Characteristics of zero-absenteeism in hospital care

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1 Occuptionl Medicine 2013;63: Advnce Access publiction 17 April 2013 doi: /occmed/kqt033 Chrcteristics of zero-bsenteeism in hospitl cre J. A. H. Schreuder 1, C. A. M. Roelen 2, J. J. L. vn der Klink 1 nd J. W. Groothoff 1 1 Deprtment of Helth Sciences, University Medicl Center Groningen, University of Groningen, PO Box 196, Groningen 9700 AD, The Netherlnds, 2 Corporte Accounts, ArboNed Occuptionl Helth Services, PO Box 158, Zwolle 8000 AD, The Netherlnds. Correspondence to: J. A. H. Schreuder, Deprtment of Helth Sciences, University Medicl Center Groningen, University of Groningen, PO Box 196, 9700 AD, Groningen, The Netherlnds. e-mil: info@schreuderrbo.nl Bckground Literture on sickness presenteeism is emerging, but still little is known bout employees who re never bsent from work due to injuries or illness. Insight into the determinnts nd chrcteristics of such zero-bsentees my provide clues for preventing sickness bsence. Aims Methods Results To investigte the chrcteristics of zero-bsentees, defined s employees without sickness bsence over period of 5 yers. A mixed-method qulittive study comprising semi-structured interviews nd focus groups for which Azjen nd Fishbein s theory of plnned behviour ws used s frmework. Zero-bsentees working in hospitl cre were invited for semi-structured interviews until sturtion ws reched. The results of semi-structured interviews were vlidted in two focus groups. Of 1053 hospitl employees, 47 were zero-bsentees of whom 31 (66%) greed to prticipte in the study. After 16 semi-structured interviews, no new insights or informtion were gthered from the interviews. The remining 15 employees were invited to two (n = 8 nd n = 7) focus groups. Personl ttitudes nd self-efficcy were more importnt in zero-bsenteeism thn socil pressures of mngers, collegues or ptients. Zero-bsentees were found to be intrinsiclly motivted to try ttending work when ill. Conclusions In the present study popultion of hospitl employees, we found indictions tht zero-bsenteeism nd sickness presenteeism might be different types of work ttendnce. Mngers should relize tht zero-bsentees re driven by intrinsic motivtion rther thn socil pressures to ttend work. Key words Introduction Focus groups; helth cre; qulittive reserch; sick-leve; zero-bsenteeism. There is lrge body of knowledge bout the determinnts of sickness bsence, while reserch on work ttendnce is only beginning to emerge in the literture. Determinnts of work ttendnce hve been found in one s personl bckground s well s in work-relted vribles [1]. Dellve et l. reported tht one-third of 3275 employees working in the service sector were work ttendees in the sense tht they took no sick-leve over period of 1 yer [2]. In The Netherlnds, the 1 yer work ttendnce rte is 37.4% in helth cre nd 38.2% in hospitl cre [3]. Dellve et l. lso showed tht 1 yer work ttendnce is n imprecise mesure, becuse it does not discriminte between ttendnce t work when well nd when unwell [4]. Work ttendnce when unwell is usully referred to s presenteeism. A third of the employees in strtified subsmple of 3801 employees of the Swedish workforce hd worked two or more times during the preceding yer despite feeling unwell [5]. More thn 70% of rndom smple of employees of the Dnish workforce reported working through illness t lest once during 12 month period [6]. Thus, sickness presenteeism seems to be more common thn sickness bsence, nd the costs of productivity losses due to performnce below pr might even be higher [7,8]. Presenteeism is ssocited with work-relted demnds nd person-relted demnds [5]. Work-relted determinnts of presenteeism include difficulties in stff The Author Published by Oxford University Press on behlf of the Society of Occuptionl Medicine. All rights reserved. For Permissions, plese emil: journls.permissions@oup.com

2 J. A. H. SCHREUDER ET AL.: CHARACTERISTICS OF ZERO-ABSENTEEISM IN HOSPITAL CARE 267 replcement, conflicting job demnds, work pce nd pressure nd worklod. Hving supervisory role nd/ or working >45 h per week nd the reltionship with collegues were lso found to increse the likelihood of sickness presenteeism [6]. Personl (finncil) circumstnces nd ttitudes such s low ssertiveness (i.e. difficulties in sying no ) nd being overcommitted to work led to higher levels of presenteeism [5,6]. Johnsson nd Lundberg (2004) proposed tht two dimensions, djustment ltitude nd ttendnce requirements were ssocited with sickness bsence nd sickness ttendnce [9]. Work djustment ltitude includes the opportunities individuls hve to reduce work efforts, for exmple by choosing esier work tsks or working t slower pce. Attendnce requirements result from the negtive consequences of being wy from work tht cn ffect the individul, temmtes or third persons such s ptients. This implictes tht going to work or stying off work is, t lest prtilly, type of socil behviour. Azjen nd Fishbein s theory of plnned behviour is generlly ccepted theory to explin socil behviour [10]. The theory sttes tht personl ttitudes, socil context nd self-efficcy determine someone s intention to chnge certin behviour (Figure 1). The theory of plnned behviour hs been used in occuptionl helth reserch [11] nd my explin why some people report sick frequently, while others re zerobsentees in the sense tht they never report sick. The theory of plnned behviour ws used s frmework in this mixed-method qulittive study to explore the chrcteristics of zero-bsentees. Methods The study popultion consisted of 1053 employees working in regionl Dutch hospitl. Employees who ATTITUDE SOCIAL NORMS hd not reported sick in the period from Jnury 2006 to December 2010 were eligible for this qulittive study nd were invited for the study. They were informed bout the im of the study nd the benefits of its potentil outcomes (Figure 2). Rndom numbers were ssigned to the prticipnts by using rndom number tbles. Subsequently, prticipnts were ordered from the lowest rndom number to the highest. Prticipnts with odd rnkings were selected for semi-structured interviews nd prticipnts with even rnkings were ssigned to one of two focus groups. The semi-structured interviews strted with the key question: Wht mkes you zero-bsentee? The further directions in the interviews were guided by the zerobsentees nswers nd individul experiences [12]. Azjen nd Fishbein s theory of plnned behviour provided the frmework for topic guide for questions bout personl ttitudes, socil context nd self-efficcy. All interviews were performed by the sme modertor nd lsted ~50 (rnge 40 65) min. After ech set of four interviews, the interviewer nd reserchers discussed the results nd grouped the informtion in key themes. Sturtion ws concluded if no new key themes hd occurred from the next set of four interviews. Focus group meetings re usully performed to gther informtion nd shre perspectives in group discussion without the pressure to rech consensus. An importnt sset of focus group discussions is tht prticipnts interct with ech other nd yield extr informtion in doing so. The key themes occurring from the semi-structured interviews were used s input for the focus groups. Focus group prticipnts were encourged to develop or reject the concepts nd ides from the semi-structured interviews, which is method of respondent vlidtion [13]. Respondent vlidtion is common in qulittive reserch to ssess the relibility nd vlidity of results by seeking prticipnts verifiction [14]. Both focus groups INTENTION MOTIVATION BARRIERS BEHAVIOUR SELF-EFFICACY Figure 1. The model of plnned behviour.

3 268 OCCUPATIONAL MEDICINE Aim study identified Topic guide & prompts n = 47 zero-bsentees Selection from sickness bsence registry n = 1006 non zero-bsentees were performed by the sme modertor, who hd lso performed the semi-structured interviews. The modertor ws not fmilir with the hospitl orgniztion, but hd been mnger in occuptionl nd medicl insurnce settings, nd ws n experienced coch in behviourl mngement. The focus groups lsted 55 nd 70 min, were tped nd trnscribed verbtim. Key themes were mrked with series of codes nd the codes were grouped ccording to the concepts of the theory of plnned behviour [10]. The Medicl Ethics Committee of the University Medicl Center Groningen dvised us tht ethicl pprovl ws not necessry becuse the Medicl Reserch Involving Humn Subjects Act did not pply to the study. Results Invittion to prticipte n = 16 (34%) non-prticipnts Figure 2. Flow chrt of the study design nd procedure. n = 31 (66%) prticipnts Next four odd rnkings interviewed A totl of 47 employees (43 women nd four men) fulfilled the inclusion criteri nd 31 zero-bsentees greed to prticipte (Figure 2). The two focus groups hd eight nd seven prticipnts. Prticipting zero-bsentees were 30 women nd one mn, hd men (stndrd devition) ge of 47.1 (9.1) yers nd worked n verge of 24.8 (6.8) h/week s nurses (81%), nurse ssistnts (10%), lb ssistnts (6%) or dministrtor (3%). Tble 1 shows tht there were no differences in ge, gender, job, work hours/ Rndom numbering & rnking First four odd rnkings interviewed Anlysis & dt reduction by modertor nd reserchers Even rnkings two focus groups Adjusted topic guide & prompts week nd tenure between interviewees nd focus group prticipnts. The first set of four semi-structured interviews yielded 100% new informtion, the second set 10% nd the third set 5%. No new key themes emerged in the fourth set of interviews. Hence, the interviewer nd reserchers decided tht sturtion ws reched nd no further interviews were necessry. Interviewees mentioned good helth, upbringing nd stisfction with work s most importnt fctors ssocited with their zero-bsenteeism (Tble 2). Furthermore, they mentioned optimism/positivism, gol chievement nd determintion s fctors for being zero-bsentee. Wht I lerned (from prents) ws to be positive, it will lwys turn out better thn expected. Positive thinking helps me to be less bsent. Interviewees stted tht they were helthy nd never felt so ill tht they hd to sty off work. Actully I just feel helthy, I m never ill. I find helthy living very importnt nd tke cre of myself, tht s why I feel helthy. Going home before ending the work shift hppened sometimes if complints worsened nd becme too serious to continue working. Most zero-bsentees judged tht ttending work ws fesible nd meningful despite their helth complints. None of the zero-bsentees in this study felt tht complints negtively ffected their productivity t work: Hving complints does not men it impcts my work ( ) when it does I would decide to go home but

4 J. A. H. SCHREUDER ET AL.: CHARACTERISTICS OF ZERO-ABSENTEEISM IN HOSPITAL CARE 269 Tble 1. Popultion chrcteristics Interviews (n = 16) Focus groups (n = 15) Anlysis Age in yers, men (SD) 47.3 (9.7) 46.9 (8.7) P = 0.89 Gender, n (%) Women 15 (94) 15 (100) P = 0.52 b Men 1 (6) 0 Job, n (%) Nurse 12 (75) 13 (87) P = 0.34 b Nurse ssistnt 1 (6) 2 (13) Lb ssistnt 2 (13) 0 Administrtor 1 (6) 0 Hours/week, men (SD) 25.2 (6.3) 24.4 (7.6) P = 0.75 Tenure in yers, men (SD) 21.0 (8.6) 20.3 (7.4) P = 0.80 t-test for independent smples. b Fisher s exct test. Tble 2. Wht mkes you zero-bsentee? Interviews (n = 16) n (%) Good helth 13 (81) Upbringing 8 (50) Job stisfction 4 (25) Tem 4 (25) Optimism/positivism 3 (19) b Work djustment ltitude 1 (6) Supervisor 1 (6) c Other 4 (25) c Mentioned by four or more prticipnts. b Not mentioned. c Mentioned by from one to three prticipnts. Focus groups (n = 8 nd n = 7) tht hs never hppened to me. Becuse of my experience I know how to mnge my tsk in the tem even when I don t feel well. When you re ill you lwys cn men something for your ptients or collegues. Tht s just me, being productive even when I do not feel well. In the interviews, five nurses nd one dministrtor mentioned chronic medicl conditions, prticulrly depression nd low bck pin; 10 interviewees (eight nurses, one lb ssistnt nd one dministrtor) mentioned hving suffered stressful life-events. Interviewees found themselves self-efficcious in coping with these problems. I relly py lot of ttention to how I feel ( ) when I m depressed I go to doctor to sk for tretment ( ) then I cn keep myself in blnce nd do not need sick-leve. When confronted with stressful life events, interviewees ctively sought instrumentl support sking for guidnce nd coching rther thn emotionl support in terms of comfort nd understnding. When my dd ws terminlly ill, I greed with the tem to leve my work erlier so tht I could spend time with my dd ( ) I strted swimming to mke sure I styed in good physicl condition. When brriers nd setbcks occurred, interviewees showed their cretivity in exploring the opportunities to ttend work. When I hd bck pin nd could not bend, I told my ptients to pick things up themselves or sk my collegue nd they dropped lot less. Another interviewee sid: I hd n cute infection in my legs ( ) it ws holidy time so then you do not find it esy to replce someone ( ) I put wet clothes round my legs to cool down nd put supportive pntyhose on ( ) when my legs got worse I went to the dermtologist during my shift, fter putting tpe round my legs it went fine. All prticipnts in the focus groups greed tht prentl eduction ws the most importnt bsis for personl norms nd beliefs bout work ttendnce nd sickness bsence. They often mentioned tht their fther or both prents were self-employed, for exmple in frming or horticulture, nd rrely hd dys off work due to illness. As children, the prticipnts were tught by their prents to go to school in spite of not feeling well. This ws regrded s the bsis for their current zero-bsenteeism (Tble 3). Some focus group prticipnts, especilly the older ones, dded tht these norms nd beliefs developed over time. In the first prt of my creer I sometimes thought bout clling in sick when I did not feel well ( ) I do not do tht nymore, becuse my norms hve chnged over the yers. Differences in norms between older nd younger employees were ttributed to different views on the mening of work creer nd privte life. Young employees combine cring for children with hving job nd the older employees thought they would prefer to tke sick-leve for exmple when child is ill or when there re domestic problems. Tking sick-leve becuse of sick child is ridiculous ( ) you ought to rrnge good dycre ( ) you hve responsibility towrds your work ( ) I ssume tht younger collegues think differently bout this. In the focus groups, socil norms, in terms of pressure from the supervisor or tem members to ttend work, were

5 270 OCCUPATIONAL MEDICINE Tble 3. Results from interviews nd focus groups Questions nd prompts Interviews (n = 16) Focus groups (n = 8 nd n = 7) Attitudes Wht would hold you bck from tking sick leve when you think bout stying home from work? Prompts: model behviour, sttus, supervisor, temmtes, ptients, privte circumstnces, personl feelings Socil norms nd context With who do you discus your decision when to tke sick leve, look for n lterntive or do dditionl work? Who cn influence your decision to cll in sick or go to work? Prompts: prtner, prents, friends, supervisor, collegues, doctor Self-efficcy Wht mkes you go to work while others cll in sick? Prompts: confidence, perceived bilities, intentions to complete tsks or rech gols The tble shows questions, prompts nd themes of interviews nd focus groups. Mentioned t lest by from one to three prticipnts. b Mentioned by four or more prticipnts. You cn only cll in sick when you re not ble to function. If you hve job, you hve to be t your work, you cnnot tke sick-leve when your children re sick. To cll in sick is the result of your bckground nd upbringing ( ) it is ctully the exmple you get from your prents. Work is importnt for me ( ) I like wht I do nd I feel stisfied nd content with my job nd my tem. For me tem spirit mkes the difference, when I would work in less enthusistic tem I would be less motivted to go to work. I do not discuss my decision to cll in sick or go to work with nybody, only with myself. When I cll in sick I m sick, my supervisor is of no influence. When I hd thrombosis temmtes told me to go home ( ) I did not feel sick so I styed t work. For me, knowing I did good job is importnt ( ) I know temmtes pprecite my work lthough they do not tell me ll tht often. I keep rhythm tht s importnt. ( ) even level lower, but you cn go on. I hve lot of persevernce ( ) I hve gol nd work on it, keep n overview ( ) tht s how I cope with ll sd things in life. When the sme complints occur you lern how to del with it ( ) the first time you cll in sick ( ) now I do not do tht nymore (...) you re ble to do your work. I lwys try to see the other side of things, from the negtive lso find the positive side, I m esy going nd I lerned to let things go. Things do not distress me so quick in work ( ) when not feeling well I tke n Aspirin nd then I don t hve to cll in sick. You do not cll in sick becuse of snow or icy rods ( ) you get pid for your job, so you go to work when you re ble to. You hve to be ble to orgnise things t home nd if you do not succeed it would be better if you did not hve job. I ws rised with the ethos: not to complin, get over it nd move on. I lwys like my work ( ) fter my holidy I lwys look forwrd to going to work gin. Feeling responsible for your work is prt of your professionl profile s nurse. Sometimes my prtner sks me why I do not cll in sick, but he knows I will go to work. Feeling committed to the tem is importnt ( ) it mkes me tke sick-leve less esily. For me positive driver to go to work nd not tke sick leve is respect from my collegues nd ptients. When there re problems I know I cn cope with it ( ) nd find solutions. In period of stress t home you cn inform your collegues nd sk them to py ttention ( ) then you cn still do your work nd void mking mistkes. My experience is tht you feel worse when you sty t home, so you better go to work ( ) it gives you energy when you succeed finishing your shift. When you hve physicl hevy job, it is your responsibility to sty in good condition nd prevent helth conditions tht limit your physicl functioning. I keep in mind when I hve to work the next dy, then I do not go out until lte ( ) I wnt to be fit for my ptients.

6 J. A. H. SCHREUDER ET AL.: CHARACTERISTICS OF ZERO-ABSENTEEISM IN HOSPITAL CARE 271 not mentioned spontneously. When sked, focus group prticipnts sid they did not perceive socil pressures to ttend work. Zero-bsentees even perceived tem norm of work bsence rther thn work ttendnce when collegues re ill. Some prticipnts mentioned esteem nd respect from temmtes nd ptients or commitment to the tem s motivtions to ttend work. In comprison to other temmtes, focus group prticipnts thought tht they were less susceptible to stress t work, hd better blnce between work nd personl circumstnces, were more cretive nd tencious in finding solutions to solve brriers to ttend work nd were more resilient when setbcks occurred. When they told me my rthritis could get worse nd being nurse would become too hevy, I decided to strt exercising every dy nd visited specilized physiotherpist ( ) I reduced my contrct nd strted trining for nurse specilist, which is n dvisory function nd less physiclly demnding. Discussion The results of this qulittive study show tht personl ttitudes nd self-efficcy were more importnt thn socil norms in terms of motivtion to ttend work. Zero-bsentees were personlly motivted to ttend work rther thn from the pressure of supervisors nd temmtes or responsibility towrds their ptients. The strength of the study ws its mixed-method design, combining semi-structured interviews nd focus group meetings. Semi-structured interviews llowed individuls to respond with complete nonymity, but disdvntge ws tht individuls did not receive feedbck from others. Feedbck of others ssists reflective prctice, nd individuls my elborte on their vlues, beliefs, ides nd viewpoints. This disdvntge ws overcome by the focus group meetings llowing prticipnts to discuss the issues rised. Thus, the mixed-method design combined the dvntges of semi-structured interviews nd focus groups to provide insight into the chrcteristics of zero-bsentees. However, modertor bis my hve occurred, becuse the sme person performed the interviews nd focus groups. The modertor might hve gined ides bout zero-bsenteeism from the interviews, which my subsequently hve influenced the course nd discussions in the focus groups. We tried to del with this type of bis by resercher supervision, i.e. one of the reserchers ttended the focus groups nd prompted the modertor to void giving opinions nd to stick to the originl interview trnscripts to ensure tht themes reflected the ctul dt nd not the interprettion of the modertor [13]. The dvntge of the single sme modertor ws tht the constructs of the theory of plnned behviour were used consistently in interviews nd focus groups, which fcilitted the trnsition of key themes from interviews to focus groups for respondent vlidtion. This is the first study tht hs investigted zerobsenteeism in terms of uninterrupted long-term work ttendnce over period of 5 yers. Until now, only 1 yer work ttendnce ws exmined, which is n imprecise mesure for work ttendnce [4]. All employees worked in the sme orgniztion nd were therefore comprble with regrd to work conditions nd orgniztionl sickness bsence prctices, which is importnt becuse sickness bsence cn be regrded s socil exchnge process influenced by orgniztionl cultures [15 17]. The disdvntge of including zero-bsentees working t one orgniztion is tht the results my not generlize to other working popultions. However, the im of this mixed-method qulittive study ws not to find results tht re widely pplicble, but to gin detiled insight into the chrcteristics of zero-bsentees nd the mechnisms underlying zero-bsenteeism. The results of this study should be vlidted by further quntittive reserch in lrger working popultions. Although the zero-bsentees in this study experienced good helth, there is no reson to believe tht they re helthier thn the hospitl employees who were bsent from time to time. However, when zero-bsentees in this study were ill, they never felt sick enough to sty off work, prticulrly due to their prents influence nd upbringing. In this study, zero-bsentees were driven by personl ttitudes nd self-efficcy to go to work when hving helth complints. The phenomenon tht employees go to work despite feeling ill is clled sickness presenteeism. Aronsson et l. showed tht >50% of rndom smple of Swedish employees reported sickness presenteeism, prticulrly employees working in helth cre nd eduction [18]. Helth cre workers nd techers might experience pressure to ttend work, becuse they feel responsible for ptients or children. Ashby nd Mhdon found tht personl work-relted stress nd perceived workplce pressure predicted higher rtes of sickness presenteeism [8]. However, the prticipnts in the present study seem to be driven by intrinsic motivtion to ttend work rther thn workplce pressures. It hs lso been reported tht presenteeism ws ssocited with impired performnce [5 7,19 21]. Zero-bsentees in this study perceived no impired performnce when working while unwell, lthough it would hve been informtive to sk supervisors nd temmtes bout the productivity of zero-bsentees t work when ill. Zero-bsentees might find working despite being ill meningful, becuse they were ble to choose esier work tsks. In terms of the illness flexibility model, they used their work djustment ltitude to fcilitte work ttendnce rther thn giving in to work ttendnce requirements. Possibly, the individuls who re present despite sickness s consequence of pressures to ttend work or who force themselves to do their usul work when ill re t risk of poor helth [19,20] nd n incresed risk

7 272 OCCUPATIONAL MEDICINE of future sickness bsence [20 22]. Although they were sometimes sickness present, zero-bsentees in our study did not report themselves sick over period of 5 yers. They believed helth complints could be prevented by helthier lifestyle. Furthermore, zero-bsentees in this study felt confident nd self-efficcious in mnging helth complints nd djusting work tsks to fcilitte work ttendnce when ill. Though the socil context nd socil norms hve previously been found to be importnt in sickness presenteeism, work pressures were not mentioned by the zero-bsentees in this study s reson to ttend work. This is n importnt finding for supervisors, who usully ply n importnt role in mnging sickness bsence. Nyberg et l. found tht inspirtionl ledership ws ssocited with fewer short episodes of sickness bsence in the Swedish workforce [23]. Schreuder et l. found tht effective leders hd lower numbers of both sickness bsence dys nd short episodes of sickness bsence in their tems [24]. The current results show tht supervisors my not hve s importnt role in mnging work ttendnce of zero-bsentees, becuse their work ttendnce seems to be driven by intrinsic rther thn extrinsic motivtion. Zero-bsentees in this study were intrinsiclly determined to ttend work nd ctively sought solutions for brriers nd setbcks hindering work ttendnce. The reserchers felt tht self-efficcy lone could not explin the zero-bsentees positivity, their persevernce when setbcks emerged nd their cretivity in ccommodting work. These cpcities refer to construct clled positive psychologicl cpitl [25]. Now tht there is lrge body of knowledge bout risk fctors incresing sickness bsence, it would be interesting to investigte how zerobsentees nd their positive psychologicl cpitl cn be used to reduce sickness bsence levels [26,27]. Key points In this study, personl ttitudes nd self-efficcy ppered to be more importnt for ttending work thn the socil context. Zero-bsentees were intrinsiclly motivted to ttend work when ill nd less influenced by pressures or responsibilities towrds supervisors, temmtes or ptients. Zero-bsentees provided their collegues with good models of stying helthy, chieving blnce in their lives nd preventing work-fmily interference. Conflicts of interest None declred. References 1. Engström LG, Jnson S. Predictors of work presence sickness bsence in slutogenic perspective. Work 2009;33: Dellve L, Eriksson J, Vilhelmsson R. Assessment of longterm work ttendnce within humn service orgnistions. Work 2007;29: Vernet. onderzoek/verzuim_sector_zorg/zorg-breed_jr2010. pdf (9 Jnury 2013, dte lst ccessed). 4. Dellve L, Hdzibjrmovic E, Ahlborg G Jr. Work ttendnce mong helthcre workers: prevlence, incentives, nd long-term consequences for helth nd performnce. J Adv Nurs 2011;67: Aronsson G, Gustfsson K. Sickness presenteeism: prevlence, ttendnce-pressure fctors, nd n outline of model for reserch. J Occup Environ Med 2005;47: Hnsen CD, Andersen JH. Going ill to work wht personl circumstnces, ttitudes nd work-relted fctors re ssocited with sickness presenteeism? Soc Sci Med 2008;67: Cooper C, Dewe P. Well-being bsenteeism, presenteeism, costs nd chllenges. Occup Med (Lond) 2008;58: Ashby K, Mhdon M. Why do Employees Come to Work When Ill? An Investigtion into Sickness Presence in the Workplce. Report/242_FINAL%20Why%20do%20employees%20 come%20to%20work%20when%20ill.pdf (9 Jnury 2013, dte lst ccessed). 9. Johnsson G, Lundberg I. Adjustment ltitude nd ttendnce requirements s determinnts of sickness bsence or ttendnce. Empiricl tests of the illness flexibility model. Soc Sci Med 2004;58: Azjen I, Fishbein M. Understnding Attitudes nd Predicting Socil Behviour. Englewood Cliffs: Prentice-Hll, Steenbeek R, Schellrt AJ, Mulders H, Anem JR, Kronemn H, Besseling J. The development of instruments to mesure the work disbility ssessment behviour of insurnce physicins. BMC Public Helth 2011;11: Kvle S. Interviews: An Introduction to Qulittive Reserch Interviewing. London: Sge Publictions, Kuper A, Lingrd L, Levinson W. Criticlly pprising qulittive reserch. BMJ 2008;337: Brymn A. Socil Reserch Methods. 3rd edn. Oxford: Oxford University Press Chdwick-Jones JK, Nicholson N, Brown C. Socil Psychology of Absenteeism. New York: Preger, Johns G, Nicholson N. The menings of bsence: new strtegies for theory nd reserch. In: Cummings LL, Stw BM, eds. Evlution nd Employment in Orgniztions. Greenwich: JAI Press, 1990; Crmeli A. The reltionship between orgniztionl culture nd withdrwl intentions nd behviour. Int J Mnpow 2005;26: Aronsson G, Gustfsson K, Dllner M. Sick but yet t work. An empiricl study of sickness presenteeism. J Epidemiol Community Helth 2000;54: Bergström G, Bodin L, Hgberg J, Lindh T, Aronsson G, Josephson M. Does sickness presenteeism hve n impct

8 J. A. H. SCHREUDER ET AL.: CHARACTERISTICS OF ZERO-ABSENTEEISM IN HOSPITAL CARE Nyberg A, Westerlund H, Mgnusson Hnson LL, Theorell T. Mngeril ledership is ssocited with selfreported sickness bsence nd sickness presenteeism mong Swedish men nd women. Scnd J Public Helth 2008;36: Schreuder JA, Roelen CA, Vn Zweeden NF, Jongsm D, Vn der Klink JJ, Groothoff JW. Ledership effectiveness nd recorded sickness bsence mong nursing stff: crosssectionl pilot study. J Nurs Mng 2011;19: Luthns F, Youssef CM, Avolio BJ. Psychologicl Cpitl. Oxford: Oxford University Press, Avey JB, Luthns F, Youssef CM. The dditive vlue of positive psychologicl cpitl in predicting work ttitudes nd behviors. J Mng 2010;36: Avey JB, Pter JL, Brdley J. The implictions of positive psychologicl cpitl on employee bsenteeism. J Ledersh Orgn Stud 2006;13: on future generl helth? Int Arch Occup Environ Helth 2009;82: Tloyn M, Aronsson G, Leineweber C, Mgnusson Hnson L, Alexnderson K, Westerlund H. Sickness presenteeism predicts suboptiml self-rted helth nd sickness bsence: ntionlly representtive study of the Swedish working popultion. PLoS ONE 2012;7:e Bergström G, Bodin L, Hgberg J, Aronsson G, Josephson M. Sickness presenteeism tody, sickness bsenteeism tomorrow? A prospective study on sickness presenteeism nd future sickness bsenteeism. J Occup Environ Med 2009;51: Leineweber C, Westerlund H, Hgberg J, Svedberg P, Alexnderson K. Sickness presenteeism is more thn n lterntive to sickness bsence: results from the popultion-bsed SLOSH study. Int Arch Occup Environ Helth 2012;85: