How Sick Is Too Sick to Work? Presenteeism in Healthcare

Expert Interview With Michael Edmond, MD, MPH, MPA

Michael B. Edmond, MD, MPH, MPA


September 23, 2015

Editor's Note:
Attention has often been given to the cost burden of absenteeism in the healthcare workforce, but it is increasingly apparent that the low productivity and other risks associated with those who work while sick should not be lightly dismissed.[1] Presenteeism, defined as "workers being on the job but, because of illness or other medical conditions, not fully functioning,"[2] has been implicated in disease transmission to patients in healthcare settings.[3] However, very little is done to prevent or reduce presenteeism in healthcare. A recent anonymous survey[4] of attending physicians, advanced practice nurses, and physician assistants revealed that most of these clinicians frequently work while sick despite recognizing that this choice puts patients at risk. Working while sick was in many cases viewed as a moral obligation and driven by policies and logistical issues that do not support absenteeism, cultural norms that discourage absenteeism, and ambiguity about what constitutes "too sick to be at work."[5] Presenteeism is clearly considered the lesser of two evils when the healthcare worker is sick.

After a news report about this survey appeared on Medscape, a plethora of comments from healthcare workers suggested that they struggle with the dual issues of presenteeism and absenteeism, and they have witnessed few attempts by employers to resolve this conflict. Medscape spoke with Michael Edmond, MD, MPH, MPA, chief quality officer at the University of Iowa Hospitals & Clinics, about presenteeism and some potential approaches to alleviating this problem in healthcare.

Medscape: In the JAMA study,[4] as well as in comments on Medscape, clincians overwhelmingly admit to presenteeism, almost viewing it as a "badge of courage" to show up for work when sick. Is this consistent with your experience with presenteeism in healthcare?

Dr Edmond: The issues faced by nurses and physicians are somewhat different. Most healthcare settings have no mechanism for what to do when a doctor suddenly can't come to work. There is no coverage—no substitute doctor. Everyone just assumes some of the sick physician's workload. It's the way that physicians have always handled it, but it makes the sick physician feel guilty about not coming to work.

There is a general expectation among physicians that you don't miss work, and this is one of the negative implications of professionalism. Professionalism is the standards set by the profession for its members, and part of the professional ethos of physicians is that they don't miss work, even when they know they shouldn't be there.

Nurses have better systems in general for how to manage when people are absent. However, in some hospitals, nurses don't have "sick time," per se—they have what is called "paid time off" (PTO), which combines sick and vacation time. It serves as a disincentive to stay home when sick because nurses view it as using up their vacation days.

Medscape: We don't hear much about solutions to presenteeism. What steps should healthcare employers be taking to ensure that healthcare workers stay home when they are sick?

Dr Edmond: Presenteeism is the elephant in the room that nobody wants to talk or do anything about. Healthcare employers are much more likely to take a single step in isolation that doesn't really address the problem, such as mandating influenza vaccination. We recently went through a period in which many organizations came out with very stern policies about influenza vaccination for healthcare workers, saying that if employees didn't get a flu shot, they would be fired.

You could argue that this might reduce presenteeism because fewer healthcare workers would become sick with influenza, but it doesn't make much of an impact. Two hundred different pathogens can cause influenza-like illness, and the annual flu vaccine protects against only one of them. If you truly wanted to do something about presenteeism, you would need to do more than have your employees vaccinated against influenza.

That's hard for hospitals to take on. It's much easier just to make a rule that says that everybody needs to get a flu shot or will be fired than it is to tackle the core issue of how to keep people home when they are sick. That's why we have the situation that we have with people coming in when they are sick.

Medscape: Nurses and physicians say that they are expected to come to work unless they are so sick that they are hospitalized, and that calling in sick draws an angry response from supervisors. Are healthcare employers really motivated to do anything about presenteeism?

Dr Edmond: I don't believe that hospitals have done a very good job of dealing with presenteeism. They might say that they discourage it, but they don't practice what they preach. "Don't come to work sick," but "we really need you to come in even if you are sick." It's that kind of double message. And it isn't limited to hospitals. As an infectious diseases physician, I worry about the food service industry and people with norovirus—which is very contagious—coming to work. People in low-wage jobs often have no time off of any kind—vacation or sick time—and so there is a lot of incentive to come to work sick. It's a public health issue.

Medscape: We have been talking primarily about infectious diseases, respiratory or gastrointestinal, that might be transmitted to coworkers or patients. What about other types of illness? How sick does the healthcare professional have to be to warrant staying home?

Dr Edmond: A lot of this boils down to the issue of fitness for duty. A sick healthcare worker might not have an infectious disease but is still not fit for duty. If a nurse has back pain to the point of being unable to concentrate, that's a fitness-for-duty issue. If your pain is not being appropriately managed, you may be at higher risk of making a medication error. So, it extends beyond infectious diseases. The infectious diseases add another layer to this—potential transmission to other people in the environment.

Medscape: Often when nurses have upper respiratory virus infections, they are told that they can work wearing a mask. Is this appropriate? Is it safe and effective?

Dr Edmond: It might depend on the patient population that the nurse works with. Are they relatively healthy, or are they highly immunosuppressed? The implications are different if the nurse works in a general medical ward, a bone marrow transplant unit, or another setting with highly immunosuppressed patients. Some risk can be mitigated with good infection control practices (eg, handwashing).

On the other hand, there are concerns about effectiveness, and we have very little evidence to guide us. For example, some hospitals have said that if an employee refuses to get a flu vaccine, he or she must wear a face mask throughout the entire flu season. How do you enforce that? How effective is it? It might even be counterproductive because while wearing a mask, the healthcare worker is more likely to touch his or her face and repeatedly self-inoculate. When hospitals require masks for those who aren't immunized against influenza, it isn't really being done to reduce risk. It's a punitive action.

The other problem with masks is that they are distracting and could lead to more errors. When I wear an N95 mask to see patients with tuberculosis, within 10 minutes, I'm starting to become aware that I feel short of breath. I'm completely healthy, but I have this sensation that I can't breathe properly when I'm wearing that mask, and at some point it starts to distract the wearer. We worried a lot about this when we were doing simulations and training for Ebola. When we were developing our policy, we believed that healthcare workers could work in the Ebola room in 4-hour shifts. But we realized that staff can't tolerate full personal protective equipment for 4 hours. It's hot, they are sweating, their glasses fog up, and they become dehydrated. And a lot of this is because of the mask.

The problem with much of infection control is that some of the most basic questions have never been answered because the studies are very difficult to do and would cost a lot of money.

Medscape: You have mentioned professionalism as a variable in how people approach working when sick. Here is another element of professionalism: Nurses are often told when they call in sick that they must have a doctor's note, or they won't be paid. Their response is, "I'm a professional registered nurse. I take care of sick patients. Why am I not able to judge when I am too sick or unfit to work?" What do you think of the "doctor's note" requirement for professional nurses?

Dr Edmond: This gets into the issue of how do you hold people accountable? I can guess where that is coming from—the conviction that some staff members just call in because they want to take a day off. Obviously there has to be a balance. We need to be fair to everyone and hold everyone to the same standard. Some hospitals have solved this problem by creating great employee health services where the sick worker can go in and be seen. It does add to the burden of the healthcare system, but it permits a very quick decision about fitness for duty.

You could argue that there are some good aspects to that because the employee health clinician might detect things that the healthcare working isn't even aware of. Maybe the healthcare worker is sicker than he or she thought. From an epidemiologic standpoint, I like that idea because it gives a lot of insight into what is happening in the workforce. Are we having an outbreak of infection among our healthcare workers? If we are seeing them, we can identify those outbreaks, but we can't if they stay home and self-manage their illnesses. An employee health service is able to monitor how many of the facility's healthcare workers are out on any given day and see when the outbreak is peaking and when is it starting to go away.

Medscape: You have suggested that part of the solution is to change the acculturation of physicians, nurses, and other healthcare workers so that they no longer believe that they have to come to work even when they are sick. How will healthcare services be affected if presenteeism is reduced?

Dr Edmond: There may be solutions that we haven't yet explored. If I have a cold, but am still feeling well, maybe I could stay home and Skype with my patients. I wouldn't come in and infect everyone else, but I could still be involved in the management of the patient. Obviously, I can't examine the patient, but it is a way, particularly for consulting physicians, to continue to see patients. We adopted a similar arrangement for Ebola. One of the technical solutions that we came up with was the use of telemedicine. I think we need to be more creative than we have been.

For nurses, whose work is mostly hands-on, the options are few. However, remote technology might be a useful strategy for nurses who are in positions other than direct patient care.

Medscape: Why has the problem of presenteeism gone on so long? Nurses and physicians have always gone to work sick. Being human, it can be predicted that occasionally, clinicians will be sick or unfit to work. Why haven't employers figured out a better way to manage employee absence than scrambling to find last-minute coverage?

Dr Edmond: Like most things, it comes down to money and resources. Most hospitals don't have a lot of cash lying around. They are trying to do their best with the workforce that they have without spending extra money. It's a fixed-sum game. If we developed elaborate on-call mechanisms with people waiting to come in, like substitute teachers, the real question would be: What's the opportunity cost? What would we have to give up to do that? The margins for most hospitals are not huge. Some are in the red on a good day. So, in the end, it is a simple matter of resources. And it goes back to the idea of risk. How much risk is associated with someone coming to work sick? We haven't put a dollar figure on that.

Medscape: Doctors and nurses are aging. Medical advances are keeping people working longer, but they still have exacerbations and days when they are not fit to work owing to chronic pain or illness. Could presenteeism in the healthcare workforce become even worse?

Dr Edmond: Potentially it could get worse, but we can stay on top of it if we become smarter. A lot of the solution is raising awareness. When I trained, about 30 years ago, we didn't even talk about this. You would see residents walking around, pushing intravenous poles with fluids infusing because they were dehydrated. We don't see that anymore. We have made some headway. We are talking about issues that we never talked about before because there wasn't anything to talk about; it was an expectation that you would be here. You're either dead or you're at work—those were the only two options. In some ways, we are moving in a good direction, although not as fast as we might hope. We are shining more light on all of the issues that affect hospital quality and safety.

Medscape: What is on your wish list of solutions to the problem of presenteeism? What should healthcare workers do? What should employers do?

Dr Edmond: One thing that would be helpful is to establish standards for when we don't want people to be in the hospital working. For example, if you have a fever or diarrhea, you shouldn't be working, period. We could come up with a list of conditions that would make the worker unfit for duty or at least prompt an evaluation of fitness for duty. We have not done a good job of that.

Another basic solution is to eliminate PTO and go back to a system that separates vacation and sick time. If people had sick time, they would use it when they needed to.

For some things—such as covering for a sick doctor—I don't think anyone has any good solutions to that. Some doctors are not replaced easily.

Medscape: A recent study[6] found that half of healthcare workers with confirmed influenza were afebrile. How does this affect the use of fever as a major criterion for being "too sick to work"?

Dr Edmond: It might mean that the other criteria should be added to the list. And we need to acknowledge that we will never have a perfect system for classifying personnel as too sick to work.

Medscape: When you are speaking to groups of physicians or other healthcare workers, what do you tell them about presenteeism?

Dr Edmond: When I speak to medical residents during their orientation, I tell them that if they have a fever, vomiting, or diarrhea, they should stay home. Doctors have to be given permission to do that because they come with an expectation that they can't be sick. It's part of their professionalism, the limits of what is acceptable and not acceptable. It's easier with trainees because their mindset is to be more compliant. But if you are a highly specialized physician, we might not be able to replace you. There are limits to what is reasonable.

I remember a surgeon once going into the room of a patient who was supposed to have surgery that day. He said, "We can do your surgery, but I want you to know that I haven't slept for 24 hours; I was up all night with emergency cases, and I would like to delay your surgery." I believed him to be thoughtful and courageous in doing the right thing, but some physicians might say that he should not have said that to the patient, that he has a commitment to perform that surgery. This is why professionalism is so problematic—because the expectations don't come from patients, they come from other doctors.


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