For centuries, a fundamental principle of bioethics for health care workers (HCWs) has been primum non nocere, or first, do no harm. Although this guidance is mostly applicable to therapeutic interventions, it infers that HCWs should be vigilant in not spreading infections to patients. Unfortunately due to societal, cultural, and system-level constraints, most HCWs continue working when sick, increasing the risk of infecting patients.
In 2014, a cross-sectional, anonymous survey of over 280 attending physicians and 256 advanced practice clinicians (APCs) was conducted at The Children’s Hospital of Philadelphia. In the survey, 83.1% respondents acknowledged that they came to work while sick at least once and 9.3% at least five times in the past year, even though 95.3% believed working sick poses a risk to patients.1
Survey respondents reported that they worked while exhibiting significant symptoms, including diarrhea, fever, and acute onset of respiratory symptoms. Physicians were more likely to report to work sick compared to APCs.1 Although this study was only conducted at one hospital, the authors concluded that the findings show an area of improvement for medical venues to both better protect patients and prevent HCW burnout.
Symptomatic HCWs can transmit pathogens directly to others2; contaminate surfaces3; and may have compromised judgment depending on the severity of their illness. Pathogens with high transmission potential from HCWs to patients include norovirus, respiratory infections, measles, and influenza.4 Medical literature cites many outbreaks for which symptomatic HCWs have been found to be the ultimate source of disease within health care facilities.5,6,7 A systematic review of medical literature was conducted to evaluate outbreaks caused by HCWs from 1958 to 2006.5 The review evaluated 152 outbreaks from 26 countries mainly in surgery, neonatology, and gynecology departments. Out of these, 59 outbreaks (41.5%) were derived from physicians and 56 (39.4%) from nurses.
Reasons for Working While Sick
The reasons seem well-intentioned including not wanting to let their patients or colleagues down, staffing shortages, worry about continuity of care, fear of criticism by co-workers for burdening them with extra workload, difficulty finding alternate coverage, cultural expectation to work unless severely ill, and not knowing when it is “too sick to work.”
The solution is not clear-cut because it requires a cultural change and a shift in mindset. Regardless, it is important for HCWs to be mindful of the potential to infect their patients. It may be prudent for workplaces to develop guidelines and impose restrictions for coming to work in the presence of some key symptoms, e.g., conjunctivitis, vomiting, diarrhea, jaundice, fever, etc. However, one limiting factor is that for some illnesses, e.g., many respiratory viruses, individuals are most contagious before being highly symptomatic,8 so staying home after symptoms develop may be counter-productive. Possible solutions may include increased utilization of barrier precautions during patient interactions and institutions developing back-up plans in the event of illness-related absence of medical staff that care for vulnerable or high-risk patients.
According to Dr. Jeffrey R. Starke, from the Department of Pediatrics, Baylor College of Medicine, “Creating a safer and more equitable system of sick leave for HCWs requires a culture change in many institutions to decrease stigma–internal and external–associated with HCW illness,” and “solutions to prioritize patient safety must factor in workforce demands and variability in patient census to emphasize flexibility.”9