Strikes are a strategy used by a group of employees in an attempt to force the employer to meet their demands. Generally, strikes are discussed in terms of the economic nature of the events. A third party involved may ultimately pressure the employees and employer to settle a strike. Often, this third party is the consumer of the product and may switch to other suppliers or apply political pressure for a settlement. However, in the case of a strike at a health care facility, the third party consists of patients, who may have neither the ability to switch to another provider nor the power to apply pressure on the employer and employees. This powerlessness arises from the disenfranchisement that accompanies infirmity or a lower socioeconomic class. In the event of a health care strike, the impact of the strike may range beyond the economic, which raises questions of mortality, morbidity, and the misalignment of health care resources and expenditures caused by unnecessary hospitalizations or by patients dropping out of care.
This paper reviews the literature on health care strikes for background information and then details a strike that occurred within a Community Mental Health Center (CMHC) in Worcester, Massachusetts, to determine the impact of such a strike among health care staff and patients with severe and persistent mental illnesses. At the time of the strike, two of the authors worked at the Massachusetts CMHC and one author worked for the University of Massachusetts, the parent organization of the Massachusetts CMHC.
The impact of strikes on medical services
Available analysis is limited on how the health of patients is affected during strikes in medical clinics, hospitals, or nursing homes. One study analyzed the effects that a four-month physicians' strike in Israel had on the use of emergency departments (1). Even though physicians established alternative medical aid stations before going on strike, the use of emergency departments increased. Overall hospital admissions were constant with an increase in nonemergency cases seen in emergency departments. A second analysis of the Israeli strike studied the effects of the strike on the diagnosis of acute appendicitis and found no significant effect on the treatment or outcome of the illness (2). Another study analyzed how the diagnosis of acute appendicitis was affected by a one-month boycott of operating rooms by anesthesiologists in San Francisco, which led to the cancellation of all but emergency surgeries (3). The San Francisco study found no significant effect on the increase in the number of appendectomies, the number of perforated appendices, or the ratio of normal to inflamed appendices removed (3). Los Angeles County also experienced a one-month physicians' strike over the issue of the adequacy and expense of medical malpractice insurance. A study of this strike showed no increase in the use of emergency departments, and overall mortality rates remained constant (4). However, causes of death shifted over the course of the strike: deaths from elective surgeries that were cancelled did not occur, whereas deaths associated with transfers among emergency rooms increased.
Strikes by nonphysicians in health care settings have seldom been described or analyzed. One exception was for a general labor strike that affected much of Sweden for two weeks in 1980. Large sections of the nation's economy shut down, including the nonemergency health care system. Mortality rates fell during the period in question, because of a decrease in the number of elective surgeries performed (5). Finally, another study described the impact of a six-week strike by nonclinical staff at a nursing home in New York; the strike did not affect mortality rates or the occurrence of significant illnesses or adverse events, such as falls (6). In combination these studies provide evidence that work stoppages by health care providers do not significantly affect the health of patients when emergency services remain available.
The impact of strikes on mental health services
Even fewer studies exist of strikes in mental health settings. One study analyzed the effect of a six-month strike by admission nurses at a psychiatric hospital in England (7). Not surprisingly, admissions declined significantly, decreasing 30 percent from the preceding year. Patients with severe and persistent mental illness had the greatest decline in admissions. A second study, focusing on a four-month strike at a long-term psychiatric hospital in Canada, showed that even though many admissions were simply shifted to inpatient units of general hospitals, the overall admission rates of persons with persistent mental illnesses, such as schizophrenia, fell significantly (8). Both of these studies raise questions about the impact of the strike on individuals with serious mental illnesses, because it is expected that these persons would have been admitted for services had there not been a strike.
In October 1999 nurses, social workers, case workers, and residential staff went on a strike that lasted 30 days at a CMHC in Worcester, Massachusetts. Essential clinical and residential services were maintained during the strike, because psychiatrists and nonunion clinical and administrative staff continued to work.
A confluence of events had set the stage for the strike. Like many other independent community agencies in the early 1990s, the Massachusets CMHC merged with two other CMHCs, Lipton Center and Community Healthlink, and became a subsidiary of the University of Massachusetts Medical Center health system. Merging was a long, painstaking process, which involved combining three organizations with long histories and separate missions in the hope of establishing financial stability. Funding for mental health services was directed toward large, multiservice organizations that would treat defined populations in capitated systems of care. Staff at all three organizations were led to believe that a merger would provide a financial respite, particularly because the merger would mean that they were linked to the state university's medical school.
At the same time, the international union that represented staff at many social service and health care agencies in Massachusetts was pressing organizations to improve salaries and prevent the erosion of benefits. The union had recently had a strike at a CMHC in a nearby city and appeared to be embarking on a statewide strategy to improve pay and benefits for its members, a strategy that included selective strikes.
Following a period of increasing animosity and mistrust between management and union staff, two of the three bargaining units that represented staff voted to strike. Ultimately, all employees who were represented by the union and who worked in the detoxification units, residential programs, and urban adult and children's clinics went on strike. Management staff operated all 24-hour services during the strike, including group homes, intensive community outreach programs, and drug detoxification units. Limited outpatient services remained in place, staffed primarily by psychiatrists and by a few senior clinicians. During the strike the CMHC focused on managing crises and maintaining the provision of medications.
Tremendous conflict arose between striking and nonstriking staff. Picket lines were active and ongoing verbal rebukes were directed toward those who crossed the picket line or who were working inside the center's buildings. Particularly exposed to the conflict were patients with acute addictions who were admitted to a detoxification unit and those with severe and persistent mental illnesses who were living in group homes. Special police details were used at all CMHC locations, including group homes, adding to the anxiety levels of all involved and to the economic burden of the strike on the center.
Patients with severe and persistent mental illnesses who received clinical care at one of the center's outpatient clinics and who lived in group homes run by the center were particularly hard hit by the strike. The patients who lived in group homes were confronted by the strike 24-hours a day. Unfamiliar staff from other parts of the center worked in the houses during the strike, the patients had to cross a noisy picket line to attend the clinic or their usual work and day programs, and in many cases the patients' usual therapist was unavailable. At times, unexpected and unusual attention was paid to patients—additional leisure activities, visits from nonstriking staff bringing food, and decreased demands to complete daily chores or adhere to behavioral plans, which usually were enforced by staff. Patients experienced a clear disruption of their daily routine.
No direct measure of the effect of the strike on the patients is available, although two indirect measures are: hospitalization rates and patients' levels of satisfaction. The center operated six group homes with 49 residents, all of whom suffered from severe and persistent psychiatric illnesses, usually a psychotic disorder. Reviews of the records of all 49 residents showed no significant change in the number of hospital admissions in the 12 months preceding the strike and in the 12 months following the strike. In addition, there were no admissions among residents during the one-month strike, in contrast to the average of 1.5 admissions per month in the year preceding and following the strike.
Consumer satisfaction surveys conducted among the same residents during the 12 months preceding the strike and the 12 months following the strike showed no differences in the satisfaction with CMHC services, including the perception of accessibility of staff, accessibility of leisure activity, staff's attention to the residents' treatment goals, and the ability to handle emergencies.
At first glance it appears that the impact of the CMHC strike was on the staff, sparing patients from undue burden and negative outcomes. Staff faced loss of income, loss of job, emotional suffering, long hours of work or strike activity, significant changes in job responsibilities, and disruption of long-standing work relationships. The staff suffered demoralization and economic hardship, and a complete leadership overhaul occurred. Physician time, an expensive allocation of resources, was greatly reduced overall. However, caseloads increased dramatically for the clinicians and physicians who were not on strike. The center jettisoned physician leadership roles, and developed a new leadership strategy that focused more on the social service aspects of the center. For staff, the effect of the strike cut to the core of their job, their relationship to the center, and their morale.
Despite the widespread impact the strike had on staff and the administrative structure of the center, it appears that patients were not harmed by the strike, which is consistent with the literature on other strikes in health care settings. Several researchers have raised questions about the connection between patients' perceptions of their needs and their perception that a strike adds to their burden and suffering. Studies have shown that patients' perception of added suffering is not borne out by independent indexes of negative outcomes. In a study of the physicians' strike in Israel, Carmel and colleagues (9) examined how class differences affected patients' perceptions of the effects of a strike on their well-being and on their ability to cope. The authors found that patients from lower socioeconomic classes coped less effectively with the strike and perceived greater damage to their health than patients from higher socioeconomic classes. The results of Carmel and colleagues (9) appear to differ from the satisfaction surveys in our report. However, delegation of specialized resources, such as extra attention from physicians and administrative staff, may have buffered the patients from some of the stresses of the strike.
Another finding from a study of the Israeli strike may also explain why CMHC patients did not perceive themselves as being harmed by the strike. The study found that patients from lower socioeconomic classes were less likely to criticize either party in the strike (10). In the CMHC, patients were generally from lower socioeconomic classes, and they may have been reluctant to criticize the staff with whom they had lived and worked with before and after the strike. An additional study showed that Israeli patients from lower socioeconomic classes perceived increased damage to their health in large part because of the belief that they did not have the financial resources to gain access to alternative clinics during the strike (11). In the CMHC strike described in our report, patients' financial resources did not affect their ability to access health care during the strike. In addition, the residential and rehabilitation services that patients received remained in place. Perhaps then the level of services provided during the CMHC strike may have been adequate to prevent dramatic decompensations leading to hospitalizations.
The outcome measures of patients' well-being during and after the CMHC strike—hospitalization rates and their own levels of satisfaction—may not be adequate to systematically study the impact of a strike on patients. Ratings of symptoms, observing for possible increases in the use or dosage of medications were not made, and longer-term indicators of engagement in care before and after the strike were not assessed, but these measures may have provided a more complete indication of the impact of the strike on patients.
An unknown area of impact concerns the effect on the community served by the center. One role of a well-functioning CMHC is to serve as a safety net for the community, as an access point for individuals in need of a variety of health and social services ranging from housing to entitlements and benefits. The effect on individuals who were not seen at the CMHC during the strike cannot be ascertained, nor can the losses to the community that may have resulted from the added burden of patients' unmet needs for housing, treatment, or public financial benefits, such as welfare, food stamps, or housing subsidies.
The role of psychiatric staff during the strike requires additional discussion. Psychiatrists were not direct employees of the center; instead they were seen as management staff during the negotiations between striking employees and the center. Most psychiatrists, who were inspired to work in the public sector in part by political and moral callings, were sympathetic to the situation faced by the striking employees and were reluctant to cross the picket line. However, all psychiatrists worked during the strike, often taking on additional duties in the residences and on the detoxification units. The continued work by psychiatric staff likely allowed basic clinical services to continue and alleviated the guilt that striking clinical staff may have felt if they had had to abandon patients to no care at all. The psychiatric staff were aware of the unique bridge they served between the strikers, the center, and patients. They were also aware that their continued work during the strike may have prolonged the strike by preventing a rapid decline in the quality of services. Psychiatrists also may have struggled with a number of additional ethical dilemmas during the CMHC strike (12,13,14). Ongoing tension existed for the psychiatrists who worked during the strike, because of conflicting relationships: fidelity to patients, which committed them to working during the strike; fidelity to the community at large; fidelity to their striking coworkers; and the need to support the strike and to care for patients while others involved in their care were on strike.
Three years after the strike ended, several long-lasting trends among the psychiatry staff emerged. The executive director, a psychiatrist, left the center and was replaced by a nonclinician. Three psychiatrists converted the majority of their time to clinical work, reducing the administrative time devoted by these psychiatrists by two full-time positions. An additional position for a full-time clinical psychiatrist was eliminated, as were some part-time psychiatrist hours. These reductions resulted in an overall reduction of psychiatry time of two and one-half positions. Currently, these positions have not been replaced. Initially psychiatrists felt energized in making these drastic changes for the survival of the center. The hope was that these changes would be temporary, until the organization stabilized. In reality, these changes have persisted and psychiatric leadership at the center is greatly diminished, except for a few programs. Psychiatric staff members remain committed clinicians of the center, but the sense of ownership and the ability to chart the course of the organization are greatly limited.
Although negative outcomes for patients with severe and persistent mental illnesses were not seen as a direct result of the strike, the impact on outpatients, as well as those needing access to services, was not possible to measure. The longer-term impact on staff morale and trust in leadership is a major consideration in deciding whether to strike. More research is needed as work stoppages become more commonplace in health care.
The authors are affiliated with the department of psychiatry at the University of Massachusetts Medical Center, 72 Jaques Avenue, Worcester, Massachusetts 01610 (e-mail, firstname.lastname@example.org). A version of this paper was presented at the Institute on Psychiatric Services held October 10-14, 2001, in Orlando, Florida.