This study aimed to investigate the relationship between transformational leadership and presenteeism among intensive care unit (ICU) nurses in tertiary hospitals and further investigate the chain-mediated role of perceived social support and occupational coping self-efficacy.

This is a cross-sectional survey study.

Six tertiary hospitals in Sichuan Province, China.

590 ICU nurses were recruited from six tertiary hospitals in China for the survey.

Presenteeism of ICU nurses was the primary outcome indicator. Transformational leadership, perceived social support and occupational coping self-efficacy were secondary outcome indicators. The transformational leadership scale, perceived social support, occupational coping self-efficacy and Stanford presenteeism scale were used to investigate ICU nurses through convenience sampling.

The presenteeism score of ICU nurses was 15.46±4.45 (mean±SD), in which the incidence of high presenteeism was 53.90%. Correlation analysis showed that presenteeism was negatively correlated with transformational leadership, perceived social support and occupational coping self-efficacy (r=−0.412 to −0.486; p<0.05). Perceived social support partially mediated the relationship between transformational leadership and presenteeism, with an effect value of 0.055 (95%CI: −0.102 to –0.012; p<0.001); occupational coping self-efficacy partially mediated the relationship between transformational leadership and presenteeism, with an effect value of 0.042 (95% CI: −0.074 to –0.017; p<0.001); perceived social support and occupational coping self-efficacy chain-mediated between transformational leadership and presenteeism, with an effect value of 0.029 (95% CI: −0.046 to –0.016; p<0.001).

ICU nurses’ perceived social support and occupational coping self-efficacy are chain-mediated between transformational leadership and presenteeism. Therefore, to reduce nurses’ presenteeism, nursing managers should adopt targeted interventions based on the factors influencing them to improve transformational leadership and enhance their perceived social support and occupational coping self-efficacy.

Data are available upon reasonable request. Data are available upon reasonable request. The datasets generated during and/or analysed during this study are available from the corresponding author on reasonable request.

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In recent years, the study of the relationship between the health status of occupational groups and the economy has increasingly become a hot spot of scholars’ attention. Health, as one of the most essential human capitals, not only affects individual labour performance but also influences a country’s or region’s economic growth dynamics. Presenteeism, also known as low health-related productivity, is prevalent among occupational groups, especially in the healthcare industry. There is no standardised concept of presenteeism, which was first proposed by Professor Cooper in 1996, describing it as the phenomenon of working when one should take a break from work due to illness or extended working hours that cause a reduction in health-related productivity. 1In 2005, Kivimäki et al expanded the concept of presenteeism to include working when one is in an unhealthy state.2 A systematic evaluation by Webster et al showed that the reported prevalence of presenteeism in the occupational population ranged from 35% to 97%, influenced by organisational factors, job characteristics and personal factors. 3As a major force in healthcare, nurses are a high-risk, high-stress and high-work-intensity population. In the global shortage of nursing human resources, nurses are at high risk of presenteeism, especially in developing countries or poor areas, due to heavy workloads, human resource constraints, shift work, complex interpersonal relationships and inadequate remuneration packages.4

It has been reported that 85% of healthcare workers have had the experience of attending work with illness,5 while the global rate of presenteeism reporting among nurses is about 49.2%,6 with 65.0% in the USA,7 48.7% in New Zealand8 and a high rate of 94.25% of presenteeism reporting among nurses in China.9 The impact of presenteeism on individuals and organisations is often multifaceted; on the one hand, it affects personal health, resulting in decreased productivity, lower work efficiency and increased burnout, which affects professional well-being. On the other hand, it affects patient safety by increasing the risk of medication errors, falls and infections. In addition, presenteeism can have a series of negative impacts on organisational development, directly or indirectly increasing the economic loss of the organisation. Studies have shown that due to differences in the level of economic growth, the financial loss caused by presenteeism of nurses varies slightly in different countries, from about US$4.38 billion per year in China,⁹ US$3–12 billion per year in the UAS10 and about US$3055 per capita in Japan.11 Therefore, considering the negative consequences of presenteeism on multiple domains, such as individuals, patients and organisations, it is necessary to explore the mechanisms and pathways of its impact from various perspectives.

According to the 2020 State of Global Nursing Report, there is currently a shortfall of up to 5.9 million nurses worldwide, with a projected shortfall of 5.7 million by 2030, with the shortage of nurses in developing countries and poorer regions particularly prominent. Although the shortage of nurses in China has dramatically improved in recent years, there is still a gap from the global average. Whether the allocation of human resources is reasonable and whether the appropriate ratio directly affects the quality of nursing services, work efficiency and healthcare costs, thus affecting the quality and safety of patient services. 12 13 The intensive care unit (ICU), as a special ward for the centralised treatment, resuscitation and monitoring of patients with acute, critical and severe illnesses in medical institutions, is characterised by solid professionalism, heavy workload, modern equipmentand complex treatment, which makes nurses’ workload challenging and stressful, leading to prominent chronic health problems such as chronic pain, fatigue, gastrointestinal disorders and sleep disorders. Research shows that the average ICU bed-to-nurse ratio in China is 1:1.86, with 63.3% of the regions having a 1:1.5 to <2.0 ratio.14 Therefore, the shortage of human resources for ICU nurses is still prominent in China. Presenteeism of ICU nurses is also notable due to the influence of factors such as dedication, health status, work pressure, remuneration and poor job replacement. Therefore, it is essential to pay attention to the current situation of ICU nurses' presenteeism and its influence mechanism and to develop targeted interventions to improve nurses’ health status and patient safety.

In organisations, leadership style is an essential source of employees’ emotional and psychological experience, affecting their psychological well-being and job performance.15 Transformational leadership refers to a leader’s ability to guide employees to develop proper values, resilience and a positive mindset by making them aware of their responsibilities, stimulating high-level needs and building mutual trust. Transformational leadership has four dimensions: moral example, charisma, personalised care and visionary inspiration. As a work resource, leadership style is an essential organisational contextual variable affecting employees. Transformational leadership style can improve employee performance and reduce impaired productivity by exuding leadership charisma, reinforcing leadership inspiration and personalised care to stimulate employees’ intellectual and higher-level needs.16 The positive effects of transformational leadership have been widely studied and confirmed regarding nurses’ resilience,17 burnout,18 job satisfaction 19and improved patient safety outcomes.20 Research on transformational leadership’s impact on presenteeism has not been reported. Based on this, we propose research hypothesis 1: transformational leadership negatively affects presenteeism and can further reduce the occurrence of presenteeism through mediating variables.

Previous research on the factors influencing nurses’ presenteeism has focused on demographic characteristics such as length of service and job title21; health conditions such as subfertility symptoms, chronic bodily pain, hypertension and other chronic illnesses22 23; and work-related factors such as pay and income, work environment and occupational stress.24 The synergistic effects of positive psychological work resources, such as social support and self-efficacy, are often overlooked.

Some studies have shown that social support directly predicts the mental health of healthcare workers and indirectly affects mental health through personal resilience, which directly or indirectly affects work efficiency. Perceived social support refers to an individual’s emotional experience and degree of satisfaction in feeling respected, supported and understood. It consists of three main components: family support, friend support and material or other spiritual support from the community. Perceived social support as a positive psychological resource is one of the essential protective resources for individuals, which helps to alleviate work pressure and negative emotions, maintain a healthy psychological state and a positive work state and thus reduce the phenomenon of presenteeism. The social support buffer model also points out that perceived social support can inhibit or buffer the adverse effects of stressful events on individuals.25 Some studies have shown that presenteeism is negatively related to marine social support and that high social support may improve presenteeism by reducing stress and increasing job satisfaction and performance.26 In addition, leadership styles can improve employees’ stress coping and handling abilities through support for employees, which can stimulate employees’ motivation, work attitudes and behaviours and enhance the level of perceived social support. Based on this, we propose the following research hypotheses:

Research hypothesis 2: transformational leadership can influence presenteeism among ICU nurses through the mediating role of perceived social support.

Occupational coping self-efficacy refers to an overarching self-efficacy of employees to effectively cope with and accomplish nursing care. Self-efficacy, as a positive psychological resource within an individual, is essential for enhancing occupational coping ability, reducing work stress and burnout, improving mental health and enhancing work efficiency and work quality. Research shows that the lack of coping self-efficacy may directly or indirectly affect work engagement through stress and interpersonal relationships, making employees feel inefficient.27 The Job Demands-Resources Model states that each occupation has specific risk factors associated with job stress and that when employees have high levels of job demands and job resources, it stimulates personal growth and development and helps to promote good organisational outcomes.28 Transformational leadership, perceived social support and occupational coping self-efficacy are important to nurses in achieving organisational goals as overarching components of job demands and resources. Currently, there is evidence regarding the influential relationship between transformational leadership, perceived social support and self-efficacy. However, it is not yet known whether occupational coping self-efficacy mediates the relationship between transformational leadership and presenteeism, and whether there is a chain of mediation between perceived social support and occupational coping self-efficacy between transformational leadership and presenteeism. Based on these analyses, we propose the following research hypotheses:

Research hypothesis 3: transformational leadership can influence presenteeism among ICU nurses through the mediating role of occupational coping self-efficacy.

Research hypothesis 4: transformational leaders can influence presenteeism among ICU nurses by mediating the chain of perceived social support and occupational coping self-efficacy.

Based on the above analysis, this study used the JD-R model as a theoretical guide to explore the influence mechanism of presenteeism of Chinese ICU nurses from multiple perspectives of job requirements (transformational leadership), job resources (perceived social support) and personal resources (occupational coping self-efficacy) and to establish a hypothetical model (figure 1) to provide a theoretical basis for the reduction of presenteeism of ICU nurses.

This study explored the relationship between transformational leadership, perceived social support, occupational coping self-efficacy and presenteeism among ICU nurses. The results found a direct effect of transformational leadership on presenteeism among ICU nurses. They confirmed that perceived social support and occupational coping self-efficacy were chain mediators between transformational leadership and presenteeism. This provides a new perspective for studying the relationship between transformational leadership and presenteeism among ICU nurses.

The results of this study showed that ICU nurses’ presenteeism score was (15.46±4.45), of which high presenteeism accounted for 53.9%, which indicated that China’s ICU nurses’ presenteeism was at a high level, which was worth paying attention to. To analyse the reasons for this, (1) only 56% of ICU nurses in this study had good self-assessed health. Several studies have also confirmed that individual physical and mental health conditions are the root causes of presenteeism.34 35 When nurses feel unwell or suffer from chronic illnesses, they may experience an inability to concentrate and devote themselves entirely to their work, which leads to lower work efficiency, lower productivity levels and presenteeism. (2) 48% of the ICU nurses in this study had a high level of perceived stress. ICU, as an essential area for the rescue and treatment of patients with acute and critical illnesses in healthcare institutions, has a complex working environment. ICU nurses must continuously monitor changes in patients’ conditions and cope with various first-aid situations. The high-intensity workload and prolonged work pressure may increase the nurses’ fatigue and psychological burden, which may lead to presenteeism behaviours. (3) About 35% of ICU nurses in this study had suffered from workplace violence in the past. Workplace violence is a severe threat to the personal safety of nurses. It is a stressful event that can easily trigger anxiety and depression in nurses, negatively affect employee job satisfaction and loyalty and increase concerns about the work environment and job security, leading to an inability to concentrate on work, thus resulting in presenteeism.36

The results of this study show that the transformational leadership score of ICU nurses is (104.06±17.68), which is at the medium-high level, similar to the results of foreign scholars.16 In recent years, nursing managers’ understanding of scientific management has gradually deepened, the leadership style of nursing team leaders has been continuously improved and managers who have received higher education have higher qualities and conduct and can play a corresponding exemplary role among nurses and can make wise decisions and guidance based on their professional knowledge when leading the team to make changes. Hence, the level of transformational leadership is higher.

The results of this study showed that ICU nurses perceived social support scores of (62.58±11.92), which was at a medium-high level, similar to the findings of Lu et al.37 Social support, as a positive emotional experience in which an individual subjectively feels that they receive understanding and support from family, society and friends, can reflect the degree to which an individual gets support in a stressful situation. Social support theory also states that a strengthened social support network helps to cope with external environmental challenges.38 It may be related to the fact that the survey respondents in this study were mainly bachelor’s degree holders (81.86%), and people with higher education tend to have more knowledge and skills, as well as better communication and expression skills and are more likely to establish and maintain good social relationships. The lower level of perceived social support among those with poor health and perceived high work stress may be related to the decline in participation in social activities and lack of time and energy to maintain interpersonal social relationships among this group.

The results of this study showed that ICU nurses’ occupational coping self-efficacy score was (31.13±6.58), which is at the medium level (median total score of 22.5), similar to the results of the study by Pisanti et al.39 Self-efficacy is not confidence generated for a specific domain but can predict people’s behaviour in different situations. Studies have shown that individuals with high levels of self-efficacy favour using positive or problem-focused coping strategies, which help them effectively buffer the adverse effects of stress and contribute to maintaining high levels of physical and mental health.40 It may be related to the fact that the working years of the respondents in this study were mainly 1–5 years, which accounted for about 40%. On the one hand, the ICU work environment is challenging, requiring the handling of critically ill patients and complex medical situations. Low-seniority nurses working in such a high-pressure environment may feel uneasy and anxious, which affects self-efficacy enhancement. On the other hand, newly recruited ICU nurses may lack confidence in their abilities and coping measures due to a lack of sufficient work experience and training, resulting in lower self-efficacy.

This study found that perceived social support mediates the relationship between transformational leadership and presenteeism among ICU nurses, that is, transformational leadership not only acts directly on presenteeism but also indirectly through perceived social support. According to the theory of transformational leadership, transformational leadership is an upbeat leadership style that stimulates the intrinsic motivation of employees by motivating them so that they can maximise their potential to achieve the highest level of performance, promote their personal growth and career development and thus improve team cohesion and work performance.41 On the one hand, when nurse leaders have a high transformational leadership style, they can provide the social support that nurses need. By motivating and stimulating nurses’ potential, they feel valued and supported. They are willing to devote themselves to their work in a positive frame of mind, which contributes to the joint development of themselves and the organisation and enhances nurses’ job satisfaction, which helps to reduce presenteeism; on the other hand, it is based on the theory of social exchange. When individuals receive sufficient support in social exchange, they are more confident and motivated to face challenges at work, thus reducing presenteeism. When nurses perceive the care and support from leaders, colleagues and organisations, this emotional support is not only conducive to regulating the negative emotions of nurses and reducing the negative impact of work pressure on them but also helps to enhance the nurses’ commitment to and identification with the organisation, so that they are more engaged in their work and reduce the possibility of presenteeism.26

The results of this study found that occupational coping self-efficacy mediates the relationship between transformational leadership and presenteeism among ICU nurses, which means that transformational leadership not only acts directly on presenteeism but also indirectly through occupational coping self-efficacy. Bandura’s self-efficacy theory states that when individuals believe they are competent enough to accomplish a task, they are more motivated to engage in it and strive to achieve the desired goal.42 Managers with a high level of transformational leadership style can motivate nurses through character appeal and vision sharing and stimulate positive emotions in nurses to show more energy, dedication and focused attitudes to be more confident in dealing with challenges and pressures at work. Nurses with higher occupational coping self-efficacy are more confident and capable of dealing with difficulties and challenges at work. They are more willing to take the initiative to solve problems, improve work performance and reduce presenteeism behaviour.

The results of this study found that perceived social support and occupational coping self-efficacy acted as chain mediators between transformational leadership and presenteeism among ICU nurses, that is, transformational leadership among nurses affects presenteeism through perceived social support and occupational coping self-efficacy. According to the JD-R model, job resources can buffer the negative consequences of presenteeism by stimulating employees’ internal and external motivation to cope with demanding job tasks. Transformational leadership and perceived social support as an essential external resource and occupational coping self-efficacy as a vital internal resource, managers with a high level of transformational leadership style excel at stimulating nurses’ autonomy and creativity by establishing good interpersonal relationships and a teamwork atmosphere, providing nurses with the necessary resources and support and enhancing nurses' perceptions of social support.20 When nurses feel the support and encouragement from their leaders, they will be more willing to seek and use help and support from external resources, such as colleagues, family and friends. This social support helps meet nurses’ needs at work, reduces work stress and fatigue and increases job satisfaction and well-being, enhancing nurses’ occupational coping self-efficacy. When possessing a higher level of self-efficacy, nurses are more confident that they can better cope with the challenges and pressures at work, which is conducive to maintaining good mental health and reducing the incidence of presenteeism.

Based on the results of this study, we put forward the following recommendations to improve the status of presenteeism among ICU nurses. First, cultivate and promote a transformational leadership style: leaders should pay attention to the needs and emotions of nurses and actively listen to their opinions and suggestions; stimulate nurses’ enthusiasm and innovation through incentives and encouragement so that they can feel the meaning and value of their work; establish a positive, open and inclusive work environment and encourage nurses to participate in decision-making to improve their sense of belonging and responsibility and reduce presenteeism. Second, enhance perceived social support: establish a good social support network; organisations should encourage supportive colleague relationships and teamwork and promote interactions and exchanges through regular team-building activities; nursing managers should strengthen communication with nurses, establish a good team communication mechanism and encourage information exchange and emotional support among nurses; and provide resources for mental health support by providing resources such as psychological counselling services, guidance and training on work–life balance, to help nurses cope with work stress and emotional distress, promote nurses’ physical and mental health and reduce presenteeism. Third, to improve nurses’ sense of self-efficacy in occupational coping, regular training and refresher courses are conducted to improve nurses’ professional skills and knowledge and enhance their ability to cope with work challenges; work tasks and resources are reasonably allocated to reduce nurses’ overload and stress; and appropriate incentives and recognition mechanisms are provided to stimulate nurses’ motivation and self-efficacy and to reduce presenteeism.

Data are available upon reasonable request. Data are available upon reasonable request. The datasets generated during and/or analysed during this study are available from the corresponding author on reasonable request.

The authors thank all the participating nurses and investigators in this study for their generous contribution.