Research: Why Employees Work While Sick—and How Leaders Can Stop It

Liza, an emergency medicine physician, had a fever and a persistent cough, but rigid shift requirements left her little flexibility. Returning from maternity leave recently, she worried that calling out sick would brand her as “less committed,” so she worked despite exhaustion, potentially exposing her patients and coworkers.

Jordan, a marketing manager at a tech firm, had chills and fatigue. Even with the flexibility to work remotely and explicit encouragement from his boss to take sick leave, Jordan feared that missing critical meetings and deadlines could signal unreliability. He pushed through, joining meetings camera-off and responding to emails throughout the day.

Liza and Jordan’s experiences, while distinct, point to a growing workplace challenge: presenteeism, or working while ill. Even among workplaces that offer sick leave, a 2023 survey estimated that nearly 90% of U.S. employees worked while sick during the past year, and 40% hesitated to use available sick leave. Ironically, working while sick with an infectious disease is most prevalent among those who work in healthcare, specifically physicians.

The costs of presenteeism extend beyond individual discomfort and inconvenience; it’s quietly draining U.S. businesses of up to $150 billion annually, nearly 10 times more than absenteeism. Yet many senior leaders underestimate the problem. Employees who work while sick experience reduced focus, slower decision-making, and increased errors, ultimately reducing individual productivity by one third or more. These impacts ripple throughout teams, creating bottlenecks, inefficiencies, and diminishing overall output. Presenteeism also accelerates the spread of illness and drives up absenteeism costs, which exceed $225 billion annually.

Chronic presenteeism also intensifies work-related stress and burnout. Nearly 60% of U.S. workers in 2024 experienced burnout, ranging from moderate to very high. Burnt-out employees are also far more likely to quit, with each departure costing between 40% and 200% of that employee’s annual salary.

Finally, persistent presenteeism can worsen health conditions, potentially leading to serious long-term illnesses and increasing healthcare expenses and disability claims, significantly burdening organizational resources.

For U.S. employers, the stakes are particularly high due to the lack of universal paid sick leave, rising healthcare and child care costs, and inadequate social safety nets. In this context, employees aren’t choosing between work and rest—they’re choosing which risk they can afford: their health, their next paycheck, or their career. By understanding the root causes of presenteeism, leaders can move beyond reactive policy tweaks to proactive structural change.

Here are three levers that senior leaders can directly control, and a framework to combat presenteeism at work.

Three Organizational Forces Behind Presenteeism

Our recent study, supported by broader research and drawing on a national sample weighted to represent over 168 million American workers, reveals that presenteeism isn’t just about individual decisions or even sick leave policies. It’s a symptom of deeper, structural issues: how jobs are designed, how work is structured across industries, and how cultural norms around availability and commitment are reinforced. From this, we identified three core organizational drivers that shape presenteeism:

1. Men and women experience job flexibility differently.

Women in our study with rigid, low-flexibility jobs like nursing, teaching, and administrative support reported working significantly more days while sick than men in similar roles. Concerns about job security, financial strain, and potential repercussions for taking sick leave may make it more difficult for women in these roles to prioritize their health when unwell.

In contrast, men with highly flexible roles reported working more days while sick than women in similarly flexible roles, challenging the assumption that job flexibility leads to better ability to care for one’s health (for instance, scheduling appointments, taking sick time). Even in highly flexible work arrangements, some employees—particularly men—may feel pressure to remain constantly available, reinforcing cultural norms that equate being “always on” with commitment, success, and career advancement.

2. Working while sick reflects gendered job roles and pressures.

Occupational sorting (the tendency for men and women to cluster into different sectors) further compounds these gendered pressures. Female-dominated sectors, such as education, healthcare and social services, and administration, often feature rigid schedules, strict attendance requirements, limited autonomy, and chronic understaffing, creating structural barriers that discourage sick leave use. Male-dominated sectors, such as engineering, finance, and tech, while typically offering more formal schedule flexibility, frequently perpetuate an availability culture that rewards visible responsiveness, paradoxically increasing presenteeism.

Our analysis further reveals that job security intensifies occupational presenteeism patterns. When job security was perceived as low, women consistently missed fewer workdays than men, suggesting they feel heightened pressure to demonstrate reliability under insecure conditions. However, as job security improved, women were more likely to use sick leave, indicating that stability helps alleviate fears of professional repercussions. By contrast, men continued to report presenteeism even with increased job security, indicating deeply ingrained cultural expectations of constant availability.

3. When job demands outweigh resources, people work more while sick.

The Job Demands-Resources (JD-R) model, developed by organizational psychologists, explains how workplace conditions affect employee health, productivity, and organizational performance. This framework classifies work environments into two categories:

• Job Demands: Tasks requiring sustained physical, mental, or emotional effort, such as high workloads, rigid schedules, tight deadlines, and expectations of constant availability.

• Job Resources: Factors supporting employees in managing these demands, including scheduling and location flexibility, decision autonomy, clear managerial support, backup staffing, and open communication.

When job demands consistently outpace resources, employees experience higher rates of presenteeism, burnout, absenteeism, diminished productivity, and lower job satisfaction. Conversely, balanced demands and adequate resources boost motivation, productivity, and workforce health.

This structural imbalance, exacerbated by gender norms and occupational sorting, helps explain why expanding sick leave or well-intentioned gestures such as leaders modeling time off or setting email boundaries often fall short. Without redesigning jobs to address deeper gaps in flexibility, autonomy, and support, surface-level policies alone cannot meaningfully reduce presenteeism.

A Strategic, Structural Approach for Senior Leaders

Executives who intentionally evaluate and redesign organizational structures using the JD-R framework can meaningfully reduce presenteeism, bolster employee well-being, and strengthen long-term organizational resilience.

1. Map job demands and resources across roles to identify imbalances.

Start with a broad diagnostic to assess core pressures and supports across major role categories. Map the degree of job demands (e.g., workload, scheduling, expectations of responsiveness) alongside job resources (e.g., autonomy, flexibility, backup staffing, managerial support) across roles. Use this diagnostic framework to identify where imbalances are most pronounced. Here are some strategies to gather this information:

• Conduct confidential pulse surveys, stratified by job type/role

• Host manager-led focus groups to capture qualitative insights

• Integrate questions into existing surveys to streamline data collection

• Use data visualization tools like heat maps to identify roles with consistently high demands and low resources

Roles that skew heavy on demands and low on resources are red flags for presenteeism and burnout. These imbalances provide a clear starting point for intervention: reducing excessive demands, strengthening available resources, or a combination of both.

A practical guide on applying the JD-R model describes how one of the largest hotel chains in the Netherlands—operating 22 hotels with more than 1,000 employees—used the Energy Compass, an online survey tool, to assess job demands and resources. The intervention focused on increasing job resources such as autonomy, social support, and professional development opportunities. As a result, the organization reported measurable reductions in burnout and significant improvements in employee engagement. This case demonstrates how systematically applying the JD-R framework can lead to meaningful gains in workforce well-being and organizational performance.

2. Train managers to identify and act on early signs of stress and presenteeism.

Equip managers with practical tools to proactively recognize and address early warning signs of stress and overwork. These signals can include employees working while visibly unwell, consistently sending late-night emails, or hesitating to take needed sick leave. Managers can be trained to intervene early through strategies such as redistributing tasks, offering temporary flexible schedules, and creating clear delegation plans to ease workload pressures.

A comprehensive study analyzing data from more than 7,000 U.K. firms between 2020 and 2023 found that organizations that provide line managers with training in mental health awareness were significantly less likely to report presenteeism among their employees. Managers who learned to recognize stress indicators and act early helped reduce employee burnout and improved overall organizational well-being.

3. Build ongoing feedback and response mechanisms.

While initial diagnostics highlight structural imbalances, ongoing feedback loops help leaders monitor how demands and resources shift over time and help them respond before issues escalate. Implement brief, recurring surveys to track workload, flexibility, and perceived support across teams.

What happens next is equally important: Leaders must share the results transparently and take visible, timely action, such as adjusting project timelines, reassigning tasks, or offering temporary support during peak periods. These ongoing feedback loops can reduce presenteeism and burnout as well as build trust by showing employees that leadership is listening and responding continuously—not just once.

For example, during the height of the Covid-19 pandemic, Microsoft implemented continuous “daily pulse” employee surveys to track well-being, workload, and stress levels in real time. Managers reviewed results weekly and responded by adjusting priorities, shifting project timelines, and encouraging no-meeting days to reduce overload. This type of rapid-response system allows senior leaders to intervene early—before presenteeism spirals into long-term burnout or attrition—while also reinforcing a culture of accountability, responsiveness, and care by showing employees their feedback matters.

. . .

Executives have unique leverage to reshape the structural forces that drive presenteeism. Rather than treating presenteeism as a personal failing or a mere sick-leave policy shortcoming, effective leaders recognize it as a symptom of broader issues with organizational design and cultural norms. By strategically applying the JD-R framework, leaders can cultivate healthier workplaces, boost productivity, enhance employee satisfaction, and significantly strengthen organizational resilience.

We all get sick. Forward-thinking organizations don’t merely encourage sick leave—they systematically embed employee well-being into their organizational design, culture, and business strategy.

Copyright 2025 Harvard Business School Publishing Corporation. Distributed by The New York Times Syndicate.

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