Introduction

Urinary incontinence (i.e., the involuntary loss of urine through the urethra) can affect the work performance of female healthcare workers due to their predisposed anatomy of the pelvic floor [1,2]. Urinary incontinence has a prevalence in Chile of approximately 23% in women aged 30 to 44 years and 32% in the group aged 45 to 64 years [1].

Urinary incontinence harms the quality of life and can impair work activities due to decreased ability to concentrate, perform physical activities, and self-confidence due to the constant worry of having to interrupt their work for urinary urgency or change of wet underwear [3,4].

To perform their activities, women with urinary incontinence use adaptive measures such as decreased caffeine or fluid intake, absorbent pads, change of clothes, dark underwear, and perfume or scented talcum powder [4,5]. However, urinary incontinence is a stressor and leads to presenteeism [5].

Given the high demands and commitment component in these areas, presenteeism in health care or teaching jobs is more likely to occur [6,7]. Presenteeism is the loss of work productivity by attending work with some unfavorable medical condition that decreases performance and not by individual distraction activities [6,8,9].

Due to the stress of modern life, female healthcare workers are even more prone to occupational or chronic diseases, increased physical and mental stress, demotivation, pain, and fatigue [9,10]. Presenteeism in health professionals is a multidimensional phenomenon of high prevalence [6] that reduces productivity and the quality of patient care and safety due to the propensity to error by omission or negligent behavior [6,8,11,12]. This phenomenon is mainly reproduced in recently graduated professionals due to distrust from their inexperience. On the other hand, experienced workers can adapt better to their work environment, reducing these risks through their experience and acquired skills [13].

Studies on work presenteeism associated with urinary incontinence are scarce, and no evidence was found for Chile. This research attempts to answer the question: Is urinary incontinence a clinical situation that favors presenteeism, reducing work productivity? We aim to explore the self-perception of health workers who suffer from urinary incontinence as a predisposing factor of presenteeism and the degradation of the quality of care for clients and their social relationships with their peers.

Methods

This study used a mixed exploratory-descriptive design on health workers with urinary incontinence units of analysis, deepening and documenting situations of presenteeism from self-perception. Multiple units of analysis or cases were considered, studying each participant as a case and establishing trends and points of encounter [14]. The Good Reporting of a Mixed Methods Study (GRAMMS) guidelines for reporting mixed studies in health were followed [15]. The study had an ethics committee approval.

Sample selection process

The sample was guided by a conceptual, purposive approach involving a deliberate selection of participants. The total number of interviews associated with presenteeism was defined through thematic saturation (i.e., the establishment of standard parameters that permitted a deeper understanding of the categories studied) [16,17]. The request for volunteers was disseminated through social networks, obtaining a sample of 14 women living with incontinence.

For the selection of the volunteers, the following inclusion criteria were considered: women with urine leakage for more than six months at least once a day, aged between 25 to 50 years, healthcare workers in direct clinical care, and residents in Chile.

Those who were pregnant for more than 14 weeks, had a history of childbirth of less than six months, genital prolapse, gynecological or urological pathologies that generate pressure on the pelvic floor, repeated urinary tract infections, psychoactive substance use, treatment with diuretic drugs, pathology that disturbs their work performance (such as psychiatric, rheumatologic, diabetes, chronic pain, neurodevelopmental disorder), recent graduates, students or those who are in management positions without patient care were excluded from the study.

Data Collection

Between November 2022 and March 2023, 14 semi-structured interviews were conducted with closed and open questions of sociodemographic content on urinary incontinence and loss of productivity. The findings of studies on presenteeism in health workers and the Stanford Presenteeism Scale-6 (SPS-6) were reviewed. The score on this scale is associated with the professional ability to overcome their illness while remaining without presenteeism. A higher score indicates a lower level of presenteeism [9,18].

Interview dynamics

JAR conducted the synchronous interviews, lasting 40 minutes via Zoom platform, considering the reading of the informed consent. A script was applied to contain a greeting, a presentation of the objectives, a request for informed consent, an invitation to speak freely, information on how to ensure the confidentiality of the data, and the study questions. Before finishing, the volunteer was asked if she had any doubts, thanked her for participating, and said goodbye.

Data analysis

Descriptive statistics were used to analyze the sample characterization and the SPS-6 questions, representing the results in frequency and percentage.

The level of presenteeism was measured with the SPS-6 instrument, which is composed of two dimensions. The first dimension was related to the efficiency of completing the work (items 2, 5, and 6), and the second dimension was strongly related to distraction (items 1, 3, and 4, with an inverse score from 5 to 1). Using a Likert scale, responses were classified as strongly disagree, disagree, indifferent, agree, and strongly agree [10,18,19].

The narratives were interpreted from the analysis of the transcripts through the significant phrases that could be detected in them, following a content analysis model. The reliability criteria defined by Guba [20] were considered during data processing. These include credibility, transferability, dependability, and neutrality of the interpretation or analysis of the information and the research process. The quality control of the analysis was carried out by triangulation between JAR and CBC.

For content development, significant sentences on the perception of effect were considered in the following categories of analysis on presenteeism, based on Willingham’s (2008) study [21]:

1. Work performance: observable actions directed towards a goal, where the individual manifests the willingness and ability to execute it, provided that the context is suitable to achieve them [22].

2. Quality of clinical care: achieving optimal health care, responding to the patient’s needs in a safe, efficient, accessible, and person-centered manner [23].

3. Social work relationship: links and treatment established between people with their superiors, colleagues, and subordinates that make up the organization according to their functions [24].

Results

The sample consisted of 14 female healthcare workers, all of Chilean nationality, whose age range was 25 to 50 years, with a mean age of 38.9 ± 7.08 years. The characteristics of the sample are presented in Table 1.

As for the responses corresponding to SPS-6, the mean total score was 15.8 + 3.5, showing moderate to high presenteeism, with a range of 9 to 21 points among the consultants. Table 2 shows the frequency of responses by item.

Content analysis

Perceived decrease in work performance

Regarding the time of the day when they were most interrupted by urinary incontinence, in the narratives, the interviewees report that it occurs most of the time they perform administrative tasks.

"Management, having to concentrate on analyzing data or things like that, is very much interrupted by the times I have to go to the toilette" (E.01).

"Anytime, especially when I have had to hold urine for a long time" (E.12).

"I am late sending administrative issues or closing tabs because of going to the toilette, I always leave after my time" (E.13).

"I keep tabs open and close them at home since I try to go to the toilette every hour" (E.14).

Compared with other moments of their working life or with their peers, when faced with the perception of decreased work performance, the interviewees reported less energy at the end of the day.

"Before, I could easily go through a shift without going to the toilette because there were already emergencies, so imagine now spending the whole shift trying not to go to the toilette." (E.03).

"The feeling of urine leakage, associated with the embarrassment of maybe having wet the uniform or someone noticing and having to run to the toilette to change" (E.06).

"Yes, because I am more tired daily because I sleep badly" (E.13).

Continuing with the above, most agree that urinary incontinence has a greater impact on their performance in emergency procedures or those in which they have to exert force on the patient. This is because they prefer to finish the clinical care rather than the desire to urinate. The situation is different when they have to perform scheduled procedures because it is possible to coordinate their time and go to the toilette before the procedure.

"When there are emergency procedures, I am mostly affected because in scheduled (such as cures or catheter change), I go to the toilette before the patient arrives" (E.01).

"When I can't go to the toilette on demand, I have to hold it a lot and restrict my water intake. In addition (to) the fact that I do not have a toilette in the box" (E.04).

"When I am overloaded because when I have not gone to the toilette before care, I think 'please hold it'" (E.08).

"When I have to do long procedures because I have to stand for a long time" (E.10).

"When I am doing an unpostponable activity, and I feel like urinating, I don't make it to the toilette, and I have to interrupt the next activity because I have wet myself" (E.11).

Finally, it is noteworthy that two of the interviewees from hospital centers reported that the shift system generated greater stress, increasing the perception of the desire to urinate, so they had to request a change in their work schedule.

Perception of decreased quality of care

The narratives regarding the alteration in the quality of clinical care due to urinary incontinence mostly refer to decreased concentration during some activity due to interruptions, discomfort due to the desire to urinate, or the possible odor due to urine leakage.

"When I feel the need to urinate, I get scared because if I do not go quickly to the toilet. Any effort could trigger this loss of urine" (E.02).

"Only if I did not manage to go to the toilette before an attention, or if this is taking longer than expected, there I already start to get more distracted thinking about a toilette" (E.07).

"Yes, I get distracted more easily. I have to be aware of when I feel like going to the toilet so I don't overdo it" (E.08).

Discomfort and lack of concentration were perceived as possible risk factors for patient safety due to having to defer attention or forgetfulness. Most of them agreed that when they felt the urge to urinate, their concern was directed at trying to contain themselves and not to wet themselves.

"When I come from the toilette, I sometimes don't remember what I was on. I could have some problem with medication administration, and what will I be asking the patient, so I had to look through the waste" (E.01).

"A couple of times I have had to attend to clients quickly because they have been waiting many hours to go to the toilette" (E.04).

"Yes, because I have had to delay patient care as long as possible since I do emergency care" (E.05).

"Yes, of course. I think that is what affects the most in conjunction with the discomfort of feeling damp, as well as inevitably causing just thinking about how uncomfortable it feels. If someone noticed it, that takes you out of what you are doing by thinking about what is happening to you out of the blue" (E.06).

"Yes, of course, I start thinking (about) that I'm not going to wet myself, and I have to make a double effort not to make a mistake" (E.09).

"When it happens that I have the urge to urinate at its fullest, I can only think about it" (E.12).

Affect on social relationships at work

A typical pattern was observed among the interviewees about the perceived embarrassment of possessing this condition, especially due to the odor resulting from urine leakage. This was particularly noticeable during the pandemic because, with personal protective equipment, they were concerned that this odor would increase due to sweating. Some interviewees keep this condition silent to avoid commenting on it.

"When I feel like it, I have to go. I can't hold it in for long; sometimes, people don't understand that and look at you strangely. They label you as out of place, as impertinent. So, it’s a whole issue" (E.01).

"In general, no, but I have had to talk about it with them because of urinary incontinence" (E.10).

"It does not affect, since it is something that I do not manifest. I carry it in silence and because when I manifested, it was the subject of jokes" (E.11).

"Yes, because they bother me (telling me) that I am chubbier, but because I wear a bigger uniform so that the diaper is not noticeable" (E.13).

On the other hand, it is observed that the social-work relationship is affected by being labeled as uninterested or unsociable since urinary incontinence reduces their ability to participate in social activities such as lunchtime or social gatherings outside the workday. In this context, one of their greatest fears is that leakage will occur, causing the discomfort of feeling wet or stinking of urine. Seven respondents answered in the affirmative when asked if their relationship with their coworkers had changed because of urinary incontinence.

"Yes, because in the after-dinner conversations when they start talking or things like that, I have to stop (to) go to the toilette, and I can't wait and they don't understand" (E.01).

"The smell of urine is characteristic and annoying. For example, I sneeze due to seasonal allergy; this causes a leakage of urine of about 3 to 4 milliliters, which leaves a significant amount on my underwear, causing an annoying odor, generating a ’self-isolation' from my peers to avoid them perceiving the smell" (E.02).

"Yes, they take it as that you are more antisocial, as that you are more isolated, more left; obviously, it is not something that one wants" (E.03).

"In long meetings, I have to leave several times, and sometimes they think that you are not interested, and then comes the challenge from the management. It is 'fome' (annoying) to go around explaining" (E.8).

In order to maintain their daily work and social activities, the interviewees have had to resort to multiple adaptive measures such as using daily pads, sanitary towels, double molting, or decreased fluid intake.

"I try to go to the toilette before leaving the base, but sometimes I can't, or I don't feel like it, so where I feel like it, I try to go to the toilette" (E.05).

"Emptying the bladder as soon as the urge appears, not holding it in or even going by schedule before I have it" (E.07).

"Well, I try not to strain, drink too much liquid, and care for myself from having a cold, but I worry about that issue, and it doesn't let me work calmly. As in my sex life, I also worry about it, and I am not the same because I am afraid of urinating when I have sex" (E.09).

"I have to consider very much avoiding fluid intake when entering the ward or going into labor since, as a sole practitioner, I am irreplaceable during that moment" (E.11).

"In recent months, I have had to resort to diapers when I know they are days with longer procedures, or else pads or mimi" (E.13).

"I learned about menstrual panties, and they have worked for me so far as a mitigation measure" (E.14).

Discussion

The content of the exposed narratives allows us to observe how a sense of fear, shame, and stigma accompanies the experience of urinary incontinence, coinciding with what has been documented about this experience in different parts of the world [25]. This self-perception places urinary incontinence in an abject plane, which does not circulate in public, not allowing for negotiating its incidence in the labor field.

Our results show that despite showing a moderate to high level of presenteeism among the interviewees, with a mean SPS-6 score of 15.8+ 3.5 and a range between 9 and 21 points, they strive to be able to provide clinical care without the interruption caused by the imperious desire to go to the toilette due to the commitment acquired. This is similar to the study by Silva [26], who addressed workers in a critical care unit. The mean SPS-6 score among women was 13 + 6.8 points [26], regardless of their health status.

Urinary incontinence is a factor that predisposes people to a lack of concentration and continuity in the performance of long-lasting or urgent procedures, and the second dimension of the SPS-6 regarding the avoidance of lack of concentration is altered, in agreement with Pierce and Perry [13] regarding time management and impaired concentration in incontinent women [13].

In the first dimension, an average score of 2.6 can be observed among those interviewed regarding the achievement of finishing work despite urinary incontinence, showing disagreement or indifference to this statement. This aspect is consistent with the study by Fultz [5] and Coyne [27], who suggest that the symptoms of urinary incontinence affect work activity and are comparable to other serious chronic diseases, such as asthma or rheumatoid arthritis [5,27].

Regarding the perceptions of the consequences of urinary incontinence as a predisposing factor for presenteeism, the relevant statements of the respondents are similar to the results of other research. In his systematic review, Lin KY (2018) and Rapariz [28], in his multicenter study of women aged 18 to 65 who are occupationally active, show that the impact that lower urinary tract symptoms have on the deterioration in work productivity is significantly higher, especially in those women with urinary incontinence, compared to those without this condition [28,29]. Also, the symptoms most affecting work activity were increased voiding frequency and voiding urgency [5,29].

The professions with significantly higher rates of presenteeism correspond to those who work in clinical functions due to institutional duties and the responsibility acquired with the patient and the work team [7,11,30,31]. This is evidenced by the fact that the women interviewed refer to different problems related to work and insecurity in the social dimension with their peers due to urinary incontinence, considering extra efforts during their working day in the intimate sphere.

The strength of this study is its originality in bringing together two scarcely studied topics with a mixed methodology. On the one hand, presenteeism in health personnel, and on the other hand, urinary incontinence as a predisposing factor, make visible the importance for organizations and public health of providing an effective response to urinary incontinence. Analyzing the phenomenon from two methodologies allows the triangulation of the data obtained, providing information on a clinical situation of high prevalence and known risk factors. However, very few programs allow for early prevention and/or timely and accessible treatment, thus achieving a broader perspective on the problem and validating the results by finding common ground.

One of the limitations in conducting the study was the difficulty in obtaining the number of volunteers for the sample. It was assumed that, since urinary incontinence is a highly prevalent clinical condition and the interviewees were healthcare workers, it would be simple to obtain the sample size. However, due to the social stigma that prevails about women with urinary incontinence and the fact that the interviewees had to state their work experience, several potential interviewees declined to participate. Another limitation is the mixed methodology used in this study since it makes it difficult to compare results with international studies due to the methodological difference in design, heterogeneity of the sample, or the data collection instruments based on productivity questionnaires. Furthermore, there are no national studies with which to compare our results.

The modern lifestyle, characterized by immediacy and the permanent search for quality of life in the work environment, invites organizations to consider in their management improvements the promotion of workers' health at all levels of the organization [32], inclusive conditions in infrastructure, work modality or schedule that allow to reduce absenteeism (absence) and presenteeism due to illness. Concerning the above, the United Nations Sustainable Development Goal No. 8 for 2030 mentions "promoting sustained, inclusive and sustainable economic growth, full and productive employment and decent work for all" [33], so it is recommended that further studies on this issue be conducted in order to provide more and better evidence to public policy-makers and decision-makers. It is also recommended that economic evaluations be carried out to determine the costs and benefits of urinary incontinence prevention programs in primary health care.

Conclusions

In order to fulfill their work obligations and maintain the technical quality of clinical care, incontinent women in health care use individual strategies to ameliorate impact. However, these adaptive responses make urinary incontinence invisible. Women carry this pathology in silence because of the shame or stigmatization it entails. Consequently, the lack of consultation or awareness of this clinical situation prevents understanding it as an occupational health problem that affects a significant number of women in Chile.

Considering that both the personal affectation of urinary incontinence and the presenteeism caused by it are subjective and multidimensional experiences, the results of our study suggest that urinary incontinence harms the work performance of women who suffer from it. Future research with a statistically significant population, different clinical areas of work, and sociodemographic conditions are recommended to provide empirical evidence on the association or effect of urinary incontinence with other variables on presenteeism. Further data may identify predictor variables of economic losses that allow intervention in improving the work area, along with their impact and implications on the health of workers and on the productivity and safety of patients.