What is presenteeism and why can it cost more than absence? Read about its causes, its effect on workplace safety and how employers can prevent it.
An employee arrives at work on time, clocks in and sits down at their machine or computer. According to the records, they are on the job that day. But their head is throbbing, they did not sleep last night, their mind is on their sick mother, or they have been struggling for weeks with an anxiety they cannot shake. Their body is there; their mind is not. Presenteeism is coming to work but being unable to work at full productivity because of health problems or psychological strain. Absence is recorded and noticed; presenteeism is invisible. In this article, for employers, factory managers, HR and occupational health and safety (OHS) professionals, I look at what this hidden cost is, why it arises and what organisations can do.
What Is Presenteeism?
Presenteeism is derived from the word "presence" and is used as the opposite of absenteeism. It describes an employee coming to work despite physical or psychological health problems, and as a result their productivity, attention or quality of work dropping.
Presenteeism has several different forms:
- Working with a physical illness: Coming to work despite flu, migraine, back pain or a flare-up of a chronic illness.
- Working with psychological strain: Carrying on at work with depression, anxiety, burnout, grief or post-traumatic symptoms.
- Working with sleeplessness and fatigue: Coming to work without having rested enough because of long hours, irregular shifts or personal reasons.
- Working through personal crises: The mind being occupied by situations such as divorce, stress about debt, family problems or the illness of a relative.
Presenteeism is not in itself a "crime" or a "fault". It often stems from the employee's sense of responsibility, fear of losing their job, or a culture in which "taking time off is shameful".
Why Can Presenteeism Cost More Than Absence?
Employers generally focus on absence because it is easy to measure. However, research shows that the cost of coming to work and being unable to work productively is often higher.
According to a comprehensive assessment carried out in the UK, the annual cost of employees' poor mental health to employers is £51 billion; the largest item in this cost is presenteeism, at around £24 billion (Deloitte, 2024). These figures are specific to the UK and cannot be transferred directly to Turkey; but they give a strong idea of the size of the invisible loss of productivity.
The picture is similar globally. According to the World Health Organization, an estimated 12 billion working days are lost every year because of depression and anxiety; the productivity cost of this is around 1 trillion dollars (WHO, 2026). A significant part of this loss arises among employees who come to work but cannot work at full capacity.
There are several reasons why the cost of presenteeism is high:
- Duration: Absence usually lasts a few days; being at work and unable to work productively can continue for weeks, even months.
- Invisibility: Because it goes unnoticed, intervention is also delayed. As the problem grows, it becomes harder to solve.
- Errors and quality: A mentally tired employee is more likely to make mistakes. One mistake can cost far more than a day's absence.
- Contagion: An employee who comes to work with a contagious illness can affect their colleagues as well.
- Prolonged illness: Working without rest delays recovery and lays the ground for the problem to become chronic.
Presenteeism and Workplace Safety
In an office environment presenteeism mostly appears as a problem of productivity and quality. In manufacturing businesses, however, the subject is directly a workplace safety issue. A worker who is sleepless, in pain, under the influence of medication or mentally elsewhere operating dangerous machinery, working at height or driving a forklift creates serious risks.
In Turkey in 2025, 766,039 workplace accidents and 1,931 deaths from workplace accidents were recorded; around 41% of accidents took place in the manufacturing sector (SGK Statistical Yearbook, 2025). The causes of workplace accidents are multi-dimensional; but fatigue, distraction and burnout are important psychological factors contributing to human error. A systematic review of 36 prospective studies showed that burnout can also predict later serious injuries (Salvagioni et al., 2017).
In a large survey in Europe, general fatigue comes first, at 37%, among the health problems caused or made worse by work (EU-OSHA, 2022). Fatigue is one of the most common and riskiest forms of presenteeism.
Say a press operator at a facility has not been able to sleep regularly for weeks because of a newborn baby. They are not thinking of taking leave; they fear losing their bonus, and they also think "everyone goes through this phase". The shift supervisor notices they are working more slowly but interprets it as a lack of motivation. One day, during a die change, the operator skips a safety step and a near miss occurs. In this example the problem is not an individual's carelessness; it is an invisible fatigue being carried into a risky task without being noticed or talked about. A simple "You've looked tired lately, how are you?" and a temporary adjustment of duties could have reduced this risk.
Every employee who appears "on the job" in the records may not actually be ready for work; on the production floor, this difference can be the difference between an accident and a safe day.
Why Do People Come to Work When They Are Ill or Struggling?
Understanding the causes of presenteeism is the first step in choosing the right intervention. The main causes are these:
Job loss and economic worry
In times of economic uncertainty, employees may fear that taking leave will put their job at risk. According to Gallup's 2026 report, the proportion of people in Turkey who say it is "a good time to find a job" is only 23% (Gallup, 2026, 2025 data). In an environment where finding a job is seen as hard, coming to work even when ill can become a search for security. A deduction from pay or loss of a bonus also affects this decision.
A culture where "taking leave is shameful"
In some workplaces, taking sick leave or asking for time off is perceived as "shirking". A manager keeping their distance from an employee who takes sick leave, or comments in the team such as "he's off again", push employees to come to work.
The stigma of mental health problems
While taking leave because of a physical illness is relatively accepted, taking leave because of psychological strain is still largely not spoken about. In Europe, 50% of employees think that disclosing a mental health problem would harm their career (EU-OSHA, 2022). For this reason, many people struggling with depression or anxiety carry on working while hiding their problem.
Nobody to cover
In teams where staffing is already insufficient and no cover system has been set up, employees come to work thinking "if I don't come, work stops" or "I'll be a burden on my friends". This thought is often fed by a strong sense of responsibility and is a value that deserves appreciation; but if the system runs by leaning on this sense of responsibility, the most dedicated employees become the ones who wear out fastest. Leaving a margin of flexibility in team planning to anticipate illness and leave balances this load.
High workload
An employee who knows they will have to deal with piled-up work on returning from leave may prefer to come to work even when ill. In Europe, 46% of employees have reported serious time pressure or excessive workload (EU-OSHA, 2022).
High stress levels
In Turkey, 66% of employees say they spent much of the previous day under stress (Gallup, 2026). A person working under chronic stress may, over time, come to accept strain as "normal" and stop noticing their need for rest.
Signs of Presenteeism: What Should Managers Look For?
Because presenteeism is invisible, noticing it depends on the manager's attention. The following signs may show that an employee is on the job but unable to work at full capacity:
- Errors not seen before, forgetfulness, slowing down
- Distraction, frequently drifting off
- Marked fatigue, pallor, frequent yawning
- Irritability, impatience or withdrawal from the team
- Physical complaints such as frequent headaches and stomach problems
- Staying alone during breaks, avoiding social interaction
These signs on their own do not mean a diagnosis. The manager's role is not to diagnose, but to notice, to ask calmly and without judgement, and to direct the person to the right support if needed.
What Can Employers Do to Reduce Presenteeism?
1. Make the leave culture healthy
State clearly that taking leave when ill is normal and acceptable. Managers sending an ill employee home and saying "rest, get better" is the most effective message. Welcoming an employee back from leave with "Hope you're better, how are you?" rather than "Were you off again?" is also part of this culture.
2. Set up cover and handover systems
Make sure that at least one back-up person knows about each critical task. Removing the thought "if I'm not here, work stops" is a precondition for employees being able to rest when they need to.
3. Break the silence on mental health
Stress in internal communications that psychological strain is as real as physical illness. Mental health awareness training is one of the ways of reducing stigma.
4. Train managers
Noticing an employee who is struggling and talking to them are skills that can be learned. In the WHO's guidelines on mental health at work, the recommendation with the strongest evidence is providing mental health training for managers (strong recommendation, moderate-certainty evidence) (WHO, 2022). I discussed this subject in detail in the article on mental health training for managers.
5. Provide access to confidential psychological support
A confidential support channel that employees experiencing personal or work-related difficulties can turn to allows problems to be addressed before they grow. In a large observational data set on EAP counselling cases, a reduction was observed in presenteeism reported by employees after counselling (Attridge et al., 2019); however, because these data do not include a control group, they do not establish causality. In the article on employee assistance programmes I explained how these structures work.
6. Carry out "fitness for work" checks in high-risk tasks
In tasks such as operating dangerous machinery, working at height or driving, it matters that the supervisor observes the employee's general condition at the start of a shift and can change the assignment if necessary. This check should be carried out in a protective rather than punitive spirit.
7. Review workload and shift patterns
Constant overtime, consecutive night shifts and insufficient rest periods are the main sources of fatigue-related presenteeism. These factors should be addressed as part of psychosocial risk assessment.
8. Lead by example
When managers and business owners rest when they themselves are ill, it gives the team the strongest message. A manager who comes to a meeting with a fever unwittingly reinforces the norm "there's no being ill here". A manager who looks after their own health shows the team that rest is not irresponsibility but part of sustainable performance.
How to Start in Your Organisation
- Needs analysis: With an anonymous employee survey, measure how often people have recently come to work despite health problems, the reasons for this and employees' own perception of their productivity. Evaluate it together with absence, workplace accident and near-miss records. You can find how an analysis of this kind can be designed on the corporate services page.
- Programme: According to the findings, plan together policies that shape the leave culture, manager training, mental health awareness work and confidential psychological support options. The ILO stresses that individual measures should not replace organisational measures but complement them (ILO, 2026).
- Measurement: Repeat the survey at regular intervals; monitor indicators such as absence, workplace accidents, turnover and use of support services.
Frequently Asked Questions
How is presenteeism measured?
It is difficult to measure directly because it is an invisible loss of productivity. Anonymous surveys are generally used, asking employees how many days they have recently worked despite health problems and how they rate their productivity on those days. When these data are evaluated together with absence and workplace accident records, they give a meaningful picture.
Does trying to reduce absence increase presenteeism?
It can. Practices that penalise taking leave or discourage it through loss of bonus push employees to come to work even when ill. In that case absence records look improved, but loss of productivity and accident risk go up. For this reason, the two indicators should be monitored together.
Should an employee experiencing psychological strain take leave?
This depends on the person's situation and functioning. In some cases a short rest is useful, while in others it may be better to carry on working with a temporary adjustment to workload. The decision should be made together with the employee and, where necessary, with the opinion of a health professional.
Is presenteeism only a problem for large companies?
No. In small businesses, because there is less back-up staff, employees may feel they have to come to work even when ill; this can make the problem more widespread. Even in small-scale businesses, shaping the leave culture and setting up simple cover systems make a difference.
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Eda Erkan Alapala
Klinik Psikolog. İstanbul Kent Üniversitesi Klinik Psikoloji Tezli Yüksek Lisans mezunu; bilişsel davranışçı terapi, çocuk merkezli oyun terapisi ve çocuk-ergen psikoterapisi alanlarında eğitimlerini tamamlamıştır.
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