An Exploratory Study of Presenteeism in Turkish Context

Presenteeism has been an emerging research era, where many exploratory questions may be produced. Literature is not very definitive for the conceptualization of the construct in many aspects. There are few studies about the reasons, measurement approaches and positive outcomes of the concept. Studies conducted in Turkish context are even fewer. Paper combines two studies; first study aims to investigate different conceptualizations, possible reasons, negative and positive outcomes of presenteeism. The purpose of the second study is to find out how those concepts structure and relate to each other. Findings provide useful insights for reasons, outcomes and criteria of presenteeism. They also indicate different conceptualization of the concept and there are significant relationships between variables according to the research.


Introduction
Presenteeism, briefly, showing up at work despite being sick (Aronsson and Gustafsson, 2005), is becoming more and more a focus of attention as its cost and importance for the organizations is realized.It is relatively a new concept which became a popular subject not earlier than the last two decades.Although there are many significant studies about it, this relatively new concept still provides lots of fruitful questions to be answered.
First of all, what exactly is presenteeism?Is it only illness that prevents someone from working fully functional or makes it reasonable not to attend work?How do employees perceive it?How being sick is really measured?How much illness is enough to take someone out of work?Is someone working with chronic illness always a case of presenteeism?Does presenteeism really have to be a negative concept that never give positive results?What employees think about it?Simply, why employees come to work despite they are sick?Can those reasons be clustered?What consequences and reasons for this act are perceived by employees?What may be the negative and positive consequences of presenteeism?
This paper aims to address some of these questions by investigating what literature suggests about these issues and also asking the experiences and perceptions of the employees' with open ended questions.In the second stage of the study, these answers are shaped and given in a survey to respondents for measuring their perceptions in order to understand how they are clustered and to find out possible associations among them.

Literature Review
Although there is no agreed upon definition of presenteeism, the most common conceptualization is "attending to work despite being ill" (McKevitt, et al. 1997, Aronsson, Gustafsson and Dallner, 2000, Johns 2010).In order to better understand the conceptualization of presenteeism, we should reveal the reasons for the need of such a concept.All concepts in the literature arise or became a more popular research era for some needs or realizations.The philosophy behind this conceptualization of presenteeism may be the fact that, being at work despite everything is not always the best option.Other alternative, absenteeism, as a relatively older and more frequently studied concept, is only one of the options when someone is ill.Absenteeism is sure costly and has been a concept that managers combat to decrease its level.That is why anti-absenteeism efforts increased, but they may have caused some unseen costs (Koopmanschap et al. 2005).Also, the aging population in many countries made it more important to deal with health related matters of productivity lost (Cancelliere et al. 2011).One of the main reasons of the growing interest in presenteeism may be the idea that an ill employee on work is worse than an absent one.There are many studies that suggest presenteeism is more costly than absenteeism in many ways (Hemp 2004, Collins et al., 2005, Goetzel et al. 2004;Schultz andEdington 2009, Stewart et al. 2003).
It is very reasonable that, an ill employee underperforming on work may cause productivity loss.But doesn't an absent employee also cause productivity loss?On the other hand, there are also studies which suggest that absenteeism is more costly than presenteeism.Rantanen and Tuominen (2011) indicated that absenteeism demonstrated higher monetary value than presenteeism.This finding supports the idea that nonperforming is likely to be less than underperforming, and an underperformance of let's say 30 percent is more than 0 percent.But this approach oversee that underperforming may have serious negative externalities like work accidents, decreased work satisfaction, burnout or future sickness (Demerouti et al., 2009;Aronsson and Gustafsson 2005).For example, an absent employee may be replaced by a performing one, but an underperforming employee may create customer dissatisfaction which may not be reassured.Burton et al. (1999) define the concept as "decrease in productivity for the much larger group of employees whose health problems have not necessarily led to absenteeism and the decrease in productivity for the disabled group before and after the absence period.''This definition, in a way, suggest that there is a level of sickness that doesn't necessitates absenteeism but still causes presenteeism.It may be interpreted that, by this approach absenteeism is a more serious case than presenteeism in the level of health condition and the level of productivity lost.
Assuming the productivity loss is the important matter for the conceptualization of the phenomenon, one might say that there might be other reasons for productivity loss for an employee to come work instead of not coming.If illness is not only reason for absenteeism, it might not be for presenteeism too.One early definition on the concept made by Smith (1970) as "Attending work, as opposed to being absent" supports this idea.Parallely, Hemp (2004)'s approach to concept, "Presenteeism: at work -but out of it" widens the boundaries of presenteeism concept.Adding to that, if presenteeism was asked as 'being at work but not being there, let's say, mentally or fully', it would be something that everyone would experience many work days.Accordingly, Evans (2004)'s definition of the concept adds phrases like "events that might normally compel absence" or "feeling unhealthy".This may include an employee feeling obligated to attend a meeting with his/her son's teacher about his education, but deciding to work at that hour is also acting in presenteeism according to the mentioned definition.According to this criteria, one missing an important family event due to work is also in presenteeism.Does someone in situations like these, not feeling unhealthy but feeling obligated to do something else or be somewhere else, decrease productivity?It seems likely for someone, who is not present for the family when needed, to willingly or unwillingly underperform due to the grief or burden about the situation or the perception of organizational injustice.
Hummer, Sherman and Quinn (2002) indicates other events decreasing employees' full productivity rather than health issues in the concept of presenteeism.Some authors label the concept as "sickness presenteeism" (e.g.Bergström et al. 2009), but there is no agreement upon classification provided for differentiating sickness presenteeism and other types of presenteeism (if any).There are some authors who added some other types or aspects of presenteeism, but they are not clearly identified or differentiated with different labels.For example, Lowe (2002) brought another approach to the concept by adding a second type of presenteeism to the earlier one (being sick and being at work) as working excessively after work to show commitment or deal with job insecurity.Middaugh, (2007)'s definition is also supporting that approach, being present at work, "even if one is too sick, stressed, or distracted to be productive; the feeling that one needs to work extra hours, even if one has no extra work to do".

All
these different definitions and conceptualizations suggest different ways to measure presenteeism.For example, one would ask 'how many days did the respondents attend to work despite they were ill', and another would ask 'the number of days they attended to work despite there were things that normally necessitates absence'.Questions produced with phrase like "feeling sick enough to require you not to come work" and "knowing your productivity will be low because of your health condition" may also yield to different responses.How the answers for different questions generated for these varying definitions would separate, becomes an essential question to be addressed in order to understand the influence of those different definitions on measurement of the concept and enlighten the appropriate way to measure presenteeism.So one of the main purposes of the study is to address this matter.
On the question of 'how much ill is really ill to consider for presenteeism', or 'how much illness we are talking about for presenteeism', some definitions of the concept suggest that if the illness causes employees work less than full capacity, it is presenteeism (e.g.Burton, et al. 1999).Those definitions give a very large range for health conditions in type and severity.A little cold or headache may cause employees perform in less than full capacity.It is hard to claim that in order to avoid presenteeism, any employee having less than full productivity must be sent home and managers should wait for them to regain their full capacity.Here another important issue is to conceptualize "full capacity".How many days does an employee really work in full capacity?These arguments indicate how it becomes hard and complex to conceptualize and measure presenteeism, if it is defined in the mentioned approach.
Many measurement tools used in the literature for assessing presenteeism are not specially created for the purpose of measuring presenteeism.(e.g.Health and Work Performance Questionnaire (HPQ) Kessler, et al. 2003;Work Limitations Questionnaire (WLQ) Lerner, et al., 2001;Health-Related Productivity Questionnaire Diary, Kumar et al. 2003).When scientists ask for absenteeism, they ask for the number of days people don't attend work when they are supposed to.Generally, absenteeism related production loss or absenteeism cost are the consequences of the concept and they are different than absenteeism itself.If presenteeism is measured or conceptualized as the production loss or cost, it may create the same misinterpretation.Jumping to measure the consequences of a concept rather than measuring the concept itself may cause losing valuable information.In the case of an employee attending work while ill and performing normally because of the nature of the work, but developing negative feelings towards the management because of the mandatory presenteeism and changing the attitudes towards work, it is hard to measure the cost of this attitude change.Also, if the prolonged illness causes the employee to be absent more than it was supposed to (as suggested by Hansen and Andersen, 2009), or if it affects the general health of the employee negatively in the future (as suggested by Bergström, et al. 2009 andTaloyan, et al. 2012) it would be very difficult to realize, measure and track this kind of costs.Opposed to that complexity, there are measurement approaches that turn presenteeism into monetary dollar values (Mattke, et al., 2007).
Another important matter here is that, conceptualizing an issue with only negative aspects may cause losing an open eye on its possible positive aspects.Thus, we suggest that, it is more proper to measure

Mehmet Çetin
Emerging Markets Journal | P a g e |27 presenteeism in number of days and investigate further for its positive or negative consequences.This measurement approach (to ask the number of days or hours worked despite being ill) was also adapted by many studies (e.g.Munir, Yarkir, Haslam, 2008, Rantanen andTuominen, 2011).This approach also has its own disadvantages.First, it depends on the memory of employees to remember how many times they came to work despite they felt sick.Second, it assumes that employees will understand the same thing from being sick, but this approach still seems more suitable with the conceptualization.
There isn't a certain line that determines a person as healthy or unhealthy enough to work.When a person is sick and decides to have a rest for a while, there is a fuzzy point that the illness still has its traces, but the person may work pretty well.Waiting for being %100 healthy after an illness to continue work may not be the best decision both for the employee and the organization.So, here is a subjective assessment point where the employees decide on their health condition whether they should attend work or stay home.Another purpose of the current paper is to investigate how employees assess their health condition and decide on to show up or not for work.

Data Set And Methdology (Study 1
Procedure) Open ended questions were given to respondents from differing sectors and jobs in Istanbul with simple random sampling method in order to reach a generalizable ground.All respondents were currently working.126 surveys were delivered to respondents and they were assured about their confidentiality and no personal questions like name or identity information was asked.They were encouraged to write as much as possible answers for the open ended questions.Answers collected from the respondents for each question were examined, irrelevant ones or domain specific ones (e.g.specific to only one organization) were excluded and the resembling ones were clustered.The frequency of the answers were determined.Also, the structure of the item pool that would be used in the second study was determined.
From the responses given for the first question "Why did you attend work while you were ill?Could you please list your reasons?", possible reasons for presenteeism and their frequencies in the responses were determined in the way described in the procedure part.The fourth question asking how respondents would describe their productivity yielded lots of responses indicating very low productivity to better than normal productivity.Many responses ranging from "I could do nothing", "I was very unproductive that costumers were unhappy" or "I couldn't do the job as productive as usual" to "I was more productive than normal" structured a brief classification of possible performance levels as "better than normal", "normal", "lower than normal" and "very low".
From the responses given for the first question, "How do you evaluate your health condition while you decide whether it compels absence or not?", possible criteria for deciding on the severity of the health condition whether it necessitates attending work or not are explored.Many criteria and story provided by respondents were integrated as they could represent and describe the whole picture and idea for each criterion.

Data Set And Methdology (Study 2
Procedure) The items developed in the first study were distributed to a sample of 145 respondents from various sectors and occupations in İstanbul in order to investigate if those items factor reliably and make meaningful clusters that would help us understand the structure and the dimensionality of the reasons for presenteeism, the perceived negative and positive outcomes of presenteeism and the criteria employees use for assessing their health condition when deciding between presenteeism and absenteeism.There was no discrimination against respondents about demographics or any other matters except all participants were required to be employees.The confidentiality of the respondents and the information they provide were assured.Respondents were kindly requested to provide genuine responses as no identity (ID) related questions were asked.
One of the main purposes of the study was to reconsider the definition of the concept by searching in the literature and investigating how it was perceived and experienced by employees.As mentioned, the definitions provided by the literature varies among some aspects.Different definitions and conceptualizations yielded different questions to ask for presenteeism.Four different questions were added to survey in order to investigate how they differed in the eyes of the employees.The responses given to those questions were analyzed in order to understand how they resembled and differed statistically.As it was hard to recall and remember how many days one comes to work despite an illness, we chose to ask for a six months period of time.
The respondents were instructed to think and answer each question independently and as they were asked separately.The four questions addressed to measure the same concept alone and their means and correlations are provided on the tables below.Correlation is significant at the 0.01 level (2-tailed).
Surely, those questions ask conceptually resembling factor, but they show difference as their means vary from 4.2276 to 2.1172, and their correlations are not high.Difference tests indicate significant difference (sig<0.05)among variables for each possible combination.Respondents' answers' means varied most between the questions numbered 3 and 2. This may be interpreted as there are cases which employees may think their productivity would be low, but still they do not consider themselves as sick as it requires absence.Also questions number 1 and 2 indicate difference.This shows that employees perceive "being ill" and "being ill enough to require not to attend work" differently.This means that, there is a gap between times people feel sick, but not that sick to require absence, so show up for work and when people know they are sick enough not to attend work.So, there are times people believe they are sick, but they evaluate their sickness as it doesn't necessitate absenteeism.This kind of preesenteeism and the one that people know their health condition require absence may have different consequences.For example, the former may enable people to work in a higher level of performance than the latter.There are medium to high correlations among different questionings of presenteeism.Question number 3 shows relatively lower correlations with others.The correlations are not as high that the questions may be interpreted as they are asking the same concept.None of the correlations are upper than .90, or even .70.The most common reasons seem to be the ones about work load, avoiding any delays and cancellations in work, avoidance to have the extra work burden carried from the sick day to the future, and morally believing in presenteeism, feeling responsible despite being ill.By looking at the table and the one in the collection phase, the reasons seem to be clustered conceptually in a resembling logical way.
To investigate the factor structure of the reasons given for presenteeism, exploratory factor analysis using principal components and varimax approach was conducted.Results demonstrated a 5 factor structure for reasons of presenteeism.Factors were labeled as managerial reasons, normative reasons, workload reasons and engagement reasons.All factors were highly reliable except engagement reasons (.690) factor, but still it was high enough to consider as a factor.These results provides a fruitful path to understand, cluster and conceptualize the reasons for presenteeism in the organizations.To investigate how frequent the positive outcomes of presenteeism are The positive outcome which has the highest mean score is about being mentally free from the burden of absenteeism.Interpreting from other findings of the study in the item generation phase, we may say that people find it hard to think about dealing with the paper work, the left over work load, management's attitude, and the image they build.Also, when they attend work despite they feel sick, they free themselves from all those burden mentally.The work load not being carried over from the sick day is another positive outcome that had high frequency in study 1 and has high level of mean score in the study 2. Saving unused sick days for future is another powerful positive outcome of presenteeism.Also managers observe and realize the sacrifices of the employees and maybe because of this, employees can also get an early timeout.The mean for employees that felt more identified with their jobs is also not low.Plus, employees also could use the health services of the workplace.
A quick interpretation on the results may indicate that, there are positive outcomes that are about getting rid of negative outcomes of absenteeism and positive outcomes that are actually providing additional positive consequences directly related with act of presenteeism.Results of exploratory factor analysis demonstrates a 2 factor structure in accordance with this conceptualization.Factors structured were highly reliable and differentiated as positive reinforcement and negative reinforcement positive outcomes.

Table 10: Results of Exploratory Factor Analysis for Positive Outcomes of Presenteeism
To realize how powerful the negative outcomes of presenteeism are perceived by the employees, the mean scores of the negative consequences items are given on the following table.Two resembling but different items about the length of the time that the illness got better had the highest mean scores among negative outcomes of presenteeism.The negative effect on performance and other employees is followed by the negative externalities on customer satisfaction.Presenteeism causing workplace accident is relatively rare, maybe because the study was mostly conducted in a white collar environment which is less prone to work accidents.
To investigate how the items of negative outcomes structure under factor analysis, an exploratory factor analysis using principal components and varimax approach was conducted.Results demonstrated a 3 factor structure for negative consequences of presenteeism.Study also aimed to investigate how people determined the severity of their health condition while deciding whether to go to work or not.As the earlier phases of the study demonstrated, employees could evaluate their health conditions with different criteria.The criteria used for this assessment was provided to respondents and the mean score of these criteria are demonstrated on the following table:

Table 13. Criteria Used For Deciding Between Presenteeism and Absenteeism and Their Means
Severity of the health condition in means of serious symptoms and the ability to reach and continue working seems to be the most powerful criteria in the decision process of presenteeism.Thinking about how others would feel and behave according to observations seems to be the least significant criteria used for deciding whether to show up or not.* Correlation is significant at the 0.05 level (2-tailed).
In order to understand how different reasons for presenteeism are related with different outcomes of presenteeism and perceived performance level during presenteeism, a correlation analysis was conducted.The correlations between performance perception of employees during presenteeism and their scores of reasons for presenteism reveal very essential aspects about presenteeism.Only the 'engagement reasons' factor is significantly and positively related with performance perception while other reasons didn't show any significant correlations.Employees coming to work while they are ill because of reasons related with their high engagement perceive their performance during presenteeism as higher.Also if they do it for more managerial, work load or normative reasons, they don't perceive a higher performance.These relationships support the idea that not all kinds of presenteeism cause low level of productivity.The reason behind presenteeism may change the level of performance during presenteeism.So it may be inferred that, employees coming to work while they are ill because of their high sense of engagement may demonstrate higher performance than others do it because organizational culture or managerial practices requires to do so.Engagement related reasons are positively and significantly related with positive reinforcement outcomes while shows no significant relationship with negative reinforcement related ones.Commitment and performance related negative outcomes show only significant and positive association with managerial practices sourced reasons of presenteeism.Normative reasons and engagement reasons show no significant relationship with any of the negative outcomes.Age shows positive and significant relationship with second and third kind of measurements we used in the study, while it shows no significant relationship with other two.24.1% of the respondents evaluated their performance as 'normal' and 55.9% assessed their performance as 'less than normal'.13.1% of the participants found their performance 'very low' and 6.9% of them determined their performance better than normal.This shows that, majority of the respondents experienced a level of performance which is less than normal during presenteeism, while a considerable percentage (31%) of them felt that their performance were normal or even better.Engagement based reasons only correlate significantly with second form of presenteeism, which was about attending to work despite being ill enough to require absence.Normative reasons show significant positive relationship with all measures of presenteeism, except the third one.Workload reasons and managerial reasons demonstrate no significant associations.

Discussion And Conclusion
Presenteeism is an emerging research era, where many exploratory questions may be produced.Literature is not definitive for the conceptualization of the construct.There are few studies about the reasons, measurement and positive outcomes of the concept.Literature conducted in Turkish context is even more limited.Study generated answers for many of the research questions that were set at the beginning of the paper.To begin with, the definitions of the concept yielded to differing measurement approaches and the means of the answers given to those questions were different and not showing strong correlations among each other.How you conceptualize and measure presenteeism create differing answers.Asking how many days did the employees attend to work despite they were ill, or asking the number of days they attended to work despite there were things that normally compelled absence, or asking the number of the days they felt sick enough to require them not to come work, or the number of days that they acknowledged their productivity would be low because of their health condition, produced differing answers.Their correlations with other factors were also demonstrating differences.Some of the questions measuring presenteeism correlated with some variables of the study while some others didn't.
For example, fourth question addressed to measure presenteeism is not directly asking about sickness, but the 'things normally compel absence' is the only presenteeism type that doesn't relate significantly with illness related negative outcomes.Only third form of measurement of presenteeism indicated significant association with commitment and performance related negative outcomes.That may be because this one represents a more serious condition that requires absence, but believing so employees still shop up for work.Age shows positive and significant relationship with second and third kind of measurements we used in the study.Decreased productivity and feeling sick enough to require not to come work may be associated with what increasing age brings.This is another finding that supports different measures and conceptualizations of presenteeism may show differing associations with other variables.Looking at the differing means of different measuring tools and their different correlations with study variables, it is hard to claim that they will not correlate with other variables differently.This may be one of the reasons behind opposite findings in the literature like Hemp (2004) and Rantanen and Tuominen (2011).More studies on this issue may further enlighten this path.
It may be suggested tha,t presenteeism levels of the respondents are parallel with the levels that Aronsson, Gustafsson and Dallner (2000) indicated.They indicated that at least one third of respondents experienced presenteeism 2-5 times a year and nearly one sixth of them showed up to work while ill more than 5 times.Aronsson and Gustafsson (2005) indicated even more frequency for presenteeism as more than half of the respondents declared that they experienced presenteeism two or more times in a year.
Open ended question asking about the reasons for presenteeism revealed the reasons why respondents engage in presenteeism and further analysis on them in the second study demonstrated a structure which suggests 4 sub dimensions.The reasons for presenteeism were clustered, as one group of items represents the managerial practices and organizational rules addressing issues like burden of providing evidence for sickness and convincing the managers for it, so not having pay cuts or losing the job.There are empirical evidence in the literature that supports these findings by indicating associations between sick pay, job insecurity and presenteeism (e.g.Lovell 2004;Virtanen, et al. 2003;Virtanen 1994).Grinyer and Singleton (2000) also supports the findings of the study that, managerial practices and management policies may be a reason for presenteeism .
Second group of items that factored reliably contains the ethical and normative side of presenteeism, feeling responsible and believing one must show up if it is still possible and there is a chance to be helpful.Third group of items describe reasons based on keeping the things in order like not passing the work load on other days, not disrupting the work or put the organization in a hard situation.Fourth group is representing the reasons which roots from the positive attitudes towards work like feeling better at work despite being ill and feeling bored not attending to work.Johns (2010) supports that approach by suggesting that presenteism may be seen as a citizenship behavior.
Reasons listed for the presenteeism by the respondents are parallel with the other studies' findings and conceptualizations.Bracewell et al. (2010) emphasize the link between presenteeism culture and presenteeism.Managerial practices and organizational atmosphere may be taken as components of organizational culture.There are also some other reasons not factored in the exploratory factor analysis, but were provided by respondents like 'high competition in organization'.This reason was also mentioned by Simpson, (1998), as he mentioned 'competitive presenteeism' as a result of the high competitive culture of the organization.
One of the main research purposes was to explore possible positive outcomes of the presenteism.Presenteeism is generally conceptualized as a phenomenon, that yields to negative outcomes (e.g.Collins et al., 2005).But there may also be some positive ones.Asking an open ended question on the issue provided many items to evaluate as possible positive outcomes of presenteeism.Many of them are about getting rid of the negative outcomes of absenteeism.But, there are also ones that may be claimed solely arising from presenteesim itself, like feeling more identified with the work.Hansen & Andersen (2008) also support a positive approach by suggesting that employees engage in presenteeism because of high commitment.
Proving that you are a hard worker and impressing the managers, and making use of workplace health care facilities are also other benefits of presenteeism listed by respondents that may be evaluated as positive reinforcements rather than negative reinforcements.Also, more frequently experienced ones are avoiding the negative outcomes like pay cut or getting rid of the mental burden of absenteeism.The factor structure of positive outcomes when they are investigated with explanatory factor analysis demonstrated a parallel construct.
24.1% of the respondents evaluated their performance as 'normal' and 55.9% assessed their performance as 'less than normal'.13.1% of the participants found their performance 'very low' and % 6.9 of them determined their performance better than normal.This shows that, majority of the respondents may experience a level of performance which is less than normal during presenteeism while still a considerable percentage (31%) of them feel that, their performance is normal or even better.
Employees evaluate their performance level differently while experiencing presenteeism.It may be summarized that, majority of the respondents experience a level of performance which is less than normal during presenteeism, while still a considerable percentage (31%) of them feel that, their performance is normal or even better.Differing levels of performance perceptions during presenteeism may be for many factors like the nature and structure of work, personality or the severity of the health condition.Study provides some valuable information about this difference.
Differing presenteeism forms, age or positive outcomes didn't show significant correlations with performance perception.But, evidence indicates that the reason behind presenteeism may be important to understand the performance level of employees when they come to work despite they are ill.Coming to work despite an illness because of the work load related reasons or managerial practices against presenteeism is not significantly related with presenteeism, while it is positively and significantly related with doing it for engagement reasons like feeling better at work or getting bored out of the work.This difference may be considered as a voluntary presenteeism which is powered by intrinsic motivation, while another presenteeism is mandatory that takes its energy from extrinsic motivators.More studies may help to better conceptualize and differentiate these presenteeism forms.
Study also revealed some negative outcomes of presenteeism experienced by employees.The outcomes were clustered as health related negative outcomes, which is about prolonging sickness or defecting others; and commitment and performance related negative outcomes which caused decrease in customer satisfaction and commitment and love towards work.Engagement related reasons are positively and significantly related with positive reinforcement outcomes, while shows no significant relationship with negative reinforcement related ones.Commitment and performance related negative outcomes show only significant and positive association with managerial practice sourced reasons of presenteeism.Commitment related negative outcomes show no other significant relationship with other reasons for presenteeism.This means that, when employees come to work despite they are ill because of the management and culture related reasons, their organizational commitment is affected negatively.But if they do it for normative and engagement reasons, their organizational commitment is not significantly affected.This is another evidence for differently characterized presenteeism and their differing consequences.Normative reasons and engagement reasons show no significant relationship with any of the negative outcomes.
This study must be considered as an exploration of essential questions about presenteeism, hopefully opening new windows for further studies and inspiring some new questions, classifications and associations about the concept.Positive and negative consequences of the concept and how may negative ones be avoided while benefiting the positive ones, require more investigations.
The research provides many useful insights for managers and leaders.As presenteeism has both positive and negative outcomes, leaders may change the perception and circumstances for presenteeism to avoid the negative sides and they can further benefit the positive sides.One fact that study revealed is, if engagement related reasons are the drive behind presenteeism, or in another saying presenteeism is voluntary, it doesn't relate with negative outcomes.When the drive is normative, employees experience more health related negative outcomes, but not performance or commitment related ones.But if the reason is management related, it may affect commitment and performance negatively.So leaders, by setting an unsporting climate or practices may cause involuntary presenteeism, which will cause negative outcomes on the attitude of employees toward work and their commitment.

Table 1 : Reasons Provided for Presenteeism by Respondents
Table below lists the reasons for presenteeism provided by respondents.The responses for the question "What negative consequences did you observe when you attended work despite you were ill?" help to explore the negative consequences of presenteeism.Responses are clustered and the frequencies are given on the table.
22. High competition in the organizationAn Exploratory Study of Presenteeism in Turkish ContextPage |28| Emerging Markets Journal

Table 2 : Negative Outcomes Provided for Presenteeism by Respondents Negative Outcome Frequency
Answers for the third question, "What positive consequences did you observe when you attend to work despite you were ill?" demonstrate the positive consequences of presenteeism.Responses are clustered and the frequencies are given on the table.

Table 4 : Criteria Used For Deciding on Presenteeism
1.I would consider if I could reach the workplace and continue my job without disruptions all day.If I would feel good enough to continue my work this way or another, I would go.If I thought I would feel bad as much as it would necessitate me to return home, I wouldn't go.2. I would consider if my condition enables me physically to stand up and reach the workplace.If I was in a condition that I could go to workplace, I repeated frequently, I would attend work.If it was for one time, I wouldn't go.10.I would consider what other people would do if they would feel like me.

Table 7
supports that interpretation by showing that their means are different.To understand the distribution of the reasons for presenteeism, the means for reason items are listed below.

Table 14 : Results of Exploratory Factor Analysis for Deciding Between Presenteeism and Absenteeism Factor 1: Severity Of The Illness
consider if I could reach the workplace and continue my job without disruption all day.If I would feel good enough to continue my work this way or another, I would go.If I thoght I would feel bad as much as it would necessitate me to return home, I wouldn't go.

Table 15 : Correlations among Reasons and Outcomes of Presenteeism
*Correlation is significant at the 0.01 level (2-tailed). *

Table 16 : Correlations among Reasons and Outcomes of Presenteeism
Correlation is significant at the 0.05 level (2-tailed).