The sick treating the sick: HCWs pressured to work ill
Clarify sick policies to fight entrenched presenteeism
Employee health professionals must work with clinical colleagues to develop clear, supportive policies that clarify when ill healthcare workers should take a sick day rather than expose vulnerable patients and co-workers, researchers recommend.
Recent studies suggest that working while ill is surprisingly common, as healthcare workers with symptoms such as high fever, diarrhea, and even confirmed flu infection report for duty.
“There is no national data — no system that reports this to the CDC, but this clearly occurs everywhere,” says Jeffrey R. Starke, MD, infection control officer at Texas Children’s Hospital in Houston.
For the most part, ill healthcare workers know they could be putting their patients and co-workers at risk of infection. Ironically, concerns for co-workers and patients are often cited as the prime reasons to work sick, with the perception being that patient care will suffer and colleagues will be overly burdened by the absence of the ill. A recently published survey captured this paradox, with 95% of physicians and nurses conceding that working sick puts patients at risk — yet 83% admitted doing so at least once in the prior year.1 Indeed, 9.3% reported working ill at least five times in the previous year. The study, conducted at Children’s Hospital of Philadelphia (CHOP), found that 57% were uncertain what constitutes “too sick to work.”
Starke and co-author Mary Anne Jackson, MD, infectious disease director at Children’s Mercy Hospital in Kansas City, MO, emphasized in an editorial accompanying the study that it is essential for occupational health and infection control departments to identify what constitutes being too sick to work at their facilities.2
“There are not well-defined protocols that [state] when healthcare workers must stay home while ill,” Jackson says. “Many hospitals identify febrile respiratory illness as one criterion but allow for return to work when fever abates. The absence of fever does not [necessarily] equate to absence of risk for viral transmission. In the editorial, we suggested other potential symptoms or signs — jaundice, bloody diarrhea. Clearly, more research is needed to help define such criteria and evaluate how effective these criteria would be.”
As work cultures and peer pressure push sick workers to the bedside, the worst-case scenario is completely predictable: Frail patients will be infected by their caregivers. “The medical literature includes numerous reports of outbreaks for which symptomatic [healthcare workers] have been found to be the ultimate source of disease within healthcare facilities. Such infections include influenza, whooping cough, norovirus, and the drug-resistant superbug MRSA,” the CHOP authors concluded.
Starke has seen such cases firsthand.
“I have done infection control at Texas Children’s for 20 years and we have clearly had incidences where we had a transmission of viruses to children from ill healthcare workers,” he says. “There’s no question about it. It’s not a question of if it happens — it does. The bigger question is, how often does it happen?”
It can be hard to quantify the overall protective effect of healthcare immunization to patients and coworkers, particularly as the seasonal flu vaccine varies in efficacy depending on the match with circulating strains. However, there is clear evidence of the devastating consequences of hospital-acquired influenza in high-risk populations. In a NICU outbreak, six babies were infected and one died. Some among the poorly immunized group of caregivers admitted working while ill, with only 14% reporting they stayed home with an influenza-like illness.3 In an outbreak in a bone marrow transplant unit, six patients developed pneumonia and two died.4 Five staff members developed influenza-like illness during the outbreak, and overall there were seven cases of occupationally acquired influenza in a staff with paltry immunization rates.
Given such outbreaks, it was concerning to see how more than one-third of physicians recently surveyed said they would work with test-confirmed influenza. The unpublished study, presented recently in San Diego at the 2015 IDWeek conference, found that 36% of responding physicians said they would work even if they had lab-confirmed influenza.5 The findings were skewed by level of training, with 51% of fellows saying they would work with confirmed flu as opposed to only 16% of attending physicians. Overall, the 474 physicians responding to a survey included 88 medical students, 193 residents, 40 fellows, and 153 attending doctors. Surgeons and emergency room physicians were the most likely to show up regardless of condition.
While the interdepartmental findings may vary by institution, the overall finding of physicians willing to work while sick is probably similar in other facilities, says Shruti K. Gohil, MD, one of the authors of the study and associate medical director of Epidemiology & Infection Prevention at the University of California, Irvine School of Medicine. “We got a pretty good slice of the pie with a 61% response rate,” she says. “Intuitively, [the results] were not surprising to me.”
The findings make a strong case for mandating flu vaccination for healthcare workers, a position that the American Academy of Pediatrics vigorously endorsed in a recently issued position paper. The IDWeek study led to a policy at UC Irvine that calls for physicians and other healthcare workers to stay home if they have any of the following symptoms:
- fever greater than 101,
- active diarrhea/vomiting, and
- confirmed contagious illness (e.g. flu).
In addition to having a clear definition of what constitutes too ill to work, 70% of the physicians in the UC Irvine survey said the following factors would improve their willingness to stay home if ill:
- department chair/chief sets protocol for what to do if ill,
- seeing colleagues sent home if working ill, and
- a lack of negative repercussions when physicians stay home if ill.
In the absence of such symptomatic definitions and supportive policies, employee health professionals should be aware that healthcare workers might be caring for patients alongside co-workers despite having fever, diarrhea, vomiting, or flulike illness. Nurses will certainly work sick, but the culture among physicians appears to be more engrained.
“The logistical problems of finding coverage are often problematic for physicians,” Jackson says. “There’s also a culture among residents and physicians that suggest that those who do not show up because of illness are not pulling their weight. Many often have a personal mindset that they are indispensable. While most understand the potential risk of working while ill, the full extent of the risk to [patients] with various conditions is not explicitly defined.”
“[The physician work] culture is not gender-based — it’s just as strong in women as in men,” Starke says. “Unless you are on death’s doorstep, you are supposed to be there doing your job.”
How powerful is the temptation for physicians to work while sick?
Even distinguished epidemiologist William Schaffner, MD, admits he once showed up with flu to begin working his shift as a young resident. Now a leading national vaccine advocate and professor of preventive medicine at Vanderbilt University in Nashville, Schaffner recalls being infected with influenza and a temperature of 103.
“I was a macho young guy and sure enough, I showed up ready to go to work and do my shift,” he says. “My chief resident took one look at me and wisely sent me home. Having done that, I know that others do that. Healthcare workers do come to work sick. It happens so frequently that they have a name for it: presenteeism.”
The aforementioned CHOP study included responses from 280 attending physicians and more than 250 advanced practice clinicians (APCs), including certified registered nurse practitioners, physician assistants, clinical nurse specialists, and other highly trained healthcare providers. This APC group was consistently less willing to work ill than their physician colleagues, with 20% vs. 39% saying they would work with diarrhea; 10% vs 22% for fever; and 51% vs 60% with acute respiratory symptoms.
Though some hospitals are stepping up to address the problem, other hospitals have policies that include disincentives to stay home if ill. The survey found that 56% of doctors and nurses felt supervisors in their departments were “not supportive” of staying out sick.
“There are actually hospitals that have punitive policies and make people take their own time off before they can take sick days or if they are out more than a day or two you have to get a doctor’s note,” Starke says. “There are some punitive elements to this.”
For the most part, however, healthcare workers honor the engrained expectations of their work culture, with the survey study reporting 61% of all respondents cited a strong cultural norm to come to work unless remarkably ill. More insidious, 64% of the physicians and nurses feared they would be ostracized by colleagues if they missed work.
“Respondents recounted critical comments made by colleagues about those who take sick leave, stories of working (or seeing others work) while so ill that they needed intravenous hydration, and the general impression of an unspoken understanding that attending physicians and APCs should ‘buck up’ and work,” the authors of the CHOP study concluded.
Staffing concerns were cited by 94% overall, suggesting both physicians and nursing specialties have thin reserves of supplemental staff.
“A lot of hospitals have cut back on staff so much to save money, the margin if you will, has been drastically cut,” Starke says. “I personally feel that hospitals have a duty to make sure that their work force is healthy.”
In that regard, hospitals could plan ahead for replacing ill staff during the winter months marked by colds and flu, he says.
“This is predictable because you know the majority of these illnesses are going to occur between November and March,” Starke notes. “Unfortunately, hospitals tend to be full at that time as well, as people in the community are getting sick — especially with influenza. The point is you can look at your staffing patterns and do some planning and account for the fact that a certain percentage of your employees are going to be out at any given time [during this period].”
If the presenteeism culture is so entrenched that healthcare workers are going to continue to show up sick even with clear and supportive sick policies, the best single practice to advocate is hand hygiene. At Texas Children’s, a major institutional effort pushed compliance with hand washing toward 100%, drastically reducing hospital-acquired respiratory infections in patients, Starke says.
“The vast majority of respiratory viruses are transmitted through direct contact,” he says. “In fact, they are not particularly airborne — though influenza is a little different in that it can be spread through droplets through the air that can go several feet. So if every healthcare worker got immunized for flu and then if we really do a superb job with hand hygiene, we would block the vast majority of transmission of viruses from healthcare workers to patients.”
REFERENCES
- Szymczak JE, Smathers S, Hoegg C, et al. Reasons why physicians and advanced practice clinicians work while sick: A mixed methods analysis [published online ahead of print July 6, 2015]. JAMA Pediatr doi:10.1001/jamapediatrics.2015.0684.
- Starke JR, Jackson MA. When the health care worker is sick: primum non nocere [published online ahead of print July 6, 2015]. JAMA Pediatr. doi:10.1001/jamapediatrics.2015.0994.
- Cunney RJ, Bialachowski A, Thornley D, et al. An outbreak of influenza A in a neonatal intensive care unit. Infect Control Hosp Epidemiol. 2000;21(7):449–454pmid:10926394.
- Weinstock DM, Eagan J, Malak SA, et al. Control of influenza A on a bone marrow transplant unit. Infect Control Hosp Epidemiol. 2000;21(11):730–732pmid:11089659.
- Trunong KK, Huang, SA, Dickey Linda, et al. Do no Harm: Attitudes among Physicians and Trainees about Working when Ill. IDWeek. Session 53. HAI: Occupational Health. San Diego, CA. Oct.7-11, 2015.
Employee health professionals must work with clinical colleagues to develop clear, supportive policies that clarify when ill healthcare workers should take a sick day rather than expose vulnerable patients and co-workers, researchers recommend.
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