Nurse Sick and FIRED: Exploring Nursing Absenteeism

You work long hours, rotating shifts, and holidays. The schedule alone is enough to leave you feeling run down, tired, and needing a day off. But, what happens when you are in fact sick? Does your facility’s call-off policy protect you from discipline or termination? Nurses General Nursing Video Interview

Updated:   Published

Meet Theresa Puckett

If you do a Google search for "nurse fired for being sick" you will be inundated with articles about Theresa Puckett, PhD, RN, CRCP, CNE, a nurse from Northeast Ohio who found herself terminated after a legitimate bout of the Flu during one of the worst Flu seasons our country has seen.

According to an article in Becker's Hospital Review, Theresa worked as a PRN Nurse at University Hospitals, based in Cleveland. She called in sick one day at the end of December 2017 with flu symptoms. Theresa visited a physician and tested positive for the flu virus. She was treated with Tamiflu and ended up missing two days of work. Her physician provided a note excusing her from work for these days. She returned to work a few days later and was instructed by a supervisor to leave early due to continued illness.

The next day, she saw a Nurse Practitioner who diagnosed her with a sinus infection and provided her with another note stating she should not return to work for a few more days. However, returning to work was never an option for Nurse Puckett because she was terminated.

You may be thinking - How does that happen?

According to the University Hospitals statement to Becker's Hospital Review, they allow six unscheduled absences for full and part-time staff within a 12 month period, and nine absences may result in termination. For "as needed" or PRN staff, two occurrences of unscheduled absences within a 60-day period may result in termination. Because Theresa returned to work for one shift in between her two absences, this counted as two occurrences and qualified her for termination.

Presentism versus Absenteeism

If you have ever gone to work sick, raise your hand. As hands of nurses around the world are raised high, let's discuss the reasons we've all done it. To really understand both sides of the issue, you need to understand the difference between absenteeism and presenteeism.

Absenteeism is the practice of staying home from work or school when you are ill. Of course, there are other reasons people call off, but for this article, we are only exploring this issue concerning illness. So, what's the opposite of absenteeism? Presenteeism - the act of going to work when you are ill.

Nurses have high standards for themselves and the care they provide to patients, even when they are ill. A 2000 study by Aronsson, et al. reported that rates of presenteeism were highest among nurses and teachers. But, we know that presenteeism may result in adverse patient outcomes, poor nurse health, and cost consequences. So, why is it so difficult to take a sick day?

Let's consider a few of the most important factors when deciding which side of the issue you support.

The Team Needs You

Your throat is on fire, your head feels like a giant elephant is jumping on it and crawling back into bed sounds like the best possible plan - but, you know your teammates need you. You don't want to let others down. Staffing on many units is kept to a minimum so even one call off could cause your co-workers to take on larger assignments, be in unsafe situations, or be upset with you for calling off.

A February 2018 article by News 5 Cleveland quoted one nurse as saying "Nurses are often commended for coming into work sick, so they don't put their comrades at a disservice for being understaffed." It seems the issues of teamwork, loyalty, and service is a double-edged sword on nursing units.

Patients Need You

Nurses spend more time with patients than any other healthcare professional. You recognize minor changes in assessments and notify physicians. Yes, the doctors diagnose and order new treatments, but it's the nurses who carry out these orders that are often life-saving treatments.

A 2015 study published in JAMA Pediatrics explored the reasons physicians and advanced practice nurses work while ill. While 95% of the respondents believed working while sick put patients at risk, 83% reported working at least one time in the prior year while sick, and 9% reported working while ill at least 5 times. Symptoms reported in this study included fever, diarrhea and acute onset of respiratory symptoms. 92.5% of these clinicians cited not wanting to let patients down as one of the reasons they headed to work with these signs of illness.

So, as you lie in bed contemplating calling in - that's what runs through your mind, right? Without you - who will care for your patients? And, what if you are not the only one with this dreaded illness? So, off to work you go.

Sick Time Policies

Are sick time policies created to protect or punish you? This is a hard question to answer. And, it often leaves nurses faced with difficult decisions that end in absenteeism or presenteeism.

Let's explore a few sick time policy practices.

Forfeiting Pay

Some call-off policies will withhold pay from nurses if you call off at specific times. This might mean that calling off the day before a holiday will result in forfeiture of holiday pay. Or, if you call off on your last scheduled day before a planned vacation or on your first scheduled day after a planned vacation - you forfeit vacation pay.

In a world where many people live paycheck to paycheck, this policy might result in nurses putting themselves and their patients at risk to keep pay that many would argue is rightfully yours. You can't plan illness, so if you are sick around these specific time points, what are you to do?

Unexcused Absences

Most policies give a number of 'unexcused" absences allowed over a period of time, such as 12 months. Typically after missing this number of days, you will be reprimanded. You may also be given a specific amount of time, such as the remainder of the year or 90 days, in which you must not miss any more work.

Of course, if you end up legitimately ill during this time, you are probably going to go to work or risk disciplinary action.

No Sick Pay

Nurses who work a limited number of hours per week or PRN often have no sick time. This leaves you making financial decisions in the face of illness.

Or, your policy may require you to use vacation time before using sick pay. This may seem counterintuitive given the fact that nurse burnout and fatigue runs rampant on many nursing units and days off are necessary.

Physician Notes

Some sick policies require a physician's note for any unplanned absences. Others might state that no MD note is necessary because all unscheduled absences are unapproved. Or, you may also find policies that require a doctor's note after a certain number of days, which may be due to the Family Medical Leave Act.

No matter what your policy reads in regards to doctors notes, you need to understand it before you need to use it. Be sure to get notes when they are required to remain compliant with your facilities policies.

Termination

Almost all sick policies will lead to termination as an end result. And, when such procedures are executed the same across the board, most nurses find these policies to be acceptable. However, when these policies are not carried out consistently, you may feel that they are being used against you or other staff on your unit to force your hand at finding a new job.

Some of the allnurses team met Theresa at the NursesTakeDC rally earlier this year. Nurse Beth was able to interview Theresa and learn more about her ordeal. Thank you for sharing with us, Theresa.

What are Your Thoughts?

So, where does all of this leave you? Do you stay home when ill or head to work in an attempt to avoid discipline, even when you know it is not best for you or your patients? Now it's time for you to decide.

Tell us your thoughts and experiences with nurse absenteeism, presenteeism, and termination.

You can be fired for any reason in North Carolina - they don't have to even tell you why. I was fired two years ago - it's complicated - not for being sick though.

North Carolina *is* a right to work state, for the most part. Your statement is correct regarding almost all right to work states. However, there are always exceptions. Like, working for the state or federal government. In general, neither of those systems are like private industry jobs. For what it's worth, in most states, it's pretty difficult to fire state employees and you have to have solid proof. I've worked for state agencies in two different states...and several private employers in other states...

The only time the time and attendance policy caused me any trouble was when I worked per diem during school. The facility only allowed call outs equivalent to your hired FTE in a year. If you were a 5% FTE, you could only call out 8 hours in 365 days. So, if you were scheduled for a 12 hour shift, and had to call out - or leave before working 4 full hours, *boom* already over your allowance.

In all of my full time jobs, the attendance policy has been pretty manageable. Perfect? No. Better than the corporate world? Yes. Also, all of the policies have allowed for enforcement at the discretion of the manager or director. As in, they could choose to hold you exactly to the policy, or they could use their judgement to allow an overage (not likely to routinely happen, but sometimes circumstances matter).

I'm surprised that the example centers on flu. My current employer has a list of issues/diagnoses/complaints where if we are seen by employee health (or our PCP, or in urgent care or in some cases the ED) and are provided an excuse from work - those days do not count against our time and attendance occurrences. We have to use PTO or if we don't have enough PTO, unpaid time, but those several things do not count negatively. I know flu and pink eye are on the list...the are more but I cannot remember the whole list.

For those of you suggesting that "if it can be contained by a mask" you're a-okay to be at work? Please think long and hard on that one. Masks aren't the end all be all, and in many cases, masks used on floors/units are not evaluated for fluid protection/containment (runny nose drops, coughing, etc).

Also - for those of you suggesting FMLA. Just a friendly reminder - FMLA is only required to be offered, per government regulation, if an employee works over a specific number of hours in the preceding year, there are a certain number of employees (nearly all hospitals surpass this requirement), etc - there are conditions to it. There are other conditions to what you can get FMLA approved for. Generally, being out for the flu probably won't get approved...FMLA is designed to help cover more serious and generally long term or repeating issues - new child(ren), care of yourself or a dependent/sibling/parent (not in-law unless you have custody/guardianship), etc. Repetitive migraines, may get approved. Family member admitted to the ICU and diagnosed with cancer, a stroke, etc - probably a good chance that will get approved. Some people manage to get FMLA approved for injuries they have sustained which makes sense too. My point is simply that it is not guaranteed, and may be harder to obtain than you would imagine. Also - fun fact, your specific job (shift, etc) does not have to be held for/given back when you return. They have to provide you with a similar/equivalent position and cannot terminate you if you are on a FMLA covered absence until you exceed the amount of days you can have off work under FMLA in a 12 month period (12 weeks/3 months) - they CAN terminate you if you are out longer if they could otherwise terminate you (occurrence numbers, etc).

Specializes in NICU/Mother-Baby/Peds/Mgmt.
In the hospital where I used to work, we had a nurse who called in sick. The manager said he did not believe her and she needed to come in and threatened her job. During her shift, she fainted and fell. She ended up being admitted in the same hospital for head trauma and laceration. I am told the she and her husband settled out of court.

Good for her! Did they fire the manager?

Specializes in Mental Health, Gerontology, Palliative.
"If you have ever gone to work sick, raise your hand. As hands of nurses around the world are raised high, let's discuss the reasons we've all done it."

Sorry, but not all around the world. In UK for example policy is for 1 week to be self certified and if over that then a fit to work line from a doctor has to be obtained. (Fit to work is in fact a sick line that states you are not fit to work).

Here we get 5-10days paid sick leave a year, an employer can ask for a medical certificate at an time but the employer has to pay for the employee to see the doctor

If a person has an accident and is injured thats when ACC kicks in and will pay up to 80% of the employees wage up up until when the employee is fit to go back to work.

It scares me that experienced, knowledgeable staff are afraid to take time off when needed in case the get fired.

Me too

I find it outrageous that nurses are being fired for being sensible and calling in sick when they are unwell

Specializes in Cardiac-ICU-IV-M/S, Anticoag Clinic-MH.

I believe you might have nurses present less for note for their employers because they may have friends/colleagues who are willing to help them out. Because the requirement of a doctor's note when you l know your sick with an illness that doesn't require a prescription and don't need to pay a co-pay, while dragging your sick kids to an office visit to help infect the rest of the community. The cycle never ends with flu, cold and URI infection season.

Specializes in Emergency Department.
An extremely generous policy. One wonders how this is financially sustainable.

Staff are being paid anyway so why give them grief for being off sick?

Should also add, hospitals in UK (except private ones) do not make profits.

Everyone in UK who is employed pays national insurance from their salary/wage before they get the money - it is part of your deductions like tax.

National Insurance - GOV.UK

Even outwith NHS employees are entitled to sick pay when they are off.

Statutory Sick Pay (SSP) - GOV.UK

These benefits mean that although I have had several long term illnesses with a few operations and stays in hospital I still own my house and have (some) money in the bank.

Specializes in Emergency Department.

Although I was never fired for absenteeism I was placed on a 90-day probation with the "threat" of termination if I called in during those 90 days. As a Type 1 diabetic with severe gastroparesis having to work the night shift was difficult for me. It screwed up my entire system and I often had GI issues. At that time there was no Disabilities Act to protect me . Another nurse who had diabetes and had issues working night shift was provided the opportunity to switch to days despite being a less seasoned nurse and an LPN. I love my career but I believe nurses are expected to go way above and beyond what is expected from any other position. For some reason we are supposed to be superhuman and to not have the same obligations as other working adults. When I worked in a supervisory role I had to apply those ridiculous rules about providing doctor's notes after a certain number of days off, which caused the employee to get out of their sick bed, pay for a bill when they "knew" they were unable to fulfill their job requirements. It also required my constant monitoring of "habitual" absenteeism, such as calling off from work before a scheduled weekend off or the day before a holiday, etc. Nurses do an amazing job and need to be given a little leeway for their own health. Could this also be one of the reasons there is so much burnout??? Hmmmm...

Specializes in CCRN.

This is a prime example of why nurses need unions. Allowing the suits and clipboards to dictate working conditions and policies leads to punitive cultures.

Puzzling how nurses are charged with caring for the sick but getting sick is the hightest of crimes. If you contracted something that landed you in the hospital and the situation was such that you were unable to call off, would you be terminated as a no call no show? Probably. And who does rotating shifts anymore? We already know it's bad for our health yet employers make us do it anyway. The only people that should be working nights are the ones who want to. I was once forced to a night shift after working 3-11, and I immediately quit without notice, which I'm allowed to do in a right to work state. My health and sanity will always come first. Yes, even before coworkers, patients, and the employer. Always.

Specializes in LTC & Teaching.

Unfortunately this happens all too often.

The Long Term Care facility where I worked, the employer often implemented an attendance mamagement policy where an employee would advance along various steps. Once the employee reached step 4 or 5 they would likely be terminated. The reality is that the policy was never followed properly. Furthermore, neither the union or the employer took into account regulatory guidelines that nurses had to adhere to with regards to physical and mental incapacity and being at work. In addition, it was never taken into account that nurses and other staff had an ethical responsibility to not be at work when they were sick, for risk of getting the elderly residents sick and potentially trigger an outbreak.

The reality is that we had about 2-3 different major outbreaks per year whether it be respiratory of gastro. In addition, during a major outbreak, even more staff members and nurses got sick. I often wondered how many of those outbreaks could have been prevented.

In general, I do go to work somewhat under the weather, if it is not a contagious situation. It is not uncommon for me to have moderate to mild cold symptoms for a month, and no one allows you to be off that long.

I have worked with acute back pain, headaches, urinary tract infections, ear infections, and severe menstrual cramps. Among other things. There are drugs to help relieve the suffering.

I do have paid sick time, but it is not unlimited.

On the other hand, I went to work last year with a pretty severe URI. I would not repeat that. It was a mistake.

And yes, I have been guilty of presenteeism.

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