In ever changing social and political cultures, it is important that nurses are able to work together and support each other in upholding the core values which are important to the profession. Different forms of collective organizations are available for nurses, including professional organizations and trade unions. Despite notional and philosophical differences, the workplace practices of the representative organizations tend to be similar, and nurses can accrue particular benefits from membership of a collective. Local organizing strength is often the best predictor of which organization nurses will join, and ultimately collective strength requires mass membership. Professional bodies and trade unions are involved in substantial efforts to maintain strong representation of nurses, and an ultimate goal is the democratization of healthcare workplaces.
There are two main forms of collective membership organizations for nurses in the UK, which are professional associations and trade unions.
The main professional association is the Royal College of Nursing (RCN), the structure of which is modelled on medical royal colleges. The Royal College of Midwives (RCM) similarly represents midwives. Professional associations serve a representative function for nurses, with a focus on professional role and identity.
A number of trade unions also represent nurses, the biggest being Unison, the public service union. Unite, the large general union, also represents nurses and includes the Mental Health Nurses Association (MHNA) and the Community Practitioners & Health Visitors Association (CPHVA). Because of its organizational powers and bargaining experience, Unison often takes the lead in national nursing pay negotiations and the provision of evidence to the NHS Pay Review Body. The trade unions are affiliated to the Trades Union Congress (TUC) and the Labour Party, and they prioritize workplace rights and terms and conditions of employment.
The professional bodies and trade unions are all concerned with employment relations and professional interests and operate across these boundaries. The major difference between the trade unions and professional associations is that the unions are more thoroughly integrated into a broader labour movement and have a more diverse membership base, organizing occupational groups beyond nursing. The professional associations eschew political affiliations and only recruit nurses to their membership. For most of its history, the RCN was only concerned with registered nurses but has changed its rules to allow healthcare assistants to be members. Hence distinctions between professional associations and trade unions are increasingly blurred.
All of these representative organizations are committed to working together in alliances, and typically they also seek to work in partnership with NHS employers.
Trade unions and professional associations often offer a package of benefits as incentives to recruitment of members. Arguably, for nurses, the major incentive of this sort is professional indemnity insurance. Both Unison and the RCN offer student nurses substantially cut-price membership for the period of their pre-registration training, with a view to recruiting them as full members on registration and their taking up employment. The RCN also produces journals, notably the Nursing Standard, and organizes various annual conferences for practitioners and academics.
Unison and Unite also operate professional services, with Unite producing the Mental Health Nursing and Community Practitioner journals that are distributed to members. Unison operates a National Nursing and Midwifery Occupational Group, staffed by professional officers who provide advice and produce guidance on professional matters relating to employment relations.
All of the respective representative organizations offer packages of member benefits. These typically include special deals on car and home insurance, and holiday and other shopping discounts. More importantly, the benefits of membership are essentially a contingency on which to rely if trouble occurs within the workplace. These benefits can include:
• Support, advice, and help at work.
• Help with grievances or disciplinary matters.
• Legal help—often extending beyond the workplace to include assistance with family legal problems or making wills.
• Covering the costs of registering a claim at an employment tribunal.
• Assistance in securing compensation for injury or accident at work.
Unions and professional associations are structured to deliver their work through a mixture of paid officers and volunteer representatives, the latter often referred to as ‘reps’, ‘stewards’, or ‘activists’.
Individual nurses often join the organization that is best organized within their immediate workplace, and it is this level of organization that will be most useful if the member experiences difficulties in their employment which requires representation or support.
All representative organizations offer to support members should they wish to action grievances, escalate concerns about patient welfare, or if they find themselves subject to managerial censure or discipline or in circumstances of organizational change leading to insecure employment.
UK NHS pay and other terms and conditions of employment are negotiated centrally and subject to the deliberations of an independent Pay Review Body. Increasingly, however, the restructuring of the NHS into semi-autonomous Trusts and the different strategic direction and financial settlements within the devolved nations of the UK have created pressures for local negotiation and bargaining over terms and conditions and pay. In these circumstances, it is vital that nurses have access to well-organized local representation of their interests.
The major representative organizations offer their nurse and midwifery members substantial indemnity insurance. This is insurance cover for risks to third parties, such as patients, due to nursing practices, mistakes, or errors of judgement that result in harm. The indemnity insurance on offer from trade unions and professional associations explicitly excludes independent practitioners, such as independent midwives, who are more vulnerable to litigation.
In the UK, by common law, the NHS Employer is subject to vicarious liability, meaning the NHS has to cover damages due to employees’ actions. NHS employees are therefore unlikely to be sued as individuals, as persons seeking to pursue a legal claim will usually be advised to sue the NHS Trust.
However, as the NHS becomes increasingly commercialized and fragmented, and citizens become more litigious, there may be an increase in occasions where individual nurses are taken to court and sued for damages.
Following the global banking crisis of 2008, the wider political economy is now dominated by neo-liberalism and associated austerity policies. In UK health and social care services, this has led to enormous cost-cutting pressures and increasing encroachment of market forces and privatization into the NHS.
These factors have contributed to a health workforce crisis and an acute shortage of nurses at the same time as austerity policies attempt to restrain pay and dilute other terms and conditions of employment. In addition to this, nursing itself is subject to public criticism following various public enquiries into failures of care services.
These conditions make for turbulent employment relations and put partnership working under strain. When employment relations are stressed or rigid impositions, such as pay restraint, are placed upon negotiations, representative organizations seek to marshal their collective strength behind bargaining aims. This can involve forms of industrial action, up to and including strike action.
Until recently, the RCN famously operated a no-strike rule, because of concerns over potential detriment to patient care. Although this has now been rescinded, the RCN remains largely opposed to strike action.
Nursing unions across the world, however, have successfully used strike action to further a range of demands without compromising patient care. Many examples of nursing industrial action have targeted the defence of services, rather than employment or workforce issues.
Nurses have an important professional role responsibility in advocacy and safeguarding, particularly on behalf of vulnerable patients ( www.nmc.org.uk). This can place nurses at the forefront of raising or escalating concerns over the safety of patients or colleagues.
Most good employers will have a policy to protect nurses or other staff who feel professionally obliged to highlight concerns in this way. Local policy and practices should involve recognition of professional values and responsibilities, together with a clear organizational process by which concerns can be brought to the attention of the relevant managers, and a pathway for escalation as necessary.
Where concerns are not addressed within an organization, the ultimate stage of escalation is reporting bad practice or service failings in the public domain. This practice is commonly referred to as ‘whistle-blowing’ and should normally only be considered if internal processes and procedures for raising concerns have been exhausted.
Whilst it will sometimes take considerable courage to uphold professional nursing values and pursue a legitimate concern, nurses should also be aware of their vulnerability. They can be subject to disciplinary action if the employer takes a view that due process has not been followed. Because of this, it is imperative that nurses who wish to raise or escalate concerns seek the support of their representative organization.
The NMC provides guidance in the Code of Practice and Raising and escalating concerns: guidance for nurses and midwives ( www.nmc.org.uk). Unison also offers guidance for nurses and other healthcare workers facing such circumstances in the Duty of care handbook and Speaking up, speaking out ( www.unison.org.uk). (See also Chapter 9, Communicating concerns in healthcare.)
Most nursing collective organizations recognize the importance of recruiting members and getting people more actively involved once they are members. The particular social and relational ways in which people are persuaded to join and become more active in representative groups is known as ‘organizing’.
Representative organizations, such as trade unions or professional associations, are more powerful when they are able to demonstrate collective strength. This requires a number of things:
• A strong base, ideally with a representative in each workplace or team.
• Recruitment of as many staff as possible into membership.
• Commitment amongst the membership to the aims of the collective organization.
• Establishment of close social ties between members, activists, and officers.
• Active involvement in systems of internal democracy.
• Solidarity and respectful working relations between different representative organizations.
• Interests and connections to groups outside of the workplace who have an interest in healthcare work.
In any workplace, the membership density is the proportion of all staff eligible to be in a staff-side organization who actually are a member of one. However, many people do not see the immediate benefit of being in a union. To some extent, there is an effect where non-members can get some of the benefits of membership without paying subscription fees if the collective is fairly successful locally or nationally. Ultimately, however, dilution of collective strength weakens everybody’s position.
The efforts of professional bodies and unions to become better organized in the UK health sector have been fairly successful in maintaining membership figures in the face of service cuts and job losses.
However, it is also recognized that the defence of UK health services needs to work with patients and the public. Engaging in alliances with members of the public and organized patient groups can help professional bodies and trade unions become mutually, cooperatively, and reciprocally involved in communities, rather than solely focused on workplace concerns.
Engaging the public in nursing and healthcare campaigns can also help the nursing profession by fostering understanding about nursing work. Greater understanding may make it less likely that individual nurses, or nursing in general, are blamed for apparent failures of care and compassion.
All of the various representative organizations open to nurse membership are organized democratically. Various local, regional, and national meetings and delegate conferences decide policy and strategic direction of the collective.
Important issues such as leadership and executive positions and key policy issues are often decided by full-membership postal ballots. UK employment law requires that votes for industrial action are delivered by independent postal ballot. All of this voting means that unions and professional associations are amongst the most democratic organizations in contemporary society. However, internal democracy can always be strengthened, largely by increasing the level of participation of the membership.
Although nursing collectives are democratically organized, it is perhaps surprising that the majority of healthcare workplaces are most often operated by hierarchical managerial command structures.
It is not outside the bounds of imagination that nurses, other healthcare workers, their collective organizations, patients, ex-patients, carers, and the public at large could find creative ways to have dialogue and deliberation that would actually help organize healthcare work and make service provider organizations more democratically accountable.
The desirability of more democratic involvement in organizational decisions and planning is also implicated in calls for more horizontal, distributed approaches to leadership. It may actually prove to be the case that democracy at work is most suited to public health services where the ultimate goals of high-quality care are not in dispute.