Sick of Going to Work Sick
Imagine this scenario. You are an experienced, professional registered nurse who works the night shift in the coronary care unit. Every night, the hospital, the physicians, and everyone else depend on your acute assessment skills and your sound professional judgment to monitor very sick patients, detect the status changes that might precede deterioration, and take steps to ensure that your patients do not come to harm. Today, at 4:00 pm, you wake up with a sore throat, fever, and malaise. You call your supervisor and say that you are sick and cannot work tonight. The response? "You will need a doctor's note, or you won't be paid."Seriously? The health and fate of scores of sick patients are regularly placed in your hands, but you are incapable of determining whether you are too sick to go to work? It would be comical if it wasn't such a serious and frequent problem. Every shift, every day of the year, nurses and physicians are compelled, through fear, guilt, or intimidation, to go to work when they are sick (known as "presenteeism"). And although healthcare employers profess to decry presenteeism, their policies and responses when employees call in sick suggest otherwise.
The news report "Many Docs Come to Work Sick: Survey", described a survey that found that many doctors, nurses, midwives, and physician assistants routinely go to work sick primarily because there is no coverage, and they don't want to abandon their colleagues or patients. More than 95% believed that working while sick puts patients at risk, but 83% still said they had gone to work with such symptoms as diarrhea, fever, and respiratory complaints during the previous year. Doctors were more likely than nurses or physician assistants to work while sick. Many expressed a strong cultural norm to go to work unless extraordinarily ill. This report provoked a swift and strong reaction from Medscape readers, beginning with the nurse (at work, sick) who found the news timely:
I am the first to say "shame on me" for coming to work today. I am so sick that I cannot stop coughing. Why am I here? We have an "attendance management program." If I am sick "too often," I will automatically be enrolled in this program to help "manage my sick time." My horribly inappropriate reasons for being absent earlier this year were chicken pox and whiplash following an accident. I guess I am just another nurse trying to "suck it up" today, and infecting my fellow nurses, to avoid disciplinary measures. My boss can clearly see and hear how sick I am yet has not offered to send me home.
The Guilt Trippers
Commenters overwhelmingly agreed that a strong motivation for going to work sick was the lack of coverage for the unit and the guilt that this engendered. Calling in sick invariably leaves your unit short-staffed. Knowing that you won't be replaced, and that your peers will have to carry the added burden created by your absence, is often enough to prompt clinicians to take acetaminophen or cough and cold preparations and drag their ill bodies into work. It is an age-old problem. "I have been a nurse for 43 years and nothing has changed," wrote a nurse. "There is no one to cover if you call off. Or your absence compels another nurse to work 14 days in a row or a 16- to 24-hour shift." Healthcare employers rarely make contingency plans for illness among the workforce. A Medscape reader wryly commented that nurses don't have the type of job in which we can just say, "No big deal if we don't give the meds today—we can catch up tomorrow."Physicians and other clinicians who see patients regularly have similar problems when they are sick. An optometrist wrote, "I come to work sick because I feel guilty for cancelling an appointment that someone may have waited 2 months for."
One Medscape reader believes that physicians are victims of their socialization and acculturation, which begin in medical school:
It has been made clear since the onset of their education that only the strong survive, that there are no replacements, everyone is needed every day, and that to need time off for personal or family illness is a sign of personal failure and weakness. Surgeries and clinics cannot be canceled; what can we tell the patients who are depending on us? This is institution-speak for how will we replace the revenue, and how will we deal with the disappointment and inconvenience of the patients? It makes little sense. Who wants a compromised surgeon operating or a sick nurse or physician providing care in the clinic or hospital?And a nurse added this: "I've caught some nasty viruses from sick doctors who should have been at home—I can appreciate their work ethic, but if I know when I'm not fit to work, why don't they?"
A family medicine physician agreed, saying, "We are too conscientious for our own good, and that of our patients! You can't heal anyone if you don't heal yourself first! And let's never forget: primum non nocere! Stay home when you are sick!"
In a sense, presenteeism is the response to a conflict of interest on the part of the nurse or other healthcare worker—the conflict between taking care of oneself (or family member) and fulfilling one's obligation to the workplace. Is it better to go to work and be "half a nurse," than no nurse at all?
Major nursing associations such as the American Nurses Association (ANA) do not have position statements on the issue of presenteeism, but they do have a code of ethics for nurses, which is particularly relevant to these issues. Thinking through the situation critically, and bearing in mind the nurse's ethical obligations to patients and to themselves, can be helpful. The ANA's newly revised Code of Ethics for Nurses With Interpretive Statements[1] states in part: "The nurse's primary commitment is to the patient." But what about the unit, coworkers, supervisors, and other colleagues who might suffer because of the nurse's absence?
Pertinent to presenteeism, the code of ethics addresses conflicts of interest directly, saying, "Nurses may experience conflicts arising from competing loyalties in the workplace, including conflicting expectations from patients...colleagues, [and] healthcare organizations... Nurses must examine the conflicts arising from their own personal and professional values, [and] the values and interests of others who are also responsible for patient care and healthcare decisions...Nurses address such conflicts in ways that ensure patient safety, and that promote the patient's best interests, while preserving the professional integrity of the nurse..."[1]
If the nurse is sick or otherwise unfit for duty, he or she may appropriately view it as an ethical obligation to not put patients at risk, either by exposing them to contagious illness or threatening their welfare by providing substandard care. The guilt that might accompany such a decision should be outweighed by the satisfaction of doing what is right for patients, not to mention coworkers who might become ill from close working contact with a sick colleague.
"You Are the Fourth Call-in"
Speaking of guilt, who hasn't heard this when calling in sick? Translation: "You are the straw that breaks the camel's back." What is the nurse supposed to say in reply? It always seems inadequate, but it's probably best just to whisper or croak, "I'm sorry," and hang up before the appeals to come to work anyway begin. Sympathy? Forget it. And the nurse who goes to work sick, hoping to be sent home, is delusional, according to readers.One of my colleagues was sick with a stomach bug at work and became so dehydrated from nausea, vomiting, and diarrhea that she required intravenous (IV) fluids. But because she was on the "weekend option" and we were short staffed, she had to stay. They gave her ondansetron to stop her vomiting and made sure her IV catheter was in her nondominant hand so that she could still triage laboring women and check cervixes with her right hand.Many nurses shared anecdotes about calling in sick and being pressured to reconsider. "I once called the house supervisor at 8:00 am to say that I would be too sick to work the evening shift. She began grilling me about whether I was really too sick to come in. Fortunately, I had a spontaneous episode of vomiting, and that ended the conversation." Another nurse, when the supervisor voiced skepticism about the need to stay home, countered by saying, "if the hospital can trust me to provide top quality care to patients, then they should respect my ability to know when I am too ill to work."
During orientation to the neonatal intensive care unit, a new nurse was concerned that her upper respiratory illness and constant, productive cough exposed her patients to infection but was told, "Everybody comes to work, sick or not. Wear a mask."
A few of the anecdotes describe behaviors bordering on bullying. A nurse who was sick on a holiday and couldn’t find anyone to take her place wrote, "I worked one Christmas with pneumonia and a fever of 104 degrees F. I tried to call in but was told that if I wasn't wearing a toe tag, I needed to come in or risk termination."
Administrators have reportedly been known to respond to sick calls or to nurses who become ill on the job with disbelief, anger, resentment, or coercion, all of which are unacceptable. All nurses, including those in administrative positions, must work hard to create "an ethical environment and culture of civility and kindness, treating colleagues, coworkers, employees...and others with dignity and respect. The standard of conduct includes an affirmative duty to prevent harm."[1] ANA's latest position statement, Incivility, Bullying, and Workplace Violence contains best-practice civility recommendations for registered nurses and employers.
"Sick" Policies (Pun Intended)
One reader objected to the idea that altruism induces doctors and nurses to go to work when they are sick. "They are afraid to call in sick not because of worries about a lack of coverage but owing to fear of incurring infractions and penalties assigned by punitive, draconian attendance policies." In other words, presenteeism is actually encouraged. Using sick time is certainly discouraged, as evidenced by the policies reported by nurse readers:- If you call in sick on a weekend shift, you are assigned a makeup weekend.
- If you call in sick on the last day before or the first day after any vacation time, you forfeit your paid vacation days.
- If you call in sick X number of times, you are subject to an "attendance review," after which no further sick calls will be allowed for a year.
- No sick time is offered because it will encourage people to be sick.
- Used sick days count against you in evaluations and promotion policies and can result in denial of scheduling requests.
- You are required to use 2 or 3 vacation days before using any sick time.
In spite of declarations that staff should stay home when ill, healthcare employers use covert means to discourage sick calls. One such strategy is combining vacation and short-term illness time into "paid time off" (PTO), a practice that not only encourages but practically guarantees presenteeism. Nurses and other clinicians who must use PTO when they are sick are reluctant to call in because it is viewed as using up vacation time. The benefit that is actually labeled "sick time," can typically only be used after 3 or more days of illness, during which PTO must be used.
Hospital sick call policies place nurses in a no-win situation. Go to work sick, and you incite anger by exposing your patients and your coworkers to your illness or by being unable to work effectively. Stay at home, and you anger your supervisor and suffer the consequences of the attendance policy. "Pick your poison," said a nurse.
A reader described the ramifications for not coming to work sick, even in institutions with policies that threaten disciplinary action for doing do. "With punitive consequences—attendance review (disallowing additional call outs for a year; termination if violated), financial repercussions, termination, negative performance evaluations, and denial of scheduling requests—the institution forces the hand of its frontline staff, leaving an unhealthy and dissatisfied workforce at the bedside. Removing such radical punitive consequences and engaging staff on a professional level may result in higher respect for patient safety and infection prevention/control at those institutions."
Another nurse suggested that sick-call policies are backwards. Instead of thanking "Typhoid Mary" for coming to work and disciplining staff for calling in sick, "coming in ill and putting your patients and coworkers at risk should be the occasion for writing up a nurse for poor clinical judgment."
Punitive sick-call policies are inconsistent with the respect and trust that should be extended to employees. The ANA's 2010 Social Policy Statement[2] emphasizes collaboration in healthcare that "includes mutual safeguarding of the legitimate interests of each party and a commonality of goals...parties base their relationship upon trust."
Speaking as a registered nurse, ANA Policy Associate Holly Carpenter said, "Sick time is there for the health and safety of patients, nurses, and other healthcare workers. Nurses should not incur any punishment for using sick time."
How Sick Is Too Sick to Work?
"I don't think that healthcare workers should stay home for a simple sore throat; however, we know when we are really coming down with something. In those cases, workers should stay home or seek medical attention." So, how sick must a healthcare professional be to miss work?One nurse offered her thoughts on this issue and her own definition of "too sick to work:"
There are many different ways to be sick. Did you stay up until 3 am partying, and this morning you are tired and hung over? Do you have mild cold symptoms? Are you mentally exhausted? Are you vomiting? Are you in the hospital? I have found the standard to be an inability to work at all; in other words, I cannot get out of bed.Illness in the family poses a dilemma for nurses, who are often the primary caretakers, but staying home to care for a sick husband, child, or mother is typically frowned upon. Consequently, nurses feel that they must lie and say that they are sick, a deceit that doesn't sit well with them. One nurse was told by her supervisor that she had to report to duty as scheduled even though her 2-year-old child had been hospitalized. Another nurse, who occasionally missed work when her children were sick, suggested to the nursing director that some of the sick days be converted to "illness in the family" days, to avoid nurses having to lie when their children were sick. She was told, "We do not employ your family."
Misusers and Abusers
The first and really only justification offered by employers for their punitive sick-call policies is the tired old excuse about people abusing the system and the implication that all nurses would call in sick willy-nilly if it wasn't for the threat of losing their jobs. "Apparently, nurses go to nursing school so they can stay home and pretend to be sick," said a nurse.No one disputes the fact that some people are sick more often than others or that a few of their colleagues might use sick calls to create a more favorable social schedule. "Sadly," wrote one nurse, "there are those who just call in to have a day off."
But is that a reason to treat all nurses—the great majority—as though they are faking illness whenever they call in? Another person wrote, "Firing people for sick calls is an example of the many being punished for the sins of a few. They don't know how to fix 'dishonest,' so they punish 'honest' instead."
Showing a lack of trust in all nurses simply because a few are believed to be untrustworthy or malingering is common, according to comments posted on Medscape. Such a lack of trust can act like a poison, destroying collaborative relationships in healthcare.
Of interest, not a single administrator or manager contributed any thoughts to this discussion. A former nursing supervisor offered this slightly different perspective:
It is an expectation that nurses come to work, ill or not. The hospitals and clinics are short staffed, and one call-off is devastating. I worked in place of an ill employee many times. Most supervisors do not take that initiative. I believe hospitals and clinics need to provide healthy foods and flex scheduling to assist their employees in maintaining health.However, these solutions are dismissed as untenable, according to one reader, who wrote:
Most nursing supervisors and administrative that I have known don't have the skills to work on the floor. If they were required to work 1-2 shifts every week, they would be better administrators and supervisors because they would have a realistic idea of what the staff nurses do, they would keep up their nursing skills, and they would be able to substitute when the staff nurses are out sick.
Unhealthy Double Standards
Another theme among the comments was the "mind-boggling hypocrisy" demonstrated by the punitive attendance policies that are nearly universal in American hospitals:For hospitals to market themselves to the public as centers of care and compassion and treat their own employees as soldiers who must not succumb to common illnesses is totally ridiculous. During my 30 years of doing direct patient care, I was never at my best when compelled to come in sick, and the potential to harm patients was high. There is always a way to staff a hospital if employees are sick. Shame on the hospital industry.Similar sentiments were expressed by another reader, along with a strong rebuke for administrators:
Healthcare institutions speak out of both sides of their mouths—their ostensible concern for infection control, yet their clear disregard for it when they send vectors of disease in the form of unwell medical personnel into patient rooms daily. Concern for employee welfare? The "best place to work?" Yet they have brutal, punitive regulations governing sick leave out of fear that a few might abuse it. And note that administrators take sick leave with impunity because no one really notices if they are there anyway.Many agree, suggesting that it is high time for this issue to see the light of day. "I always wonder when the public is going to realize that nurses are the most likely source of many nosocomial infections," wrote a reader.
Why don't healthcare employers put plans into place for sick-call replacements? The suggestion is viewed as ridiculous. "Most hospitals can't even provide extra personnel to relieve staff for breaks," said one nurse. No, as usual, the bottom line is the bottom line—it would cost too much.
Fear of lost revenue, either directly or indirectly when patients are inconvenienced, is thought to be the main driver of presenteeism.
Nurses are notorious for trying to shoulder the burdens of the entire world. When they are sick, they immediately become anxious about leaving the department short-handed. However, nurses are not responsible for inadequate staffing.
"It should come as no surprise to healthcare employers that healthcare workers will sometimes be sick and miss work. It is incumbent on the employers to provide safe, optimal staffing levels and to maintain those safe levels even if some of the staff are sick," said Carpenter. "It is unfortunate that the nurse feels personal responsibility for staffing. His or her responsibility is to provide excellent care to patients."
Many healthcare professionals commented on the irony of working in a hospital, which is supposed to be about helping people become healthy, yet caring little about the health of its staff.
At my hospital, a nurse is as important as a floor polishing machine or an adjustable bed. When one breaks, you throw it out and get another. If you are sick, you had better be hospitalized. Nurses and doctors come to work ill, injured, and sleep-deprived. We are expected to provide care for our patients, yet cannot expect any consideration from our employers. Yes, healthcare workers come to work sick, but they have to because the focus is no longer on care but on profit. Until it is no longer considered a crime for sick healthcare workers to stay home and care for themselves, we will continue to have the ill caring for the ill.It might be helpful to print out Section 5 of the ANA Code of Ethics, which states: "The same duties that we owe to others, we owe to ourselves." As professionals who promote the health and safety of others, "nurses have a duty to take the same care for their own health and safety." Nurses must seek a work-life balance, including attention to their physical health, and "it is the responsibility of nurse leaders to foster this balance within their organizations."
Treating nurses differently from patients is also in defiance of the ANA Scope and Standards,[2] which states: "All must be mindful of the health and safety of both the healthcare consumer and the healthcare worker in any setting providing healthcare, providing a sense of safety, respect, and empowerment to and for all persons."
Healthcare employers are supposed to protect the health of their nurses (and others), but do they? An employer might argue that it is difficult to tell over the phone that an employee is unable to work. But what about when that employee's unfitness for duty is right before the supervisor's eyes? This article began with a quote from a nurse who said, "My boss can clearly see how sick I am but has not offered to send me home." Typically, the nurse soldiers on, hoping to make it through the shift because what are his or her options if supervisors refuse to release or replace the sick nurse? The nurse cannot just leave because that might constitute patient abandonment.
Trying to resolve this problem when you are already sick is probably not the best approach. Conditions under which presenteeism is expected (or encouraged by PTO systems), nurses are told to just "wear a mask," or nurses are not permitted to leave when they become unfit for duty while at work, can be unsafe for patients, and nurses have an obligation to ensure that unsafe practices are not allowed to persist. The code of ethics states that nurses must follow the policies of their employing organizations but also that when practices threaten the welfare of patients, nurses should express their concerns to the appropriate higher authority. It is possible that the policy itself is sound, but its interpretation is faulty, and it must be clarified to prevent unfair consequences to the nurse who calls in sick.
References
- American Nurses Association. Code of Ethics With Interpretive Statements. Silver Spring, MD: ANA; 2015.
- American Nurses Association. Social Policy Statement. Silver Spring, MD: ANA; 2010.
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