Perspectives on Safety—Presenteeism: A Patient Safety Challenge

In an accompanying perspective, Julia E. Szymczak, PhD, of the University of Pennsylvania, explores the risks of presenteeism among health care workers and factors, such as cultural expectations, that contribute to its occurrence.

Perspectives on Safety
Published October 2017

Health Care Worker Presenteeism: A Challenge for Patient Safety

by Julia E. Szymczak, PhD

Perspective

Introduction

Health care–associated infections are among the most common complications of medical care in the United States. They exact a tremendous toll in morbidity, mortality, and costs.(1-3) The transmission of infectious diseases in health care facilities, where there is frequently a high concentration of individuals with immunosuppression, severe chronic disease, or vulnerability due to age, is a major threat to patient safety. Although infection prevention efforts have traditionally focused on preventing transmission of infection between patients, increased attention has been paid to another vector: sick health care workers.

Health Care Worker Presenteeism Is Common and Dangerous

Working while ill, known as presenteeism, is a particularly pervasive problem in health care, with serious consequences. When health care workers provide care while experiencing symptoms of infectious disease, they put their patients and colleagues at risk.(4) A symptomatic health care worker can transmit pathogens directly to others; contaminate shared, high-touch surfaces (5); and experience impaired judgement based on the severity of their illness. There are numerous reports of outbreaks within health care facilities for which sick health care workers have been identified as the primary source of disease from pathogens such as influenza, Bordetella pertussis, methicillin-resistant Staphylococcus aureus, and norovirus.(6)

Despite how risky health care worker presenteeism is for patients, it commonly occurs. When health care workers from different occupational roles have been surveyed, 50%–90% of them report that they have worked or would work while experiencing significant symptoms of infection.(7-13) In a survey study of 536 attending physicians and advanced practice clinicians at a large children's hospital, 83% reported working sick at least once in the past year, 9% reported having worked sick more than 5 times in the past year, 55% said that they would come to work with the acute onset of significant respiratory symptoms, and 30% reported they would work while experiencing diarrhea.(6) In a multihospital survey study of internal medicine, pediatric, general surgery, and obstetrics/gynecology residents, the authors found that 58% of residents reported working when sick at least once and 31% reported doing so more than once in the previous year.(12) Though it has been demonstrated that all health care workers report coming to work while sick at times, physicians typically do so with a higher frequency than other occupational groups.(11)

Reasons for Presenteeism: Logistics, Culture, and Knowledge

Like many threats to patient safety, the reasons why health care worker presenteeism occurs are complex and include a combination of logistic, cultural, and knowledge-based factors. In studies that have investigated this issue, researchers consistently find that the logistical challenges of staffing a health care facility continuously makes sick relief systems difficult to operationalize, implement, and monitor.(4,6) In a climate where many health care organizations are fiscally constrained, the financial resources needed to build enough staffing "slack" to cover the workload of a sick health care worker may be unavailable. Different clinical areas may have diverse staffing challenges, suggesting that a one-size-fits-all approach will not work.(6) For example, in surgical settings or ambulatory visits with specialists, patients may have waited months to be seen by a particular provider. A canceled visit could lead to another long wait to receive care. Many of these health care workers perceive that their work cannot be delegated easily to others, suggesting they are balancing the need for continuity of care versus the risk they present to a patient by working while ill.(9) Clinical schedules can be very complex, and in organizations without clear sick relief systems (particularly when health care workers are responsible for arranging their own coverage), it may be easier to come to work while ill.(6)

In additional to logistic factors, health care worker presenteeism is a product of social norms that underpin the culture of health care work. Numerous studies have found that health care workers report coming to work sick because of a strong desire to not burden their colleagues with additional work, a belief that it is "unprofessional" to take a sick day, a desire to not disappoint patients, and fear of being ostracized by unsupportive colleagues.(7-10) As one physician explained in an open-ended question on a survey (6) investigating the reasons for health care worker presenteeism:

This is a delicate issue as there is clearly a cultural expectation that we as physicians do not let our patients or colleagues down by calling out sick. Calling out is very poorly regarded and deemed unprofessional by many. Much like the hospital expects us to be here after a two foot snowfall, I believe that we still expect people to come to work even if they are sick. I personally draw the line at fever, but likely only because I have trouble performing my job and keeping up when I'm febrile. I know it puts our patients and other staff at risk, but I think the cultural expectation about work performance is a higher motivator. It probably shouldn't be. I'm not irreplaceable, but might make a patient sick.(J.E.S., unpublished data, 2015)

The decision to come to work when ill is shaped by these perceived cultural norms which are communicated to health care workers early in their training experiences and echoed throughout their interactions with colleagues. Health care workers also report that there is some ambiguity about what symptoms truly justify sick leave—that there are "degrees" of sickness and it is not always clear what is "too sick" to work or truly risky for patients.(6) The lack of knowledge about what symptoms justifies calling out, coupled with a strong cultural norm not to do so within a complex organizational system with little slack leads many otherwise well-intentioned health care workers to engage in this risky behavior.

Change Is Complex and Requires Attention to All Drivers of Health Care Worker Presenteeism

Health care worker presenteeism is a particularly thorny challenge for all health care organizations, one that resists simple solutions. Reducing it will require attention to all drivers of the problem: logistics, culture, and knowledge. Authoring policies, generating evidence about what level of illness necessitates leave, and directing resources to the creation of sick relief systems are all necessary. However, implementing any of them in a vacuum is unlikely to lead to sustained improvement. Reducing health care worker presenteeism will require a redefinition of what it means to be a professional in health care.(14) New social norms that prioritize health care worker wellness and fitness for duty as a crucial component of patient safety need to be created and nurtured. These norms must be championed and constantly illustrated by the behavior of all health care workers—from those in leadership roles to those still in training. Although the decision to come to work while ill appears at first glance to be an individual choice, it is highly social in nature. Health care workers are frequently caught between a rock and a hard place when it comes to presenteeism. Both logistic resources and social supports are required to make the choice to prioritize patient safety in this case the easy one.

Julia E. Szymczak, PhD
Assistant Professor of Epidemiology
Department of Biostatistics, Epidemiology and Informatics
Center for Clinical Epidemiology and Biostatistics
Perelman School of Medicine
University of Pennsylvania

References

1. National Action Plan to Prevent Health Care–Associated Infections: Roadmap to Elimination. Washington, DC: US Department of Health and Human Services; 2013. [Available at]

2. Magill SS, Edwards JR, Fridkin SK; Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. Survey of health care–associated infections. N Engl J Med. 2014;370:2542-2543. [go to PubMed]

3. Zimlichman E, Henderson D, Tamir O, et al. Health care–associated infections: a meta-analysis of costs and financial impact on the US health care system. JAMA Intern Med. 2013;173:2039-2046. [go to PubMed]

4. Huttunen R, Syrjänen J. Healthcare workers as vectors of infectious diseases. Eur J Clin Microbiol Infect Dis. 2014;33:1477-1488. [go to PubMed]

5. Otter JA, Yezli S, French GL. The role played by contaminated surfaces in the transmission of nosocomial pathogens. Infect Control Hosp Epidemiol. 2011;32:687-699. [go to PubMed]

6. Szymczak JE, Smathers S, Hoegg C, Klieger S, Coffin SE, Sammons JS. Reasons why physicians and advanced practice clinicians work while sick: a mixed-methods analysis. JAMA Pediatr. 2015;169:815-821. [go to PubMed]

7. Jena AB, Meltzer DO, Press VG, Arora VM. Why physicians work when sick. Arch Intern Med. 2012;172:1107-1108. [go to PubMed]

8. Weingarten S, Riedinger M, Bolton LB, Miles P, Ault M. Barriers to influenza vaccine acceptance. A survey of physicians and nurses. Am J Infect Control. 1989;17:202-207. [go to PubMed]

9. McKevitt C, Morgan M, Dundas R, Holland WW. Sickness absence and 'working through' illness: a comparison of two professional groups. J Public Health Med. 1997;19:295-300. [go to PubMed]

10. Crout LA, Chang E, Cioffi J. Why do registered nurses work when ill? J Nurs Adm. 2005;35:23-28. [go to PubMed]

11. Chiu S, Black CL, Yue X, et al. Working with influenza-like illness: presenteeism among US health care personnel during the 2014–2015 influenza season. Am J Infect Control. 2017 May 16; [Epub ahead of print]. [go to PubMed]

12. Jena AB, Baldwin DC Jr, Daugherty SR, Meltzer DO, Arora VM. Presenteeism among resident physicians. JAMA. 2010;304:1166-1168. [go to PubMed]

13. Ohrt CK, McKinney WP. Achieving compliance with influenza immunization of medical house staff and students. A randomized controlled trial. JAMA. 1992;267:1377-1380. [go to PubMed]

14. Tanksley AL, Wolfson RK, Arora VM. Changing the "working while sick" culture: promoting fitness for duty in health care. JAMA. 2016;315:603-604. [go to PubMed]