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Should Providers Work When Sick?

By Mike Bassett

Financial concerns as well as those related to adequate patient and professional responsibility coverage can influence providers' decisions to work when they themselves are ill.

The problem of presenteeism among health care workers has long been acknowledged but persists as a significant concern.

In a study published in November 2017 in the American Journal of Infection Control, researchers led by Sophia Chiu, MD, MPH, of the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health, found a large percentage of health care professionals (HCPs) neglects to follow the advice they give to their patients: stay home when you are sick.

"The main takeaway from the study is that more than 40% of health care personnel who had flulike symptoms worked while they were sick," says Chiu, who called the numbers alarming and suggested that health care facilities take steps to encourage staff not to show up to work while they are sick.

The study, conducted via a national online survey, collected data from 1,914 HCPs—including physicians, nurse practitioners, physician assistants, nurses, pharmacists, and assistants and aides—during the 2014–2015 influenza season. Respondents to the survey self-reported influenzalike illness (ILI) and listed reasons they continued to report to work while sick.

Of the 1,914 HCPs surveyed, 414 reported ILI, and of those 414, 41% reported working for a median three days while experiencing influenzalike symptoms.

Hospital-based HCPs had the highest frequency of working with ILI (49.3%), compared with HCPs at long term care facilities (28.5%). Clinical professional HCPs were the most likely to work with ILI (44.3%), with pharmacists (67.2%) and physicians (63.2%) among those with the highest frequency.

The researchers also found that assistants and aides (40.8%), nonclinical HCPs (40.4%), nurse practitioners/physician assistants (37.9%), and other clinical HCPs (32.1%) worked while sick.

In addition, previous published results from the survey indicated that only 77.3% of respondents reporting having received a flu shot.

"Despite a relatively small sample size, these numbers seem to be about right to me," says Khai Nguyen, MD, MHS, HMDC, clinical services chief of geriatrics at University of California San Diego Health. "They may even be understated in some circumstances, but it is quite true on the inpatient side that [HCPs] will be less likely to miss days due to illness."

Is There a Rationale?
Why do HCPs show up to work when they are ill? "The most common reasons [HCPs] work while they are sick is that they didn't feel sick enough to miss work, and still felt able to perform their jobs," Chiu says. "Other reasons mentioned in the survey included feeling like they weren't contagious, sensing a professional obligation to be at work, or having difficulty finding a coworker to cover for them."

Among HCPs in long term care settings, 49.8% of those who reported for work while sick said they did so because they couldn't afford to lose pay.

According to Nguyen, there are other potential factors at play when looking at the issue of presenteeism among HCPs who provide care for older adults. "It is often difficult for geriatric patients to make their appointments," Nguyen says, noting that last minute cancellations due to illness among HCPs can adversely affect older patients.

"Also, there are already access issues related to geriatric patients in the health system," he says, adding, "The problem is certainly exacerbated when health care providers can't make it to work."

And there have been several studies suggesting that presenteeism can be a particularly severe problem among workers in long term care facilities. In a 2000 study published in the Journal of Epidemiology and Public Health, researchers found that nursing home aides were among workers with the highest rates of working while sick.

In a 2010 study by Widera and colleagues published in the Journal of General Internal Medicine, researchers examined the outbreak of viral gastroenteritis in a long term care facility and the role presenteeism played in transmitting the disease and extending the outbreak. They found during the course of a norovirus outbreak that ill staff members continued to work despite recommendations to the contrary and that voluntary measures to prevent presenteeism failed. This forced the local department of public health to mandate the enforcement of back-to-work rules, which forbid employees' return to work before 48 symptom-free hours had elapsed.

Another study of a norovirus outbreak—this one in 2007 at a long term residential facility in Oregon—found that 94% of surveyed workers had gone to work when ill, and 8% had actually vomited while at the facility.

A 2001 survey of more than 1,000 Norwegian physicians published in the Scandinavian Journal of Public Health found that during a calendar year, 80% had gone to work with an illness for which they would have "sick listed" a patient.

Inherent Risks
What are the risks involved in continuing to work in health care settings while ill? First, according to Nguyen, there's the obvious possibility that a sick health care worker can spread his or her illness to patients as well as coworkers. And despite the fact that an HCP might do this for the purest of reasons, she might run the risk of alienating coworkers and patients by showing up to work when sick.

"And medical decision making and medical care could potentially be compromised," he says. "Or at least give the impression [to patients] that their health care provider is not up to the task." And when it comes to older adults, Nguyen says, HCPs need to remember that "they have weaker immune systems and are more likely to die or develop greater morbidity from influenzalike illnesses."

As to effectively addressing the issue of presenteeism, Chiu suggests that employers should update sick leave policies and clearly communicate workplace policies regarding showing up at work while ill.

In the study by Widera and colleagues in the Journal of General Internal Medicine, the researchers' first recommendation for dealing with this issue was "to ensure the availability of unrestricted paid sick leave for all employees working in a health care setting in order to decrease the financial pressure to return to work when ill."

Widera and his colleagues also suggest that other logistical challenges need to be addressed in order to reduce presenteeism. For example, policies with strict back-to-work rules should be accompanied by adequate staffing and coverage of health care personnel "to limit feelings of personal responsibility that encourage presenteeism."

Nguyen suggests that health care facilities could take the following steps to reduce the incidence of presenteeism:

• Have strict protocols in place regarding presenteeism that clearly set out rules and expectations.

• Follow the protocols.

• Ease any barriers that prevent HCPs from taking days off when needed.

• Institute immunization requirements.

• Institute and enforce strict mask/glove protocols to prevent transmission of ILI.

In a recent article in Perspectives on Safety, a publication published by the Agency for Healthcare Research and Quality, Julia E. Szymczak, PhD, an assistant professor of epidemiology at the Perelman School of Medicine at the University of Pennsylvania, makes the point that change must involve changes in culture as well as logistics.

"Although the decision to come to work while ill appears at first glance to be an individual choice, it is highly social in nature," Szymczak wrote. "Health care workers are frequently caught between a rock and a hard place when it comes to presenteeism. Both logistic resources and social supports are required to make the choice to prioritize patient safety in this case the easy one."

— Mike Bassett is a freelance writer based in Holliston, Massachusetts.