Absence from work is a difficult management problem in industry, since it introduces considerable uncertainty into the scheduling of work and of staff assignments, is an important cause of lost productivity, and is a very common precipitating cause of labor-management conflict and misunderstanding. Indeed, an entire mythology has arisen around unauthorized absence from work, featuring such characters as the lazy worker, the selfish and inflexible boss, the manager who phones in sick from the golf course, and the unreliable, happy-go-lucky ethnic or racial or class stereotype of one's choice. Because absence from work is viewed very differently depending on one's cultural background, the issue is laden with prejudice, misperceptions, and hidden hostility. There is no other area of working life where the rigid, quasireligious expectations of the work ethic are more likely to conflict with notions regarding personal freedom and flexibility, and where abuse so directly undermines the relationship between manager and worker.
Because absence triggers emotional responses and attempts to control unauthorized absence often makes matters worse, human resources personnel often persuade management to take a more "objective" approach by treating the problem as one of validation and documentation. Much of the total absence experience in industry is because of sickness and even more is claimed to be sickness. From management's point of view, therefore, it may be only logical that absence be dealt with through medical means by requiring employee screening to identify workers likely to be frequently absent, medical certification of claimed illness, and investigation of individual cases. Some go so far as to expect their occupational health service, if they have one in-house, to monitor absence directly as a principal responsibility. Unfortunately, such responsibilities work no better than other tactics and have the potential to destroy the effectiveness of the occupational health service overall.
This chapter will discuss the role of the occupational health service in dealing with issues related to absence, technical aspects of absence monitoring (with an emphasis on issues that tend to involve the occupational health service, and the certification of sickness absence by physicians.
The transfer of responsibility for absence monitoring and control from the personnel or human resources department to the occupational health service converts an administrative problem into a medical and programmatic nightmare. It succeeds in getting the human resources department off the hook but presents the occupational health service with a fundamental inconsistency that workers are quick to see and some managers are quick to exploit further. In Chapter 5 the situation of the corporate or in-plant occupational health service is compared to a balance weighing employee trust against responsibility to the management. Without question, a soundly run occupational health service can reduce absence due to incapacity but to involve it in the routine monitoring and control of absence destroys the delicate balance. Under these circumstances, the occupational health service becomes the personnel manager. When workers view the occupational health service as the means by which management reviews their attendance and singles them out for discipline, cooperation and goodwill promptly evaporate and are seldom if ever regained. The physician in such a position becomes labelled as just another management functionary and medical judgements from the occupational health service are viewed as untrustworthy and prejudicial to the worker. Having taken the occupational health service this far down the road, insensitive managers may then press even further for the physician to become a "team player" siding with management or for violations of confidentiality (see Chapter 30).
Although the occupational health service should never accept monitoring and control of absence as an operational responsibility, there are many ways in which the occupational health service can have a positive effect on the absence experience of an employer to the mutual benefit of employer and worker. These include evaluating employees who are referred either voluntarily or individually by their supervisors for frequent or prolonged absence due to apparent health problems. This evaluation is an extension of the fitness-to-work concept (see Chapter 18). A private, confidential interview and examination may uncover a treatable illness, may suggest a means by which the patient could be treated at work conveniently and without disruption to the work schedule (see Chapter 21), may suggest a minor modification in the work environment or in responsibilities that would allow the worker to stay on the job (see Chapter 21), and may identify a worker with emotional or substance dependancy problems that might benefit from referral to an employee assistance program (see Chapter 25 and 26). In all such cases, the emphasis should be an fitness-to-work and the well-being of the worker, not on policing compliance with the policy on sick leave.
The occupational physician is primarily concerned with work-related health problems, but a question of at least as great significance in practice is the assessment of a patient's ability to work in the presence of a personal health problem. There are many circumstances where a personal health problem is better managed and monitored in the worksite, as has been shown for hyper tension, or where the occasional attention of the occupational physician at the worksite may prevent subsequent problems leading to absenteeism or loss of work time as in the management of brittle diabetics. Such individual patient management at the worksite should be considered competitive complementary to the management of the worker's personal physician, providing the patient/worker with the best opportunity to remain on the job while insuring that health care needs are met.
There is no area of occupational medicine more sensitive than the identification and evaluation of individuals with personal health behaviors that are self-destructive and interfere with work performance. The occupational physician engaged in providing employee assistance services either directly or more commonly in supervising the referral of troubled employees to outside services quickly realizes the degree to which personal health problems play a role in employee satisfaction and performance.
Health promotion programs in the workplace are one clear way in which occupational medicine addresses nonoccupational factors determining health. Participation by the employee in such programs may reduce absence in many ways. Participation is predicated on the implicit assumption that the employer will not accumulate personal health data as a means of validating or predicting sickness absence, avoid responsibility for later workers' compensation claims or evading responsibility for occupational health conditions. This is discussed in greater detail in Chapter 27.
For minor illnesses occurring among workers presently on the worksite, the occupational health service may play a useful role by providing simple assessment and treatment for the convenience and comfort of workers. Such care should not replace personal health care by the worker's own physician but can keep an employee safely on the job who would otherwise stay home due to minor symptoms. Occupational health services are seldom equipped for sophisticated treatment and diagnosis, however, and must limit their involvement in personal health care to avoid overextending their limited resources. Occupational health problems must take priority but it can be a real convenience for the service to provide simple dispensary care for the common cold and other minor ailments.
Limited involvement in personal health care and the recording of personal health-related information on workers has another, more esoteric benefit as well in situations where new occupational health problems are suspected. The occupational health physician must have a working knowledge of personal health problems prevalent among the group of workers of concern in order to be able to interpret the likelihood of newly recognized health outcomes being occupationally related. One of the major criticisms of occupational epidemiology, for example, is that smoking data are rarely available for occupational groups of interest and the absence of such data often calls into question the findings of a study. As occupational medicine becomes more sophisticated, the need to sort out occupational from nonoccupational risk factors becomes even greater. This requires an appreciation of the personal health of workers as well as their occupational experience.
Although there are general measures that may have a positive effect on absence in the workplace, there is no way to predict individual absence with reliability and screening programs for that purpose are not very effective.
There are only two possible ways to keep track of absence: to record attendance at work or to record incidents of absence, assuming attendance unless notified otherwise. For a variety of reasons that have much to do with assumptions regarding social class and behavior, attendance recording is normally used for blue collar and manual labor occupations and some office workers in automated or data-entry jobs where wages are calculated by the hour and productivity is measured by quantitative standards or on a group basis. Absence recording, on the other hand, is usual for professional, white-collar, and most office workers who are more often paid on a salary basis and whose productivity is judged primarily by qualitative standards of individual performance. Absence recording is inherently less accurate but the implicit assumption is that professional and white-collar workers need mainly to jutify their output to prove their worth. At higher levels of responsibility, the freedom to take time off whenever one's schedule permits is tantamount to an executive perquisite but the socialization process of executives is such that while the option is provided it is not expected to be taken very often because the executive demonstrates commitment to the employer by assuming the compulsive behavior that at an extreme characterizes the workaholic. By contrast, the blue-collar worker or laborer is assumed to have little commitment to the employer, to require constant supervision, and to be essentially interchangeable with other workers. Thus, the mere recording of attendance or absence, as symbolized by punching a time clock or by the freedom to play golf on a weekday afternoon, already raises sensitive issues and suggests that measurement of absence is not a simple matter.
Qualification of absence is usually in terms of days, since this is the most convenient and universal unit to record. There are other measurements, however. Hours or, more ????, shifts lost both reflect loss of productivity more directly, although it should be kept in mind that presence at the worksite may represent the opportunity to be productive better than actual productivity. For example, a worker in an academic or creative field may find inspiration at any time on or off the job and may spend relatively little time actually producing a tangible product while an office worker with ambiguous or poorly defined responsibilities in a large and complex organization may sit at a desk daily for years with no substantial output. For most jobs, however, time put into the task bears some relationship to productivity. The frequency of spells, or identifiable episodes, of absence may be more revealing of a pattern suggestive of a medical cause or a periodicity that could suggest a problem. For example, binge drinkers not uncommonly lose a day or so preceding or following weekends or holidays, so that their pattern of absence can be frequent but may not be reflected in the numerical count of days of work lost. An individual with a severe, chronic illness may lose many days but on recovery may only have a few episodes of illness per year.
Once counted, absence can be compared and monitored by the calculation of summary measures, each with their own limitations:
In practice, employers use many different systems to calculate and to express absence and there is little consistency among companies or between private corporations and public agencies except for the crude measurement of days lost. The crude nature of absence counting and the questionable validity of its classification in practice makes detailed statistical analysis pointless except in unusual situations. Comparisons are also very difficult and no absolute standards exist by which to compare an employee's experience with others in their industry or community. Also, it is important not to confuse measures of absence with epidemiologic measures of the frequency of illness such as morbidity, incidence, point prevalence, and period prevalence, each of which have precisely defined meanings. Absence measurement is just that and cannot be readily converted into measurements of morbidity without additional information rarely available in practice.
Absence can be categorized in many ways but the most satisfactory simple system is to recognize five basic categores:
Each of these has further subcategories and nuances of measurement, as suggested in Table 22.l. Sickness absence and personal leave will be discussed in greater detail.
A further problem with monitoring
absence is that it is often to the employee's
or the employer's benefit to misclassify
absence. A worker may call in sick rather
than take allowed vacation time in order to
preserve paid sick leave or to take the day at
a more convenient or spontaneous time. An
employer may count a real illness that is
inadequately documented against an employee's
vacation time in order to avoid paying wages
for the time off. Abuses of the system occur
in every industry and in almost every
workplace; a perfect system has yet to be
devised.
Sickness absence (up to maximum allowed by sick leave policy)
certified (by physician
uncertified (up to 3-5 days usually permitted), or "self-certified"
prior authorization (e.g., for a physician's appointment for
an on-going problem)
Personal leave (with or without pay, with or without authorization)
personal business
family illness
bereavement
jury duty
Occupational injuries and illness. ("time-lost")
Pregnancy and child care leave
antenatal and confinement
postpartum and early child care
paternal
Partial absence
late arrival
early departure
prolonged absence from post
The primary classification problem from the point of view of industry is differentiating sickness absence from unauthorized personal leave. This is typically done by requiring a physician's "certification" of the illness. This is intended to be a check on the employee's declaration of illness, but leads to its own problems and complications as will be discussed in the final section of this chapter.
There are generalities one may make with regard to patterns of absence. Women are absent from work, on average, at about twice the rate of men if pregnancy is not counted. The reason is not that women use health services more often than men, although this is true, but that women generally have greater domestic responsibilities and are more likely to be employed in lower-status occupations where timekeeping is rigidly enforced and hours are inflexible. These generalizations, not applicable to individual cases, and describe the world as it is, with persistent inequalities, not as one might wish it to be. Women do not seem to have more severe illnesses on average than men, and are less likely to work in hazardous occupations. Smokers are, in general, absent more often with minor illnesses than nonsmokers. Abusers of alcohol not infrequently are absent sporadically, often on days following weekends and holidays and often without communication or notice. Absence rates vary greatly from place to place, employer-to-employer, industry-to-industry, and with socioeconomic factors such as the state of the economy and available sick leave benefits. There is no generally accepted "normal" absence rate that can be used as a standard of comparison. In general, however, absence rates have slowly risen over the last 30 years; this is true throughout the developed world.
Despite these general trends, there is no accurate way of predicting absence for individual workers. Those with chronic illnesses are not uncommonly among the most reliable because they are committed and have learned to adapt. Normal, healthy workers may be absent for reasons having little to do with health or other characteristics that can be assessed in advance. The only predictor of absence in the individual case is the worker's individual history of absence. Even than, a person's pattern can often change, either for the better or for the worse.
Control of absence has been a major challenge to human resource managers in all industries. Few universally successful strategies have been identified but a few observations have emerged. Personal leave, including unauthorized personal leave masquerading as sickness absence, may be reduced by introducing flexible hours or permitting a certain number of days off per month or year to attend to personal business, subject to prior notification. This reduces the disruption caused by the need to attend to pressing personal errands or appointments during regular working hours and reduces the incentive to claim paid sick days. Institution of a sensible sick leave policy removes abuses engendered by the desire of some workers to "get back" what they may feel is owed them; a policy of requiring medical certification only after three days absence, as long as the worker phones to inform the supervisor daily, shows some degree of trust while minimizing the opportunity for flagrant abuse. The most effective control measure, however, seems to be an overall improvement in attitude and relations between labor and management. Absence is often affected by personal attitudes toward the employer, personal identification with the performance work and objectives of the group, and personal attitudes of self-respect. A general sense of personal satisfaction and of identification with the success and objectives of the employer may remove the temptation for abuse while motivating workers who are only somewhat inconvenienced by minor complaints to come to work.
Absence is determined in large part by attitude. Persons who have similar levels of illness and discomfort may vary considerably in their adoption of "sick" behavior, with one stoically carrying on and another taking to bed. Some of this difference is cultural, some is due to family attitudes and upbringing, and some is due to circumstances such as other stresses in the worker's life and individual patterns of strength and weakness. There are always a few individuals in any large group who are immature and who seize on any inconvenience as an excuse to avoid work; such people are a small minority, however, and it antagonizes all others to be treated in the way the immature few may need to be treated. The majority see work as a responsibility to be met with varying degrees of commitment and use their working environment as an opportunity to make friends, to engage in social interaction, and to develop a social support system. Such workers may even come to work when they should stay home out of identification with their group. The task of the human resources manager is to put into place human resource policies that are also humane - that allow the ill worker to take time off without harrassment but that motivate the well or only slightly inconvenienced worker to come to work. That, however, is the job of personnel officials, not of the physician or the occupational health service.
One of the most common duties of a physician in practice is to certify that a patient has missed or will miss work due to illness. This function places considerable responsibility on the physician, who has rarely had any triaining in how to do it. Assessing a worker's ability to work as a result of personal health problems is a function that few clinicians in the community are prepared to undertake systematically. Reviewing job requirements and matching them to documented capabilities requires more familiarity with human factors and occupational demands than most physicians possess, although in obvious cases physicians are seldom hesitant to excuse their patients from work or to certify return to work. For occupational physicians to become involved in approving return to work and certifying time off work is a clear commitment to understanding the worker's personal health problems. Unfortunately, this commitment is rarely recognized as such and physicians continue to treat medical certification very casually.
In fairness to the practicing physician, patients frequently ask for certification or a "note from the doctor" after the fact or for complaints that are impossible to confirm or deny. A busy physician is not likely to spend much time on a seemingly administrative task; a moments' reflection on the contents of Chapter 18, however, should suggest that this is actually a less structured variation of the fitness-to-work evaluation and is therefore more involved than it would seem at first glance. The implication of certification of sickness absence are significant and the physician is obliged to accept the act as a serious responsibility. When a question arises, it is worthwhile routinely communicating with the employer, either by telephone or by written means, as by the form provided at the end of this chapter. If the employer has an occupational health service in-house, such communication is greatly facilitated and one can be much freer in discussing with the physician or nurse involved matters that the management is not entitled to know, such as the specific diagnosis. Ofteh the occupational health service can facilitate reentry into the workplace.
There is no excuse, however, for knowingly acquiescing to a false certification or to extending the leave period beyond the time when the worker is fit to return to work. Physicians are often urged by the patient to stretch the time off work, particularly if there is a holiday or weekend or social event ahead. The pressure may be even greater if the physician treats the patient's family or has many other patients who know the insistent patient or has close ties with the community and will inevitably run across the patient and his or her close associates again and again. It may seem a small matter to bend on a seemingly administrative issue. Such an act is not good medicine nor good occupational health practice, however. It is very costly to the employer and further delays the return of the patient to a normal life, which is part of the recovery process. The patient should return to work when the patient becomes fit to work, definitely not before but also not long after.
Finally, the alert physician whether in a corporate setting or in community-based practice may spot a pattern in absence from work that leads to the identification of a health problem. One should be particularly alert to the following:
The form that follows is modified from
that developed by the Employers' Health Cost
Coalition, a council with representatives from
business and medicine, in San Diego,
California, in 1982. It represents an attempt
by employers to standardize the granting of
medical leave by creating a document that
specifically requires the physician to state
the duration of absence and reason for
certifying that the employee is unfit for
work. It is therefore reproduced as an
example for physicians to use in communicating
with employers.
I have examined _________________________________ and have determined
(employee name)
it is medically necessary that he/she be given a medical leave of absence
from ____________________ to ______________________ .
It is physically difficult or not medically desirable for him/her to work
during this period because:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
( ) Check if applicable:
If sitting or otherwise physically limited work may be available for this
worker, I recommend such assignment until the worker is certified as fit
to return to normal duties.
SIGNED: ________________________________ DATE: ________________________
PHYSICIAN'S TELEPHONE NUMBER FOR FURTHER INFORMATION: ______________
Anonymous Workers' health - occupational or personal? Lancet 1984; i:1390-1391.
Brown JAC: The Social Psychology of Industry. New York. Penguin, 1954.
Hilker RRJ. Problem employees, in Zenz C. Occupational Medicine: Principles and Practical Applications. Chicago, Yearbook Medical Publishers, 1975, p. 902.
Taylor P. Aspects of sickness absence, Chapter 21 in Gardner AW. Current Approaches to Occupational Medicine. Bristol (UK), John Wright and Sons, 1979, pp. 322-338.
Taylor PJ, Pocock SJ. Sickness absence - its measurement and control. In: Schilling RSF, ed. Occupational Health Practice. 2nd ed. London, Butterworth, 1981, pp. 339-359.