The justification for strike action in healthcare: A systematic critical interpretive synthesis

Impacts of industrial actions, protests, strikes and lockouts by health and care workers during COVID-19 and other pandemic contexts: a systematic review

BACKGROUND

Public health emergencies of international concern (PHEICs) as the COVID-19 pandemic and others that have occurred since the early 2000s put enormous pressure on health and care systems. This is being a context for protests by health and care workers (HCWs) because of additional workload, working conditions and effects on mental and physical health. In this paper, we intended to analyze the demands of HCWs associated with industrial actions, protests, strikes and lockouts (IAPSLs) which occurred during COVID-19 pandemic and other PHEICs; to identify the impact of these grievances; and describe the relevant interventions to address these IAPSLs.

METHODS

We included studies published between January 2000 and March 2022 in PubMed, Embase, Scopus, BVS/LILACS, WHO's COVID-19 Research Database, ILO, OECD, HSRM, and Google Scholar for grey literature. Eligibility criteria were HCWs as participants, IAPSLs as phenomenon of interest occurring in the context of COVID-19 and other PHEICs. GRADE CERQual was used to assess risk of bias and confidence of evidence.

RESULTS

1656 records were retrieved, and 91 were selected for full-text screening. We included 18 publications. A system-wide approach, rather than a limited approach to institutions on strike, makes it possible to understand the full impact of the strike on health and care services. PHEICs tend to aggravate already adverse working conditions of HCWs, acting as drivers for HCWs strikes, leading to staff shortages, and financial issues, both in the North and in the Global South, particularly evident in Asia and Africa. In addition, issues related to deficiencies in leadership and governance in heath sector and lack of medical products and technologies (e.g., lack of personal protective equipment) were the main drivers of strikes, each contributing 25% of the total drivers identified.

CONCLUSIONS

It is necessary to focus on the preparedness of health and care systems to respond adequately to PHEICs, and this includes being prepared for HCWs' IAPSLs, talked much in the context of COVID-19 pandemic. Evidence to assist policymakers in defining strategies to respond adequately to the health and care needs of the population during IAPSLs is crucial. The main impact of strikes is on the disruption of health care services' provision. Gender inequality being a major issue among HCWs, a proper understanding of the full impact of the strike on health and care services will only be possible if gender lens is combined with a systemic approach, rather than gender-undifferentiated approaches limited to the institutions on strike.

Strikes of physicians and other health care workers in sub-Saharan African countries: a systematic review

Introduction

Strikes in the health sector have been of growing concern, given their disruptive nature, negatively impacting the provision of health care and jeopardizing the well-being of patients. This study aims to identify the main actors, the reasons behind industrial actions protests, strikes and lockouts (IAPSL) in sub-Saharan African countries and their impact on health care workers (specifically doctors) and health services, as well as to identify the main strategies adopted to reduce their impact on healthcare services.

Methods

Studies published between January 2000 and December 2021 and archived in MEDLINE, Google Scholar, Scopus, ProQuest, and Science Direct were included. Quantitative, observational (i.e., cohort, case-control, cross-sectional, and ecological) and experimental studies, as well as mixed methods, quasi-experimental, and qualitative studies were eligible.

Results

A total of 5521 studies were identified and after eliminating duplicates, applying the inclusion criteria, and assessing the risk of bias, a total of 11 studies were included in the review. Nurses and doctors are the actors most commonly involved in strikes. The main causes of strikes were salary claims and poor working conditions. The main strategies adopted to mitigate the strike consequences were to restrict services and prioritize emergency and chronic care, greater cooperation with the private sector and rearrange tasks of the available staff. The strikes led to a reduction in hospitalizations and in the number of women giving birth in health units, an increase in maternal and child morbidities and delays in the immunization process. Increased mortality was only reported in faith-based hospitals.

Discussion

This evidence can assist decision-makers in developing strategies and interventions to address IAPSL by health care workers, contributing to strengthen the health system. Strikes in the health sector disrupt healthcare services provision and compromise the well-being of patients, especially the most disadvantaged, with consequences that may be difficult to overcome ever. The potential health impacts of strikes highlights the importance of their prevention or timely resolution through regulation and negotiations to balance the rights of health care workers and the rights of patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=334173, identifier CRD42022334173.

'Enough is enough': a mixed methods study on the key factors driving UK NHS nurses' decision to strike

BACKGROUND

The UK National Health Service (NHS) is one of the largest employers in the world and employs around 360,000 registered nurses. Following a protracted pay dispute in December 2022 NHS nurses engaged in industrial action resulting in the largest nurse strikes in the 74-year history of the NHS. Initially it appeared these strikes were a direct consequence of pay disputes but evidence suggests that the situation was more complex. This study aimed to explore what the key factors were in driving UK NHS nurses' decision to strike.

METHODS

A convergent parallel mixed methods design was used. The study was conducted throughout the UK and involved participants who were nurses working for the NHS who voted in favour of strike action. Data collection involved the use of an online survey completed by 468 nurses and 13 semi-structured interviews. Descriptive and inferential statistics were used for quantitative data analysis and a process of inductive thematic analysis for the qualitative data. The quantitative and qualitative data were analysed separately and then integrated to generate mixed methods inferences.

RESULTS

The quantitative findings showed that patient safety, followed by staff shortages, pay, and unmanageable work demands were the most important factors encouraging nurses' decision to strike. The qualitative findings served to further the understanding of these factors particularly in relation to participants' perception of the NHS and the consequences of inadequate pay and staff shortages. Three overarching and overlapping themes represented the qualitative findings: Save our NHS, Money talks, and It's untenable. Integration of the findings showed a high level of concordance between the two data sets and suggest that the factors involved are interconnected and inextricably linked.

CONCLUSIONS

The UK NHS is a challenging and demanding work environment in which the well-being of its patients is dependent on the well-being of those who care for them. Concerns relating to patient welfare, the nursing profession and the NHS played a large part in driving UK NHS nurses' decision to strike. In order to address these concerns a focus on recruitment and retention of nurses in the NHS is needed.

Social media opposition to the 2022/2023 UK nurse strikes

Previous research has established that the success of strikes, and social movements more broadly, depends on their ability to garner support from the public. However, there is scant published research investigating the response of the public to strike action by healthcare workers. In this study, we address this gap through a study of public responses to UK nursing strikes in 2022-2023, using a data set drawn from Twitter of more than 2300 publicly available tweets. We focus on negative tweets, investigating which societal discourses social media users draw on to oppose strike action by nurses. Using a combination of corpus-based approaches and discourse analysis, we identified five categories of opposition: (i) discourse discrediting nurses; (ii) discourse discrediting strikes by nurses; (iii) discourse on the National Health System; (iv) discourse about the fairness of strikers' demands and (v) discourse about potential harmful impact. Our findings show how social media users operationalise wider societal discourses about the nursing profession (e.g., associations with care, gender, vocation and sacrifice) as well as recent crises such as the Covid-19 pandemic to justify their opposition. The results also provide valuable insights into misconceptions about nursing, strike action and patient harm, which can inform strategies for public communication.

From plaster casts to picket lines: Public support for industrial action in the National Health Service in England

This paper explores public sentiment towards strike action among healthcare workers, as a result of their perceived inadequate pay. By analysing survey data collected in England between 2022 and 2023, the study focuses on NHS nurses and junior doctors, due to their critical role in delivering essential public services. Results indicate higher public support for strikes by nurses and junior doctors compared to other professions such as postal workers, teachers, rail workers, airport workers, civil servants and university lecturers. However, variation in support for strikes by healthcare workers is observed across societal segments. Significant disparities in support are linked to individual political affiliations, left-right ideological positions and trust in the NHS. In short, nonconservative voters, individuals leaning towards left-wing politics and those with greater trust in the NHS demonstrate higher likelihoods of supporting strikes by health workers. These findings carry implications for future strike decisions and highlight specific target groups for enhanced communication efforts to garner increased public support.

A deliberative framework to assess the justifiability of strike action in healthcare

Healthcare strikes have been a remarkably common and varied phenomenon. Strikes have taken a number of forms, lasting from days to months, involving a range of different staff and impacting a range of healthcare systems, structured and resourced vastly differently. While there has been much debate about strike action, this appears to have done little to resolve the often polarising debate that surrounds such action. Building on the existing normative literature and a recent synthesis of the empirical literature, this paper will present a deliberative framework to assess the justifiability of strike action. I will first review the empirical literature that explores the impact of strike action, on patient outcomes and healthcare delivery. I will then discuss the debates that have occurred in this area, including an existing deliberative framework proposed by Selemogo (2014). I will argue that this framework is overly restrictive in that it could lead us to find otherwise justified strike action, unjust. I will then propose a framework that remedies these shortcomings. The framework outlines two broad conditions that should be met if strike action is to be justified. It then goes on to outline two deliberative, interrelated questions that should be used to assess whether strike action meets these conditions. For the purposes of this framework, healthcare strike action is justified when 1) it makes demands or raises grievances about some form of injustice, unfairness or threat to health and when 2) the risks in striking are proportionate to its demands or grievances. These two conditions should be considered in light of two further questions, namely, the 3) social and political context of the strike and 4) the characteristics of the strike. I will offer some further reflections on the application of this framework and its shortcomings.

Physician Unionization: Opportunities and Challenges for Anesthesiologists in the United States

Physician unionization is gaining traction in the United States, with <10% of practicing physicians now members, up from historically weak support. Factors that drive interest in unions include a decreased number of independent practitioners, an increase in workloads, and the erosion of autonomy. Approximately 56% of anesthesiologists are considered employees and may be eligible for union membership. Physician unions may provide higher wages, better working conditions, and legal protection. However, they also raise concerns about patient care and professionalism. This article discusses the legal and regulatory framework governing the unionization of physicians, benefits, challenges, and potential future developments. Continued analysis and debate are necessary to determine the optimal role of physician unions in the health care industry.

Contract doctors' strike in Malaysia: A content analysis of the perception of medical fraternity and stakeholders on Facebook

Contract appointment policy for newly graduated medical officers was implemented by the Ministry of Health Malaysia in 2016 to overcome the lack of permanent posts. Contract officers faced disadvantages in terms of salary, leave provision, and career prospects. A nationwide strike, Hartal Doktor Kontrak (HDK) was organised on 26th July 2021. Besides generating widespread public attention, HDK was also closely scrutinised by the medical fraternity and stakeholders. This content analysis aimed to explore how the medical fraternity and stakeholders viewed the strike as their perception would offer vital insights into the fundamental causes and viable solutions to the contract appointment policy. A qualitative content analysis of Facebook (FB) posts on the HDK strike was conducted from 1st June 2021 until 28th February 2022. A total of 182 FB posts were retrieved from stakeholders, medical fraternity groups, and medical key opinion personnel. Inductive coding was used in the thematic analysis to identify pertinent themes. Three main themes emerged: triggering factors, reactions to the strike, and outcomes of the strike. Factors that led to the strike included unequal treatment faced by contract officers, frustration with the government's lack of long-term solutions, and aggravation by the COVID-19 pandemic. In terms of reactions, there was a mixture of supportive and opposing voices. No substantial negative impact on the healthcare service resulted from the strike. Instead, it generated widespread attention that propelled the government into implementing solutions to prevent adverse short and long-term consequences. Various suggestions were proposed, including the reform of human resource planning and undergraduate medical education. The results highlight the importance of proactive systemic measures by the government to prevent further strikes that may jeopardise healthcare provision. In summary, social media was found to influence the progress and outcome of HDK, thus demonstrating the impact of media influence on similar issues.

Improving patient safety: Did we learn from the story of Jean-Pierre Adams?

The safety of surgery and anesthesia has seen many advances over the last several decades; however, the frequency of complications experienced by patients undergoing surgical operations remains high. Most of these complications are avoidable, with a considerable portion of surgical patient injuries originating from human factors. Telling stories and assessing what went wrong and why for lessons to be learned are proven methods used to improve patient safety in anesthesia. In this narrative, we revisited a case of an anesthesia mishap that occurred in 1982, leaving the victim in a coma for nearly four decades until his death in September 2021. The patient reported for his operation, but a number of the hospital's staff were on strike. His operation, however, went ahead and the reduction in anesthesia care team members and its consequential increase in workload resulted in a series of avoidable errors. Decades after this event, many of the issues identified still remain a challenge in anesthesia care; there are still lessons to learn. We identified and discussed three major issues of concern: the non-cancellation of his procedure amid a strike action, giving a delicate anesthetic duty to a trainee without active supervision, and poor coordination and teamwork among team members in the operating room.

The impact of strike action on healthcare delivery: A scoping review

BACKGROUND

Strike action carried out by healthcare workers raises a range of ethical issues. Most fundamentally, as a strike is designed to disrupt, it has the potential to impact patient outcomes and healthcare delivery. This paper synthesises and analyses the empirical literature that details the impact of strike action on healthcare delivery.

METHODS

A systematic scoping review was utilised to examine the extent, range and nature of research activity. Embase, Medline, CINAHL, Bioethicsline, EconLit and Web of Science were searched, yielding 5644 results. Papers were included if they examined the impact that strike action had on healthcare delivery (i.e., admissions, presentations, waiting time). After screening, 43 papers met inclusion criteria.

RESULTS

Nineteen studies explored presentations to emergency or admissions to hospital. Both dropped dramatically when comparing non-strike to strike periods. Ten studies examined length of stay in hospital and waiting times. No clear relationship was found with strike action, with some studies showing that wait times decreased. Nine studies examined the impact of strike action in facilities that were not on strike, but were impacted by nearby strike action along with the impact that strike action had on treatment seeking. Hospitals dealing with these upstream impacts often saw increase in presentations at hospitals, but results relates to treatment seeking during strike action were mixed.

CONCLUSION

Strike action can have a substantial impact on the delivery of healthcare, but this impact is not felt uniformly across services. While many services are disrupted, a number are not, with several studies reporting increased efficiency.

A last resort? A scoping review of patient and healthcare worker attitudes toward strike action

While strike action has been common since the industrial revolution, it often invokes a passionate and polarising response, from the strikers themselves, from employers, governments and the general public. Support or lack thereof from health workers and the general public is an important consideration in the justification of strike action. This systematic review sought to examine the impact of strike action on patient and clinician attitudes, specifically to explore (1) patient and health worker support for strike action and (2) the predictors for supporting strike action and the reasons given for engaging in strike action. A systematic scoping review was employed to identify all relevant literature, followed by a textual narrative synthesis. A total of 34 studies met inclusion criteria. Support for strike action was largely context-dependent. A range of factors impact support for strike action; broader cultural and structural factors, such as unionisation and general acceptance of strike action; systemic factors, such as the nature of the healthcare system, including infrastructure and work conditions; the strike itself and a range of individual factors, the most notable of which was being a student or in an early career stage. There were also some surprising results, for example, during doctors strike, nurses were provided with the opportunity to expand their role, which led to greater professional autonomy and job satisfaction.

Vulnerability, Moral responsibility, and Moral Obligations: the case of Industrial Action in the Medical and Allied Professions

The article addresses issues at the nexus of physician industrial action, moral agency, and responsibility. There are situations in which we find ourselves best placed to offer aid to those who may be in vulnerable positions, a behavior that is consistent with our everyday moral intuitions. In both our interpersonal relationships and social life, we make frequent judgments about whether to praise or blame someone for their actions when we determine that they should have acted to help a vulnerable person. While the average person is unlikely to confront these kinds of situations often, those in the medical professions, physicians especially, may confront these and similar situations regularly. Therefore, when physicians withhold their services for whatever reason in support of industrial action, it raises issues of moral responsibility to patients who may be in a vulnerable position. Using theories of moral responsibility, vulnerability, and ethics, this paper explores the moral implications of physician industrial action. We explore issues of vulnerability of patients, as well as the moral responsibility and moral agency of doctors to patients. Determining when a person is vulnerable, and when an individual becomes a moral agent, worthy of praise or blame for an act or non-action, is at the core of the framework. Notwithstanding the right of physicians to act in their self-interest, we argue that vulnerability leads to moral obligations, that physicians are moral agents, and the imperatives of their obligations to patients clear, even if limited by certain conditions. We suggest that both doctors and governments have a collective responsibility to prevent harm to patients and present the theoretical and practical implications of the paper.

How Resistance Shapes Health and Well-Being

Resistance involves a range of actions such as disobedience, insubordination, misbehaviour, agitation, advocacy, subversion, and opposition. Action that occurs both publicly, privately, and day-to-day in the delivery of care, in discourse and knowledge. In this article I will demonstrate how resistance plays an important (but often overlooked) role in shaping health and well-being, for better and worse. To show how it can be largely productive and protective, I will argue that resistance intersects with health in at least two ways. First, it acts as an important counterbalance to power; undermining harmful policies, disobeying unfair instructions, challenging rights abuses, confronting those who would otherwise turn a blind eye and even holding ourselves to account when simply accepting the status quo. Second, and beyond being oppositional, resistance is a constructive, productive force, that is fundamental to imagining alternatives; new and better futures and perhaps most fundamentally resistance is cause for hope that we are not resigned to the status quo. While there are numerous examples of how resistance has been employed in service of health and well-being, resistance is not always rational or productive, it can also harm health. I will briefly explore this point. Finally, I will offer some reflections on the intersections of power and health and why this makes resistance both distinct and important when it comes to how it shapes health and well-being.