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Patient Safety and Ethical Implications of Health Care Sick Leave Policies in the Pandemic Era

      Case

      Ms. F is an employee of a hospital-affiliated nursing home (NH) where she develops cough, shortness of breath, and malaise while working her shift. She presents to the emergency department (ED) at the same hospital for evaluation of these symptoms after finishing her shift. Ms. F has a history of asthma and has been working during an outbreak of coronavirus disease 2019 (COVID-19) that occurred at the facility where she is employed.
      Dr. H evaluates Ms. F in the ED, determining that she is stable and does not require inpatient treatment, and recommends testing for COVID-19. She is agreeable with testing until Dr. H informs her that she must stay home from work awaiting test results. Ms. F becomes visibly upset. When prompted, she reports both a sense of duty to her patients and a fear of financial hardship. She does not have any remaining sick leave, and her husband has been out of work during the pandemic. She declines testing and leaves the ED stating her intention to return to work in the NH.

      Commentary

      Great strides have been made since the beginning of the pandemic, but sudden acute respiratory syndrome coronavirus-2 (SARS-CoV-2) continues to circulate in the community.

      Centers for Disease Control and Prevention. COVID Data Tracker. (Updated: Jul 7, 2021.) Accessed Jul 8, 2021. https://covid.cdc.gov/covid-data-tracker/#datatracker-home.

      Although vaccination efforts are evolving to include hard-to-reach communities, individuals susceptible to infection remain, and the future impact of more transmissible SARS-CoV-2 variants of concern remains unknown.
      • Galloway SE
      • et al.
      Emergence of SARS-CoV-2 B.1.1.7 lineage—United States, December 29, 2020–January 12, 2021.
      As long as community transmission persists, unvaccinated older adults and those with comorbidities are at particularly high risk of severe disease.
      • Wu Z
      • McGoogan JM.
      Characteristics of and important lessons from the coronavirus disease 2019 (COVID-19) outbreak in China: summary of a report of 72 314 cases from the Chinese Center for Disease Control and Prevention.
      Physical distance remains a cornerstone in limiting disease spread, with documented major outbreaks associated with confined living spaces.
      • Kakimoto K
      • et al.
      Initial investigation of transmission of COVID-19 among crew members during quarantine of a cruise ship—Yokohama, Japan, February 2020.
      ,
      • Saloner B
      • et al.
      COVID-19 cases and deaths in federal and state prisons.
      Patients in the congregated living arrangement of NHs, often with advanced age, significant comorbidities, and inability to care for themselves, are especially vulnerable and have experienced particularly devastating outcomes when infected with COVID-19.
      • McMichael TM
      • et al.
      Epidemiology of Covid-19 in a long-term care facility in King County, Washington.
      Patients and employees of NHs represent a significant percentage of all COVID-19 deaths in the United States.

      Kaiser Family Foundation. State COVID-19 Data and Policy Actions. (Updated: Jul 6, 2021.) Accessed Jul 8, 2021. https://www.kff.org/coronavirus-covid-19/issue-brief/state-covid-19-data-and-policy-actions/.

      With the generally limited mobility of NH residents. it is likely that the major route for illness introduction is through employees, when visitation is restricted.
      This case involves consideration of the factors influencing employee illness behavior, the ethical responsibilities of the leadership of the health care system to its workforce and patients, and how local policy influences the risk of nosocomial illness transmission.

      Patient Safety Considerations

      An employee who becomes sick is immediately presented with two options—stay home and recover or report to work while feeling ill. Literature shows that multiple factors influence this decision, including individual attributes such as job title and socioeconomic status, workplace characteristics such as culture and sick leave policies, and, finally, federal and state regulations mandating paid sick leave.
      • Prater T
      • Smith K.
      Underlying factors contributing to presenteeism and absenteeism.
      ,
      • Pichler S
      • Wen K
      • Ziebarth NR.
      COVID-19 emergency sick leave has helped flatten the curve in the United States.
      Prior to the COVID-19 pandemic, it was well-documented that presenteeism—continuing to work despite illness—was widespread overall and very common among HCWs, with as many as 80% of medical providers continuing to work despite symptoms of an influenza-like illness.
      • Turnberg W
      • Daniell W
      • Duchin J.
      Influenza vaccination and sick leave practices and perceptions reported by health care workers in ambulatory care settings.
      • Webster RK
      • et al.
      A systematic review of infectious illness presenteeism: prevalence, reasons and risk factors.
      • Jena AB
      • et al.
      Presenteeism among resident physicians.
      • Tartari E
      • et al.
      Not sick enough to worry? “Influenza-like” symptoms and work-related behavior among healthcare workers and other professionals: results of a global survey.
      HCW presenteeism risks the transmission of illness to vulnerable patients and puts fellow HCWs at risk.
      • Widera E
      • Chang A
      • Chen HL.
      Presenteeism: a public health hazard.
      HCW–to-patient transmission has been implicated in local outbreaks during the COVID-19 pandemic,
      • Asad H
      • et al.
      Health care workers and patients as Trojan horses: a COVID19 ward outbreak.
      ,
      • Chow EJ
      • et al.
      Symptom screening at illness onset of health care personnel with SARS-CoV-2 infection in King County, Washington.
      with infected HCWs continuing to work for a median of two days after symptom onset in one study.
      • Chow EJ
      • et al.
      Symptom screening at illness onset of health care personnel with SARS-CoV-2 infection in King County, Washington.
      The underlying motivations for working during illness can vary by individual and by circumstance. Some HCWs may report to work while sick from a sense of duty to their patients and colleagues.
      • Webster RK
      • et al.
      A systematic review of infectious illness presenteeism: prevalence, reasons and risk factors.
      Among others, presenteeism may result from the estimation that the financial harm one experiences from staying home is greater than the perceived harm to others of working while sick. Employees with the most tenuous hold on economic stability and with the highest perceived risk of losing their job for not coming to work report the highest likelihood of presenteeism during a pandemic.
      • Blake KD
      • Blendon RJ
      • Viswanath K.
      Employment and compliance with pandemic influenza mitigation recommendations.
      Workplaces with a high perceived threat of discipline are also associated with increased likelihood of working while sick.
      • Webster RK
      • et al.
      A systematic review of infectious illness presenteeism: prevalence, reasons and risk factors.
      Not surprisingly, employees who do not have paid sick leave, or who have run out of available sick time and would be required to take unpaid leave, are also more likely to work while ill.
      • Webster RK
      • et al.
      A systematic review of infectious illness presenteeism: prevalence, reasons and risk factors.
      This observation has important implications for health care, as the rate of presenteeism is lower in organizations with paid sick leave policies, and these facilities benefit from lower rates of infection transmission both to patients and among staff.
      • Li J
      • et al.
      Impact of institution size, staffing patterns, and infection control practices on communicable disease outbreaks in New York State nursing homes.
      ,
      • Asfaw A
      • Rosa R
      • Pana-Cryan R.
      Potential economic benefits of paid sick leave in reducing absenteeism related to the spread of influenza-like illness.
      Accordingly, health care facilities that enact restrictive sick leave policies with the intention of maximizing per-employee productivity could reasonably expect the imposition of barriers to be associated with increased presenteeism. For these reasons, the Centers for Disease Control and Prevention (CDC) recommends sick leave policies for HCWs that are nonpunitive and flexible.

      Centers for Disease Control and Prevention. Infection Control in Healthcare Personnel: Infrastructure and Routine Practices for Occupational Infection Prevention and Control Services (2019). (Updated: Oct 28, 2019.) Accessed Jul 8, 2021. https://www.cdc.gov/infectioncontrol/guidelines/healthcare-personnel/index.html.

      Among physicians, those most vulnerable to coercion due to their educational or training status report the highest impact of external factors on their decision to present to work while ill.
      • Kaldjian LC
      • et al.
      Attitudes about sickness presenteeism in medical training: is there a hidden curriculum?.
      ,
      • Gudgeon P
      • et al.
      Do you come to work with a respiratory tract infection?.
      Special consideration must be paid when crafting policies regarding medical student and resident physician sick leave to mitigate the risk of these groups feeling undue pressure to work despite illness. Among more senior physicians, both a culture of wariness of burdening colleagues and a feeling of overwork may contribute to presenteeism.
      • Webster RK
      • et al.
      A systematic review of infectious illness presenteeism: prevalence, reasons and risk factors.
      ,
      • Kaldjian LC
      • et al.
      Attitudes about sickness presenteeism in medical training: is there a hidden curriculum?.
      ,
      • Wrate RM.
      Increase in staff numbers may reduce doctors’ “presenteeism.
      There also appears to be a belief among physicians that by taking adequate precautions they are able to minimize the risk of illness transmission, thereby resolving the ethical conflict between the duty to care for their patients, the desire not to impose on their colleagues, and the duty not to harm.
      • Kaldjian LC
      • et al.
      Attitudes about sickness presenteeism in medical training: is there a hidden curriculum?.
      This may in part explain the high rate of presenteeism seen among physicians and can inform strategies to encourage physicians to stay home when sick.
      In addition to organizational policies, workplace culture plays a role in reporting to work while ill, and in some settings this may be a normalized behavior.
      • Webster RK
      • et al.
      A systematic review of infectious illness presenteeism: prevalence, reasons and risk factors.
      In this way presenteeism, although it violates stated policies, may propagate. Supervisors can increase the likelihood of presenteeism during illness whether through pressure on employees not to use sick leave or by questioning the legitimacy of sick leave requests.
      • Webster RK
      • et al.
      A systematic review of infectious illness presenteeism: prevalence, reasons and risk factors.
      It is the responsibility of the leadership of the health care organization to establish a culture of safety that includes using sick leave during illness. A health care organization that fosters a culture of workplace safety, valuing the protection and well-being of employees over their productivity, tends to engender trust, which in turn is associated with reduced presenteeism.
      • Liu B
      • Lu Q.
      Creating a sustainable workplace environment: influence of workplace safety climate on Chinese healthcare employees’ presenteeism from the perspective of affect and cognition.
      Trust is engendered before and during a pandemic by clear, frequent, and honest communication on the part of health care leadership.
      • Iserson KV.
      Healthcare ethics during a pandemic.
      The burdens borne by HCWs who become ill will be most harmful to those least equipped to handle the challenges incurred by illness. The lowest paid, those with the least status and having the least agency, are those least prepared to adjust to the challenges of staying home during illness. This unequal burden should not be borne by these individuals but rather by health care organizations.
      • Upshur R.
      The ethics of quarantine.
      ,
      Johns Hopkins Berman Institute of Bioethics

      Ethical Considerations

      In addition to the patient safety benefits of flexible sick leave policies, a number of ethical principles support their adoption. Given the risk borne by HCWs in caring for the sick during a pandemic, it is recognized that society must adequately address the needs of HCWs.
      • Thompson AK
      • et al.
      Pandemic influenza preparedness: an ethical framework to guide decision-making.
      At the level of the health care system, this includes mitigating the risk of illness contraction and the harms encountered if it occurs. The principle of reciprocity, in addition to supporting adequate personal protective equipment, vaccination, and provision of antivirals, requires that health care facilities address the potential loss of income due to home isolation with the provision of accessible paid sick leave. Holm advocates for the compensation of self-isolating sick individuals during a pandemic, in part supported by reciprocity.
      • Holm S.
      A general approach to compensation for losses incurred due to public health interventions in the infectious disease context.
      Indeed, with anxiety prevalent early in the COVID-19 pandemic, HCWs expressed the need for these and other reciprocity-based measures as a way for their organizations to support and care for them.
      • Shanafelt T
      • Ripp J
      • Trockel M.
      Understanding and addressing sources of anxiety among health care professionals during the COVID-19 pandemic.
      Society benefits from reduced disease transmission when those experiencing illness isolate and should ensure compensation in recognition of this contribution. For employed individuals, the employer is the natural agent to execute this compensation by way of paid sick leave.
      The ethical response to a pandemic requires the public be protected from harm.
      • Thompson AK
      • et al.
      Pandemic influenza preparedness: an ethical framework to guide decision-making.
      At the level of the health care facility, this requires policies that recognize and mitigate the factors influencing presenteeism. Such policies respect the autonomy and inherent dignity of all employees while avoiding coercion.
      At the individual level, working despite illness and risking disease transmission in a health care setting is in contradiction with the ethical principle of nonmaleficence, the obligation not to harm others, a cornerstone to medical practice. This individual decision must be considered in the broader context of the environment in which it occurs, as external factors exert significant influence on presenteeism.
      • Landry M
      • Miller C.
      Presenteeism: are we hurting the patients we are trying to help?.
      Internal tracking of employee illness is needed to monitor the health of the facility's workforce, detect nosocomial outbreaks, and make forward-looking plans. However, this consideration needs to be balanced with patients’ right to privacy. Whenever possible, internal reporting of HCW illness should be anonymized to respect employee privacy.
      • Thompson AK
      • et al.
      Pandemic influenza preparedness: an ethical framework to guide decision-making.
      When disclosure of private health information is required, it should contain the minimum information necessary and be shared with the fewest people possible. For example, a disclosure might reasonably include, in addition to local public health authorities, the employee's supervisor and a member of either infection control or employee health to perform internal contact tracing and follow-up.
      It should also be noted that, despite adequate planning and well-conceived policies, a respiratory pandemic may threaten shortages of trained personnel due to either illness or an overwhelmed health system. In this crisis scenario, the harms of a severe shortage of HCWs could be more severe than the harms of HCWs with mild symptoms continuing to care for likewise infected patients. These circumstances may necessitate crisis standards of care, which should prospectively consider equity.

      Hastings Center. Ethical Framework for Health Care Institutions Responding to Novel Coronavirus SARS-CoV-2 (COVID-19): Guidelines for Institutional Ethics Services Responding to COVID-19: Managing Uncertainty, Safeguarding Communities, Guiding Practice. Berlinger N, et al. Mar 16, 2020. Accessed Jul 8, 2021. https://mk0thehastingsc1jg1a.kinstacdn.com/wp-content/uploads/HastingsCenterCovidFramework2020.pdf.

      ,
      • Gershengorn HB
      • et al.
      Assessment of disparities associated with a crisis standards of care resource allocation algorithm for patients in 2 US hospitals during the COVID-19 pandemic.
      In summation, the disparate ethical principles that gird the pandemic response are linked by trust—that society will protect the individual, that individuals will protect each other, and that health care facilities will protect their patients and employees.
      • Thompson AK
      • et al.
      Pandemic influenza preparedness: an ethical framework to guide decision-making.

      Conclusion

      Sick leave policies that are flexible and nonpunitive are essential patient safety and ethical components of a health care facility's strategy to reduce the spread of illness due to presenteeism. With an organizational pandemic response that includes these policies, Ms. F would not experience loss of income in going home, a course of action that would be in line with the culture of safety supported by her supervisor, and she would not be putting her patients and HCW colleagues at risk.

      Conflicts of Interest

      All authors report no conflicts of interest.

      Disclaimer

      The views expressed within this article are solely those of the authors and do not necessarily represent the views of the Department of Veterans Affairs or the US Government.

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