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BY: ROXANNE O’BRIEN, PhD, RN

The emergence of large nursing unions in U.S. hospitals presents both the challenge and the opportunity for individual nurses to reflect on ethical decision-making and moral courage. Catholic social teaching and the American Nurses Association's 2015 Code of Ethics for Nurses with Interpretive Statements is a useful tool of discernment that can help nurses examine their values and maintain their personal integrity, foster collaboration with colleagues and ensure that the patient remains the center of care.

Hospital nursing is a profession that can be emotionally, mentally and physically demanding, and nurses expect to be heard regarding their working conditions, wage and benefit corrections, appropriate staffing and patient safety. In 2012, licensed registered nurses were the single largest occupation in California health care organizations, numbering more than 300,000. Approximately 270,000 are actively working as RNs and more than half of them are working in the acute care setting.¹

The U.S. Bureau of Labor Statistics states that health care organizations in the U.S. employed more than 3 million registered nurses in 2012, with approximately half of these nurses working in hospitals.² The BLS projects a 16.6 percent increase in the rate of job growth from 2012-2020 for RNs working in hospitals. Given the growth projections in the number of RNs and the need for hospital nursing staff, the assumption is that nursing unions will continue to campaign for increasing membership in hospitals in California and other states.

NURSES AND COLLECTIVE BARGAINING
In 1974, the National Labor Relations Act extended the rights and protections of collective bargaining units to employees of nonprofit hospitals, including Catholic hospitals.³ State nursing associations launched campaigns to organize nurses to address labor and management issues through the collective bargaining process.⁴

Collective bargaining provides a tool for union members and employers to address such issues as terms and conditions of employment, overtime (mandatory and voluntary), staffing structure and other concerns. The use of strikes and work stoppages as a means to assert control over nursing practice is a collective bargaining strategy.⁵ The national ANA, whose purpose is to foster excellence in nursing practice, reversed its no-strike stance in 1968, recognizing that nurses have a right to strike as a tool for union negotiation with hospital organizations.

A strike is defined as "a full or partial organized work stoppage by a group of workers including slow-downs and other organized disturbances of the routine work process."⁶ A strike also is defined as withholding one's professional skills or labor until specific conditions are met.⁷ The overriding principle in professional nursing is respect for persons — health care team members, patients and families — so for some nurses, a strike or work stoppage may represent an ethical and moral dilemma in terms of his or her obligation to provide care for patients.⁸

CODE OF ETHICS FOR NURSES
Clearly, unfair work practices (mandatory overtime, inadequate number of staff, lack of breaks, wage and benefit discrepancies) will have a significant impact on morale and job satisfaction. These same issues may potentially affect patient care. ⁹

The 2015 ANA Code of Ethics for Nurses with Interpretive Statements provides registered nurses with guidance and directives for nursing practice.^{10, 11} It is not a legal document, rather, it is a voluntary set of guidelines applicable to nurses in their various roles and settings of health care environments. The code's nine provisions set out the nurse's obligations, ethics and duties in his or her professional practice, and it offers insight useful for nurses weighing their duty to care against the implications of participating in a work stoppage or strike.

Provision 2 states: "The nurse's primary commitment is to the patient, whether an individual, family, group, community, or population." Interpretive statements under this provision specify that the patient's interests come first. They address conflicts that may arise when nurses are caring for patients. Conflicts may be generated by varying expectations across the health care setting by the patients themselves, colleagues and the health care organization. Nurses are to consider and analyze their own personal and professional values, as well as those of other members of the health care team and the patients' values.

Provision 5 states: "The nurse owes the same duties to self as to others, including the responsibility to promote health and safety, preserve wholeness of character and integrity, maintain competence, and continue personal and professional growth." Thus if faced with actions that they morally cannot support, nurses have a "right and a duty according to their personal and professional values" to communicate this to the appropriate leaders. A nurse has the right and duty to refuse to participate in an action that is in conflict with his/her morals.¹²

Provision 6 states: "The nurse, through individual and collective effort, establishes, maintains, and improves the ethical environment of the work setting and conditions of employment that are conducive to safe, quality health care." This provision recognizes that the public and health care team members expect nurses to encompass the virtues of "knowledge, skill, wisdom, patience, compassion, honesty, altruism, and courage."¹³

The workplace itself poses barriers as well as opportunities for ethical practice associated with compensation, grievance procedures, and patient and staff safety initiatives. Peer pressure poses both opportunities and obstacles to create the moral tone of the workplace. Nurses are responsible for creating a moral environment where respect, honesty and discussion of challenging issues — including ethical problems — can be addressed.¹⁴

CATHOLIC SOCIAL TEACHING
Catholic social teaching provides the vision and foundational principles to build a just society.¹⁵ Nurses in Catholic health care will draw on that context as they consider how actions like strikes and stoppages relate to upholding the dignity of vulnerable patients.

Part of the discernment process includes evaluating how the nurse expresses his or her own dignity within the context of the community of the hospital environment. The teaching of the common good means nurses will carefully deliberate who benefits from union activities, because the well-being of others is connected to our own well-being. In the case of strikes or work stoppages, each nurse must determine for himself or herself if participation in these activities supports the common good — that is, will the action bring out the best opportunities for everyone involved? Or will any perceived benefits apply more to one group (staff) than any other (patients)? Will the benefits outweigh the risks that could have an impact on both patients and staff?

SUBSIDIARITY AND SOLIDARITY
The principle of subsidiarity means we empower ourselves to address workplace and social issues at the lowest level in an organization that will be effective.^{16, 17} In hospitals, this would be direct contact by staff with administration or representatives who can address problems that arise. Unions may serve as the middleman, but it is important that messages to hospital administrators not be deflected or altered in order to achieve the union's goals, rather than those of direct care staff.

Hand in hand with subsidiarity, the principle of solidarity recognizes that humans exist in interdependence with one another. Solidarity within a community not only invites service for the common good, but it also calls for each individual to participate and share in that community.¹⁸

Catholic social teaching regarding the value and necessity of work upholds the rights of workers to organize and join unions or other organizations to represent them in negotiating fair wages, benefits and decent working conditions.¹⁹

As nurses think about proposed union actions, they will need to determine if the principle of solidarity is represented between union representatives and the organization's leadership, as well as within the organizational community. Organizations and workers must find the moral courage to question proposed actions — by both unions and by organizations — and to take actions to build a just society and serve the common good.

Moral courage means to stand up for what one believes is right, even if you are alone in doing so.²⁰ Moral courage provides the framework to remain true to personal values yet remain open to differing opinions on ethical principles, in keeping with the ANA's Code of Ethics.²¹

Health care systems and hospitals serve their communities in contributing to the overall health of the population and in providing an important employment source to the community. As members of the community, nurses and their own families may receive care in the community hospital in which they are employed.

In support of a nurse's internal dialogue over whether to participate in collective bargaining actions with which she or he does not agree, we know that Catholic teaching supports the value and necessity of work and our moral responsibility to the common good. The ANA Code of Ethics provides the ethical standards for professional nursing practice and incorporates them in the embodiment of a nursing professional. As the presence of nursing union activity grows in California and elsewhere in the United States, hospitals and nursing staff must learn how to examine and discern ethical dilemmas associated with collective bargaining strategies such as the threat of strikes.

Ultimately, each nurse must think carefully about his or her own ethics. Taking advantage of the guidance available in Catholic teachings and the ANA Code of Ethics will help in discerning the options to participate or not and how to frame a decision.

According to a 2014 Gallup poll, 80 percent of Americans who participated rated nurses as having the highest honesty and ethical standards in the health care professions when compared to medicine and pharmacy.²² As the most trusted and largest occupation within the health care industry, professional nurses are presented with the circumstances, the time and the place to represent dignity, the common good, subsidiarity and solidarity in the drive for justice in the workplace.

ROXANNE O'BRIEN has worked for St. Joseph Health (Humboldt County and St. Mary Medical Center), the Veterans Affairs (VA) Puget Sound Health Care System, and Kaiser Permanente Northern California Regional Offices. She currently is a lecturer for nursing master's degree students in the School of Nursing at California State University, Fullerton, California.

NOTES

1. Tim Bates and Joanne Spetz, California Health Care Almanac — California Nurses: Taking the Pulse (Oakland, California: California Healthcare Foundation, March 2014). www.chcf.org/~/media/MEDIA%20LIBRARY%20Files/PDF/PDF%20C/PDF%20CaliforniaNurses2014.pdf.
2. Emily Richards and Dave Terkanian, "Occupational Employment Projections to 2022," Monthly Labor Review (Washington, D.C.: Bureau of Labor Statistics, December 2013), www.bls.gov/opub/mlr/2013/article/occupational-employment-projections-to-2022.htm.
3. National Labor Relations Board, "1974 Health Care Amendments," www.nlrb.gov/who-we-are/our-history/1974-health-care-amendments.
4. Lyndia Flanagan, Collective Bargaining and the Nursing Profession (Kansas City, Missouri: American Nurses Association, 1983).
5. Karen Budd, Linda Warino and Mary Ellen Patton, "Traditional and Non-Traditional Collective Bargaining: Strategies to Improve the Patient Care Environment," Online Journal of Issues in Nursing 9, no. 1 (January 2004), www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume92004/No1Jan04/CollectiveBargainingStrategies.html.
6. Nili Tabak and Nurit Wagner, "Professional Solidarity Versus Responsibility for the Health of the Public: Is a Nurses' Strike Morally Defensible?" Nursing Ethics 4, no. 4 (1997): 283.
7. Sylvester C. Chima, "Global Medicine: Is It Ethically or Morally Justifiable for Doctors and Other Healthcare Workers to Go on Strike?" BMC Medical Ethics 14, Supplement 1, S5 (Dec. 19, 2013):1-10. www.biomedcentral.com/1472-6939/14/S1/S5.
8. Paul Neiman, "Nursing Strikes: An Ethical Perspective on the US Healthcare Community," Nursing Ethics 18, no. 4 (July 25, 2011): 596-605.
9. Neiman, "Nursing Strikes."
10. American Nurses Association, Code of Ethics for Nurses with Interpretive Statements 2015.
11. Kathleen O. Williams, "Ethics and Collective Bargaining: Calls to Action," Online Journal of Issues in Nursing 9, no. 3 (July 23, 2004). www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Columns/Ethics/EthicsandCollectiveBargaining.html.
12. American Nurses Association, Code of Ethics.
13. American Nurses Association, Code of Ethics.
14. American Nurses Association, Code of Ethics.
15. Susan Stabile, "CST 101: Basic Principles of Catholic Social Thought," Review of Business 27, no. 2 (Spring 2006): 7-12.
16. Kenneth R. Himes, ed., Modern Catholic Social Teaching: Commentaries and Interpretations (Washington, D.C.: Georgetown University Press, 2004).
17. Himes, Modern Catholic Social Teaching.
18. United States Conference of Catholic Bishops, "A Catholic Framework for Economic Life, a Statement of the U.S. Catholic Bishops," November 1996, www.usccb.org/issues-and-action/human-life-and-dignity/economic-justice-economy/upload/catholic-framework-economic-life.pdf.
19. USCCB, "A Catholic Framework."
20. John S. Murray, "Moral Courage in Healthcare: Acting Ethically Even in the Presence of Risk," Online Journal of Issues in Nursing 15 no. 3 (Sept. 30, 2010), www.nursingworld.org/mainmenucategories/ethicsstandards/courage-and-distress/moral-courage-and-risk.html.
21. American Nurses Association, Code of Ethics.
22. Rebecca Riffkin,"Americans Rate Nurses Highest on Honesty, Ethical Standards," Gallup Social Issues, www.gallup.com/poll/180260/americans-rate-nurses-highest-honesty-ethical-standards.aspx.