Attitudes of Psychiatry Residents Toward a Strike by Nursing Staff A Case Report Robert Kohn, M.D. Ronald M. Wintrob, M.D. A study oftheattitudes of psychiatry residents andattending psychiatrists toward a strike by nurses andmental health workers in a psychiatrie ieaching hospital was performed. All residents (n =20)and 47 (83% oftheattending psychiatrists) completed a questionnaire within 4 weeks after thestrike. The responses to thequestionnaire indicated thatresident's behavior in response to thestrike was significantly different from thebehavior oftheattendings:20% oftheresidents volunteered service during thestrike compared with 66% of theattendings (p ~ 0.0001). The attending psychiatrists, when asked what action theywould have taken if theywere residenis, indicated somewhat less ofan inclination to volunteer; 16.7% changed their position about volunteering (NS). When asked whattheywould have done if theywere attendings, 55% (p ~ 0.(08) of theresidents indicaied theywould have volunteered service. The significance of these findings is thatresidents identify themselves more withthe"frontline" mental health workers engaged in thestrike than with thefaculty/attending psychiatrists who serve astheir professional role models.
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trikes by hospital staff have become an increasingly common occurrence in the past 10 years. Much has been written about the ethical dilemmas faced by those health care professionals who go on strike (1,2). Several papers have also examined the impact of hospital strikes on health care delivery (3-5). However, little is known about the attitudes of physicians toward strikes by health care workers other than those studies on physicians involved in strlkes (6,7). Physicians have favored strlkes for themselves where issues of remuneration, working conditions, or government restrictions on the practice of medicine have been involved (813). As more hospital professional staffs unionize, the possibility that physicians, including residents, will be faced with a strike by their physician colleagues or other health
care workers increases. No systematic studies that address the attitudes of residents, physicians, or, in particular, psychiatrists toward a strlke by non-physician health care workers have been previously reported.Previous reports on labor actions involving residents have been based on descriptive accounts (9,10). Residents are in a particularly sensitive and ambiguous position in the event of a strike by nursing staff because residents From the Department of Psychiatry and Human Behavior, Brown University, Providenc:e,Rhode Island, where Dr. Wintrob is a Professor of Psychiatry and the Residency Director. Dr. Kohn Is an Assistant Clinical Psychiatrist at Columbia University. Address correspondence to Robert Kohn, M.D., 154 Haven Avenue 1406, New York, NY 10032. Copyright Cl1991 Aaulemic Psychiatry.
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work closely with both nursing staff and attending physicians but are not part of either group. Often they are not employees of the hospital, but rather of the university. Thus there are no clear role expectations for residents in a labor dispute. When there is a strike by either hospital staff nurses or attending physicians, residents are faced with the decision of whether to support the striking staff or to cross the picket line to help with the clinical care of their own and other patients. This study examines the attitudes of psychiatry residents and attending psychiatrists toward a labor dispute over wages and benefits between staff nurses and mental health workers and the management of a university-affiliated private psychiatric hospital. This New England facility is a primary teaching hospital and the administrative center for the psychiatry residency program of the university. Clinical assignments in the residency program occur at a number of affiliated hospitals. The hospital at which the labor dispute occurred is the central administrative base for the academic Department of Psychiatry. The offices of the department chairman and of the residency training director are located here, Most residents are assigned to this hospital for part of each year, and they get most of their on-call experience here. They see their outpatients at this hospital and have all their seminars here. HistoricaIly, the residents identify this hospital as being synonymous with the residency program and spend more time here than at any other facility during the course of training. The program accepts six residents per year. In March 1988,union nurses and mental health workers went out on strike for over 3 weeks. The strike resulted in closure of alI the outpatient facilities and half the hospital inpatient units, as weIl as curtailment of admissions. This was the first major labor dispute at the hospital. There had been abrief strike 5 years earlier; however, it was resolved in 5 days without disruption of clinihh
cal services. Several other labor contracts were subsequently negotiated without incident. The union became active in the hospital in 1980. The primary issues resulting in the strike were related to salaries and benefits. Although psychiatry residents were not obliged to assume additional clinical duties, they were expected to fulfill their own clinical obligations, attend seminars, and provide on-eall service at the hospital. Those residents who did volunteer their time to provide additional clinicalcare for their own patients and others, services that would normally be done by nursing staff then on strike, were offered additional reimbursement at a rate consistent with their salary at that time. Those who volunteered dispensed and administered medications, conducted the nursing charting, and provided supportive therapy given under normal circumstances by a psychiatric nurse. At the time of the strike, 22% of the residents in the university's residency in psychiatry were assigned to inpatient rotations at the hospital where the strike occurred. This resident group was nonunionized and university employed, with salaries partially funded by the hospital. The residents were permitted by hospital and residency administrators to decide their own course of action during the strike. Unsolicited input was not given by the training director or the chief resident. This situation created an environment that made possible examination of the roles and attitudes of the residents and their attendings. The strike provided an opportunity to examine not only individual attitudes toward a strike by professional staff, but also an occasion to examine how residents' attitudes change based on role identification. Despite the difficulty in generalizing results when only one residency group is examined, the increasing reality of strikes at health care facilities gives this report general interest. The role identification of psychiatry residents is the main focus of this report. \(l it \11 I" · \. ! \11>1 1, 2 · "I \1 \i l l,
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METHODS
Abrief multiple-choice questionnaire was developed to investigate the attitudes and behavior of residents and attending physicians affected by the strike. Questionnaires introduced by a cover letter guaranteeing anonymity to individuals who responded were distributed by mail to all attending psychiatrists affiliated with the hospital and all psychiatry residents 1 week after resolution of the strike. This was followed 2 weeks later by a second mailing. Data collection was conducted as dose to the end of the strike as possible in order to tap respondents' attitudes while the issue remained fresh in their minds and was viewed as important to everyone concemed. Data collection near the time the strike ended also minimized the risk of changes in attitudes due to subsequent re-analysis of positions taken during the strike. The questionnaire consisted of 11 questions and Likert scale responses, primarily using three levels of agreement: opposing, favoring, or being neutral toward astatement. After each question, the respondent was given space to provide comments, which were used in clarifying data and in discussion of the results. The development of the questions was based on issues that arose during the strike and were related to the behavior of both the residents and the attending psychiatrists affected by the strike. No prototype questionnaire existed in the literature. Data were gathered on the course of action each individual took during the strike: how they feIt about the strike (including the actions taken by the residents), what factors they thought residents considered in deciding to volunteer or not, and whether the residents' behavior would have a longterm impact. The questionnaire was modified slightly for the two groups under investigation in order to inquire into what each would have done if the roles were reversed. Analysis of the data was conducted using nonparametric statistics, Mann-Whit\ \ \ I )i \ 11 \. I" ,') \ I 11 \ I 1( ')
II~ ,
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neyand the Wilcoxon signed rank test, with ordinal ranking of the response categories.
RESULTS All questionnaires were retumed within 4 weeks. All residents (n = 20) and 47 (83%of the attending psychiatrists) completed the questionnaire. Attending psychiatrists 07%) who were nonresponders were not found to be different on gender or hospital affiliation (full-time faculty, clinical faculty, or non-faculty) compared with the attending psychiatrists who completed the questionnaire. The distribution by sex, hospital affiliation, seniority of attending psychiatrists, and postgraduate year (PGY) of the residents is noted in Table 1. Twenty percent of the residents decided to volunteer (i.e., assume some of the clinical care responsibilities of the nurses or mental health workers): 10%supported the strikers; and 70% remained neutral. No PGY-2, one PGY-3, and three PGY-4 residents volunteered. No PGY-4 resident actively supported the union by picketing, whereas one PGY-3 and one PGY-2 did so. Most of those who volunteered were male residents. There was no relationship between being assigned to any particular clinical rotation within the residency and volunteering or supporting the picketing nursing staff. Only one resident assigned to an inpatient rotation at the hospital affected by the strike volunteered; the three others who volunteered service were assigned to other facilities. The residents' actions were significantly different (Mann-Whitney test statistic 657.0, p$O.OOOl) than the attending psychiatrists, among whom 65.9% volunteered. Two-thirds of the attendings felt that the decision about residents volunteering service, remaining neutral, or supporting the strikers should be left to the discretion of each resident. Attending psychiatrists were significantly more unsympathetic (Mann-Whitney test statistic 267.5, p~.OO5) toward striking ""
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S
trikes by hospital staff have become an increasingly common occurrence in the past 10 years. Much has been written about the ethical dilemmas faced by those health care professionals who go on strike (1,2). Several papers have also examined the impact of hospital strikes on health care delivery (3-5). However, little is known about the attitudes of physicians toward strikes by health care workers other than those studies on physicians involved in strlkes (6,7). Physicians have favored strlkes for themselves where issues of remuneration, working conditions, or government restrictions on the practice of medicine have been involved (813). As more hospital professional staffs unionize, the possibility that physicians, including residents, will be faced with a strike by their physician colleagues or other health
care workers increases. No systematic studies that address the attitudes of residents, physicians, or, in particular, psychiatrists toward a strlke by non-physician health care workers have been previously reported.Previous reports on labor actions involving residents have been based on descriptive accounts (9,10). Residents are in a particularly sensitive and ambiguous position in the event of a strike by nursing staff because residents From the Department of Psychiatry and Human Behavior, Brown University, Providenc:e,Rhode Island, where Dr. Wintrob is a Professor of Psychiatry and the Residency Director. Dr. Kohn Is an Assistant Clinical Psychiatrist at Columbia University. Address correspondence to Robert Kohn, M.D., 154 Haven Avenue 1406, New York, NY 10032. Copyright Cl1991 Aaulemic Psychiatry.
\l lllt 111"01 " -,\ ( III \ I R\ RI '-,11)1 \.1-'
work closely with both nursing staff and attending physicians but are not part of either group. Often they are not employees of the hospital, but rather of the university. Thus there are no clear role expectations for residents in a labor dispute. When there is a strike by either hospital staff nurses or attending physicians, residents are faced with the decision of whether to support the striking staff or to cross the picket line to help with the clinical care of their own and other patients. This study examines the attitudes of psychiatry residents and attending psychiatrists toward a labor dispute over wages and benefits between staff nurses and mental health workers and the management of a university-affiliated private psychiatric hospital. This New England facility is a primary teaching hospital and the administrative center for the psychiatry residency program of the university. Clinical assignments in the residency program occur at a number of affiliated hospitals. The hospital at which the labor dispute occurred is the central administrative base for the academic Department of Psychiatry. The offices of the department chairman and of the residency training director are located here, Most residents are assigned to this hospital for part of each year, and they get most of their on-call experience here. They see their outpatients at this hospital and have all their seminars here. HistoricaIly, the residents identify this hospital as being synonymous with the residency program and spend more time here than at any other facility during the course of training. The program accepts six residents per year. In March 1988,union nurses and mental health workers went out on strike for over 3 weeks. The strike resulted in closure of alI the outpatient facilities and half the hospital inpatient units, as weIl as curtailment of admissions. This was the first major labor dispute at the hospital. There had been abrief strike 5 years earlier; however, it was resolved in 5 days without disruption of clinihh
cal services. Several other labor contracts were subsequently negotiated without incident. The union became active in the hospital in 1980. The primary issues resulting in the strike were related to salaries and benefits. Although psychiatry residents were not obliged to assume additional clinical duties, they were expected to fulfill their own clinical obligations, attend seminars, and provide on-eall service at the hospital. Those residents who did volunteer their time to provide additional clinicalcare for their own patients and others, services that would normally be done by nursing staff then on strike, were offered additional reimbursement at a rate consistent with their salary at that time. Those who volunteered dispensed and administered medications, conducted the nursing charting, and provided supportive therapy given under normal circumstances by a psychiatric nurse. At the time of the strike, 22% of the residents in the university's residency in psychiatry were assigned to inpatient rotations at the hospital where the strike occurred. This resident group was nonunionized and university employed, with salaries partially funded by the hospital. The residents were permitted by hospital and residency administrators to decide their own course of action during the strike. Unsolicited input was not given by the training director or the chief resident. This situation created an environment that made possible examination of the roles and attitudes of the residents and their attendings. The strike provided an opportunity to examine not only individual attitudes toward a strike by professional staff, but also an occasion to examine how residents' attitudes change based on role identification. Despite the difficulty in generalizing results when only one residency group is examined, the increasing reality of strikes at health care facilities gives this report general interest. The role identification of psychiatry residents is the main focus of this report. \(l it \11 I" · \. ! \11>1 1, 2 · "I \1 \i l l,
I "li
i--Oll'\ \'\1' \\ 1'\
METHODS
Abrief multiple-choice questionnaire was developed to investigate the attitudes and behavior of residents and attending physicians affected by the strike. Questionnaires introduced by a cover letter guaranteeing anonymity to individuals who responded were distributed by mail to all attending psychiatrists affiliated with the hospital and all psychiatry residents 1 week after resolution of the strike. This was followed 2 weeks later by a second mailing. Data collection was conducted as dose to the end of the strike as possible in order to tap respondents' attitudes while the issue remained fresh in their minds and was viewed as important to everyone concemed. Data collection near the time the strike ended also minimized the risk of changes in attitudes due to subsequent re-analysis of positions taken during the strike. The questionnaire consisted of 11 questions and Likert scale responses, primarily using three levels of agreement: opposing, favoring, or being neutral toward astatement. After each question, the respondent was given space to provide comments, which were used in clarifying data and in discussion of the results. The development of the questions was based on issues that arose during the strike and were related to the behavior of both the residents and the attending psychiatrists affected by the strike. No prototype questionnaire existed in the literature. Data were gathered on the course of action each individual took during the strike: how they feIt about the strike (including the actions taken by the residents), what factors they thought residents considered in deciding to volunteer or not, and whether the residents' behavior would have a longterm impact. The questionnaire was modified slightly for the two groups under investigation in order to inquire into what each would have done if the roles were reversed. Analysis of the data was conducted using nonparametric statistics, Mann-Whit\ \ \ I )i \ 11 \. I" ,') \ I 11 \ I 1( ')
II~ ,
11 ;
neyand the Wilcoxon signed rank test, with ordinal ranking of the response categories.
RESULTS All questionnaires were retumed within 4 weeks. All residents (n = 20) and 47 (83%of the attending psychiatrists) completed the questionnaire. Attending psychiatrists 07%) who were nonresponders were not found to be different on gender or hospital affiliation (full-time faculty, clinical faculty, or non-faculty) compared with the attending psychiatrists who completed the questionnaire. The distribution by sex, hospital affiliation, seniority of attending psychiatrists, and postgraduate year (PGY) of the residents is noted in Table 1. Twenty percent of the residents decided to volunteer (i.e., assume some of the clinical care responsibilities of the nurses or mental health workers): 10%supported the strikers; and 70% remained neutral. No PGY-2, one PGY-3, and three PGY-4 residents volunteered. No PGY-4 resident actively supported the union by picketing, whereas one PGY-3 and one PGY-2 did so. Most of those who volunteered were male residents. There was no relationship between being assigned to any particular clinical rotation within the residency and volunteering or supporting the picketing nursing staff. Only one resident assigned to an inpatient rotation at the hospital affected by the strike volunteered; the three others who volunteered service were assigned to other facilities. The residents' actions were significantly different (Mann-Whitney test statistic 657.0, p$O.OOOl) than the attending psychiatrists, among whom 65.9% volunteered. Two-thirds of the attendings felt that the decision about residents volunteering service, remaining neutral, or supporting the strikers should be left to the discretion of each resident. Attending psychiatrists were significantly more unsympathetic (Mann-Whitney test statistic 267.5, p~.OO5) toward striking ""
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