Have you ever been on your way to work and asked yourself “I don’t really feel well . . . should I really be working clinically today” – and yet still turned up and completed a full day’s work?
In my work as a GP, I vividly remember an incident a few years ago cutting out a skin cancer from a patient's back while sweating profusely and feeling very unwell. Once I finished the procedure, I stopped to take my heart rate - it was 130! I was admitted to hospital that day with severe pneumonia, yet I had still dragged myself into work because I had patients to see and didn't want to let anyone down.
Many health professionals feel compelled to turn up to work, even if their internal answer to the question above is a resounding “No”. For healthcare workers, the challenge does not seem to be absenteeism (abstaining from work while well) but presenteeism - to be working while not fit to work.
The IMSAFE protocol
International aviation protocol mandates that all pilots ask themselves that same question every day prior to flying – “Am I fit to be flying today”. The IMSAFE protocol asks pilots whether they can answer “Yes” to all of the questions below:
Illness - Do I have any symptoms that are impairing my ability to work effectively?
Medication - Have I been taking prescription or over-the counter drugs that may impact my cognitive or physical ability?
Stress - Am I under psychological pressure at work? Do I have significant personal, family or financial problems that are distracting me?
Alcohol - Is alcohol or other recreational substances impairing my decision-making capacity?
Fatigue - Am I tired and not adequately rested to function as a valuable member of the team?
Eating - Have I eaten sufficiently to remain adequately nourished until my next break? Am I dehydrated? Do I need to go to the bathroom?
If they answer “No” to any of the questions, then they do not fly, and it is the responsibility of the carrier to find another pilot who can fly that schedule.
Can we apply the IMSAFE principle to healthcare practitioners?
I have recently been thinking that healthcare practitioners could benefit from applying this same principle. This will require us to be comfortable in asking the question of ourselves, as well as a reasonable degree of self-awareness to identify when we are tired, stressed or unwell.
The field of healthcare has parallels to aviation - decision making is often time critical and mistakes can be costly and involve human lives. Recently the healthcare sector (particularly in the Critical Care context) has adopted a number of aviation safety protocols including "Team Time out" and "Closed Loop Communication".
I have been familiar with the acronym "HALT - Hungry Angry Late and Tired" since medical school. I wonder if the IMSAFE principle is more powerful, as it is more comprehensive (particularly taking into account the presence of illness) and has a greater emphasis on clinical decision making and patient safety.
When principles of patient safety and clinician self-care converge
There is no doubt that it is in the best interests of our self-care to stay at home when were are physically or emotionally unwell. Yet, in addressing the healthcare workplace culture of presenteeism, I suspect we may have more success by framing the problem as a patient safety issue. Clearly the two are not mutually exclusive, it is both in our best interest and for the safety of our patients that healthcare practitioners do not work when they are unfit to work. By framing presenteeism as a safety issue, we can work towards creating a workplace culture where team members feel it is safe to be honest about their health without fear of judgement or punishment.
When I think of my patient who had a skin cancer removed that day, I know that they would have preferred for me to be at my peak performance for such an important procedure, and we could have easily rescheduled the appointment. Our patients deserve us at our best. Adopting the IMSAFE principle from our colleagues in the aviation industry could be a powerful step in addressing the issue of presenteeism for healthcare professionals.
For more information on the history of healthcare implementing aviation principles read an article from the New York Times here
 Federal Aviation Administration (2016) Pilot’s Handbook of Aeronautical Knowledge retrieved online
 SA Health I’M SAFE Checklist. (2017) Facilitation Guide, Situation Monitoring. Retrieved online