Presenteeism in multiprofessional team workers in the Adult Intensive Care Unit

Rev Bras Enferm [Internet]. 2019;72(Suppl 1):96-104. http://dx.doi.org/10.1590/0034-7167-2017-0779 ABSTRACT Objective: To analyze the occurrence of presenteeism in multiprofessional team workers of an Adult Intensive Care Unit, relating it to sociodemographic and labor characteristics. Method: It is an analytical cross-sectional qualitative study, which used a questionnaire for sociodemographic data collection, and Stanford Presenteeism Scale(SPS-6) to assess presenteeism. Results: There was predominance of women (75.9%), nursing workers (66.7%), mean age of 39.81 years, and 6 to 10 years (31.6%) of experience in the labor market. Regarding presenteeism, 48.7% presented work impairment and 31.8% presentedperformance and completion of tasks altered by this phenomenon. Conclusion: Expressive numbers of general presenteeism were identified, with results indicating impairment in completing work. When connecting presenteeism to sociodemographic and labor characteristics, the variables sex, dependent children and absence from work presented values with statistical significance among the studied workers. Descriptors: Occupational Health; Working Conditions; Health Personnel; Presenteeism; Nurse Practitioners.


INTRODUCTION
The work in health areas fundamental to the maintenance of human life (1) ; it consists of taking care of people, which is a complex activity (2) . As a result, workers suffer from exhaustion due to organizational, physical and psychic burdens, regardless of professional class. Events arising from work organization, management strategies, autonomy disrespect and power abuse may be predecessors of such exhaustion (3) . Besides, workers experience situations in which they have to deal with pain, suffering, and physical, social and emotional malaise (4) .
In health care establishments, Intensive Care Units (ICUs) are critical and specialized areas aimed at patients who are in serious need of skilled professional assistance. In these places, there must be human resources, necessary technologies and adequate materials to perform monitoring and therapy of critical patients, offering them specialized and safe assistance (5) .To work at the ICU, workers need to have high degree of specialization (6) at a complex work environment that includes behavioral conflicts, such as poor team communication or situations of verbal abuse (7) .
Collective cooperation is needed at those places; the severity of patients' conditions imposes need to deal with sophisticated equipment, performing constant clinical evaluations and complex procedures with immediate decisions. The work cannot be performed by a single professional health category; it requires other members as administrative technicians, cleaning workers, among others (8) , although there is always predominance of the nursing team.
In addition, the intensification of work daily routine has become a source of physical exhaustion and mental breakdown, which may result in stress (9) , since the person frequently goes to work without being able to perform his/her tasks (10) . This is the situation that occurs in presenteeism, condition in which the worker goes to work, however not developing his/her labor activities in a productive way, presenting low performance. Decreased productivity may be related to possible physical and mental issues externalized by the person (11) , since he/she is present, in spite of his/her deficient health state, but this does not justify his/her absence from work (12) . In some situations, this person is not able to satisfactorily perform what is expected from him/her. Dedication, fear of overloading co-workers, lack of payment for leaves or absence, and difficulties for another professional to replace the person are factors that justify the practice of going to work (13) .
It can be noted that presenteeism is a complex phenomenon, and it is related to absenteeism, in a way that working even sick -characteristic of presenteeism -becomes a risk factor for the occurrence of absenteeism (12) .
This study was motivated by the few investigations which were identified regarding this phenomenon among ICU multiprofessional team.

OBJECTIVE
To analyze the occurrence of the presenteeism in multiprofessional team workers of an Adult Intensive Care Unit, relating it to sociodemographic and labor characteristics.

Ethical Aspects
The study was approved by the Research Ethics Committee of the Nursing School of Ribeirão Preto-USP, and the participants were included after agreeing upon participating in the study, reading and signing the Informed Consent Form.

Design, study place and period
This is an analytical cross-sectional, correlational qualitative study, developed at an Adult Intensive Care Unit (AICU) of a largesized Brazilian hospital, an institution whose work contracts are carried out by means of civil service examination or through its support foundation.
Data collection took place at the AICU between November and December 2016, by the first author of this study, including weekends and holidays, after having obtained the institutional authorizations and performed the necessary ethical procedures.

Population or sample; inclusion and exclusion criteria
The participants were members of the AICU multiprofessional team. The total number of workers at the time of data collection was 62, and the group was composed of 24 nursing technicians, 10 nurses, eight physicians, seven nursing assistants, four sanitation collaborators, four physiotherapists, two administrative assistants, one psychologist, one nutritionist and one technical support technician, that is, most of these workers (62.12%) belonged to the nursing team.
The following criteria were used for the inclusion of participants: they should be members of the multidisciplinary team working at the hospital ICU; of both sexes; without distinction of shifts, profession/function exercised and work contracts; with training/ performance time in the institution and working at the AICU for over one year, due to need of the individual's labor experience (14) . Once these criteria were met, there was inclusion of 54 (87.09% of the total) people.

Study protocol
For the collection of workers' information and obtainment of sociodemographic and occupational variables, there was employment of an instrument containing questions about age, sex, type of union, dependent children, occupation/function performed at the AICU, working hours, overtime in the last month prior to collection, performance of some other professional activity, and absence from work.
For the evaluation of presenteeism, the Stanford Presenteeism Scale (SPS-6), instrument validated in Brazil, was applied to evaluate labor productivity losses by means of two different dimensions. The first -Completing Work -relates to the physical causes of presenteeism, which correspond to the amount of work performed under the effect of the causes of this event. The second dimension -Avoiding Distraction -refers to the amount of concentration mobilized to produce when there is an effect of presenteeism (15) .
Each of these factors is analyzed by three items, totaling six questions on a 5-answer-option scale. SPS-6 score in dimension 2 uses reverse score, that is, it should consider the opposite value for the total score of presenteeism. For the individual evaluation of each dimension, the sum of the values should be used in a traditional way, without using the reverse score (15) .
The collection instruments were delivered in closed and unidentified envelopes to professionals who had interest, agreed upon participating in the research and signed the Informed Consent Forms (ICFs), which have been filled during the shifts but without disturbing the Unit functioning. In the end, the said author, who remained at the scene, collected the forms, taking care to note that there had been no communication between the workers on the issues of the instruments.

Analysis of results and statistics
The descriptive analysis was used for sociodemographic and occupational characterization; to evaluate the continuous variables, there was calculation of mean, standard deviation, median, and minimum and maximum; for the categorical variables, frequency and percentage were calculated. In order to relate presenteeism to sociodemographic and labor characteristics, tests were conducted for statistical average differences of the categorical variables (age, sex, civil union, dependent children, other professional activity, working schedule, overtime and absence from work), and the regression analyzes were performed. Mann-Whitney test and Kruskal-Wallis test of independent samples (used for statistical analyzes in which the data do not present normal distribution) were used, considering α = 0.05.

RESULTS
Most of the 54 participants (42.6%) were between 30 and 39 years old, presenting mean of39.8 years; median age, 39 years; minimum and maximum ages of 25 and 62 years, respectively, and standard deviation (SD) of 9.0. These individuals were female (75.9%), living in civil union (56.0%), and reported having dependent children (53.7%).
The work schedule with the highest number of participants (18, or 33.15%) was the 6-hour day shift with a 12-hour double shift. Twenty respondents (37%) reported developing another professional activity in addition to that in the hospital, and 18 (90%) among these worked in the health segment. Working overtime in the last six months was confirmed by 30 (55.6%) participants, with an average of 38.23 hours/month; median of 36.0; minimum of 6.0 and maximum of 84; and SD of 17.12. Regarding absence from work, 29 (53.7%) participants have not been away from work since they started the professional activities at the AICU.
Analyzing the results obtained with the use of the SPS-6, the following total presenteeism values were found: median, 16.5; mean, 14.8; SD, 6.8; study range, 6 -27 points. The values found for median and mean of the total score were lower than 18; it is clear that values from 6 to 18 indicate a lower concentration capacity and reduction in performance at work, and high values in the total score, close to 30, indicate greater concentration capacity and better performance at work, although the individual presents some health issues (15) .
The analysis of dimension 1 (Completing Work) is shown below (Table 1). Table 2 shows the analysis of dimension 2 (Avoiding Distraction). Table 3 below presents the values found in total presenteeism and its relation to sociodemographic and occupational/ labor variables.  Mann-Whitney test was used for the analysis of variables age, sex, civil union, dependent children, other professional activity, overtime and absence from work; Kruskal-Wallis test was used for the analysis of the working schedule.
The variable absence from work presented statistical significance (p = 0.040). The mean of those stating absence from work (25) was 16.88, with median of 17.00; SD, 6.710, and range, 6-27. The mean of those who have declared no absence from work (29) was 13.10, with median of 14.00; SD, 6.608, and range, 6-23.
The values of dimension 1 and their relation with the participants' sociodemographic and occupational variables are presented below (Table 4).
Mann-Whitney and Kruskal-Wallis tests were chosen in order to perform the analyzes of the variables age, sex, civil union, dependent children, other professional activity, overtime and absence from work, both of independent samples.
Those who reported having dependent children presented higher values when compared with those who did not have them.
Among those who reported having already been away from work, it was possible to verify higher values in relation to those who have not been absent from work. Among the first (25), the values were: mean, 10.52; median, 12.00; SD, 4.41; and range, 3-15; for those who have not been absent from work (29 workers), the values were: mean, 7.97; median, 9.00; SD, 4.51. The range for this group was 3-15, and this variable presented p = 0.026, indicating statistical significance. Table 5 shows the results obtained for the second dimension of SPS-6 (Avoiding Distraction).
The Mann-Whitney test was used to analyze the variables age, sex, civil union, dependent children, other professional activity, overtime and absence from work; Kruskal-Wallis test was used to analyze the working schedule; both tests of independent samples.

DISCUSSION
Workers who carry out their activities, especially in hospitals, coexist with complex and stressful scenarios (16) . ICUs are places of care for patients in critical states with variations in prognosis; therefore, those who work in these places experience situations of patients' life and death, which may result in emotional vulnerability, anxiety, guilt and impotence (17) .
In this study, 85.2% respondents were younger than 49 years old, indicating a population of still relatively young adults. A Korean study demonstrated the relationship between age and the prevalence of pathologies in workers' joints; older individuals are more likely to develop this type of pathologies (18) , which possibly end up hampering their work.
Most of the workers were women, and belonging to the nursing team (66.7%). In health services, the presence of female labor is expressive (19)(20) ; at the ICU, the presence of the nursing team is fundamental, since it is a place where patients are at imminent risk of death, are highly dependent, and require complex care (21) .
Among the workers, 56% affirmed to live in civil union; these unions are those in which people live in a consensual lasting relationship, established for the purpose of family constitution, without the need for a marriage certificate in the notary's office (22) . The presence of dependent children was confirmed by 53.7% respondents. If the individuals have children, in addition to their working hours, they may still develop household activities and care to offspring, which results in work double/triple shifts, especially for women (23) .
The professionals that worked at the AICU faced different amount of working hours due to their types of contractual ties. The amount of working hours is an essential element in worker's life; working hours should be established in rules or legislation which prioritize workers' safety and health by ensuring that they are not exposed to excessive working hours, besides enjoyment of rest periods and vacation (24) . Excessive working hours may lead to physical and mental exhaustion, which may result in psychological and physical changes (25) .
In this study, 55.6% participants performed overtime in the month prior to data collection. When the individual faces long working days, performs excessive overtime, or has a double employment relationship, the person may have his/her quality of life influenced negatively and submit to the highest levels of occupational stress (19,26) . Overtime may lead to excessive workload, which may favor the occurrence of adverse events (27)(28) .
With regard to absence from work, 53.7% participants have not been absent since they began their professional activities at the AICU. Ways of working may result in physical and mental exhaustion, capable of provoking accidents and illnesses in workers. Sick leave is related to work accidents, several physical problems, as well as suffering and mental illness (29) .
Presenteeism is commonly found in healthcare professionals; musculoskeletal pain may be responsible for decreased work performance, and may cause difficulty in making the movements necessary for the exercise of the function (30) . Changes in physical and mental health, reduced ability to work and occurrence of presenteeism are likely to occur due to the organizational context of the workplace and the relationships between teams (31) . Workers with greater sense of well-being are less absent from work, reduce presenteeism and show the intention to remain in their work stations (32) .
Productivity consists of carrying out activities during working hours; it is the relationship between the results of production and the productive resources applied to it (33) . Work productivity reduction may be related to depression, anxiety, financial issues, increased workloads and health issues. It is important to investigate the presenteeism among workers, since they reduce their productivity but are not absent from their work stations, causing this phenomenon (34) .
In the statistical analyzes of this study, differences with statistical significance were found: in the general SPS-6 score, for the variables sex and absence from work; in dimension 1, for the variables having dependent children and absence from work; and in dimension 2 for the variable sex.
Regarding the assessments of the two dimensions of this scale, in the first dimension (Completing Work), the score three among 17 workers (31.8%) was found, considering that in this dimension the lower the score, the greater the difficulties for the worker to finish his/her activities, indicating how much the health condition may interfere with the accomplishment and completion of the tasks at work; it should be noted that they account for about one-third of  respondents. Regarding dimension 2 (Avoiding Distraction), most of the values found were for score three (48.7%), considering that the higher the score, the lower the concentration of the individual at work, indicating greater impairment of concentration, and that lower values indicate a better psychological state (15) , there being lower impairment in this dimension Stress experienced at work is capable of influencing the occurrence of presenteeism among workers; the support from colleagues can ease this stress and, consequently, the presence of this phenomenon, as proven in an American research (35) . A Polish study has shown that costs associated with its occurrence can exceed two to five times the expenses incurred with absenteeism, when comparing both (36) .
The occurrence of presenteeism may result in generation of high costs for the institutions, since it is a phenomenon of difficult evaluation and measurement. Because of the increase of costs that it may represent, its investigation is essential, since it is possible to formulate strategies and means to mitigate its occurrence (37) by knowing it better. It is a phenomenon that may result in financial losses for institutions and organizations; however, it is important to consider it not only because of the financial impact and its consequences, but also due to its psychosocial relevance (38) .
Workers with chronic diseases are more likely to present presenteeism than healthy workers (39) ; individual characteristics such as affect, motivation, commitment and engagement in activities can influence the decision of the worker to go to work even when ill (38) . Psychological support can prevent mental disorders from becoming chronic by early identification of changes that may compromise them. Such interventions are capable of reducing presenteeism, absenteeism, absence from work, sick leave and costs to the employer (40) .

Study limitations
This study had limitations because it was performed at a single AICU; larger number of respondents may make it possible to find more values of statistical significance.

Contributions to nursing and health areas or public policies
The study advances in knowledge since it evaluated presenteeism regarding the multiprofessional team that works at this type of complex Unit. It is expected that the results may contribute to workers' health, since presenteeism may result from damages and physical and psychological health issues among them.

CONCLUSION
In the evaluated AICU, expressive presenteeism numbers have been verified in the general evaluation. By evaluating the SPS-6 different dimensions, with regard to the first one, the results found indicated impairment in completing work, and in the second dimension, it was possible to identify better psychological state among the multiprofessional team workers. When relating presenteeism results to sociodemographic and labor characteristics, the variables sex, having dependent children and absence from work presented values with statistical significance among the multiprofessional team workers studied.