A key argument in the movement to expand sick leave to all workers is that such policies help curb the spread of contagious diseases. And there are few workplaces where that concept is more important than in health care settings, where common diseases can be especially dangerous for patients with compromised immune systems. However, a new study finds that despite such risks, doctors and nurses still feel pressured to report to work while sick.

Published earlier this week in JAMA Pediatrics, the study is based on anonymous surveys conducted in a large children’s hospital in Philadelphia and among 459 attending physicians and 470 advanced practice clinicians, which includes nurse practitioners, physician assistants, clinical nurse specialists, nurse anesthetists and nurse midwives. Among the 280 physicians and 256 advanced practice clinicians who participated in the survey, the overwhelming majority — more than 95 percent — believed that working while sick is bad for patients. Still, just more than 83 percent said they had worked while sick at least once in the past year, and about 9 percent reported working while sick at least five times.

And what’s really fascinating are the reasons why the providers showed up to work while sick. (This is particularly interesting because even in a setting where working while sick can have dire consequences and even among occupations that typically come with paid sick leave benefits, employees still seem to feel that their workplace cultures look negatively on using sick leave.) According to the study, the top reasons for deciding to work while sick were not wanting to let fellow colleagues down, staffing concerns, not wanting to let patients down, fear of being ostracized by colleagues, and concerns about continuity of care. Other reasons included difficulties in finding someone to fill in for a sick worker, a strong cultural norm to report to work unless seriously ill and uncertainty as to what constitutes being “too sick to work.” Study authors Julia Szymczak, Sarah Smathers, Cindy Hoegg, Sarah Klieger, Susan Coffin and Julia Sammons write:

Respondents recounted critical comments made by colleagues about those who take sick leave, stories of working (or seeing others work) while so ill that they needed intravenous hydration, and the general impression of an unspoken understanding that attending physicians and (advanced practice clinicians) should “buck up” and work while symptomatic. Some physicians described working while sick to be part of their professional identity (e.g., 9 stated simply, “physicians do not take days off”) and that calling out for illness is unprofessional. Echoing our closed-ended findings, respondents expressed a very strong desire to not burden their colleagues with additional work, extreme guilt about having to ask for coverage, and fear of stoking resentment in others for calling out sick.

While physicians were more likely than advanced practice clinicians to report being worried about continuity of care, the study found that advanced practice clinicians were more likely to report fears of being ostracized by colleagues as well as unsupportive leadership. Some survey respondents wrote about a complete absence of a sick relief system in their departments, while others acknowledged the presence of a sick leave policy, but said it wasn’t used in practice. Other survey participants said the logistics of clinical scheduling, such as patients making appointments months in advance or needing to meet volume quotas, made it unrealistic to take sick leave, describing the impact of sick leave with words such as “nightmare” and “chaos.”

Among the write-in comments from 316 survey respondents, researchers found that 57 percent were uncertain as to what types of symptoms constitute being too sick to work. Most said vomiting, diarrhea and fever were clear reasons to call in sick; however, many said they still felt pressures to report to work even with severe illness symptoms. With regard to upper respiratory tract infections, which can be particularly risky for patients, many respondents said staying home is simply impractical, as recovering from such an infection could take many days. Overall, researchers found that the barriers to taking sick leave vary among different clinical settings, such as outpatient versus impatient care, and so sick leave systems should be tailored accordingly.

While the study noted that more research is needed before making definitive recommendations, the researchers did suggest some strategies that could help, such as work duty reassignments and teleworking. They write: “…the decision to work while sick was shaped by systems-level and sociocultural factors that interacted to cause our respondents to work while symptomatic despite recognizing that this choice may put patients and colleagues at risk.”

In an accompanying editorial by Jeffrey Starke of Baylor College of Medicine and Mary Anne Jackson of the University of Missouri-Kansas City School of Medicine, the physicians write that developing fair sick leave systems for health care workers will require a “culture change in many institutions to decrease the stigma — internal and external — associated with (health care worker) illness.”

“Hospital leadership must ensure that the culture supports a paid sick leave policy that is adequate and nonpunitive,” they write.

To read a full copy of the health care worker study, visit JAMA Pediatrics.

Kim Krisberg is a freelance public health writer living in Austin, Texas, and has been writing about public health for more than a decade.