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( ')
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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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unionized health professionals in regard to this particular hospital strike than were residents. However, when the issue was generalized to any strike by health professionals, the attendings' responses became similar to those of the residents, more supportive of labor actions. Both the resident and attending psychiatrist groups indicated that physicians should not actively support union activity, such as by picketing (Mann-Whitney test statistic 425.5, NS). Residents as a group were more strongly opposed to either attending psychiatrists (Mann-Whitney test statistic 263.5, pg).OOOl) or residents (Mann-Whitney test statistic 629.5, p~O.OO2) crossing the picket line to maintain clinical services than the attending staff. The attendings favored both groups crossing the picket line to maintain clinical services for patients (80.4%). The p0sition taken by the residents was disappointing to almost half the attending physicians (41.9%), with 32.6% supporting the residents' position and the remainder feeling neutral about this issue. Despite the disappointment of the attendings, residents reported a greater feeling ofbeing pressured by the union or the strikers than they were by hospital administrative staff as to which role they should assume. Attending psychiatrists were asked what action they would have taken if they were residents. Three changed their position; two would have supported the strikers had they been residents, an action taken by no attending physician. In response to a similar question, 55% of the residents responded that they would volunteer if they were attending psychiatrists rather than residents. This constitutes a marked and significant shift in the residents' position (Wilcoxon signed rank test, Z = -2.646, P g).()()8). Although residents demonstrated a shift in attitude as they changed roles to become attending physicians, they held steadfast to resisting alteration of their stance as a resident even under pressure from their own attending. Fifty-five percent stated that they "I'
TADLEt. Demographie characteristies of residents and attending psychiatrists n
Percent
10 10
50.0 50.0
8 8
4
20.0 40.0 40.0
7 37
15.9 84.1
12 15 17 3
25.5 31.9 36.2 6.4
3 6 9 27
6.7 13.3 20.0 60.0
10 26 10
21.8 56.5 21.7
Resident Psychiatrists (n=20)
Sex
Female Male PGY 2 3 ~4
Attending Psyehiatrists (n=47)
Sex
Female Male Age 30s 40s 50s 60s
Years of affiliation with hospital <1 1-2 3-5 >5 Type of faculty affiliation Full time Clinical Non-faculty
would resist volunteering if encouraged by their attending psychiatrist to do so. Thirty percent, however, indicated that they would comply with the attending's wishes, and 15%indicated that they would do SO in order not to antagonize the attending. The attending psychiatrists viewed this issue differently; 76% feIt that the residents should comply with their attending's wishes. The issues that were most important to the residents in deciding their response to the strike were examined. The issue listed by residents as most important in explaining their behavior was not wanting to be personally involved in a labor dispute. Feeling already overburdened was ranked second in importance by residents. Not wanting to cross a picket line for ethical reasons and feeling personally uninvolved due to not currently doing a rotation at the hospital affected by the strike were the next most common explanations given by residents. \ O l l \ 11 ! , . '\1 \IHI I, : . l·l \1\11 " !"'II
The 5th-ranked explanation, of the 10 items listed, given by the residents was either disagreeing or agreeing with the union's position or with the hospital administration's position on the strike. The same choices were presented to the attending psychiatrists when asked what criteria they feIt the residents used to determine their behavior. Their responses indicated a slightly different ranking. The attendings indicated that feeling overburdened was the most likely explanation of residents' behavior during the strike, while not wanting to cross a picket line due to ethical reasons was the next most likely factor. They ranked equally a third reason for not wanting to get involved in a labor dispute: disagreeing or agreeing with the union's or hospital administration's position. DISCUSSION
The results of this survey demonstrate the differences between the attitudes of attending psychiatrists and of residents toward a strike by nursing staff and specifically toward the role residents ought to take during such labor disputes. These differences are highlighted by their responses to the strike by nurses and mental health workers. Residents as a group, unlike attending psychiatrists, were much less willing to volunteer to provide clinical care for patients at the hospital affected by the strike, were more sympathetic to the actions of the striking health professionals, and were less supportive of physicians crossing the picket line. However, the residents' position toward strikes did not appear to be a fixed stance, since most residents indicated that they would have behaved differently if they had been attending psychiatrists at the time of the strike. Furthermore, residents' attitudes seem to evolve as they progress from PGY-1 toPGY-4. As residents become more identified with their role as psychiatrists as they progress in their training, there is a trend toward \ ( \ I ) I \ 11( I",) \ I 11 \ I In
responding to the strike more like the artendings, as shown by the direct correlation between residents volunteering to provide clinical services during the strike and their PGY in the residency. That is, PGY-4 residents volunteered, whereas PGY-2 residents did not. PGY-3 residents took an intermediate position, but in the majority, their attitude and behavior more closely resembled their PGY-2 peer group. In PGY-} and PGY-2, residents tend to view themselves in the student role and in a clinical role not unllke that of the frontline non-physician clinical staff. Residents early in their training are assigned to inpatient units where they work closely with non-physician clinical staff and develop an interdependency with them in relation to patient care. When a conflict arises they align themselves with these frontline staff: nurses and mental health workers. As residents are assigned to clinical settings other than inpatient units in PGY-3 and PGY-4, changes in their work relationships and allegiances occur. At the same time that these more senior residents' skills consolidate, their role identification shifts toward attendings. PGY-3 and PGY-4 residents begin to see themselves more as medical specialists and potential attending psychiatrists and faculty members. This evolution in the residents' sense of themselves as specialists correlates with residents' professional role satisfaction and sense of technical competence, as well as with their need for less supervisionfromattendingsthatoccursduring PGY-3 and PGY-4 (14). Psychiatry residents appear to identify their role and conform their behavior more closely with those with whom they associate most closely as clinicians and with whom they need to maintain good working relations, that is, nurses and mental health workers during PGY-1 and PGY-2 and increasingly with attending psychiatrists during PGY-3 and PGY-4. An alternative explanation is that residents feel the need to keep themselves emo"I
tionally and behaviorally uninvolved in labor disputes. Whatever explanation applies in a given resident's case, our findings indicate that, as long as they are in the resident role, they do not appear to strongly identify with the role of their attending physician supervisors during the early years of their resideney training and are unwilling to disrupt their important relationship with non-physician dinical staff. This lack of role identification with attending psychiatrists may also be a result of the ambivalent position a resident is placed in by attendings, who often expect residents to assurne the responsibilities ofan attending physician yet often treat them as dependents and reinforce the residents' role as student rather than as a member of the professional staff and a junior colleague. An undear professional role such as this seems to engender in residents a feeling of greater empathy and increased identification with frontline non-physician clinical staff during the early years of their resideney, as weIl as sympathy for these frontline clinical staff fighting for improved pay and other benefits against a hospital administration they perceive as unappreciative of their work. A difference in attitudes between attending psychiatrists and residents appears to develop during labor disputes such as the one described in this report. Residents are stiIllearning professional values, and if they do not conform to their supervisors expectations, they may be criticized and sanctioned by their attending supervisors (15). The more senior attending psychiatrists seem to have a difficult time understanding why the residents do not behave like professional colleagues, and the residents view their request to do so with suspicion and as another instance of heing used as inexpensive and expedient labor. Such a dichotomy between attending physicians and residents has p0tential for generating a crisis within the resideney when a strike occurs, since mutual resentments may result. This was seen in the disappointment expressed by the attending
psychiatrists toward the residents' hehavior during the strike, and the feeling expressed by so me attending physicians that the residents' behavior should be taken into account when deciding their future post-resideney relationship with the hospital. Strikes and labor disputes, however, do not preclude residents from meeting their responsibilities, such as treating their own inpatients and outpatients, attending seminars, and providing on-eall service. From the available evidence it appears that allowing the residents to arrive at their own decisions regarding their role during a strike may be the most prudent course of action for attending physicians and hospital administrators. CONCLUSIONS Labor disputes and strikes are taking place in clinical settings where residents are developing their skills and professional roles. To create an atmosphere that will permit residents to leam from the experience and to minimize resentment resu1ting from individual residents' decisions regarding labor disputes, supervision should be given to the residents as a group as soon as the strike occurs and again after the condusion of the strike. Such supervision shou1d be provided by a faculty supervisor not involved in the labor dispute, possibly from another hospital in the university network. Supervision should address several issues: the ethics of health care workers striking and the impact on patients, the ethics of physicians "abandoning" their patient care responsibilities by honoring picket lines, and the ethics of residents crossing a picket line during a labor dispute at the hospital to which they are assigned. This supervision would permit the residents a dearer understanding of the issues that result in such labor disputes, an understanding of their future colleagues' philosophical position, an opportunity to evaluate their own heliefs, and real-life experience in dealing with issues of professional role identification. Resideney should be an
opportunity for the resident to solidify his or tion of residents is needed. This study proher professional role and identity as a physi- vides some insight into these issues. Howclan. UnfortunateIy, labor disputes seem to ever, the ability to generalize these results to emphasize the gap residents pereeive be- other groups is Iimited until there is replicatween their status as physician trainees and tion of these results in studies of other traintheir not-so-distant future roles as attending ing centers involving larger numbers of physicians and faculty. residents affected by similar labor disputes. As labor disputes and strikes by frontUne cIinicaI staff are becoming a more comThis study was presented in part at the mon occurrence in psychiatrie facilities, 142nd AnnualMeeting oftheAmerican Psychimore investigation of their effects on psychi- atrie Association, San Francisco, California, atrie residency programs and role identifiea- May1989 . References 1. Brecher R: Striking responsibilities. J Med Ethies 1985;11:66-69 2 RaUton P: Health care personnel and the right to strike: a sodal perspective. Prog Clin Biol Res 1980; 38:309-310 3. Norman RM: The effect of a mental hospital strike on general hospital psychiatrie services. Psychol Med 1984; 14:913-921 4. Rosenberg G, Speedling EJ, Rehr H, et al: Some effects of a hospital employee strike on patient satisfaction. Mt Sinai J Med 1985; 52:259-264 5. Schlosberg A, ZUber N, Avraham F: Effects of a psychiatrists' strike on emergency psychiatrie referral and admissions. Soc Psychiatry Psychiatr Epidemiol1989; 24:84-87 6. Cofler H:On the physician's right to strike. ProgClin Biol Res 1980; 38:303-307 7. Sachdev PS: Doctors' strike-an ethical justification. N Z Med J 1986; 99:412-414 8. Arnold P: Australian doctors on strike , Br Me
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9. Drobinski G, Thomas 0, Grosgogeat Y: Medical strikes in France. Ann Intern Med 1983; 99:862-863 10. Gapen P: The Committee of Intems and Residents: New York's big, brash union. New Physician 1981; 30:14-18 11. Grosskopf I, Buckman G, Garty M: Ethical dilemmas of the doctors' strike in Israel. J Me
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