The experience of the Nurses’ Initiative in Czech Republic

This article was published in the Czech medical journal ‘Tempus Medicorum’ in June 2018

The Nurses’ Initiative has been operating in the Karlovy Vary Regional Hospital (KKN) for a year and a half. That is why we want to recapitulate what it has managed to do, what it has not had the strength to do, what methods it has adopted and what obstacles it has had to overcome. We appreciate the opportunity to summarize our balance sheet in a medical magazine, we want to share our experience with the medical ones.

The nurses’ initiative grew out of KKN workers’ realization in January 2017 that no one would stand up for us. So far we have won for a triple pay rise in KKN from the regional operator. In addition, last summer, the hospital paid a “shift bonus” to all nurses and assistants (and to a lesser extent, to carers and paramedics). Without having to negotiate for it. We all received a ten percent increase, automatically, starting in January 2018. There was no negotiation required. We got better off, noticeably.

We gained more in one year than we had in many years before. It wasn’t free on our part. We had to take a step into the unknown and rely on a long-run self-organisation and pressure from below, from the ground terrain, on the regional politicians, but most importantly on the management directly in the hospital. First of all, however, it was necessary to understand that even in the hospital, in the workplace, where we cannot strike effectively, it is possible to fight, not just negotiate. The road to that understanding was not and is not easy. It is necessary to deal with the dictates of long-established stereotypes.

To sacrifice ourselve means to deepen the crisis

There are many of these stereotypes, and they are ingrained in the operation of hospitals and in the health workers’ mentality. We began to untangle them when we asked the question: Why do nurses, etc. endure the devastation to their work and personal lives and to the quality of care so submissively and for so long? The answer offered itself: First and foremost, because our profession is a caring profession and we have, unfortunately, been indoctrinated that it must entail a willingness to sacrifice ourselves. But that is only the beginning of the answer.

In fact, we were sometimes even proud of ourselves for managing the work for absent colleagues and other professions. Sometimes we hoped that the more we did so, the more “someone would notice” and take pity on us and compensate us. We believed that it was enough if our testimonies reached the media, the public. But the list of obstacles that stand in the way of the self-confidence of nurses and the lower healthcare staff is much longer.

However, a following trap stands in the way not just to the nurses’ self-confidence for the struggle: there is a belief that those in charge, the politicians, the management, are just uninformed and therefore have no idea. However, that’s wrong, they have had their plan, their “solution” how to get through the hospital crisis, for a long time: it consists precisely in sacrificing staff, nurses and doctors, and making us endure it. This was and is their “crisis management”. Very cynical because it exploits the fact that politicians and management are not in touch with patients, their loved ones and the crisis of care on a daily basis. We are. We don’t hide in our offices.

But even that’s not all, there’s still the “Become the unpaid Minister of Health” trap: when health care workers speak up, they are being asked to sort out the entire health care system. “Are you complaining that this is unbearable? Ok, so propose a different plan, preferably for the whole country,” we hear… Yes, after the n-th night shift in a row, the hospital staff should probably do the work of ministers, governors, hospital directors for free!?

“My job is to put patients to sleep and wake them up, yours is to provide the money to keep the hospital running,” one of us, an anaesthesiology nurse, replied to the appeal of a regional councillor to join just another, a millionth committee. Her answer was right! It’s time to finally start from the needs of hospital staff and their patients. To put the system on its feet.

But how? How to make our voices heard so that those in charge feel it, concretely, practically, in a service where we are not allowed to strike?

To say “no” to the patching up of the service

Last spring, KKN’s infectious disease ward was threatened with closure due to the staff shortages, and the county politicians toured the facilities in the region to lure the nurses to get a side-job by offering better rates. At the time, we urged our colleagues not to come to our infectious diseases wards to help out. It caused an uproar in the county. It was reported that “the Initiative was threatening colleagues”. However, the external nurses understood why we did not want such “help”.

When KKN’s internal medicine unit was threatened with closure this January, the surgical department refused to join. Out of consideration for the internal and surgical staff and patients. And subsequently, some nurses from eleven KKN wards wrote declarations refusing to help out in the internal medicine ward. For the “privilege” of the double pay for helping out in the internal medicine, management finally managed to find two nurses from the entire hospital!

To say “no” to such patching up, to refuse to participate in such faking of the service, required courage, planning, organization and great responsibility. However, it was the understanding that it was such patching up and fiddling that brought the hospital, and not only ours, to its present state. Overpaying nurses from other departments and from outside the hospital, not following adaptation processes, forcing staff to go beyond their competencies and job descriptions… These are the ways of not solving the crisis, but prolonging it. If the managers and politicians refuse to take responsibility, the workers have to.

It’s about working conditions, not just the money

We have not opened the balance sheet by listing what we have achieved in terms of wages for the sake of boasting. After all, we did not achieve our demand for the introduction of national pay grades in the KKN. Regarding the pay grades, politicians, led by the regional governor Jana Vildumetzová and the councillor Jan Bures, as well as the management of the hospital director Jitka Samáková, deceived us for many months with promises that were only meant to calm down the KKN staff. When the time came to meet the promises, they ran away from them. We do not forget this. Nor do we forget that the state is increasing wages by 10 per cent in our sector, which has long been underfunded, in a situation where wages, and therefore competition, are rising throughout the labour market.

In taking stock of our experience, we wanted to move from the obvious to the harder but more important issues. We started with money to emphasise that it is not just about money. It is not a sensible choice to accept the devastation of one’s own profession and life, the decline of patient care, the deterioration of working conditions in exchange for more money.

It is all about refusing to cooperate with management and politicians in their gambling with care, in their trampling on the profession, in devastating the working and living conditions of the staff, nurses and doctors. The big “no’s”, of which we at KKN have only been able to say “a few” through much of the hospital, are obvious. But it is the small “no’s” on the ground in the workplaces which really matter: to refuse to do the work instead of another profession (important, but not my job!), to insist on having a break or its reimbursement, to refuse to exceed the workload, that my superiors force me to do because of the staffing crisis and thus risk legal action against me, to refuse to have a staff “reinforcement” assigned to the ward, who as a non-nurse is supposed to do the nurse’s work and for whose misconduct I will then be responsible…

Such “small” but immediate “no’s” will get inscribed into the self-esteem of the staff. They have the power to change the practices of the service. They require individual courage, collective intelligence and co-operation. They are the “no’s” of breaking the rules. It is a method of struggle how to push, step by step, from below, from the practice, for a solution. How to create, through our own responsibility (for our own health and our lives, and for the health and lives of the patients), a situation in which politicians and managers can no longer run away from their responsibilities. To ensure that the impact of us sticking to the rulebook will reach from the bottom of the hospital, through the middle ranks, up to the top levels and above the hospital, to the national level.

We are very grateful for the opportunity to look back on our year and a half in this medical journal. For many reasons. Because we share a workplace with the doctors. Because it is good to exchange experiences of fighting for better money, conditions and greater professional pride, which the crisis in hospitals is taking away from us (after all, it was from the experience of the doctors’ movement “Thank you, we are leaving” that we started to organize). Because the better working conditions the doctors and nurses have, the easier it will be to work together.

The nurses’ initiative


Two leaflets from the Initiative

Experience from practice: how we fight in our department

Even a “small” rebellion on the ward is the beginning of a journey towards self-confidence. The following “NO” (“NO” to regulations’ violations) experiences are proof of this. They may seem “trivial”, but at KKN they have actually opened the way for other “NOs”, they inspired and gave courage. They set an example. And in the end, with other “NOs” from other departments, they created a collective force and generated pressure. And from the other side – they required courage to start, to hold the line and act as an organized collective.

Our experience is from the central operating theatres: we agreed collectively that we did not want to refuse overtime work (each of us had her own reasons). Therefore, we were looking for another way how to put the management under pressure.

The very first thing was the observance of lunch breaks. As simple as it sounds, even that was a fight. Following the Labour Code, we began to take our lunch break at peace, no later than 1pm. We had to break their resistance to get that.

The next step was to comply with the standards when admitting and handing over the patients: from now on, nice and easy, with regard for the patient, not at mad speed. Not as before in a rush and with an often stressed out patient on the operating table.

Then we looked around for what other regulations say. Hygiene, for example. These, for example, impose an exposure time for each disinfection (but we can call it a “mopping break” because that’s what the term means :)). So? So, after wiping, we began to wait for 15 minutes, as our disinfection rules require. Only then we moved on to the next patient. Sure, it may sound boring, too basic, but what a fight was it! “Who do you think you are?” “How dare you to slow down the procedural order?”

All these little steps, one after another, led to a general outrage. It took a long time to get them accepted even by those who should have followed them in the first place.

And what has it given to us? Many gains, in every respect. For example, we don’t slip on wet floors anymore, we don’t breathe in the fumes of disinfectant solutions (there are studies on the harm of inhaling these fumes over a long period of time), operating rooms are disinfected as they should be. We eat lunch around noon like humans. We don’t rush around as we used to. Patients benefit from our approach.

But it has brought out something extra, something that actually reaches beyond our department. Someone may believe that these are just some small things (but those who deal with such things know that changing them is not an easy ride). But when more and more departments start to change the existing, established way of working on similar “little things”, when the amount of those little things grows and grows, many little flames will turn into fires. And gradually they will burn their way up to management. And yes, eventually management will realize that the old ways just don’t cut it. That we need to bring in new nurses. That there is no other option – that it just can’t and never will be done without nurses.

Each department has its own specifics, its own procedures. But working conditions can be improved everywhere. This is for a longer conversation. Everywhere you can “use a lever” to change the stereotypes (and the given awareness of nurses). It just needs taking a distance from the learned, from the automated. These are all steps that are consistent with the standards, regulations, the Labour code. They are all by the book. No one can accuse us of doing something wrong, let alone punish us for it.

Of course, many of us have been targeted by colleagues who, from a position of power, thought they could bring us back to the “obedience”. We stood our ground. And we will continue to fight in this way. Firstly, because although the leadership in KKN promised us the national pay grades, they have not kept their promise – and we do not want to work with someone who does not keep their promises. And secondly, because we aim to straighten our professional pride and working conditions for good.

Finally, I would like to say that it is sad that we as health professionals have to use sticking to the Labour code as a threat. After all, it should be the alpha and omega. That is why it must be emphasised: the entire health sector today is based on non-compliance with the Labour Code, and those responsible are ignoring this dangerous fact.

It is up to us to change this.


How to seek a pay rise in your hospital

Union negotiations with the government are unlikely to yield even 10% pay rise. In any case, they will guarantee less than a quarter of a percent pay rise to the staff in private health care. They have been thrown over the board. However, they (but not only them) have a chance to gain more. Hospitals will get a record amount of money from the government through the compensation scheme. Now the point is to force our managements to spend these money on wages. To give it to the people who keep the health care afloat. To those to who the management owes a lot. To those who are paying for the staffing crisis without having had caused it. To give it to the staff – nurses, assistants, carers, paramedics, doctors, cleaners.

To force the management… Does it seem mission impossible? It’s not impossible. We have a proof, an example, that it can be done. The first issue of our paper will be about how to do just that.

Yes, we can! An example from the Karlovy Vary Regional Hospital (KKN)

Three pay rises in one year, which also meant that some of the nursing categories in the joint-stock company get better basic pay than according to the national state pay grades. Shift allowance from summer 2017 for all nurses, not just those on shifts, and to a lesser extent for others, nursing assistants and paramedics. As of January 2018, the national 10 percent rise. Better working conditions on the militant wards. And above all: more self-confidence in relation to the management.

This is the result of the struggle that began in February 2017 at KKN. Yet, as recently as December 2016, no one there could have imagined that such a thing was possible. At the beginning, there were several female colleagues. Gradually, the initiative grew into a self-organisation, a force that was able to put a lot of pressure on the regional government and on the leadership.

The Initiative made it in KKN also because it understood the following:

Staff must stand up for themselves. Poor pay and conditions are also the result of relying on “someone to sort it out for us” (unions, media, politicians, labour inspections…).

The strength is in the departments uniting from below. In practice, this meant mapping and comparing workplace conditions, our own meetings (outside working time), producing a newspaper, setting up different whatsapp and email groups…

→ We need to have the basics of self-organisation before we start talking to management. Not the other way around.

The strength is in the struggle, not in negotiations! Our potential strength (read on to see what it may look like) is in the hospital, in the terrain, in the wards, on the job, not in the office at a negotiating table.

→ The principle is: as much direct pressure as possible from the bottom of the ward first, negotiation afterwards and as little as possible.

We don’t care where the employer will find the money for higher wages. “We don’t have the money for wages”, “we are in debt” are the first answers we hear. In KKN, the nurses said, “You – the politicians and management – don’t care where we find the money to pay our bills from our miserable wages, or who is looking after our kids when we are doing the n-th shift in a row… We, in turn, don’t care where you get the money for higher wages.”

→ Let’s not get sucked into the responsibility of “finding resources”. We’re nurses, assistants, carers, paramedics, we’re not managers – that’s their job. Let’s not get sucked into the task forces and endless meetings.

The struggle, the pressure, must be based on the conditions in specific wards. Perhaps in every hospital, in every ward, operations are “patched up” with overtime beyond the legal mandatory limit, with violations of regulations, job descriptions, standards… If we say “NO” to this, management will have to back down.

→ There is no single method of fighting. It has to fit the workplace. But the fight must be coordinated.

We need to be radical and patient. It’s not just a fight with management. It’s also a fight with passivity, obedience, the mentality of “don’t get yourself into a trouble…” and “the negotiation is still on, just be patient and see how it turns out, the fight is not appropriate at the moment…”. All of this has intoxicated our departments for years. It’s taken its toll on us. It’s a long haul to change that.

There are many more lessons to be learned. These are the most basic. Others will be spelled out in the future issues of the paper. And you yourselves will discover yet other lessons as soon as you will you launch yourselves into building self-organization and struggle (with us). Contact us!

Let’s be strong and smart = let’s organize, independently, from below.

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