With the rapid growth of healthcare demands and the acceleration of population aging, China's nursing workforce has long been under strain (1). Under the “patient-centered” care model, nurses face dual pressures from high workloads and emotional labor (2). Presenteeism, defined as attending work despite health issues that normally require rest, has become increasingly common among nurses. This is compounded by a cultural perception in Chinese workplaces where “engaging in work duties despite illness” (3, 4). The concept of presenteeism was first introduced by Professor Cooper in 1996, describing employees who continue working despite physical or mental unwellness (5). The results of a recent Meta-analysis showed that the overall estimate of the global detection rate of hidden absenteeism among nursing staff was 49.2% (6). Nurses are recognized as a high-risk group for work-related stress. They often face time pressure, role conflict, and overload (7). The occurrence of hidden absenteeism not only negatively affects nurses' personal health, quality of life, and well-being index, but also professionally causes a decrease in work motivation, mental acuity, and communication skills, as well as possible adverse consequences for patient safety and quality of care (8). Due to the influence of traditional thinking and culture, China still largely promotes the idea of “working with illness” and recognizes it as a form of professionalism. However, Lui et al. (9) that the seasonal influenza-associated surge in hospital occupancy in Hong Kong resulted in an implicit absenteeism productivity loss for nurses in three hospitals of ~US$24,096/year, which is one of the high costs reported in global healthcare workforce studies. Another survey of employees from different industries in China and the UK showed that Chinese employees exhibited higher levels of hidden absenteeism than UK employees (10). Therefore, it is important to conduct a study on hidden absenteeism in the nurse population based on the cultural context of China.

Professional self-concept plays an important central and driving role in one's career choice and professional development, and is a reflection of self-concept in professional choice and professional development (11). It comes from an individual's knowledge of self and of the profession, and on this basis, it forms an individual's attitude toward the profession, sense of professional responsibility, professional ideals, professional ethics and professional values (12). The formation and development of professional self-concept occurs throughout a person's life, develops with physiological and psychological growth, and develops gradually based on the individual's observation and experience of the profession, and the family, school, and society also have a certain influence on the formation of the individual's professional self-concept (13).

Perceived social support refers to a psychological experience in which an individual subjectively feels that he or she is understood, respected, and able to receive help and support from others in the process of interacting with others (14). Research has shown that those individuals with higher perceptions of social support tend to be more likely to gain emotional understanding and help from their surroundings, thus accumulating more positive psychological resources (15). A related study found an association between higher levels of perceived social support and higher work efficiency as well as lower attendance list behavior (16). According to conservation of resources (COR) theory, when individuals perceive a threat to their resources (e.g., time, energy, self-efficacy, or social support), they feel stress and may adopt maladaptive behaviors such as presenteeism as a compensatory strategy (17). In nursing, a weak occupational self-concept may imply a depletion of personal resources (e.g., confidence, professional identity), whereas lower social support may reflect a lack of external resources. Both conditions may increase the likelihood that presenteeism will occur. However, current research has under-explored the relationship between occupational self-concept, social support, and presenteeism.

Based on the above theoretical model, this study took nurses' professional self-concept and social support as independent variables and hidden absenteeism as dependent variable and proposed the following hypotheses: hypothesis 1: nurses' professional self-concept is negatively correlated with hidden absenteeism; hypothesis 2: nurses' perceived social support is negatively correlated with hidden absenteeism; and hypothesis 3: social support mediates the relationship between professional self-concept and hidden absenteeism (Figure 1).

This study is the for the first time, the effects of professional self-concept and perceived social support on presenteeism were examined simultaneously in a group of Chinese nurses to provide a reference basis for improving nursing quality and ensuring patient safety.

Presenteeism is a well-recognized public health concern due to its close link to health outcomes and has been studied across various occupational groups (25). Nurses represent a typical population experiencing high rates of presenteeism (26). A meta-analysis of 28 studies from 14 countries reported a nearly 50% overall prevalence of presenteeism among nurses (6). This highlights the widespread nature of the issue within the nursing profession. For example, a cross-sectional survey in Switzerland found an 84.3% prevalence among nurses and midwives (27). Similarly, in China, Li et al. (28) surveyed 3,491 nurses across 14 hospitals in Shandong Province and identified a 70.6% prevalence rate. These findings underscore the global nature of presenteeism among nurses. Growing evidence highlights the detrimental effects of presenteeism, which outweigh its benefits. It not only impairs nurses‘ physical and mental health but also increases patient safety risks, reduces care quality, and may result in greater economic losses than absenteeism (26, 29, 30). This study examined the relationship between professional self-concept, perceived social support, and presenteeism among Chinese nurses. Therefore, understanding nurses' current status and needs can help address presenteeism among nursing professionals, reduce absenteeism disguised as presence, and play a crucial role in enhancing clinical care quality, stabilizing the nursing workforce, and minimizing productivity losses.

The total presenteeism score in this study was 15.14 ± 4.58 points, which was lower than the 21.00 ± 4.3 reported by Shdaifat (31). The total career self-concept score in this study was 86.79 ± 11.01 (moderate), which was higher than the results of Cho et al.'s (13) study in Korea (69.92 ± 7.19). This discrepancy may stem from cross-national cultural differences in language, educational systems, or cultural values. Our demographic analysis of presenteeism identified high-risk groups among nurses with heavy workloads, significant economic pressures, and insufficient support. In China, older nurses are more likely to have permanent positions or long-term contracts that guarantee a stable income and predictable retirement benefits. This institutional protection reduces the financial pressure to work during periods of illness. In contrast, younger nurses, especially those on short-term or agency contracts, may face performance-based pay and the threat of non-renewal, making “presenteeism” a rational survival strategy (32). Specifically, internal medicine nurses exhibited significantly higher presenteeism scores than surgical or operating room nurses. Nurses working night shifts or reporting “very high” workloads showed increased presenteeism due to physiological fatigue and diminished focus. Psychological and economic factors were particularly salient: nurses expressing “very dissatisfaction” with compensation or facing “severe financial strain” experienced reduced productivity due to burnout or financial distraction. Conversely, those satisfied with salaries and in stable economic conditions demonstrated lower presenteeism risks due to positive mindsets (33, 34).

Studies show that examining nurses' professional self-concept advances research on job satisfaction and occupational stress. A positive professional self-concept in nursing fosters higher occupational identity, job satisfaction, and reduces burnout and turnover intentions. Nurses with stronger professional self-concept exhibit greater professional identity and belonging, facilitating career adaptation and growth (12, 35, 36). This study reveals a “high at both ends, low in the middle” pattern in perceived social support differences. Younger nurses (< 25) may receive more mentorship, while those ≥40 gain respect through seniority. Nurses aged 35–39 reported lower perceived social support, possibly due to mid-career stressors like promotion barriers and work-family conflict, though this remains speculative without interaction testing. Occupational factors also matter: administrative roles and permanent positions offer greater resources, while night shifts and long hours limit social interaction. Economic status influences support too-higher income and financial comfort enhance perceived support, whereas dissatisfaction with pay or financial strain may reduce it, creating a negative cycle (37–39). However, it is important to note that this interpretation remains speculative, as the current study has not yet conducted statistical tests for interaction effects (age × social support) to empirically validate this relationship.

The study findings revealed a significant negative correlation between total perceived social support scores and presenteeism scores. Specifically, dimensions such as family support, friend support, and other forms of support (e.g., from colleagues, supervisors) all showed significant negative correlations with presenteeism. This suggests that perceived social support is predictive of lower levels of presenteeism behaviors in nurses. Nurses with strong family support can obtain adequate rest and care outside of work, maintaining physical and mental well-being for their job. Those with robust friend support gain emotional encouragement and advice during work pressures, enhancing their stress-coping abilities. Other forms of support, such as assistance from colleagues and supervisors, help nurses address practical challenges, improve job satisfaction, and ultimately reduce presenteeism (16, 40).

Hierarchical regression analysis identified surgical departments as a consistent predictor of presenteeism. High-risk environments, frequent emergencies, and prolonged standing in surgical units may lead to chronic fatigue and mental detachment, increasing presenteeism (e.g., reduced focus) (41). The positive link between perceived workload and presenteeism suggests compensatory behaviors (e.g., task delays) to manage overload. Self-rated workload measures, however, may introduce bias; future studies should incorporate objective metrics (e.g., surgeries per hour) (42). The persistent significance of management skills (Models 2–3) highlights self-efficacy's role: strong planners reduce disorganization-related presenteeism. Models 1, 2, and 3 explained 6.6%, 16.1%, and 17.4% of presenteeism variance, respectively. Adding professional self-concept (particularly management skills) increased explanatory power from 6.6% to 16.1%. The results of the regression model in this study showed limited explanatory power. And the omission of relevant variables that were not measured in this study may have affected the variance explained by the model. For example, in a study by Demerouti et al. (43), the inclusion of variables such as job resources (e.g., job autonomy, social support) and individual resources (e.g., optimism, self-esteem) explained about 25% of the variance in presenteeism. In addition, Bergström et al. (44) showed that the variables of work environment, health status, and job stress explained about 30% of the variance in presenteeism. Another study conducted by Aronsson and Gustafsson (45) showed that the variables of job insecurity, sense of organizational fairness, and health status significantly predicted the occurrence of presenteeism. These studies suggest that presenteeism is a complex phenomenon influenced by multiple factors. The limited inclusion of variables in this study may have limited the model's ability to capture the true complexity of the phenomenon. Therefore, future studies should consider incorporating additional variables that may contribute to the variability of presenteeism.

Our study found that perceived social support was a mediator between professional self-concept and presenteeism, and that perceived social support and professional self-concept were negatively related with presenteeism. Lin et al. (46) surveyed 468 registered nurses in Sichuan Province, China at Level IIIA and showed that presenteeism was negatively related to perceived social support. The above findings are consistent with our findings. However, the relationship between professional self-concept and presenteeism has not been studied yet. This study on perceived social support playing a role in professional self-concept and presenteeism has important implications for nurses. This can be explained by COR, where social support can be considered as a psychological resource (47). And professional self-concept can be considered as an important internal energy resource for nurses (48). This reflects their recognition and confidence in their professional competence and professional value. This positive self-concept is associated with more efficient coping with work challenges among nurses and may predict lower resource consumption linked to self-doubt or competence anxiety, thus showing an inverse relationship with presenteeism (33). The role of perceived social support as a mediating variable in this study further supports the logic of “resource interaction” in COR theory: nurses with a strong professional self-concept are more likely to establish and perceive social support around them (i.e., intrinsic resources facilitate access to extrinsic resources), and such activated resources of social support will further enhance their ability to cope with stress. However, frequent presenteeism may likewise lead to a gradual weakening of self-concept. This finding provides implications for nursing management practice: reducing nurse presentism should not only focus on adjustments at the individual level, but should also be considered from a resource conservation perspective. We should enhance nurses' professional self-concept through professional training and professional identity education (strengthening internal resources), and on the other hand, we should build a perfect social support system (supplementing external resources), such as optimizing the teamwork mechanism, establishing a leadership care system, improving family-work balance support, and so on. On the other hand, it is necessary to build a perfect social support system (supplementing external resources), such as optimizing the teamwork mechanism, establishing a leadership care system, and improving the family-work balance support. Through the synergistic protection of internal and external resources, we can more effectively reduce presenteeism and maintain the physical and mental health of nurses and the quality of nursing work.

This study found that nurses' occupational self-concept, perceived social support and presenteeism are negatively correlated, and that social support partially mediates the relationship between occupational self-concept and presenteeism. Based on this finding, the following specific and evidence-supported policy recommendations are put forward for hospital administrators: establish a mentorship program for early-career nurses, and help early-career nurses understand their occupational roles, abilities, and values more clearly by providing them with guidance through experienced nurses. For early career nurses, a mentorship program should be established to help early career nurses have a clearer understanding of their professional roles, abilities and values through the guidance of experienced nurses, so that they can strengthen their professional self-concept and reduce the likelihood of attendanceism. The role of social support in mitigating attendanceism; the assessment of professional self-concept and perceived social support is incorporated into the daily management system of nurses, so as to regularly understand the status of nurses in these two aspects, and for nurses with deficiencies, targeted interventions are taken in a timely manner, such as carrying out career development training, providing psychological counseling, etc., so as to reduce the phenomenon of attendanceism from an overall perspective.

While this study offers new insights for nursing management, limitations exist. This study has limitations in regional sampling. Differences exist in medical resource allocation, nursing work environments, work pressures and career development opportunities across regions and between medical institutions of different levels, which may affect nurses' professional self-concept, social support and presenteeism. Since samples only come from tertiary hospitals in Guangdong Province, whose nurses differ greatly from those in primary medical institutions or rural areas in work scenarios and professional experiences, the conclusions on the correlation between the three can only reflect the situation of nurses in such hospitals and cannot be directly extended to others, thus limiting the universality of the research conclusions to a certain extent. Therefore, the follow-up study will consider expanding the geographic scope to include samples of nurses from more provinces and different levels of healthcare institutions (including first- and second-level hospitals and healthcare institutions in rural areas, etc.), to further validate the applicability of the findings of the present study by comparatively analyzing the relationship between occupational self-concept, social support, and presenteeism among the different groups, and to enhance the generalizability and generalizable value of the findings.

This study adopted a cross-sectional design. It only collected data on nurses‘ professional self-concept, social support and presenteeism at a specific time point, and then analyzed the associations among the three. It should be made clear that such associations only reflect the coexistence relationship between variables and do not equal causal relationships. Because the cross-sectional design could not track the dynamic changes of variables over time, nor determine the order of variables, it was impossible to infer whether changes in nurses' professional self-concept or social support led to changes in presenteeism, or whether the status of presenteeism affected their professional self-concept or the social support they received. In view of this, future studies can consider adopting a longitudinal design. By tracking the same group of nurses for a long time and collecting data at different time points, they can explore the possible causal relationships among the three more deeply, so as to provide a more solid theoretical basis for the formulation of relevant intervention measures.