative assistant for repeat of the email to the initial distribution list, in addition to adding the surgery north and surgery south nurses. Interested participants are to contact the researcher by phone or by email: Lynn MacDonald at (250) 649-7177 or (250) 612-8134 (daytime/evenings) or email: macdo00@unbc.ca Definition of Presenteeism: "When people show up for work sick, injured, stressed or burned-out there is a drain on productivity. This is the problem of presenteeism" (Thorpe Benefits, 2002). Most commonly, the term presenteeism has been coined with losses in work productivity in those experiencing illness or injury. For the purpose of this study, presenteeism will refer to those who attend work despite the feeling that they should have stayed home. How is confidentiality addressed? Research data will not be linked to a participant's personal identity. The names of the participants will be removed from the actual data that is obtained and labeled with identification numbers. Names that are recorded during an interview will not be transcribed. No names will appear on any documentation. A code sheet will be kept in a locked cabinet, with only the researcher and the project supervisor having access to it. The external auditors will sign a confidentiality agreement. Presenteeism in Nursing 87 Voluntary nature of participation: Participation in this study is voluntary and, as such, is not entitled to any monetary compensation. Participants have the right to withdraw at any time during the research study. Please note that participation in this research project will not affect you in any way. The decision to participate or not, or to withdraw from participation, will not impact the employment status of the participant. Right to withdraw from study: Subjects will be informed of their right to withdraw at anytime during the study. Data from any participant wishing to withdraw from the study will be removed from the study. All data will remain confidential. How information is stored and for how long: Data collected from this research will be used only for the purposes of this study. Data will be kept in a locked filing cabinet or on a secure computer. No one other than the researcher and project supervisor will have access to the participant's personal information. All data will be destroyed one year upon successful completion of the thesis defense. All papers will be shredded and disks will be physically destroyed. How to get copy of the research results: Please contact Lynn MacDonald if you wish to have a copy of the research results. Contact information is listed below. Name and phone number of person to contact in case questions arise or for more information: Please contact Lynn MacDonald at (250) 649-7177 or (250) 612-8134 (daytime/evenings) or email: macdoQO(fl>unbc.ca Please note that any complaints and/or concerns about the project should be directed to the Supervisor, Dr Henry G Harder at (250) 960-6506, fax (250) 960-5744 or email: harderh@unbc.ca and the Research Ethics Board, email: reb@unbc.ca The participant must receive a copy of his or her signed consent form. Presenteeism in Nursing 88 Appendix C The Experience of Presenteeism: Acute Care Nurses Working in Northern Health INFORMED CONSENT Do you understand that you have been asked to be in a research study? Yes No Have you read and received a copy of the attached information sheet? Yes No Do you understand that the research interviews will be recorded? Yes No Do you understand the risks involved in participating in this study? Yes No Have you had an opportunity to ask questions and discuss this study? Yes No Do you understand that you are free to refuse to participate or to withdraw from the study at any time? You do not have to give a reason and it will not affect you in any way. Yes No Has the issue of confidentiality been explained to you? Yes No Do you understand who will have access to the information you provide? Yes No Do you understand that the researcher has a legal and ethical duty to disseminate the research findings to all appropriate parties (ie: to yourself and the employer) if information obtained identifies a possible negative impact on the larger organization as a whole? Yes No This study was explained to me by: Print Name I agree to take part in this study: Signature of Research Participant Date Printed Name of Research Participant Date Signature of Witness Date Printed Name of Witness Date I believe the person signing this form understands what is involved in the study and voluntarily agrees to participate. Signature of Investigator Date The Information Sheet must be attached to this Consent Form and a copy given to the Research Participant Presenteeism in Nursing 89 Appendix D The Experience of Presenteeism: Acute Care Nurses Working in Northern Health TRANSCRIBER'S AGREEMENT I have agreed to transcribe audio tapes for this research study. The researcher has explained (or in the case of the researcher herself is aware of) the expectations regarding this process. Do you understand that you must maintain confidentiality of all research data and materials that you have access to? Yes No Do you understand that the documents are only to be saved on a memory stick provided by the researcher? Yes No Do you understand that you all audio tapes and transcribed documentation must be stored in a locked cabinet while in your possession? Yes No The remuneration for transcription will be I agree to the conditions as indicated on this transcriber agreement: Printed Name of Transcriber Name of Investigator Signature Signature Date Date Presenteeism in Nursing 90 Appendix E The Experience of Presenteeism: Acute Care Nurses Working in Northern Health EXTERNAL AUDITOR'S AGREEMENT I have agreed to audit the summaries and audio tapes for this research study. The researcher has explained (or in the case of the researcher herself is aware of) the expectations regarding this process. Do you understand that you must maintain confidentiality of all research data and materials that you have access to? Yes No Do you understand that the documents are only to be saved on a memory stick provided by the researcher? Yes No Do you understand that all transcribed documentation must be stored in a locked cabinet while in your possession? Yes No The remuneration for auditing will be I agree to the conditions as indicated on this external auditor agreement: Printed Name of External Auditor Name of Investigator Signature Signature Date Date Presenteeism in Nursing Appendix F The Experience of Presenteeism: Acute Care Nurses Working in Northern Health TABLE 1 Table 1 Selected Examples of Significant Statements of Persons with Presenteeism and their Related Formulated Meanings Significant Statements Formulated Meanings I was just feeling gross and my brain wasn't working that great and probably wasn't the safest thing to be there. Brain and mind are not working that great. I didn't feel safe, I didn't feel I was safe, I didn't feel my patients were safe and that was a really bad feeling I didn't feel safe and I didn't feel my patients were safe. I remember I came in the assignment was everything I was dreading, if not worse and um, they I looked I, I felt absolutely ghastly it was a ghastly day. I don't specifically remember the day but I remember feeling like I wasn't thinking well A dreadful assignment A ghastly day Not remembering the day, not thinking well That day I came in and I remember thinking I'm, I might not make it today and I didn't make it I went home sick and I was off for a couple three months I remember thinking, T might not make it today, and I didn't. Well, with my experience I have called in sick before and you feel so guilty about not coming in. Then you sit at home and you're like "Well am I really that sick or could I probably have made it, I probably could have been fine" so then you just feel harder on yourself so that's why I kind of doubt yourself so you go into work Feeling bad and guilty about not coming in I was in pain and being disabled at the time temporarily trying to keep up and its a fast moving job Trying to keep up with the fast pace while being temporarily disabled You're on your feet all day it's like you need a reliable, reliable legs I didn't have them No reliable legs when you need them I was actually called into the office my next set and warned that uh I was abusing my sick time privileges to extend my vacation which totally wasn't true Warnings of sick time abuse Being hard on myself Am I really sick? Presenteeism in Nursing Appendix G The Experience of Presenteeism: Acute Care Nurses Working in Northern Health TABLE 2 Table 2 Examples of Theme Clusters (1 to 6) and their Formulated Meanings Theme Clusters and Meanings Theme Clusters and Meanings Theme 1 Demanding Workloads Everybody has double or triple their regular assignments Everybody is over their patient quota The workload is just ridiculous and how people are getting injured or getting sick or getting unhealthy and yet they're still pushing the patients on Unable to find someone to cover for breaks Theme 4 Cracking Down on Sick Time We are allowed one sick day a month There is manager harassment We look bad if we are over There is a lot of pressure Being watched Probing into nurses' personal lives Theme 2 Caring for Oneself Okay, I can't do this I felt I shouldn't be at work I remember thinking I might not make and I didn't We don't do ourselves a favour by working that way I remember the day when I finally gave it up Think of yourself too It was a learning experience. There is a reason we call in sick Theme 3 Morale Does Suffer It just makes it bad You are like a service and that's it We were pretty disgusted It is not nice at all Definitely doesn't help the morale, that is for sure No support from anybody They want you to suck it up Theme 5 Obligated to Come to Work Didn't want to let my team mates down Feeling bad and guilty about not coming in Worried what other people will say I called but chickened out Worrying about what people will do without you A conscience burden thing I can't do that to my coworkers Theme 6 Noticing you are Unwell, Yet Please Stay - Please don't go home - Not feasible with one less body - You look so tired - Don't worry, we're here with you - Go have a nap - We can't let you go home - Do the best that you can do - Just don't leave us Presenteeism in Nursing Table 2 (continued) Examples of Theme Clusters (7 to 10) and their Formulated Meanings Theme Clusters and Meanings Theme Clusters and Meanings Theme 7 Hoping for Safe and Adequate Patient Care Brain and mind are not working that great Not doing everything for the patient Not mentally there Can't give the gold standard of care that these people need Your best is not very good anymore A fine balancing act Theme 9 Working Short Staffed Without Anyone to Call In Working short staffed is a standing issue Always hard to get anyone to come in Never staffed sufficiently Immediately envision my coworkers working short Critically short Only one or two casuals to call in for one area Theme 8 Surviving the Dreaded 12 Hour Shift, Especially at Night A nightmare Physically and mentally exhausted Distracted and stressful because of the pain Back pain was killing me Functioning without being efficient Tired and unorganized A miserable shift Trying to keep up with the fast pace while being temporarily disabled Theme 10 Solutions to Presenteeism There are just not enough people (not enough younger nurses) Not attracting younger nurses Running the units on the number of beds that are budgeted for Get staffing in the middle of the night A call out list for night shifts Bond and stand together Change lines 93 Presenteeism in Nursing 94 Appendix H The Experience of Presenteeism: Acute Care Nurses Working in Northern Health UNBC ETHICS APPROVAL LETTER UNIVERSITY OF NORTHERN BRITISH COLUMBIA RESEARCH ETHICS BOARD MEMORANDUM To: CC: Lynn MacDonald Henry Harder From: Ross Hoffman, Acting Chair Research Ethics Board Date: November 30, 2009 Re: E2009.1105.173 The Experience of Presenteeism: Acute Care Nurses Working in Northern Health Thank you for submitting the above-noted proposal and requested amendments Research Ethics Board. Your proposal has been approved. to the We are pleased to issue approval for the above named study for a period of 12 months from the date of this letter. Continuation beyond that date will require further review and renewal of REB approval. Any changes or amendments to the protocol or consent form must be approved by the Research Ethics Board. Good luck with your research. Sincerely, Ross Hoffman Presenteeism in Nursing 95 Appendix I The Experience of Presenteeism: Acute Care Nurses Working in Northern Health NH ETHICS APPROVAL LETTER ^ ( - northern health tr? m?rth*"fi ¥«&