Intended for healthcare professionals

Education And Debate

ABC of Work Related Disorders: ABSENCE FROM WORK

BMJ 1996; 313 doi: (Published 05 October 1996) Cite this as: BMJ 1996;313:874

On one level absence is easy to define and identify: it is simply non-attendance at work by an employee when attendance is expected by the employer. Despite the apparent ease of definition, absence has proved to be a complex phenomenon that resists single or straightforward explanations. The above definition is not, in fact, describing a specific behaviour but rather the non-occurrence of a specific behaviour. In this sense absence is an administrative category rather than a behaviour.

Many different circumstances and behaviours may underlie absence from work. Rather than viewing absence as a single behaviour, making careful distinctions between types of absence is vital for both understanding and managing absence.

The many types of absence include:

  • Absence attributable to sickness

  • Voluntary versus involuntary

  • Paid versus unpaid.

Distinctions can also be made between:

  • Absence events—the number of absence

  • Periods of any duration that occur—and

  • Absence duration

Evidence about absence

Even quite modest rates of absence can be costly for an organisation. Despite these costs, many organisations maintain surprisingly poor absence records, which means that obtaining good evidence about absence is often difficult. Another difficulty is that, even when organisations keep good records, establishing the types and causes of absence events is problematic.

In many cases it may be impossible to verify employees' claims about the causes of their absence. For example, it is not easy to check whether an employee really had to look after a sick relative or had a migraine or back pain. Questioning employees' claims about absence may also damage employee relations and hence be undesirable from the organisation's point of view.

Costs associated with absence from work

  • Lost production

  • Benefits paid to absentee

  • Overtime payments for replacement employees

  • Disruptions to particular sections

  • Administrative costs of managing absence and rescheduling work

Rates of absence

Although many of the available figures should be treated with caution, some patterns about rates of absence do emerge. First, there are considerable national variations in absence rates. For example, studies in Western Europe have found rates about twice as high as those found in Japan and the United States. Second, there are differences between occupations and sectors of industry in terms of self reported rates of absence due to sickness and injury. There are also differences between categories of disease in the number of self reported annual days off work.

Approximate self reported absence rates due to sickness or injury by occupation and industry*

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It should be noted that much of the evidence about absence is self reported and should therefore be treated with caution. However, as indicated above, it is difficult to obtain objective evidence about the causes of absence. Ultimately we may never know the precise causes of an absence event even though employees may be willing to attribute it to a specific cause.

Self reported sickness absence by self reported work related illness in Britain*

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Correlates of absence

Although several correlations have been found, studies have produced very inconsistent results and many correlations are weak. For example, many studies have found no correlation between job satisfaction and absence, while those that have done so found only small negative correlations, indicating that lower levels of satisfaction are only weakly associated with absence. A key point, however, is that correlates of absence have been found with several different factors including attitudes to work, biographical factors, organisational features, and job content.

In most cases, therefore, absence from work is likely to be caused by several factors and any single cause is unlikely to have a strong effect on rates of absence. Some factors, such as age and tenure, have shown both negative and positive associations with absence indicating that these variables may be associated with both higher and lower levels of absence.

Correlates of absence from work (from several studies)

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Understanding absence

Several models of absence have been proposed in order to explain it. Given that there are different kinds of absence and different correlates of absence, no single theory is likely to account for all absence events. However, the particular model of absence that is used has implications for the way that absence is managed.

Medical model—Although much absence is attributed by employees to sickness, the available evidence suggests that sickness is not always the true cause. For example, if sickness was a major cause of absence then we would expect absence rates to have fallen over the past 100 years as health care has improved, but rates do not seem to have declined—in fact, they started to rise in all industrialised countries from about 1955. In addition, patterns of self reported diagnosis in relation to sickness absence seem to follow particular trends—such as “RSI,” “ME,” “stress”—indicating that it is the label of sickness rather than sickness itself that may be associated with absence. There is also evidence that receiving a particular diagnosis (such as hypertension) increases absence even where there are no symptoms.

Deviance model—There is some evidence for this model, as a small number of employees often account for a large proportion of total absence in a workforce and one of the best predictors of future absence rates is past absence. While we may be able to identify people who are often absent or absent for long periods, this may be for reasons other than deviance, such as chronic illness or family commitments.

Models of absence from work

Medical model—Suggests that the main cause of absence is injury or sickness

Deviance model—Views employees who are absent as somehow different from other employees: they may have particularly negative attitudes such as laziness and lack of commitment

Withdrawal model—Suggests that employees are absent as a way of withdrawing from unpleasant or unsatisfying working conditions

Economic model—Suggests that leisure and activities outside work are valued by employee; thus, not attending work in order to engage in alternatives is attractive

Cultural model—Identifies causes of absence within social context of organisation and the way shared attitudes and norms influence absence rates: thus, if employees perceive their level of absence to be much lower than that of their coworkers, they may find it easier to decide not to attend work

Withdrawal model—This model reflects a common view of absence. However, as indicated earlier, job satisfaction has not been found to be a strong correlate with absence, and evidence for this model is weak.

Economic model—Rather than considering how adverse working conditions may push people away from work, the economic model suggests that employees absent themselves in order to engage in more attractive alternatives. There is some evidence that people who place more value on their time outside work are absent more often. Similarly, when unemployment is high absence rates tend to decrease, indicating that employees may be making some kind of cost-benefit analysis when they decide whether to attend work. If being absent means a greater chance of job loss when jobs are scarce, the relative value of leisure may decrease.

While sickness clearly can be a cause of absence, many other models are required to build up a comprehensive picture of absence

Cultural model—National differences in absence rates support a cultural model of absence, as do figures which indicate that mean absence rates can vary considerably across sites or work units despite other factors that may cause absence being similar.

Managing absence

The basis for managing absence effectively is a comprehensive system of monitoring absence. Now that employers have a greater responsibility for sick pay, many are developing and implementing such systems. Techniques for managing absence may be aimed at individual employees or at changing aspects of the work or the working environment.

Without good information about patterns of absence over time, across work units, and between different types of employee, accurate diagnosis and management of absence is impossible

Individual techniques include punishments for absence and rewards for attendance. For example, detailed interviews with supervisors on return to work about the causes of the absence can discourage taking time off work. Similarly, issuing warnings and using disciplinary procedures may be disincentives. Disciplinary systems are widely used, yet there is little evidence about their effectiveness. There is, however, evidence that reward systems such as attendance bonus schemes can reduce absence rates.

Changing the nature of the work in terms of job redesign may be effective, but, as indicated earlier, it depends on the extent to which features of the job are actually predictive of absence. Techniques that influence the employees' ability to attend seem to be more successful. The introduction of flexible working hours, in particular, has been shown to reduce absence.

Even with a comprehensive monitoring system, attempts to manage absence are likely to work only if they are approached systematically. In practice implementing a range of measures based on an accurate diagnosis of absence patterns is likely to be most effective. Managing absence also requires a flexible approach to employees who have long term or frequent absences. In some cases specific causes such as chronic sickness or a disability may be identified. In others, however, a range of factors both inside and outside the workplace may be important.

Techniques for managing absence Individual techniques

  • Negative incentive (punishment)

    • Setting expected levels of attendance

    • Record keeping

    • Investigating absence events (such as interview with supervisor on return)

  • Positive incentive (reward)

    • Financial rewards (such as attendance bonuses)

    • Other rewards (such as free hours, recognition programmes)

Work techniques

  • Job redesign

    • Work rotation

    • Employee participation

    • Physical working conditions

  • Influencing attendance

    • Establishing group norms

    • Flexible working hours

    • Company cr che

Roles of occupational health departments and general practitioners

Occupational health departments and general practitioners play important roles in managing absence attributable to sickness. In the past 10 years changes in legislation have altered these roles.

When statutory sickness certificates were required from the first day of absence, general practitioners were inundated with patients with minor illnesses that they felt were sufficiently serious to keep them away from work. People with high rates of sickness absence therefore made considerable demands on their general practitioner.

Self certification has ameliorated this unsatisfactory situation but has moved the responsibility for deciding the seriousness of short term sickness from patient and doctor to employee and employer. As noted earlier, questioning employees about their claims of sickness may be resented and can be difficult and embarrassing for employers.

Some employees may believe they have to take time off for particular conditions. For example, an employee with a minor cold may not attend work for fear of infecting colleagues, or a person with back pain may believe that he or she must remain in bed. Clearly, doctors have a role in providing basic health education and clarifying the advisability of attending work. In some cases—such as food handlers who have diarrhoea—the doctor may have to advise someone who may feel both willing and able to work to stay away.

Periods of continuing absence attributed to particular illnesses after which employer should seek medical advice*

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Employers clearly wish to reduce absence, including absence attributable to sickness, and an occupational health department can help employers manage sickness absence more effectively, in a way that may be fairer and that preserves medical confidentiality. Whether rates of sickness absence can be reduced clearly depends on several factors such as its present level (it may already be very low) and the specific illnesses encountered. As discussed above, however, accurate absence records are a vital first step in managing any type of absence.

Role of occupational health department or general practitioner in managing sickness absence

  • To confirm that employee is sufficiently ill to warrant absence

  • To assess likely pattern of absence associated with that illness

  • To assess whether employee's previous pattern of sickness absence is likely to be repeated

  • To confirm that employee has an ongoing medical problem but that amount of sick leave is greater than would be expected. A medical review can be suggested at this point

  • To separate domestic causes from sickness and possibly to give opinion on whether there are work related causes

  • The review can be presented in non-medical terminology and in such a way as to preserve doctor-patient confidentiality

Sickness absence that will certainly lead to permanent incapacity to do a particular job may be dealt with by medical retirement if such a scheme exists. The most difficult situation is when there is chronic sickness of an intermittent type, such as asthma, but permanent disability is not anticipated.

Another problem is when sickness absence is partly caused by the employee's own actions, such as alcohol misuse. Sickness may also combine with other factors, at work or at home, to causes absence. It may therefore be helpful to look at some cases of sickness absence in a wider context in order to improve management.

Not all employees (or employers) realise that a person can be legitimately dismissed for unacceptably high rates of absence attributed to sickness (whether “genuine” or not) provided that a proper management procedure is followed (see box).

Typical procedure for employer dealing with repeated short term absences

  • Counsel the employee

  • Investigate the causes of absence throughly and openly

  • If absence is result of an accident at work complete an accident report form, and if absence is for more than three days also complete a RIDDOR form

  • Seek medical advice through occupational health department, which will obtain employee's permission to approach his or her treating doctor. Or contact the treating doctor directly, with employee's permission under Access to Medical Reports Act 1988

  • When there is an underlying cause for absence consider possible solutions—other duties, transfer to another department, light work, flexible working arrangements, retirement on grounds of ill health

  • If spells of sickness are intermittent but too frequent and other solutions fail, caution the employee

  • When there is no underlying cause counsel the employee that disciplinary action will result if there is no improvement in absence

  • Set a time limit to review the situation for any improvement

  • If there is no improvement start disciplinary procedure, leading to a final warning and dismissal on grounds of incapacity

Absence from work: final comment

People are inclined to use their own preferred or pet theories to explain whatever absence they happen to observe. Interestingly, the theories that people use to explain their own absence are often different from those they use to explain the absence of others. Thus, we may feel that our own absence is legitimate and necessary yet regard the absence of others, particularly if it is regular or prolonged, with suspicion. However, a key point to remember is that taking a single approach when considering and managing absence is unlikely to be successful. Absence is not a single or simple phenomenon and should not be treated as such.

Key references

  • Fitzgibbons DE. A critical examination of employee absence: the impact of relational contracting, the negotiated order, and the employment relationship. Research in Personnel and Human Resources Management 1992;10: 73–120

  • Hodgson JT, Jones JR, Elliott RC, Osman J. Self-reported work-related illness: results from a trailer questionnaire on the 1990 labour force survey in England and Wales. Suffolk: HSE Books, 1993.

  • Huczynski AA, Fitzpatrick MJ. Managing employee absence for a competitive edge. London: Pitman, 1989.

  • Johns G. Understanding and managing absence from work. In: Dolan SL, Schuler RS, eds. Canadian readings in personnel and human resource management. St Paul, MN: West, 1987: 324–35.

Rob B Briner is a lecturer in the department of organisational psychology, Birkbeck College, University of London.

The ABC of Work related disorders is edited by David Snashall, clinical director of Occupational Health Services, Guy's and St Thomas's Hospitals NHS Trust, London.

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