Health is a fundamental right of every human being, while also being an inevitable requirement for promoting an individual’s overall development. Employees constitute one of the most important resources of organizations [1]; thus, maintaining employees’ health is crucial for the sustainable development of organizations. However, presenteeism, the behavior of working in a state of ill health [2], has become a widespread phenomenon in the workplace, which has attracted the attention of multidisciplinary researchers in the fields of industrial and organizational psychology, occupational health psychology, epidemiology, and nursing management in recent years [3]. Presenteeism has been defined as the behavior of people who still turn up at their jobs despite complaints of ill health that should prompt rest and absence from work [4]. Its prevalence has been documented in more than a dozen countries, such as the US, Canada, the UK, the Netherlands, Spain, and China, with presenteeism rates ranging from 30% to more than 90% [5]. Existing studies have shown that nurses tend to experience a high incidence of presenteeism [4, 6], despite being equipped with abundant health knowledge and high levels of health literacy [7]. For example, the occurrence of presenteeism among Dutch nurses reached 50% [8], and the overall presenteeism rate was 85.5% among nursing students in the USA, Japan, and South Korea [9]. Whereas the incidence of presenteeism among Chinese nurses reached 94.25% [7]. Furthermore, nurses working under unhealthy conditions (i.e., presenteeism) tends to lead to a series of negative consequences for the health and productivity of individuals, safety of their patients, and development of organizations. For instance, it may affect the healthy recovery of nurses [10], increase the number of falls in patients and drug errors [11], and cause financial burden and productivity loss in medical organizations [7].
Considering the severely negative outcomes that nurses’ presenteeism can cause in multiple fields, it is essential to explore its occurrence mechanism. Previous research has preliminarily examined leader-related factors that are closely related to presenteeism, such as leader behavior, leader pressures, and leader–follower relationships [12,13,14]. Moreover, the impact of leadership on subordinates’ behaviors is also noticeable in that leadership would likely play a vital role in shaping the healthy work behaviors of subordinates. Limited empirical research showed that health-promoting leadership and supportive leadership behavior were conducive for reducing the incidence of employees’ presenteeism [15, 16]. From the theory of paternalistic leadership [17], the work team is analogous to a family in which a leader acts as the father with two typical characteristics, majesty and mercy, while the subordinates play the role of a child, thereby reflecting the concept of “superior and inferior” in traditional Chinese culture. To some extent, supportive leadership behaviors and health-promoting leadership are more similar to the merciful father side of leaders, which provides guidance and supports work resources for subordinates. However, nursing management is also characterized by a strict rank and authority that embodies the majestic father side of leaders, and its role mechanism on presenteeism has not been extensively examined. To understand the entire picture of the influence of leaders on subordinates in the Chinese cultural context, this study mainly examined the impact mechanism of authoritarian leadership on nurses’ presenteeism. Authoritarian leadership refers to a leadership style that emphasizes the use of authority to control one’s subordinates [18], which requires employees to obey and follow the leader’s teachings to ensure efficient operation of the organization [19]. Hence, the authoritarian leadership prevalent in the nursing field may encourage nurses to prioritize their career over their health, leading to presenteeism.
Existing studies have demonstrated that leaders’ particular behaviors or leadership style can inherently be either stressful or positive for subordinates, and can consequently influence their levels of stress and affective wellbeing [20]. According to the main features of authoritarian leadership, authoritarian leaders expect unquestioning obedience, thereby controlling information and restricting subordinates’ autonomy [21], which can lead to more job demands for subordinates. Moreover, previous research has demonstrated that a heavy workload is a crucial factor in the occurrence of presenteeism [8, 22]. Thus, authoritarian leadership may have an indirect impact on presenteeism through increasing employees’ workload. Meanwhile, identification with leaders implies that the employees consider the leader as a self-reference point or model of self-definition, and have acceptance of the leader’s perception and attitude [23]. When subordinates strongly identify with their leader, they would respect them, feel proud of them, and will be more likely to exhibit behaviors that are encouraged by the leader [24]. Therefore, when nurses have high identification with their leader, they may accept more organizational tasks and a heavier workload, as expected by the authoritarian leader. In contrast, when subordinates rarely identify with leaders, despite their workload being affected by authoritarian leaders, they hardly take the initiative to undertake additional tasks according to authoritarian leaders’ expectations. As a consequence, the correlation between authoritarian leadership and workload would be stronger under high leader identification rather than low, and leader identification may moderate the relationship between authoritarian leadership and workload. In summary, the present study aims to explore the occurrence mechanism of presenteeism and focused on the impact of authoritarian leadership in the Chinese workplace culture, which would contribute to examining the impact of a leader’s authoritative side on presenteeism and enrich the application of paternalistic leadership theory. Furthermore, this study draws an overview of the relational mechanism of authoritarian leadership and presenteeism through the combination of the paternalistic leadership theory and conservation of resources theory, which would be instructive in the effective implementation of nursing management to prevent and reduce nurse presenteeism.
Authoritarian leadership and nurse’s presenteeism
Presenteeism is more prevalent among nurses, compared with other occupational groups; this could be attributed to the characteristics of nursing work, such as high stress, night shift work, and low substitutability [4, 25, 26]. Previous studies have indicated that the prevalence of presenteeism reached 94.25% among Chinese nurses [7]. Furthermore, multiple negative consequences result from presenteeism among nurses who undertake vital tasks in the healthy development of nationals. For example, nurse presenteeism could impair their health and well-being [27], pose a high risk to their patients and work environment [25], and even cause productivity and economic losses to organizations and society [7, 28]. Therefore, paying attention to nurses’ presenteeism and its causes would be conducive to promoting individuals’ health and the quality of healthcare services.
In the work-related value system embedded in the Confucian tradition of China, although some effort-related work values (e.g., endurance, persistence, and hard work) may enhance work outcomes among employees, they could also contribute to a “long-hour working culture” and the high prevalence of presenteeism [29]. Moreover, the Chinese culture also attaches importance to hierarchy; therefore, the relationship between leaders and subordinates follows a superior/inferior rationale, wherein leaders control the resources and fate of subordinates [30], which nourishes authoritarian leadership. Based on the theory of paternalistic leadership, the typical characteristics of authoritarian leaders could be considered as comprising four aspects: the autocratic style that manifests as grabbing power, controlling information, and strictly monitoring subordinates; derogate the ability of subordinates that manifests as willful disregard for subordinates’ contributions and suggestions; image decoration that manifests as manipulating information to create a good image; and instructional behaviors that manifest as emphasis on the importance of performance and providing guidance to ensure subordinates high performance [18]. Existing research indicates that the effect of authoritarian leadership on organizations and subordinates is controversial. On one side, an authoritarian leader is dedicated to ensuring the efficient operation of an organization, demonstrates high performance standards for subordinates, and promotes subordinates to agree with and complete assignments [18, 31], which may result in rapid completion of tasks, performing work accurately, and meeting the organizational performance standards in a timely manner. On the flip side, an authoritarian leader is canonical and unchallenged while strictly controlling their subordinates and berating dissent [18]. From the perspective of subordinates, the strict requirements and tight monitoring from authoritarian leaders tend to trigger feelings of uncertainty and decrease the subordinates’ psychological safety [32, 33]. As a result, when employees feel sick, to relieve the sense of insecurity, they are inclined to resort to presenteeism [26]. Combined with the conservation of resources theory [34], the underlying threats of psychological resource loss that evocated from the strict requirements and tight monitoring of authoritarian leaders would increase pressure and tension for subordinates. When individuals are in poor health, presenteeism would be considered an effective way to maintain the existing resources and confront the psychological threat from strict controls and intensive surveillance. Moreover, authoritarian leaders signal a strong disregard for the interests and perspectives of their subordinates [35, 36], consequently neglecting the health complaints of subordinates and encourage those with poor health to guard collective benefits, thereby generating more presenteeism behaviors of subordinates. Consequently, we proposed the following hypothesis:
Mediation effect of workload
According to the conservation of resources theory [37], people strive to retain, protect, and build resources, and psychological stress occurs with the potential or actual loss of these valued resources. Resources refer to those objects, conditions, personal characteristics, and energies that are valued by the individual or that serve as a means for the attainment of these objects, conditions, personal characteristics, or energies. Workload, a stressor in a work environment, consumes psychological, physical, or other valued personal resources. It represents a demand pressed on employees that is only met through the continual consumption of resources [38], which reflects the work demands that individuals perceive as being placed upon them [39]. From this perspective, when an individual is in poor health, presenteeism can allow them to maintain the existing resource level to cope with the loss of job-related resources. Continuing to work when sick would be an effective way to capitalize on other available resources. In other words, since heavy workloads have to be met in order to perform adequately, employees will be inclined to do everything they can to meet these demands so that their performance remains at the desired level [8]. Existing empirical research has also demonstrated that workloads exhibited strong positive correlations with presenteeism, whether in the general perceived workload or the quantitative demands placed on individual [8, 22, 40]. Therefore, the potential resource threatens that heavy workload brought is likely to be a vital trigger of presenteeism.
Excessive demands imposed by the organization or leader are likely to result in work overload for subordinates [41]. As one of three elements in paternalistic leadership, a typical leadership style in Chinese societies, authoritarian leadership emphasizes leaders’ awe-inspiring behaviors, including powerfully subduing their subordinates, authority and control, intention hiding, rigorousness, and doctrine [18]. On one hand, the characteristics of strong pressure and high control among authoritarian leaders may increase employees’ job pressure and decrease their resources [42]. Following the conservation of resources theory, such stressed leadership tends to trigger resource threats as well as individual stress responses such as burnout, which may increase individuals’ sense of overload. In contrast, the theory of paternalistic leadership indicates that authoritarian leaders emphasize their authoritative position and power to perform tasks regardless of subordinates’ conditions [32]; thus, authoritarian leaders are oriented toward work results and tend to express elevated job demands to their subordinates. Consequently, authoritarian leadership may increase nurses’ workloads, which may further facilitate the prevalence of presenteeism. The following second hypothesis was proposed:
Moderation effect of leader identification
Leader identification concerns a person’s perception of “oneness” with the leader [43], which reflects the extent to which a follower’s beliefs about the leader are self-defining or self-referential [44, 45]. To a certain degree, the identification of leaders plays a role in the effectiveness of leadership [46]. Since the leader is the spokesperson of their organization, the identification of leaders leads to employees being more willing to abide by the norms and values of the organization [47]. Subordinates with high leader identification are likely to accept leaders’ goals as their own and conform to their will [48]. Meanwhile, when subordinates identify with their leader, they tend to align their interests with those of the leader and produce a strong desire to contribute to the leader’s goals and success [49]. When nurses have high identification with their leader, they may shoulder more organizational tasks and job demands on their own initiative to meet the expectations and interests of highly authoritarian leaders. The more work stress and tasks they seek to undertake under such conditions, the heavier workload they would perceive invisibly. On the contrary, the workload of nurses who have weak identification with their leader may be less susceptible to the will of authoritarian leaders, due to the bottom level of initiative for contributing to the leader’s success. Accordingly, leader identification would play a moderating role between authoritarian leadership and workload, and the third hypothesis was proposed as follows:
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Hypothesis 3: Leader identification would moderate the relationship
between authoritarian leadership and workload, and for the nurses with high
level of leader identification, the relationship would be strengthened.
As outlined above, to reveal the relationship between the localization leadership, in the Chinese cultural context, and nurses’ presenteeism, the present study was designed to explore the direct cross-level influence of authoritarian leadership on subordinates’ presenteeism. Simultaneously, the indirect impact of authoritarian leadership on nurses’ presenteeism was also examined, specifically regarding the mediated effect of workload and the moderated effect of leader identification. The integrated conceptual model is illustrated in Fig. 1.