Improving work conditions through strike: Examination of nurses’ attitudes through perceptions of two physician strikes in Israel

Abstract

BACKGROUND: Strikes are means to influence policies related to working conditions, yet raise ethical dilemmas for healthcare workers. Nurse strikes have become more prominent around the world.

OBJECTIVE: To assess the change in Israeli nurses’ attitudes towards strikes in light of two physician strikes that have preceded a nursing strike.

METHODS: An anonymous survey was administered once in 2000 (N = 106) and again in 2011 (n = 175) following 110 days of a physician strike, to assess nurses’ attitudes towards the strike and resulting ethical issues.

RESULTS: A statistically significant change (p < 0.05) between administrations revealed that in 2011 more nurses identified striking as a legitimate mechanism, would strike under the same circumstances, and felt that collaboration with physicians persisted despite the strike. Additionally, an increasing number of nurses said that the suffering of patients due to the strike is somewhat or entirely justified, although they were faced with a difficult dilemma of loyalty to physician colleagues vs. patients. Nurses reported finding ways to mitigate the suffering of patients resulting from the strike.

CONCLUSIONS: While patient-centered care remains nurses’ first and foremost priority, findings indicate an increasing support of collective bargaining and strike to promote working conditions related to professional and public health agendas.

Keywords

Advocacy ethics public health

1 Introduction

Nurses and doctors who work in hospitals share many common values and challenges as they collaborate to address the varied needs of patients and healthcare systems. Both professions share similar ethical guidelines and working conditions in hospitals. These include an obligation to place their patients’ interests above their own, to respect patients’ autonomy, provide care that they think will be beneficial (beneficence), to avoid harm (nonmaleficence), and to administer the care justly [1]. Both professions also share causes for occupational stress and quality of work-life, specifically in public hospitals [2, 3] where time demands are high, and compensation is comparatively low. Additional concerns are violence against healthcare professionals [4 –7], and work-related musculoskeletal injuries [8, 9]. All of these factors may influence the health and job performance of nurses and physicians.

In Israel, like in many other places around the world, there is a great shortage of nurses and doctors with medical and nursing graduates currently being among the lowest in OECD countries [10, 11]. Although it has been shown that positive work environments enhance retention and entrance of new professionals, Israeli healthcare professionals still report a poor quality practice environment and compensation, decreased job satisfaction and low retention [12 –14]. These issues have been addressed by the professional unions throughout the past decades, and historically when negotiations were unsuccessful, they led to a strike.

The right of workers to strike is regarded as one of the basic socio-economic rights in a democracy, and it is recognized as such in international law [15] and also in the statutes and case law of various countries [16]. The ethics of healthcare personnel’s strikes have been gaining growing attention [17 –26] with a particular focus on the ethical issues that characterize the medical professions. At the end of the 20th century, the American Society of Nursing and the Israeli Medical Association have officially identified striking as a last resort [27, 28]. However, more recent scholars have been suggesting that in fact, healthcare professional’s dedication to caring work may encourage rather than dissuade them from going on strike, recognizing its legitimacy [17].

In democratic countries including Israel, the right to strike has been recognized both in legislation and in practice legal rulings, and is considered a legitimate tool to promote working conditions and public agendas [16]. Physician strikes have been used to draw attention to different physician concerns several times in Israel (in the years 1956, 1967, 1976, 1983, 1994, 2000, and 2011). The two most recent strikes, in 2000 and 2011, are the focus of this paper. The 2000 physician strike lasted 217 days. The focus and main accomplishments included an agreement to improve compensation and working conditions, and an establishment of a public commission to examine the state of public health and status of the physician [14].

The 2011 physician strike lasted four and a half months, and included a partial, rather than a full strike as not all doctors were involved and many of those involved continued to work part of the time. Strike actions included delay or cancellation of non-life-saving procedures, along with engagement in demonstrations, a protest march, a hunger strike and a mass resignation. The declared focus in this strike was “saving public health” and beyond a demand for increased compensation included finding solutions to shortages of doctors and medical equipment, supporting areas of specialty where there is shortage of professionals, improving the working conditions of the interns and promotion of health in peripheral areas by directing additional resources to hospitals and clinics in the periphery.

Approximately a year following the 2011 physician strike, in December 2012, the Israeli nursing association declared a strike after failed negotiations aiming to improve working conditions and compensation, in order to promote patient care and attract incoming professionals. Nursing union representatives expressed satisfaction with the “historic” work agreement achieved after 17 days of strike, along with confidence regarding significant improvement in the quality of work conditions and care provision [29]. As has been reported for nurse strikes taking place in other countries including USA [25, 30], Poland [19], and South Africa [31], this strike too was criticized for its ethical validity. For example, the Israeli Ministry of Health, however, criticized the strike and reported that it caused damage to the health system estimated in millions of dollars in delayed or cancelled services [29]. This comment has been mild in comparison to reactions to the Israeli nurse strike of 1986, in which Health Ministry officials claimed that “Patients are losing their lives as a direct result of the nurses’ strike” [32].

The aim of this study was to assess changes in nurses’ perspectives regarding the two prolonged strikes declared by their close colleagues, the physicians, to better understand change in attitude that prepared them to agree and support a strike to benefit their profession and patients.

2 Methods

During each of the prolonged physician strikes in 2000 and 2011, nurses completed anonymous survey questionnaires. Inclusion criteria were employment as a nurse at the time of the prolonged strikes in the hospital. The successive questionnaires included identical questions regarding nurses’ attitudes to the strike, particularly involving ethical issues. Flowing IRB review and exemption, data was collected at Rambam Medical Center in Haifa, Israel, a 900-bed tertiary general care hospital with 4,123 employees (879 physicians, 1,506 nurses, 890 para-medical personnel and others). Surveys were distributed to potential participants. In 2000 the questionnaires were hand-distributed by head nurses; in 2011, the questionnaires were sent out by the organizational e-mail. The questions asked surveyed academic status, nursing roles, and beliefs regarding the legitimacy of striking, support of the strike, preference for concurrent nurse and physician striking, impressions of the public understanding of and support for the strike, and the justification of the strike (see Table 1 and 2). The 2011 survey included two additional reflective open-ended questions. Quantitative data was analyzed in collaboration with a medical statistician and included descriptive statistics and Chi Square analysis using SPSS 17 software. Qualitative findings from open-ended questions were coded and ranked for themes by the researchers.

Table 1
Survey questions and significant differences in responses

Survey question Possible responses 2000 2011 P value

response response

1 I believe that striking is a legitimate protest method for physicians Yes 86% 91% 0.05

No 14% 9%

2 If I were a physician I would support the current strike Yes 86.5% 94% 0.034

No 13.5% 6%

3 I would prefer that the physicians’ strike would be concurrent with a nursing strike Yes 43% 45% NS

No 66% 63%

4 As a nurse I try to encourage public support for the strike Yes 70% 72% NS

No 29% 27%

5 The physicians take into consideration my opinion regarding patients who need urgent consultation even though the doctors are on strike Yes 63% 81% 0.004

No 27% 19%

6 My fellow physicians follow the strikes’ instructions No 0.4% 5% NS

Partially 59% 61%

Yes 36% 33%

7 The public is familiar with the strikes’ aims Yes 58% 60% NS

No 42% 40%

8 To what degree, if at all, is the patients’ suffering caused by the physicians’ strike justified? Not at all 52% 38% 0.05

Partially justified 37% 43%

Completely justified 11% 19%

9 How do you cope with the loyalty conflict -physicians vs. patients – that arises due to the physicians’ strike? open-ended question (in 2011 only)

10 Please describe the similarities and differences between the current physicians’ strike and that held in 2000? open-ended question (in 2011 only)

	Survey question	Possible responses	2000	2011	P value
1	I believe that striking is a legitimate protest method for physicians	Yes	86%	91%	0.05
		No	14%	9%
2	If I were a physician I would support the current strike	Yes	86.5%	94%	0.034
		No	13.5%	6%
3	I would prefer that the physicians’ strike would be concurrent with a nursing strike	Yes	43%	45%	NS
		No	66%	63%
4	As a nurse I try to encourage public support for the strike	Yes	70%	72%	NS
		No	29%	27%
5	The physicians take into consideration my opinion regarding patients who need urgent consultation even though the doctors are on strike	Yes	63%	81%	0.004
		No	27%	19%
6	My fellow physicians follow the strikes’ instructions	No	0.4%	5%	NS
		Partially	59%	61%
		Yes	36%	33%
7	The public is familiar with the strikes’ aims	Yes	58%	60%	NS
		No	42%	40%
8	To what degree, if at all, is the patients’ suffering caused by the physicians’ strike justified?	Not at all	52%	38%	0.05
		Partially justified	37%	43%
		Completely justified	11%	19%
9	How do you cope with the loyalty conflict -physicians vs. patients – that arises due to the physicians’ strike?	open-ended question (in 2011 only)
10	Please describe the similarities and differences between the current physicians’ strike and that held in 2000?	open-ended question (in 2011 only)

Table 2

Demographic Data

	2000 Cohort	2011 Cohort
N=	106	175
Response rate	42% (250 hand-delivered surveys	45% (385 surveys sent)
Number of years working as nurse	19.55±8.8years	20.37±10.12 years
Professional preparation
Licensed Practical Nurse	16%	3%
Registered Nurse	46%	7%
Registered Nurse with	38%	90%
academic degree
Full-time job	86%	94%

3 Results

As seen in Table 2, both cohorts included diverse participants regarding years of practice, professional preparation, and job partiality. The 2011 sample had a higher percentage of academically prepared nurses (90% vs. 38%).

Table 1 presents the responses to survey questions. Significant differences were found in response to 4 yes/no questions, demonstrating a trend of more positive attitude towards the strike. In 2011, more nurses (91% vs. 86%, p = 0.05) reported believing that striking is a legitimate protest method for the physicians. More nurses replied in 2011 that if they were physicians, they would have supported the current strike (94% vs. 86.5%, P < 0.05). Nurses in the 2011 sample also felt that physicians value their opinion regarding patients who need urgent consultation (81% vs. 63%, P < 0.005). Finally, in the second sample more nurses accepted patients’ suffering caused by the physicians’ strike as justified (partially justified: 43% vs. 37%, completely justified: 19% vs. 11%, p≤0.05).

The first open-ended question sought information regarding nurses’ solution to the conflict between loyalties to patients and the physicians, and yielded three main solution themes. The first recurring theme was “being torn”: sentiments shared included a desire to be supportive and loyal to colleague physicians so as to improve the healthcare system, but on the other hand wanted to be patient advocates. Nurses shared that they and the general public acknowledged the difficulties that physicians, especially at the beginning of their medical careers, go through. The anger and frustration of both the physicians and patients were described as understandable due to the relative indifference showed by the Israeli Ministry of Health and the Ministry of Finances to the situation at the time.

A second theme was “not my concern”: some respondents claimed that they did not feel any conflict during the physicians’ strike. Some nurses claimed that they were not a part of this strike – “I do my job, and the doctor does his job,” “the strike is none of my concern, the ball is in the doctors’ hands,” “in every strike someone is hurt. I perform my duty in my most professional way; that’s all”.

The third theme was a practical approach to “the golden path.” Nurses shared their solutions to resolving the loyalty dilemma and addressing the needs of patients and physicians. Some examples were confronting physicians when a patient needs important and immediate care, reporting test results directly to patients, helping reschedule patients’ appointments, and bridging between angry patients and doctors.

Responses to the second open-ended questions revealed that nurses had a more positive attitude towards the 2011 strike. Nurses felt that physicians are more united, with more effective demands such as asking for more staffing, not only more compensation. They felt that the younger generation of physicians is bolder and determined to make the strike work and that there is more public understanding and support. Some felt that the first strike was more aggressive yet some believed the second one was.

4 Discussion

The goal of this study was to assess the trends or changes in nurses’ attitudes towards physician strikes in Israel, as they were assessed during two prolonged strikes. As hospital-based nurses’ professional environments are profoundly suffused with nurse-physician interactions, nurses undergo particular stresses during physician strikes, and the attitudes of nurses towards these strikes may have a significant impact on the outcome of the strike, as well as impacting subsequent professional relationships. The current findings indicate a change in perspectives and attitudes over a decade towards striking as a legitimate tool to elicit change. This change has been instrumental in setting the stage for a nurse strike a year after the successful 2011 physician strike in Israel.

The responses to the same questions when delivered 11 years apart show a fairly consistent unidirectional trend. Nurses reported a greater acceptance and tolerance of strike-related patient suffering and increasingly saw striking as a legitimate action for physicians of the public health system. Nurses reported feeling a strong need to align themselves with striking doctors. However they cited primary allegiance to the patients. Nurses’ role-changes during strikes have emphasized how during those times some head nurses expanded their activities, and responsibilities and consequently felt more professional autonomy and job satisfaction, as well as an improvement in professional self-image [33]. While nurses accepted some inconveniences to patients, including prolongation of suffering as waiting times grew longer, the nurses clearly identified increasingly with the patients and kept patient interest above loyalty to physician-colleagues.

Key ethical dilemmas regarding strikes involve the tension between selflessness and altruism towards patients, vs. professional self-interests which rise a conflict regarding loyalty to professional colleagues vs. loyalty to patients [32]. In a strike situation, the specific strike goals and how they are advocated for can make a major difference as to how each staff member identifies with the strike and how one may judge colleagues’ actions. In both strikes under discussion, the physicians’ goals for the strikes included both altruistic goals of improving the public health system for all citizens, and also self-serving goals of increasing financial compensation for physicians in the public health system. Adding to salaries in the public health system makes this a more attractive place to work, thus enabling the public health system to attract and retain professionals who could otherwise command higher levels of compensation in the private sector. Recognizing that enhancing work conditions and compensations to healthcare workers will enhance the health outcomes of their patients appears to have been a major turning point in the acceptance of the legitimacy of the second strike. It should be noted that the 2011 cohort of nurses had more academic training (90% with academic degree in 2011 vs. 38% in 2000). This difference may very well explain the difference in perspective. Academic education may have contributed to a broader understanding of the role of social policy in enabling care leading to more identification with the physicians. Additionally, the advancement in academic training may be related to higher aspirations in regards to appropriate compensation for advanced education and skilled work.

Neiman [30] suggests that the ethical dilemma raised by physicians’ and nurses’ strikes can be resolved by examining their role in the system of competing interests, which includes responsibility for the health of the community, fair employment of healthcare providers, and financial sustainability of the healthcare system. The balance between all elements in ever-changing environments is a complex task. The common moral argument is that when physicians and nurses strike – patients suffer. But in fact, patients suffer most commonly due to budget based policy decisions that impact them directly or through their overly strained care providers. In the process of providing quality care and addressing the best interests of their patients, nurses and physicians often find that they need to go beyond direct care to consider policy issues effecting their ability to provide the care. Strikes are the last resort used to influence the overall healthcare but may be the only way to achieve these goals.

5 Study limitations

First, this study evaluated the opinions of nurses in one hospital in Israel. The international literature from strike situations suggests that the ethical issues discussed herein are universal [17 , 30–32], yet cultural and political differences influence the work environment. As health systems vary between more universal and governmentally regulated healthcare and private for-profit healthcare, each country may see incentive-driven swings of attitudes of the medical caregivers.

Second, this study involves surveys during different eras; comparing 2000 to 2011 is both a strength and a limitation of this study. The same nurses were not surveyed twice, but the nurses who replied had nearly the same seniority and thus were at the same stage of their professional careers. However, differenced in the academic education level may indicate other important differences in socio-economic demographics.

6 Conclusions

The current findings indicate a change in nurses’ perspectives and attitudes over ten years towards striking as a legitimate tool to promote public’s interests, which is aligned with a change of nurses’ perspectives around the world at that time [30, 31]. This change has been instrumental in setting the stage for a nurse strike a year after the successful 2011 physician strike.

Although there are differences between work conditions and professional-ethical obligations of physicians and nurses, core principles are shared, including a commitment to place their patients’ interests above their own [25]. However, if healthcare professionals do not consider their working condition, the best interests of patients will be harmed. As we educate healthcare providers to advocate for their patients, it is important to consider how they are trained to effectively advocate for their profession. There is a growing global awareness and agreement on the ethical right of healthcare professionals to collectively bargain and negotiate their working conditions, with an understanding that this is imperative for the health of the public [25]. The advocacy and communication for professional goals have an influence on public support. In the current example, key issues raised by physicians may have influenced the level of nurse support for a physician strike. Physicians striking for improved health care conditions for patients in the later strike appeared to be easier for nurses to support than physicians striking for improved salaries and compensations.

As the trend of striking is seen across the globe, policymakers of each country should plan to prevent strikes which are a last resort and consider ways to promote the welfare of healthcare workers for better patient outcomes and healthier communities.

Conflict of interest

None to report.

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