Striking a balance: patient safety during industrial action

When strike action happens in the nursing community, there’s a fine line between maintaining patient safety and causing enough disruption to get the employers and the government back to the negotiating table.  

In 2019, for the first time in the history of the RCN, nursing staff went on strike in Northern Ireland, demanding urgent measures to address unsafe staffing levels and deliver pay parity. 

They felt passionate about the need to demand change, but for many the prospect of going on strike caused immense personal conflict. Jill Fleming was one of those who took part. 

“I never would have thought back in 1985, when I started nursing, that I would end up on a picket line,” she says. “It really goes against our grain. We’re our patients' advocates. But that’s why we had to act – to fight for patient safety. There was huge support from patients, and that shows they understood that we did it in their interests.”

Preserving patient safety 

The RCN is committed to ensuring any industrial action it initiates has the preservation of patient safety at its core. A way of maintaining this and safe staffing levels is through derogations. This is an exemption provided to a member or service from taking part in industrial action. 

• For the latest information on strike action and derogations, visit our strike hub

Any RCN industrial action must follow the life-preserving care model. This exempts:  

• emergency intervention for the preservation of life or the prevention of permanent disability
• care required for therapeutic services without which life would be jeopardised or permanent disability would occur
• urgent diagnostic procedures and assessment required to obtain information on potentially life-threatening conditions or conditions that could potentially lead to permanent disability.  

The RCN’s Industrial Action Handbook says derogations beyond the life-preserving care model should be avoided, but it is entirely dependent on the individual workplace circumstances on any day of industrial action.

Rita Devlin, Director of RCN Northern Ireland, then Associate Director, was heavily involved in organising the industrial action. She explains that during the strike, there were three models for derogations, depending on the service and need:  

• complete derogation, with an entire service being exempt (for example, intensive care units)
• a Sunday service or Christmas Day service
• a night duty model, where the night duty numbers were agreed to cover the day duties (with requests for further staffing considered on a case-by-case basis). 

Using a night duty model greatly concerned employers as they felt it wouldn’t meet patient needs. Rita had to continually reinforce the message that decisions were about maintaining safety and not conducting business as usual. “I had to say: ‘This is industrial action. This is meant to cause disruption. We're giving you night duty staff to keep patients safe.’” 

Organising derogations 

Generally, the employer will request derogations, which are discussed by  RCN committees responsible for overseeing the strike action, before being agreed.

Cardiology nurse Andrew Doherty sat on one of those committees during the strike action in Northern Ireland. He was joined by other elected RCN members and nurse specialists in oncology, cardiology and renal who helped advise on specific derogations.

You need to have people who know and understand the service that’s being asked to be derogated

Andrew’s committee came up with a “master list” of services that would be derogated. “We had to be really strict about the definitions of life-preserving care and prevention of permanent disability,” says Andrew.

Derogated staff in Northern Ireland were provided with badges that showed their support for the strike action. “This made them feel part of the action, and we reassured them of their crucial role in the success of the strike,” says Rita. 

A balancing act 

There’s a fine balance between safety and striking, and to hit this equilibrium, Rita says it’s vital to have local knowledge on the committees involved in organising derogations and strike action.

“You need to have people who know and understand the service that’s being asked to be derogated, or who have the contacts that can tell them about it,” she says.

“You woke up on the morning of industrial action with fear in your stomach that something could go wrong, but also knowing that you were doing the right thing because every other option had been exhausted.

“Our strike action was about safe staffing and pay parity, and we knew that if we didn’t take a stand and advocate for our patients, it would just continue. So, there was a worry for a day, hopefully for an improved future.”

Keep your code of conduct at the front of your mind and preserve safety

Andrew says it’s difficult to find the balance, but it’s important to try and maximise the impact of the strike while minimising the impact on patients. “The patients didn’t ask for this,” he says. “Keep your code of conduct at the front of your mind and preserve safety. If you honestly think that there’s a risk to patient safety in what you’re being asked to do, then speak to your strike committee. We can’t have any harm come to any patient. Thankfully, our industrial action ended with no adverse incidents. It was done well.”

Rita thinks derogation in the Northern Ireland strike was hugely successful. “Everybody knew what they were doing,” she says. “Even our patients came and stood beside us on the picket lines, brought us food and drinks, and told us that they were supporting us. That galvanised people too.”