workload and stress, saw increased levels of presenteeism. Certain work environments may stimulate presenteeism. To explore this topic, Dew, Keefe, and Small qualitatively examined a private hospital, a large public hospital, and a small factory. In the private hospital, there was little pressure from management to exhibit presenteeism; however, a sense of family seemed to exist between the staff, and a strong loyalty to coworkers pushed employees to come to work while unhealthy. The public hospital had a distant management, but presenteeism was fostered by "loyalty to professional image, colleagues, and the institution as a whole." Finally, in the factory, there was strong pressure from management for employees to exhibit presenteeism. Furthermore, workers often had few other employment options, which often resulted in increased presenteeism. Ease of replacement The ease with which one can be replaced on the job also affects levels of presenteeism. Specifically, if one feels that he or she cannot be replaced, that individual is more prone to attend work while sick. Doctors are often examined in this regard. For example, Jena et al. studied residents in training and noted high rates of presenteeism, which they concluded were the result of feeling irreplaceable. Further extending the examination of the medical field, McKevitt, Morgan, Dundas, and Holland studied hundreds of healthcare professionals and found that more than 80 percent of respondents had worked while ill. Individuals listed some of the reasons they had not taken sick days, and many cited the fact that they felt large pressure to work. In some cases, general practitioners did not want to burden their partners, and many felt a strong commitment to the job that prevented them from taking sick leave. Workloads and job demands Jobs that have large workloads and many demands are often associated with higher levels of presenteeism. Caverely, Cunningham, and Macgregor studied Canadian firms and noted that presenteeism was often not the result of job insecurity. Instead individuals felt they had to come to work while ill or injured because they believed they had high workloads, many deadlines, and often very little backup support. Complementing this finding, McKevitt et al. also found that individuals feared their work would pile up if they did not go to their job. Moreover, Demerouti, Le Blanc, Bakker, Schaufeli, and Hox examined job demands and found that they had a positive relationship with presenteeism. In the case of this study, the authors defined