According to the United Nation’s 2030 Agenda for Sustainable Development, all countries should have a healthy, well-educated health care workforce with the knowledge and skills needed for productive, fulfilling work and full participation in society [1]. Inside health care systems, nurses are the primary providers of direct care, delivering vital services, and often considered the system’s backbone [2,3]. Undeniably, the SARS-CoV-2 coronavirus has emphasized that many health care settings are also workplaces where nurses face particular risks from occupational exposure to diseases and stress [4]. A perfect illustration of organizational presenteeism was seen during the COVID-19 pandemic in Australia: Hospital staff infected with SARS-CoV-2 while at work continued working for up to 7 days, even with respiratory symptoms [4]. The International Council of Nursing has confirmed that more frontline nurses were affected by SARS-CoV-2 than all the other health care professions combined [5].

Nurses often face difficult work conditions, including working long hours, overtime, and emotional stress: They are at a high risk of developing psychosocial and somatic illnesses [6]. Despite these poor working conditions, much of the absenteeism previously noted among nurses has been replaced by presenteeism [7,8]. Presenteeism may be described as the act of a health care professional who continues to work while sick or suffering from another condition that results in their underperformance at work [3,9]. One frequently used definition of presenteeism in nursing is the “act of being physically present at work when one should not be there” [10]. However, numerous studies of presenteeism have included identified etiologies as conditional for this behavior, such as “a physical presence at work when one should not to be there due to one’s health and well-being, a stressful work environment, a lack of work-life balance, or a sense of professional identity or obligation” [10-13].

Although it is widely recommended that nurses be in good health when providing health care to patients [1], in some cases and for numerous reasons, some sick nurses do not follow recommendations to stay at home and continue to work, leading to presenteeism [14]. The existence of presenteeism differs by sector, but it is more likely to occur among staff working in jobs with extensive interpersonal interactions with clients or patients [15]. There are many reasons why sick health care professionals might continue working. Nurses face pressures that contribute to presenteeism, including difficulties finding replacements due to workforce shortages, strong organizational-culture barriers, and professional-culture norms against taking sick leave [16]. Worries about presenteeism are not limited to potential loss of earnings; the lack of replacement staff; concerns about the resulting burdens on patients, clients, customers, co-workers; and a potential competitive disadvantage [14]. Presenteeism occurs not only when physically or mentally unwell nurses go to work but also when their level of awareness or responsiveness is compromised or when their emotional, behavioral, or cognitive engagement is diminished [11,12,17-20]. Nurses are 4 times more likely to exhibit presenteeism than other professions; yet, this threatens patient safety through increased falls, medication errors, and staff-to-patient disease transmission [21].

The concept of presenteeism has been described across different professions, organizations, and work environments [9,17,22]. One multisector study of presenteeism found that nurses reported 3-4 times higher rates of presenteeism than employees in management positions, and they had the highest rate among the 42 occupational groups surveyed [17]. The concept of presenteeism in nursing has been related to the Quadruple Aim Framework (population health, patient experience, provider experience, and costs) linking optimizing nurses’ performance and their own health to harmful patient outcomes and increased health care costs [23,24]. Unlike factors such as nurse staffing ratios and nursing shortages, which impact care and costs, nurses’ behaviors are seen as potentially correctable in the short term and within organizations [19]. Figure 1 presents the conceptual model of presenteeism in nursing and the underlying relationships between presenteeism’s antecedents, definition, and consequences, by Rainbow and Steeg [10].

In 2016, Barbosa [25] identified a prevalence of presenteeism among Portuguese nurses of 91.4% in the previous month, more related to psychological reasons than to physical ones. Meanwhile, 32.9% of professional care workers in 162 Swiss nursing homes reported their own presenteeism during at least one shift in the month before being surveyed [26]. A very broad range of other estimates was also reported in a systematic review, where self-reported presenteeism in relation to an infectious illness ranged from 37% to 97% in the health care sector [14]. Although these rates varied considerably, even the lower end of this range is troubling, as it would probably have resulted in increased rates of transmission of infection in the workplace [14]. The heterogeneity of prevalence rates should be considered in light of different variables: (1) the sample characteristics (population and response rate), (2) the type of presenteeism studied (sickness, nonsickness, overall), (3) the variation in presenteeism recall periods (ranging from 7 days to 1 year), (4) the frequency and experience of episodes of presenteeism, (5) the threshold for presenteeism’s seriousness, and (6) the heterogeneity of measurement instruments [14].

Presenteeism among nurses has been explored in numerous health care settings using quantitative, qualitative, and mixed methods research designs. The systematic review by Ospina et al [56] reported more than 20 self-administrated presenteeism instruments usable for different professions and work settings. Based on the COSMIN methodology [57], the instruments providing the strongest level of evidence are the 6-item Stanford Presenteeism Scale, the Endicott Work Productivity Scale, and the Health and Work Questionnaire [56]. To the best of our knowledge, there is a scarcity of qualitative research into presenteeism [44]. Most studies of nurse presenteeism have focused on the consequences for patients, linking it to increased rates of patient falls, medication errors, missed care, and changes in patient safety error reporting [58,59]. It is also possible that the consequences of presenteeism in nursing are different from those found in other industries or the patient consequences associated with presenteeism among other health care professionals. Nurses have not previously been asked to describe presenteeism's consequences but have instead completed retrospective self‐reporting surveys. Asking nurses what they perceive to be the consequences of their presenteeism will expand this body of research.

The present study aims to understand presenteeism among frontline nurses and nurse managers in acute, primary, and long-term health care settings and to contribute to the development of future interventional studies and recommendations.

To address known concerns about presenteeism and its impact on the quality and safety of care, the planned investigation should attempt to provide well-developed answers to the following research questions: What are frontline nurses’ and nurse managers’ perceptions of, attitudes toward, and experiences with the personal, professional, and contextual or organizational factors that lead to presenteeism? What are frontline nurses’ and nurse managers’ perceptions of, attitudes toward, and experiences with adverse health outcomes among patients resulting from nurse presenteeism? Are there different perceptions and attitudes about the reasons for presenteeism among frontline nurses and nurse managers?

To gain more insight into nurses’ dilemmas resulting from all causes of presenteeism, our investigation will use a qualitative design and focus on participants’ perceptions, attitudes, and experiences.

The study’s conceptual framework is based on prior work published by Pit and Hansen [60]. As an adaptive behavior aimed at meeting the demands of work or performance criteria during periods of impaired capacity due to ill health, 3 precipitating factors give rise to presenteeism, namely (1) personal health resources, (2) occupational health factors, and (3) work and personal characteristics (Figure 2) [60].

The research population will be composed of frontline nurses and nurse managers working in acute care hospitals, primary care settings, and long-term residential care facilities in Portugal’s Center region and Switzerland’s French-speaking region.

Data will be analyzed according to good clinical research practices based on the dimensions included in the theoretical framework. Responses to the clinical vignette will be analyzed according to usual practices and respondents’ responses to the open-ended questions concerning the situations described. Descriptive statistical analyses will be performed using SPSS, version 27 (IBM Corp, Armonk, NY). These will describe the sample and establish the typical profiles of participating nurses.

Analysis of the data collected during the FGDs will be carried out via a qualitative content analysis approach [51-53] using NVivo 12 QSR International software. This analysis will enable a thorough description and examination of the causes and predictors of presenteeism, as well as their impacts on the quality and safety of care. A transversal reading of the interviews can be done at the end of the category analysis. This reading will allow transversal themes to be updated (occurrence of significant themes identifiable in the interviews) even if they are not linked to the pre-established categories. The results will be presented by category, and occurrences will be illustrated with significant examples, including verbatim quotes from the interviews. Following the analysis of each FGD, a second-stage analysis will compare findings across the groups. This will involve talks within the research team to refine the discussed themes and to develop higher-level themes, that is, grouping the open codes into meaningful conceptual categories.

To ensure study reliability, the researchers will be deeply involved in data handling (eg, transcribing, reading, and rereading the transcripts; conducting the inductive analysis) and will maintain transparency while they analyze the data subjectively. The research team includes 4 nurses involved in academic teaching and with expertise in clinical nursing practices (CL, HV, AQ, FP), as well as a research psychologist (MB). Data analysis will be guided by the COREQ guidelines [61].

Nurses’ services have been in increasing demand since the outbreak of the COVID-19 pandemic. It is vital to ensure that they have the resources to mitigate the impacts of this and new pandemics—when health care professionals face greater risks than usual. Forging closer working relationships between nurse managers and frontline nurses will also enhance their mutual understanding of risk factors and help to generate more effective ways of managing absences due to sickness and rehabilitation during a pandemic. This will require health care organizations to take a proactive approach to employee well-being and to make sure their policies encourage rest and recovery rather than promoting an “always on” or “work at all costs” culture.

We expect that the findings from our Swiss-Portuguese research partnership will contribute to a better understanding of where the thresholds for presenteeism lie. Our recommendations should lead to other multicenter studies aiming to develop effective measurement scales for presenteeism, as an essential first step to designing interventions that improve the health and well-being of nurses in their workplaces.

The proposed study is relevant because, to the best of our knowledge, there have been few investigations of health care institutions’ presenteeism prevention strategies. Indeed, these may not be well-developed at all because several studies have revealed that health care professionals are often the main victims of their own presenteeism (ie, it can compound their health problems), which can lead to a greater potential for making mistakes. Furthermore, the economic and financial demands of recent decades have led to the adoption of policies to contain health sector expenditure. This study will explore the causes of presenteeism—the fact that it entails costs far higher than absenteeism makes this investigation necessary—and aims to develop effective interventions to prevent or limit it [62]. We will collect frontline nurses’ and nurse managers’ perceptions of presenteeism and its impact on their work and the quality and safety of patient care from the point of view of their job function. This will provide us with information to formulate recommendations on reducing presenteeism to strengthen nursing and health care teams and to optimize the quality and safety of patient care. Researchers in both countries will supplement their analyses with contextual information (eg, policy, regulations, workplace management, employment conditions, geographic location) that reflects the results.

The research protocol has been submitted for approval to the research ethics committees of both the institutions involved. A research information form and a consent form will be given to each participant, specifying the study’s objectives, what participation will entail, and the measures taken to protect the participants’ rights and data. All participants will be kept informed about the study and will be free to withdraw their signed consent. They will also be asked for their consent to participate in FGDs and be audio-recorded (for transcription purposes) and video-recorded (although these will not be kept). Volunteers will receive no compensation for their participation. All the data collected will be treated confidentially, coded, and kept under lock and key for 20 years. Results will be presented in a way that respects participant confidentiality, and none will be identifiable either in presentations or publications.

Knowledge transfer will be appropriately considered and outlined in a dissemination plan focused on the needs of the audience that will use that knowledge. Researchers will also collaborate with knowledge users to craft messages and help disseminate research findings. Additionally, the researchers will prepare manuscripts and publish the study’s results in relevant peer-reviewed journals and present their findings via poster and oral presentations at appropriate academic and nonscientific conferences.