Does Hospital Leadership and Policy Promote Working When Sick?

J.Adderton, BSN, MSN

There is no shortage of research and information on strategies to reduce absenteeism in nursing. A standard internet search will provide a wealth of statistical data detailing nurse absentee rates.. You can find an abundance of researched and published strategies to effective lower absenteeism in nursing. But there is another side to the issue of nurse absenteeism. Consider the following nurse scenarios:

Scenario One:

"Jones, RN is scheduled to work 7pm to 7am, but has been fatigued, coughing and oral temperature at 100.6. Jones, RN wants to be proactive and calls her nurse supervisor at 10 am to inform of illness. The nurse manager asks if Jones, RN has looked for someone to work her shift because the floor census is high. The nurse manager also states, "we will definitely need to find another nurse if you are not able to just power through the shift". Jones, RN states she will plan to work her scheduled shift."

Scenario Two:

"Hill, RN is a part-time nurse with one unplanned absence 9 months ago. Hill, RN discovered a rash on one side of her back that is now causing severe itching and pain. Hill, RN suspects the rash is shingles and knows she needs to confirm with a doctor before working. However, hospital policy states part-time employees may be terminated after 2 unplanned absences (with or without physician excuse). The hospital strictly enforces this policy and has historically terminated part-time employees meeting this criteria. Hill, RN does not want to risk losing her job and decides to work her scheduled shift."

The National Institute of Safety and Health surveyed 1,900 healthcare workers during the 2014-2015 flu season. It was revealed 414 of individuals polled admitted to working while experiencing flu-like symptoms (I.e. coughing, fever and coughing or sore throat). The findings, published in the American Journal of Infection Control (2017), demonstrate an alarming number of healthcare workers report to work despite the risk of transmitting illness to patients and co-workers. While there is an abundance of research on reducing nurse absenteeism, there is a gap in exploring the influence of hospital culture and policy on nurses' decision to calling out with illness.

In 2015, a news article titled "Many Docs Come to Work Sick: Survey" was written based on a study published in the Journal of the American Medical Association. The survey found that many physicians, physician assistants, nurses and midwives routinely work sick. Medscape.com experienced a "swift and strong" reaction to the article from nurse readers and common motivations for working sick became apparent.

Guilt Motivates

Nurses know calling in sick will likely result in their co-workers working short staffed. Nurses often experience a conflict of interest in caring for themselves and expectations of colleagues and healthcare organizations. The American Nursing Associations"s Nursing Code of Ethics states, "The nurse's primary commitment is to the patient". Ethically, it is in the patient's best interest if a nurse call out if risk of spreading illness. Does the negative impact of a nurse's absence on coworkers and supervisors outweigh the negative outcomes associated with presenteeism?

Pressure to Reconsider

Have you ever known you had legitimate need to call in sick, actually made the phone call and felt pressured to work your shift? I am a chronic "presenteeism nurse" and have heard the following responses from nursing supervisors and managers over the course of my career:

"This is going to kill staffing- 5 nurses hospital wide have already called out.”
"Could you work at least half a shift?”
"You realize this will be an unplanned absence on your record.”
"Did you actually go to the doctor?”
"You need to call the house supervisor before you make your decision.”

It is not uncommon for hospital leaders to respond with suspicion, resentment or coercion when nurses call in.

Punitive Policies

I have experienced frustration from a nurse habitually calling out without consequence from management. As with any job, there are nurses who abuse the system with frequent absences. But, a common theme in nurses' response to the news article: administrators have adopted "punitive" call in policies that imply all nurses have a tendency to abuse sick time. Consider a potential research topic " How does hospital policy impact nursing presenteeism?” in relation to the following common policies:

If you call in sick (I.e. weekend) you will be required to make up absent days.
A requirement of using vacation time before sick time can be used.
Taking sick time is counted against you in evaluations and promotion policies.
Disciplinary action for unplanned absences even with doctor's note.

Sick time is an employee benefit for the safety of patients, nurses and other healthcare providers. Yes, attendance policies are often viewed as a punitive when sick time is taken.

Double Standards

Hypocrisy is another theme to emerge from the article's comments. American hospitals universally have strict attendance policies due to the need for round the clock staff coverage. Healthcare employers have a responsibility to protect the health of nurses, but do punitive policies reflect this obligation? The ANA Code of Ethics states "the same duties that we owe to others, we owe to ourselves" and "nurses have a duty to take the same care for their own health and safety". It is fair to ask the question- does the hospital industry put effective policies and plans in place for sick-call replacements.

Hopefully, this article sparks additional thought and conversation around the issue of nurses working sick. I look forward to you sharing your perspective and experiences with presenteeism.