Striking a Balance: What Consultation-Liaison Psychiatrists Should Know About the Hospital Psychological Milieu During a Strike

New York recently experienced the largest scale nurses’ strike in the history of the city. Psychiatrists should be aware of the milieu psychodynamics of a hospital setting. We outline here observed emotional and psychodynamic issues, including moral distress, all-or-nothing thinking, abandonment, resentment, and cognitive dissonance, for the affected groups: the striking nurses, their direct colleagues, the general hospital staff, and patients.

For striking nurses, there are bidirectional relationships between a strike and burnout, anger, frustration, devaluation, and moral distress. Striking to improve conditions can paradoxically worsen these feelings, particularly devaluation when demands are unmet. Strikers experience cognitive dissonance: nurses strike in part to fight for patient safety via improved working conditions, yet strikes inevitably disrupt patient care.^1-3 Nurses do not want to see patients harmed, yet for those hoping to prove themselves essential, it can be hurtful to see colleagues obviating their roles.¹ In both these scenarios, striking nurses have to contain conflicting feelings and actions, wanting to help patients but also temporarily abandoning patients; wanting to be essential, but also not wanting their absence to cause irreparable harm. This produces discomfort and a sense of needing to defend one’s actions. Some strikers are also at odds with one another, or with the union itself: individuals have diverse perspectives, varying potential to benefit from the strike, and differing abilities to go without pay or risk dismissal, with single parents, people with limited support networks, and international staff least able to take personal risks.

Striking nurses’ closest colleagues include nurse assistants (NAs), advanced practice providers, and nonunion registered nurses including middle management. These colleagues and friends may support some union goals but also cover the strikers’ work. This creates a sense of mutual abandonment, with strikers feeling their colleagues are reducing their negotiating power and undermining their indispensability, and colleagues feeling overextended.¹ Not every worker has access to join a union, leading to jealousy. Nonunion workers may feel pressure to support their colleagues but personally lack the job protections required to strike with impunity. Finally, but pervasively, the setting of the strike encourages black-and-white thinking. The union’s negotiation strategy may cast the argument as the “good workers” vs the “bad corporate” administration.¹ Unfortunately, this can force covering colleagues into being identified as allying with the “bad” side, though the reality is considerably more complex. Colleagues are generally not hospital leaders, and especially those who are paid less or feel more devalued than the striking nurses (such as NAs) may resent those on strike. Other staff may resent the implication that continuing their own jobs is tantamount to taking the administration’s side over their colleagues.

This all-or-nothing thinking carries over into the greater hospital environment, affecting colleagues across professions. Most hospital employees want everyone to be treated and paid fairly, and begrudge feeling forced to choose between supporting their colleagues or their patients, leading to moral distress and resentment. These concerns persist upon reentry, as tensions between professions, such as scope and responsibility disputes, are exacerbated by the strike. Returning strikers, in our experience, have expressed difficulty returning to collaboration with their nonstriking peers due to feeling insufficiently supported in their negotiations.

Physicians are uniquely affected by strikes, due in part to productivity scrutiny, and largely to the extremely small number of physicians who themselves are unionized. Physicians may generally believe in the power of group negotiation and the right to strike, but may feel unable to participate ourselves.⁴ Limiting factors may include prior oaths, role in society, and personal moral views that they are unable to temporarily abandon patient care—even if it is ultimately for the better of future patients and colleagues.² The sense that physicians are excluded from union-based negotiations or tactics may cause envy. Physicians must balance the importance of a life of service without resorting to masochistic fantasies that promote a lack of personal boundaries.

Our ultimate purpose as clinicians is to serve patients. In our experience, patients often want to support their nurses and also have a vested interest in their clinicians being happy, well, and present. Patients with immediate critical needs experience anxiety that they will suffer or even die while their care is delayed. Patients may feel both abandoned and guilty about their necessarily self-focused needs. For patients accessing highly niche specialties, sometimes traveling for destination care, significant delays may require distant displacement, leading to financial toxicity. We have observed these concerns particularly impacting pediatric patients seeking niche care, as there are often few options.

Through personal interactions, news, and social media, patients are increasingly aware of negotiation perspectives. Hospitals are ordinarily seen as refuges, or psychodynamically, perfectly safe holding environments. Knowledge of internal conflict risks eroding trust in hospitals and producing fear of abandonment. This is especially troubling for patients with unstable attachments.⁵ We have observed these anxieties, and even worsened delirium, in patients hearing strikers chanting through their hospital windows. We also acknowledge that the patients most affected—those whose care has been delayed or denied—are those we do not see.

Psychiatrists should understand the myriad practical concerns of a strike, as well as the mutual resentment, abandonment, guilt, devaluation, all-or-nothing thinking, and unconscious experiences previously described. For those of us in consultation-liaison psychiatry or other hospital-based settings, we may personally interface with teams experiencing these issues. Although we do not provide direct care to our colleagues, it is nevertheless important for us to understand the psychological milieu of the hospital and to have sensitivity during these times.

Dr Mishkin is an associate professor of psychiatry at Columbia University Irving Medical Center, and the psychiatric liaison to the Blood and Marrow Transplantation and Cellular Therapies Program at New York Presbyterian Hospital.

Dr Nash is an associate professor of psychiatry at the Columbia University Irving Medical Center, and the director of the consultation-liaison service at New York Presbyterian Hospital.

Dr Garza is an assistant professor of psychiatry on the consultation-liaison service at Columbia University Irving Medical Center. She is also a psychoanalyst on the faculty at the Columbia Center for Psychoanalytic Training and Research.

References

1. Neiman P, Neiman T. Nurses on the outside, problems on the inside! The duty of nurses to support unions. Nurs Ethics. 2025;32(6):1799-812.

2. Chima SC. Doctor and healthcare workers strike: are they ethical or morally justifiable: another view. Curr Opin Anaesthesiol. 2020;33(2):203-210.

3. Ratliff HC, Yakusheva O, Costa DK. The rising wave of healthcare worker strikes: balancing advocacy and patient well-being. Ann Am Thorac Soc. 2024;21(12):1647-1650.

4. Friedmann T, Milgrim F, Tran A, et al. Impact of a hospital-wide nursing strike on an emergency medicine residency: lessons learned. J Grad Med Educ. 2025;17(2):147-149.

5. Winnicott D. Dependence in infant-care, in child-care, and in the psycho-analytic setting. Int J Psychoanal. 1963;44:339-344.