Nurses Work Sick Because They Have No Choice

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Nurses who work while sickWorking sick is frowned upon in health care. But calling in sick is frowned upon much more — so much more that the necessity of working while sick is entrenched in both budgets and attitudes at hospitals and other institutions throughout the United States.

Hardly any company in America adjusts its personnel charts to account for adequate staffing when someone calls in sick. Health care bean counters are no exception and seldom have been.

“I have been a nurse for 43 years and nothing has changed,” a respondent reported to a 2015 survey by Medscape. “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.”

Budgetary constraints are understandable. But punitive policies are beyond the pale.

“I worked one Christmas with pneumonia and a fever of 104 degrees F,” another nurse told Medscape. “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.”

Another nurse told Medscape that a fellow nurse was hospitalized about 10 days and wasn’t cleared to return to work for several more. After she returned, she was written up for excessive absenteeism.

Presenteeism in the workplace

Those are extreme examples, but they underscore why a problem known as presenteeism is getting much attention, especially after a 2015 article in JAMA Pediatrics reported that a survey of 536 workers at Children’s Hospital of Philadelphia showed that 83 percent admitted reporting to work when they felt sick, even though 95 percent of the respondents said working while sick puts patients at risk.

That it does. It harms patients directly by causing infections and spreading diseases. More than 200 patients per day die of infections contracted in hospital stays. Short-staffing is blamed for the majority of mistakes that lead to higher rates of patient infection whether the sick nurse works or not.

That’s an even larger problem than sick nurses infecting patients, the potential for which rarely receives attention with the exception of high-profile epidemics like the SARS (sudden acute respiratory syndrome) outbreak of 2003 and the Ebola scare of 2014.

“In a sense, presenteeism is the response to a conflict of interest on the part of the nurse or other health care worker — the conflict between taking care of oneself (or family member) and fulfilling one’s obligation to the workplace,” said Laura A. Stowkowski in her Medscape article coordinating the reader commentary about the JAMA report. “Is it better to go to work and be ‘half a nurse,’ than no nurse at all?”

So nurses feel they have reason to work sick, even when their own ethics codes tell them they shouldn’t. The JAMA study noted that they don’t want to let colleagues down (98.7 percent), don’t want to abandon patients and don’t want to be ostracized by colleagues.

Nursing staffing issues

Nurses who call in sick are often pressured to reconsider. A Medscape respondent said a supervisor was “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.”

More often, the nurse shows up, and a Medscape respondent laid out her reasons for dragging herself in, bad cough and all. “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.”

Even more clearly punitive than “attendance reviews” that encourage presenteeism are sick leave policies that are interwoven with vacation days, a practice called “paid time off” (PTO). Often that means no sick pay until three vacation days are cashed.

Nurses are discouraged from staying home to care for sick loved ones. A nurse suggested to her director that some sick leave regulatory language ought to include “illness in the family,” so that nurses wouldn’t feel forced lie about it. The manager said, “We do not employ your family.”

Short-staffing is blamed for the majority of mistakes that lead to higher rates of patient infection whether the sick nurse works or not.

Health administrators of course say they are determined to prevent presenteeism, but “their policies and responses when employees call in sick suggest otherwise,” Stowkowski wrote.

Instead their measures tend to run to policies that ensure stepped-up hand-washing and mandatory flu vaccinations or wearing masks that some wearers claim become incapacitating during the course of a shift.

A more drastic shift surely would involve truly adequate staffing, but the scoffing is loud when that topic is raised. “It costs too much” is a persuasive and pervasive response.

“Most hospitals can’t even provide extra personnel to relieve staff for breaks,” a nurse told Medscape.

“If we developed elaborate on-call mechanisms with people waiting to come in, like substitute teachers,” lamented Michael Edmond, MD, MPH, MPA, in a related article, “the real question would be: What’s the opportunity cost? What would we have to give up to do that?

“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.”

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