I admit it: I’ve gone to work sick when I should have stayed at home. I’ve gone with hacking coughs, sore throats, Fevers Not Yet Diagnosed, and probable gastroenteritis. I’ve gone in with migraines. Once when I was being treated for an I & D’d abscess, I went in with a saline lok, a kind of intravenous access to give me antibiotics. Should have stayed home, I confess, I know better, but there it is.
So I listened attentively to Brian Goldman’s CBC Radio show White Coat, Black Art this week (you can hear it at the link) on health care professionals coming in to work sick. We do it for reasons perhaps not unique to health care: we don’t want to let down the team, there’s no one to replace us, we’re indispensable. He mentions physicians being expected to show up unless dead or nearly so; nurses, when I was a student at least, were inculcated from our first clinical day that calling in sick was tantamont to being a bad nurse.*
However, the consequences of having sick health care professionals are, of course, unique: we tend to infect patients who are already compromised. As bad, or worse, we compromise our judgement: who can think clearly with a temperature of 39.8C, or while having to run to the toilet every ten minutes? Goldman suggests that a massive culture change in hospitals is necessary to let health care workers take sick days as needed. I agree. But it’s not going to happen any time in the near future: hospital administration itself is the biggest obstacle. There are clear choices in creating a culture that gives permission for nurses in particular to take sick time. I don’t believe hospitals have the will to make that cultural shift.
Let me explain: the problem of sick nurses, other health professionals and ancillary staff coming to work — I’m leaving out physicians, because in Ontario hospitals, they aren’t subject to the same scrutiny as nurses — highlights an internal conflict within hospital administration. In an ideal world, Infection Control in all hospitals would dearly like nurses and the rest to stay home if they’re sick. Patient safety, after all comes first. In the real world, however, hospital Human Resources departments do not consider infection control as a priority. Human Resources views sick time as a controllable cost, and frankly, sick nurses a problem to be managed.
It’s true in general that nurses take higher than average rates of sick time. The reasons for this are complex: we are, after all, exposed to infection on a daily basis, the nature of our work is highly stressful (which in of itself has health consequences), and sick time is an indicator of nursing morale which in many hospitals is quite poor. The job of human resources is to provide strong disincentives to nurses (and others) calling in sick. They d0 this in a couple of ways. In Ontario, hospitals cut sick pay for nurses by up to a third, depending on seniority. If you’re a sole-wage earner living paycheque to paycheque, it’s a substantial amount. Pragmatically speaking, if it’s between feeding your kids, and coming in sick, even if you are a conscientious nurse, guess which will win.
Further, nurses must cope with attendance management programs. In Ontario, and I know this is true in many American hospitals, nurses are subject to punishment if they take as few as three sick days, and made (with union acquiescence) to attend humiliating, disciplinary “attendance-management” meetings. For their part, hospital management and the union — the Ontario Nurses Association — will vehemently deny the attendance management process is disciplinary in nature. Personally, I have never been subject to attendance management. But I have seen nurses leave these meetings distressed to the point of tears, and I know of one nurse who left her position and the hospital because of Human Resource harassment. It’s discipline by other means and it’s a strong deterrent to taking sick leave. I’ve come in sick myself knowing I was close to the threshold of being put on “The Program.”
A conversation I had a few months ago with the Infection Control Nurse illustrates quite nicely this tension between the conflicting goals of Infection Control and Human Resources. The context was a mini-outbreak of gastroenteritis; three nurses were off sick. The Infection Control Nurse got wind of this outbreak, and wanted to ensure the nurses stayed home for 48 hours after the last symptoms, as per hospital policy. She wanted names, which I refused because of confidentiality. She then wanted me to call the nurses. I refused again. I knew at least one of them was already in some difficulty with the attendance management program, and I was unsure about the rest.
“Well,” she said. “Let me call them.”
No, I said. I explained to her how Human Resources will punish the nurses for following hospital policy.
“Oh,” she said. “That’s a human resources issue, not an infection control issue.”
Actually, I thought, if you have an otherwise diligent, handwashing-fanatical nurse like me resisting infection control directives, human resource policy is an infection control issue.
In the end, hospitals must choose between trying (and mostly, I think, failing) to control sick time costs and making infection control truly a priority. It’s no good telling nurses to stay home if they are sick, only to turn around and punishing them for fulfilling what is really a professional obligation. Half-measures, like telling nurses to mask for their 12-hour shift, or to be “extra-diligent” in handwashing are impossible to enforce. Maybe some innovation is needed on how we look at sick time. One U.S. hospital I know of recognizes only 2-3% of employees abuse sick time, and assigns twelve days a year for “personal use,” no questions asked, after which HR begins to apply the screws. Nurses who leave part or all the personal days untouched get a payout of three of those days on a pro-rated basis. A change like that would indeed entail a massive culture shift. Present practice does not truly address infection control issues raised by health care professionals working sick, and sends conflicting messages to nurses. Either infection control is a priority for hospitals, or it isn’t. Which is it?
*I’d be interested hearing from new grads whether this is still true.