In Business of Medicine, Cold and Flu, Immune System, Influenza (flu), Manual Medicine, Sinusitis, Sinusitis (Chronic)

When an infectious disease outbreak occurs in a hospital setting, attention is focused on determining the cause of the outbreak. But beyond emphasizing hand-washing and the use of personal protective gear, little attention is typically given to prevent future outbreaks. At a time when managing and preventing future outbreaks is at the forefront of our minds, it’s fair to ask: How do we plan for next time?

In some cases, minor outbreaks have been traced to hospital staff working while sick. Documented outbreaks traced to ill medical professionals include influenza [1-3], Bordetella pertussis [4], Staphylococcus aureus [5], and Norovirus [6-7]. Statistically, the death rates of patients increase when in the vicinity of or treated by healthcare workers experiencing symptoms of infectious diseases [8-9]. Unsurprisingly, patients with compromised immune systems are at substantially higher risk than those whose immune systems are functioning normally [10-13]. Due to the prevalence and high risk of infections in hospitals, there are numerous strategies in place to protect patients [14]. However, these precautions rely heavily on the assumption that healthcare workers are healthy when clocking in. To date, there is significant documentation of healthcare workers who actively treat patients whilst suffering from illness and infection themselves [7,15-17]. In recent years, medical researchers have sought to determine why healthcare workers go to work sick in order to develop strategies to prevent this.

One 2015 study attempted to analyze the frequency of this in a Philadelphia hospital. The basis of the investigation was to determine the prevalence of healthcare workers who work with and/or directly treat patients while sick, despite acknowledging the risks it poses. In the study, over 800 medical professionals were surveyed to investigate and document standard practices, beliefs, and social norms, and to shed some light on this complicated issue. While 95% of the healthcare professionals surveyed acknowledged that “working while sick put patients at risk”, a staggering 83% still reported having worked with acute symptoms at least once in the past year [18-26]. Instances like these are well documented, and yet it continues. So why does it keep happening?

Multiple reasons were listed in the study, including: (1) a desire to not have their work delegated to coworkers [18,20,22], (2) a belief that they are functional enough to work, despite their symptoms [20,27], (3) citing hospitals as a system lacking in support from supervisors and coworkers [28-29], and (4) the idea or belief that their work cannot be performed by others [22].

The survey was administered electronically with software specifically designed to streamline the data compilation process [30]. Study participants were promised anonymity, with no incentives offered for voluntary participation. Before developing the final survey, a sample of initial questions was gathered from five physicians at The Children’s Hospital of Philadelphia and reviewed. The physicians provided feedback via email, and, based on their comments, the study administrators modified their questions for appropriateness and clarity. The final survey consisted of 21 questions covering demographics, self-convicting evidence of having worked while ill, symptoms experienced, the factors that influence a hospital worker’s decision to work while sick, and a stated belief about the imposed risk to patients. Although most surveys provide closed-ended questions to gather definitive answers, two of the questions were free-text and open, allowing responders to input any appropriate information, including reasons for coming into work while ill. To provide a measurable answer to these two questions, responders were asked to rate the relevance and gravity of their responses on a scale of 1-5, with one (1) being not important at all, and five (5) being imperative.

The data was analyzed with commercially available statistics software, which performed quantitative analysis of the answers [31].  Standard methods of qualitative analyses were carried out on the open-ended, free-text questions using additional software.  These were the results of the study:

  • 929 surveys were administered; 536 completed the questionnaire [57.9% response rate]
  • Response rates by profession:
    • 280 of 459 attending physicians [61.0%]
    • 256 of 470 advanced practice clinicians [54.5%]
  • Of the 536 responses received;
    • 95.3% believe in there is increased risk to patients if they work while sick
    • 83.1% admitted to working while sick at least once in the past year
    • 9.3% admitted to working while sick at least five times in the past year
  • Documented reasons for this behavior include;
    • A desire to not ‘let down’ others, including colleagues and patients,
    • Difficulty or unwillingness to find shift coverage while sick,
    • An implied expectancy from hospital administration or others to work while sick,
    • A vague definition of what it means to be ‘too sick’ to work.

It should be noted that despite the breadth of data accounted for in these studies, a comprehensive picture cannot yet be painted as these studies are conducted regionally, and should not speak for health professionals on a national or international level. Within the United States, these studies relate specifically to physician trainees [18,21,23] while outside the United States the focus is on nurses [28-29] and attending physicians [19,22,25,27].  They don’t provide data on attending physicians or advanced practice clinicians, such as physician assistants or nurse practitioners, or why these professionals choose to work while sick. One must also consider the socio-economic factors the studies do not take into account, such as lack of paid sick leave and financial strain, lack of personnel, or the numerous strains caused by global pandemics such as the 2020 Covid-19 pandemic, which often complicate an outwardly black and white decision.

With all factors in consideration, it remains clear that there is a significant disparity between what the public expects from healthcare professionals, and what medical and hospital staff are able to do. Particularly now, amidst a global pandemic, perhaps it is time we consider whether what we ask of healthcare professionals and what our current healthcare system enables them to do, are the same.

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[1] Routes of transmission during a nosocomial influenza A(H3N2) outbreak among geriatric patients and healthcare workers | The Journal of Hospital Infection |

[2] Risk of Influenza-Like Illness in an Acute Health Care Setting During Community Influenza Epidemics in 2004-2005, 2005-2006, and 2006-2007 | Journal of the American Medical Association |

[3] Nosocomial influenza: new concepts and practice | Current Opinion in Infectious Diseases |

[4] Measures to control an outbreak of pertussis in a neonatal intermediate care nursery after exposure to a healthcare worker | Infection Control and Hospital Epidemiology |

[5] An outbreak of methicillin-resistant Staphylococcus aureus surgical-site infections initiated by a healthcare worker with chronic sinusitis | Infection Control and Hospital Epidemiology |

[6] Nosocomial transmission of norovirus is mainly caused by symptomatic cases | Clinical Infectious Diseases |

[7] Presenteeism: A Public Health Hazard | Journal of General Internal Medicine |

[8] Health Care–Associated Infections | Journal of the American Medical Association |

[9] Multistate Point-Prevalence Survey of Health Care–Associated Infections | The New England Journal of Medicine|

[10] Epidemiology and potential preventative measures for viral infections in children with malignancy and those undergoing hematopoietic cell transplantation | Pediatric Blood & Cancer |

[11] Diagnosis and epidemiology of community-acquired respiratory virus infections in the immunocompromised host | Biology of Blood & Marrow Transplantation |

[12] RSV outbreak in a pediatric intensive care unit | The Journal of Hospital Infection |

[13] Hospitalizations and Mortality Associated With Norovirus Outbreaks in Nursing Homes, 2009-2010 | Journal of the American Medical Association |

[14] Introduction to “A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: 2014 updates” | Infection Control and Hospital Epidemiology |

[15] Working with symptoms of a respiratory infection: Staff who care for high-risk individuals | American Journal of Infection Control |

[16] Effectiveness of Influenza Vaccine in Health Care Professionals: A Randomized Trial | Journal of the American Medical Association |

[17] Respiratory Virus Shedding in a Cohort of On-Duty Healthcare Workers Undergoing Prospective Surveillance | Infection Control and Hospital Epidemiology |

[18] Why Physicians Work When Sick | Journal of the American Medical Association |

[19] What makes physicians go to work while sick: a comparative study of sickness presenteeism in four European countries (HOUPE) | Swiss Medical Weekly |

[20] Barriers to influenza vaccine acceptance A survey of physicians and nurses | American Journal of Infection Control |

[21] Achieving Compliance With Influenza Immunization of Medical House Staff and Students: A Randomized Controlled Trial | Journal of the American Medical Association |

[22] Sickness absence and ‘working through’ illness: a comparison of two professional groups | Journal of Public Health |

[23] Presenteeism Among Resident Physicians | Journal of the American Medical Association |

[24] Do you come to work with a respiratory tract infection? | Occupational & Environmental Medicine |

[25] Physicians who do not take sick leave: hazardous heroes? | Scandinavian Journal of Public Health |

[26] Sickness In The Medical Profession | The Annals of Occupational Hygiene |

[27] Sickness presenteeism in a New Zealand hospital | New Zealand Medical Journal |

[28] Why Do Registered Nurses Work When Ill? | The Journal of Nursing Administration |

[29] Work factors as predictors of sickness absence attributed to airway infections; a three month prospective study of nurses’ aides | Occupational & Environmental Medicine |

[30] Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support | Journal of Biomedical Informatics |

[31] Stata Statistical Software: Release 13 [computer program] | StataCorp LP. |

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