1st August 2014, Volume 127 Number 1399

Pei Chyi (Melissa) Tan, Geoff Robinson, Sisira Jayathissa, Mark Weatherall

Sickness presenteeism is the act of working while sick.1 For health care workers, particularly doctors, this poses risks to both patients and other staff. Issues include a risk of spreading infectious diseases, if this is the cause of the illness, and also impairment of the ability of doctors to provide optimal care to patients.

Rates of sickness presenteeism for doctors working in primary or secondary care vary from 51% to 86%.2 A US study of 537 resident doctors reports that 57.9% of respondents worked whilst sick at least once in the previous year and 31.3% worked whilst sick more than once in the previous year 3.

The literature about sickness presenteeism is usually the context of infectious illness. Due to close patient contact, doctors working whilst affected by an infectious illness risk transmitting these diseases to patients. Hospitalised patients represent a vulnerable group and may be at risk of significantly higher morbidity than the general population.

A New Zealand study of rates of sickness presenteeism after a Norovirus outbreak at a regional hospital used a self-reported survey of health-care workers. Doctors were far more likely to go to work whilst affected by an infectious illness, 76.9%, than all the other occupational groups combined, 48.7%.4

The reasons for sickness presenteeism identified in previous studies include a sense of obligation to colleagues and an obligation to patient care; 57% and 56% of all residents in the US study respectively.3 The most common reasons for sickness presenteeism in hospital workers in a New Zealand study were similar; they did not want to increase the workload of others and they did not feel sick enough to stay away from work.4

Sickness presenteeism can in itself be a risk factor for poor health outcomes5 and increased rates of sickness absenteeism in the future.6 For example, if a person continued to work with a viral upper respiratory tract infection and did not improve, it may develop into a more serious complication such as pneumonia.

A similar comparison could be said about psychological health, where stress, fatigue and long hours can lead to burnout or other psychological disorders such as anxiety, depression and substance abuse. Such unwell doctors can negatively affect healthcare systems by affecting morale in departments, as well as directly affecting delivery of patient care.7

The aim of this study was to estimate the rate of sickness presenteeism in hospital doctors in a New Zealand tertiary care hospital and to also identify reasons why doctors continue to work whilst sick. Identifying these reasons has the potential to improve the health and well-being of doctors and patients.

Methods

This study was conducted at Capital and Coast DHB which provides tertiary care hospitals in New Zealand and employs 685 doctors from junior (first year post-graduate) to senior (consultant) levels. All doctors working for the organisation were invited to complete an anonymous online survey which was developed based on questions used in previous similar studies.

An invitation to complete the survey was sent to all doctors at their hospital e-mail address. The e-mail contained a link to the anonymous online survey (Appendix 1). Sickness presenteeism was defined as a response of greater than none to the question “Over the last 12 months, how many times have you gone to work despite feeling that you should have taken sick leave because of your state of health? (Physical or psychological)”.

As well as the structured part of the survey there was the ability for respondents to give 'free-text' comments about the issue of sickness presenteeism. Two further reminders were sent to all participants to improve the response rate.

We obtained data recorded on sick leave taken by doctors and other staff from Human Resources records for 12 months before the survey invitation was sent. We contacted the Health and Disability Ethics committee which advised that a study of this nature did not require formal ethics review.

Statistical analysis—Data is summarised in contingency tables by characteristics of the doctors; seniority, sex, whether full or part-time, and speciality area. ‘Days working whilst sick’ was reported on the survey as an ordinal scale variable for zero, one, two, three to five, and six or more days.

For analysis purposes respondents were further categorised by Position: House Officers, Senior House Officers, Registrars and Fellows were classed as Juniors and Consultants as Seniors; and Department, where Specialities were placed according to Clinical Directorate: Surgical, Women and Children (SWC), Medical, Cancer and Community (MCC), Mental Health Services (MHS), Clinical support services (CSS). Ordinal regression was used to examine the association between days working whilst sick, the response variable; and possible explanatory variables of:

Having a general practitioner, junior versus senior doctor, sex, full-time versus part-time, and speciality. In the tables an odds ratio of more than one means that the variable is negatively associated with more days worked whilst sick and less than one, positively associated with more days worked whilst sick. This orientation of the variables is chosen because being at work whilst sick represents poor clinical practice.

Univariate and multivariate associations, adjusted for all the individual characteristics, are reported. SAS (version 9.3) software was used (SAS institute, NC).

Results

The figure shows the monthly sick leave rates by health practitioner discipline. Doctors consistently have the lowest rate of recorded sick leave. For example in the month of September 2013, the average sick leave rate over all work categories at Capital and Coast District Health Board was 3.4%. Medical staff had an average rate of 1%

 

Figure 1. Sick leave rates in 2013

 

tan1

 

The response rate for the questionnaire was 328/685 (47.8%). Response rate by seniority was 31/65 (47.7%) for House Officers, 10/14 (71%) for Senior House Officers, 108/242 (45%) for Registrars and 179/364 (49%) for Senior Medical Officers. Table 1 shows thecharacteristics of the respondents.

325 respondents reported an average annual number of days of sick leave taken of 1.76 days (range 0 to 30). One response ‘>6 weeks’ was not included as were two responses of ‘domestic sick leave’ which didn't specify the number of days of leave taken. 111/328 (34%) took no sick leave days in the past 12 months.

Sickness presenteeism in the last 12 months was reported by 269/328 (82%) of respondents. The number of days is shown in Table 2.

Table 1. Characteristics of respondents

 

Characteristic

N/328 (%)

Position

 

House surgeon

Senior House surgeon

Registrar

Fellow

Consultant

31 (9)

10 (3)

100 (30)

8 (2)

179 (55)

Sex

 

Female

Male

148 (45)

180 (55)

Hours of work

 

Full time

Part time

250 (76)

78 (24)

Specialty

 

Medical (including sub-specialties)

Surgical (including sub-specialties)

Emergency Department

ICU/Anaesthetics

Paediatrics

Obstetrics and Gynaecology

Radiology

Mental Health

Laboratory

Other

100 (30)

52 (16)

24 (7)

46 (14)

21 (6)

15 (5)

9 (3)

40 (12)

7 (2)

14 (4)

Own GP

 

Yes

No

279(85)

49 (15)

Table 2. Number of days of sickness presenteeism in the last 12 months

 

Days

N/328 (%)

None

58 (18)

1

51 (16)

2

111 (34)

3 to 5

82 (25)

6 or more

26 (8)

 

247/328 (75%) came to work knowing they were too sick to perform to their usual standards. 255/328 (78%) reported other colleagues came to work when they were too sick to work. Of those who came to work whilst sick 162/328 (49%) reported coming to work with an infectious illness, such as an influenza like illness or diarrhoea and/or vomiting, and 167/328 (51%) reported being at work whilst they could still be infectious to others. Table 3 shows the stated reasons for not calling in sick. In this table respondents could nominate more than one reason.

Table 3. Reasons for not calling in sick (respondents could nominate more than one reason)

 

Reason

N/328 (%)

Not wanting to burden co-workers

234 (71)

Feeling of duty to patients

196 (58)

Clinics/theatre sessions already booked

147 (45)

It will create more work in the future

112 (34)

Didn’t feel sick enough

109 (33)

Didn’t want to appear weak to other co-workers or seniors

66 (20)

Sick leave had been used up/no more sick days

0 (0)

The association between respondent characteristics and the likelihood of sickness presenteeism is shown in Table 4. An odds ratio (OR) of more than one means less days of sickness presenteeism and an OR of less than one more likely to have days of sickness presenteeism.

Table 4. Ordinal odds ratio for association between respondent characteristics and likelihood of more sickness presenteeism

 

Characteristic

Univariate OR1 (95% CI)

Multivariate OR1 (95% CI)

Own GP (Yes versus No)

1.24 (0.72 to 2.14)

P=0.44

0.99 (0.57 to 1.82)

P=0.96

Junior versus senior

0.45 (0.32 to 0.67)

P<0.001

0.54 (0.34 to 0.86)

P=0.009

Female versus male

0.61 (0.41 to 0.91)

P=0.014

0.64 (0.42 to 0.96)

P=0.031

Full time versus part time

0.48 (0.30 to 0.76)

P=0.002

0.52 (0.31 to 0.88)

P=0.015

Work type2

Overall P=0.66

Overall P=0.12

CCS versus SWC

1.03 (0.42 to 2.53)

0.74 (0.30 to 1.84)

MCC versus SWC

1.13 (0.40 to 1.73)

1.17 (0.76 to 1.80)

MHS versus SWC

0.76 (0.40 to 1.42)

0.53 (0.27 to 1.01)

 

1. OR: Odds ratio, greater than one implies less likely to have days of sickness presenteeism and less than one more likely to have days of sickness presenteeism

2. Surgical, Women and Children (SWC), Medical, Cancer and Community (MCC), Mental Health Services (MHS), Clinical support services (CSS)

On univariate and multivariate analysis neither having a GP and work type were not associated with days of sickness presenteeism. For both analyses, being female, working full-time, and being a more junior doctor, were associated with more days of sickness presenteeism.

'Free text' comments about sickness presenteeism included the following themes: Burden on colleagues, patient care concerns, the intolerance of the hospital culture for sick leave, other work system issues, and uncertainty about the threshold for staying home. Particular examples of these comments are:

Burden on colleagues:

  • Very hard to take sick leave for self without huge amount of guilt for letting colleagues down
  • Calling in sick makes life worse for everyone else
  • I come to work when perhaps I wouldn’t as it is too dangerous not to and overburdens my already stretched colleagues

Patient care concerns:

  • Concerned about patient continuity of care
  • Lists get cancelled if people take sick days

Hospital culture:

  • Difficult to call in sick when …others at work will almost never believe you
  • Why work…just to get a crap reference because I took a day off
  • Concern is that others do not perceive you to be sick enough to be off work and resent you for creating extra work for them
  • Sick leave should be greeted with "take care, hope things get better soon" rather than the first comment being "when do you think you will be back?"

Work system unable to cope with illness:

  • No cover is available for sickness of SMOs
  • Very limited cover for evening and night duties
  • When we have been short staffed and I wanted to cancel some OP bookings I was told that wasn't allowed. There is insufficient staff to be able to cope with sudden sick leave (which of course is never planned).

Uncertainty about the threshold for staying home:

  • If you're not unwell enough to be stuck in bed all day I feel like I should be at work.
  • My view of what "sick" is, is probably different from the general public, because we are used to seeing VERY sick people.
  • Sometimes being infectious (flu) but not feeling bed ridden means we should be able to work even though we may spread our infection.

Discussion

Human Resources data confirm that Doctors take fewer sick leave days than any other health care workers at this tertiary care hospital in New Zealand, 1% compared to 3.4%. It is possible however that this difference may in part be due to less reliable systems for recording medical sick leave.

The rate of sickness presenteeism in this study was 82%. The main reasons for coming to work whilst sick were: ‘not wanting to burden colleagues’ and ‘feeling of duty to patients’. These reasons were not only identified by respondents as part of the questionnaire, but similar concerns were echoed in their comments.

The overall rate of sickness presenteeism in doctors in this survey is consistent with previous studies and is important as it shows there are a significant number of doctors working whilst unwell who may be compromising their own, as well as patient, health.

Another influence may be that doctors routinely interact with very sick hospital inpatients, and thus become less attuned to minor illnesses. This was reflected in a degree of uncertainty of the threshold for staying home—for example 33% listed “did not feel sick enough” as a reason for coming to work sick.

Doctors were aware that working whilst unwell was poor practice as 75% stated they came to work knowing they were too sick to perform to their usual standards and 78% reported noting other colleagues come to work when they were too sick to work. In addition 49% reported coming to work with a potentially infectious illness knowing they could still be infectious to others, which is concerning for patient safety, and may cause spread of infections to other doctors and staff. However, the impact of presenteeism on actual patient care is uncertain. For example doctors may have taken measures to prevent spread of infectious disease such as gloves, masks, and gowns; or changed work practices when unwell, such as performing more administrative tasks and reducing patient contact during the time they were unwell. The ability to do this could vary between specialities, for example Clinical support services such as Laboratory, Pathology, Radiology, and Medical administration may have less patient contact compared with other medical specialities.

The threshold for taking sick leave for infectious reasons may also vary between departments. Those working with immunosuppressed patients may have a lower threshold for staying home than those in a more administrative role. We were unable to show a difference in amounts of presenteeism when comparing work departments but likely would have lacked statistical power to detect differences by sub-specialities within large groupings. At this tertiary hospital the impact of the uniform rule requiring workers to wait for 48 hours of recovery after diarrhoea and vomiting before returning to work, seems ineffective.

We found that Junior doctors compared to Senior, women compared to men, and Full-time compared to Part-time,were all more likely to have sickness presenteeism days, and that having a general practitioner and work type were not associated. There is little previous data on senior doctors and rates of presenteeism with which to compare these results to, but both groups had similar reasons for not taking sick leave.

Additional reasons from comments from junior doctors included a perceived 'weakness' from seniors and lack of cover for out-of-hours duties. Women had higher rates of presenteeism than men, a finding similar to previous studies.1

There were several weaknesses in our study. Low response rate may have affected the final result. Non-response bias could mean that those who responded were more likely to have sickness presenteeism days than those who had used sick leave appropriately who may not have seen this as an issue important enough to respond. Recall bias may also have been an issue as this was a retrospective survey.

More measures are required to help reduce the rates of sickness presenteeism. This is likely to be difficult but the current situation is not satisfactory. The main stated reason that doctors work whilst sick is burden on colleagues. This may require employing more doctors to act as relievers for their sick colleagues or that there is a more robust culture in seeking and providing cover. There may also be a need to change in culture of ‘heroic coping’ at all costs probably engendered at medical schools and the type of students that are selected.8

It appears that many doctors commented on fear of calling in sick due to repercussions for their careers, or worried about the way they would be viewed by their peers. Doctors personality traits of perfectionism contribute to their success in medicine but also contribute to difficulties in asking for help or admitting weakness.

Promoting a culture where sickness is not viewed as a sign of weakness is important, as well as efforts to promote wellness. It is notable, for example, that 30% of doctors failed to access the free influenza vaccination provided by the DHB in 2013, which is a matter requiring ongoing attention to improve compliance.

Anecdotally, some hospitals have sick leave or short notice relievers for their junior staff, which may be a better option than paid cross-cover systems. Although cross-cover is a less expensive way of covering sick leave, when over stretched doctors are covering someone else’s work in addition, patient care can be compromised. This system could be implemented in larger hospitals where extra relieving staff could be employed to provide sick leave cover. Additionally there is currently no formal mechanism in the system for senior medical officer cover when sick and the available staff need to cover sickness. One solution may be locum cover however this would be of substantial cost to the DHB.

Some hospitals have employed specialists for leave cover and some go off periodically from acute roster for other duties. Developing a flexible pool of specialists who could be regularly employed for non-rostered duties but available to cover sick leave at short notice could help in changing the culture of “not taking sick leave” among specialist staff.

More attention should also be given to those doctors who are well enough to work but may be at residual risk of causing infections to non-clinical duties either at the hospital, or working from home with supported IT systems that are in place. Advice to doctors who are unsure of what infection control measures they should adopt must be readily available, as well as advice for the threshold for returning to work.

In summary, sickness presenteeism is an important quality and safety issue for patients and medical staff at our hospital and probably in the New Zealand health system. This requires change to systems of care provision and organisational culture to allow medical doctors to feel comfortable to take sick leave when appropriate and address the main concerns of burden on colleagues and providing patient care adequately when taking sick leave.

 

Appendix 1. Questionnaire

Tick the answers which apply to you:

Position

House surgeon

 

Senior House Officer

 

Registrar

 

Fellow

 

Consultant

 

Gender

Male

 

Female

 

Do you work Full time or Part time?

Full time

 

Part time – please specify FTE (i.e. 0.6)

 

Specialty (if you are a house surgeon please enter your current run:

Medical (incl. subspecialties)

 

Surgical (incl. subspecialties)

 

Emergency department

 

ICU/Anaesthetics

 

Paediatrics

 

Obstetrics and Gynaecology

 

Radiology

 

Mental Health

 

Laboratory

 

Other (please specify) :

 

How many sick leave days have you taken in the last 12 months?

None

 

1

 

2

 

3

 

4

 

5

 

Other (please specify)

 

For the following questions, please circle yes or no

Have you ever come to work knowing you were too sick to perform to your usual standards?

Yes/No

Do you think any of your colleagues have come in when they were too sick to work?

Yes/No/Don’t know

Have you ever come to work with an infectious illness? (flu, cold, diarrhoea, vomiting)

Yes/No

Have you ever come to work knowing you could still be infectious? (for example, not waiting 48hrs after diarrhoea or vomiting has settled before returning to work)

Yes/No

Do you have your own GP?

Yes/No

Over the last 12 months, how many times have you gone to work despite feeling that you should have taken sick leave because of your state of health? (Physical or psychological)

Never

 

1

 

2

 

3–5

 

5 or more

 

 

What are your reasons for not taking sick leave when you were unwell? (Tick as many that apply )

Feeling of duty to patients

 

Not wanting to burden co-workers

 

Clinics/theatre sessions already booked

 

Didn’t want to appear weak to other co-workers or seniors

 

It will create more work in the future

 

Sick leave had been used up/no more sick days

 

Didn’t feel sick enough

 

Other reasons:

 

Which of these is the MOST IMPORTANT reason for not taking sick leave when you were unwell?(select one only)

Feeling of duty to patients

 

Not wanting to burden co-workers

 

Clinics/theatre sessions already booked

 

Didn’t want to appear weak to other co-workers or seniors

 

It will create more work in the future

 

Sick leave had been used up/no more sick days

 

Didn’t feel sick enough

 

Other reasons:

 

Which is the 2ND MOST important reason? Please ensure you have a different answer to above. Select "None of the above" if no more reasons apply to you.

Feeling of duty to patients

 

Not wanting to burden co-workers

 

Clinics/theatre sessions already booked

 

Didn’t want to appear weak to other co-workers or seniors

 

It will create more work in the future

 

Sick leave had been used up/no more sick days

 

Didn’t feel sick enough

 

None of the above

 

Which is the 3rd MOST important reason? Please ensure you have a different answer to the previous 2 questions. Select "None of the above" if no more reasons apply to you.

Feeling of duty to patients

 

Not wanting to burden co-workers

 

Clinics/theatre sessions already booked

 

Didn’t want to appear weak to other co-workers or seniors

 

It will create more work in the future

 

Sick leave had been used up/no more sick days

 

Didn’t feel sick enough

 

None of the above

 

 

Thank you for completing this survey. Do you have any other comments?

 

Abstract

Aim

To estimate the rate of sickness presenteeism in hospital doctors in a New Zealand tertiary hospital and to also identify reasons for why doctors continue to work whilst sick.

Method

An anonymous online survey about sickness presenteeism for all hospital doctors at one tertiary care hospital in New Zealand

Results

The response rate for the survey was 328/685 (47.8%). Sickness presenteeism was reported by 269/328 (82%) of respondents. The main reasons for sickness presenteeism were: not wanting to burden co-workers and the desire to ensure care for patients.

Conclusion

Sickness presenteeism is highly prevalent in this survey. It is likely a change in attitudes by doctors towards their illnesses, and better allocation of staff resources are necessary to prevent this to avoid potential harm to patients and health care workers.

Author Information

Pei Chyi (Melissa) Tan, Medical Registrar, Capital & Coast District Health Board (CCDHB), Wellington;

Geoffrey M Robinson, Chief Medical Officer, CCDHB, Wellington;

Sisira Jayathissa, Clinical Director of Medicine and Community Health, Hutt Valley District Health Board, Wellington;

Mark Weatherall, University of Otago, Wellington

Correspondence

Melissa Tan, Wellington Hospital, Private Bag 7902, Wellington South, New Zealand.

Correspondence Email

Melissa.Tan@ccdhb.org.nz

Competing Interests

Nil.

References

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3. Jena AB, Baldwin DC, Daugherty SR, et al. Presenteeism among resident physicians. JAMA 2010;304:1166–1168

4. Bracewell LM, Campbell DI, Faure PR, et al. Sickness presenteeism in a New Zealand hospital. N Z Med J 2010;123(1314). http://journal.nzma.org.nz/journal/123-1314/4106/content.pdf

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