More than 75,000 Kaiser Permanente health care workers^[1] began a three-day strike^[2] in Virginia, California, Colorado, Washington state, Oregon and Washington, D.C., on Oct. 4, 2023, after company executives and eight unions representing aides, techs, support staff^[3] and other employees failed to agree on the terms of new contracts. This is the largest U.S. health care strike^[4] on record. In a statement it released when the walkout started, Kaiser asserted that it wanted to reach a deal^[5] soon with the striking workers.

Although hospitals and emergency rooms are still open during the strike^[6], and Kaiser is making use of temporary workers^[7], many of its noncritical services are temporarily closed or operating under reduced hours^[8]. The strike does not include any nurses unions or doctors.

The Conversation asked Michael McQuarrie^[9], an Arizona State University sociologist who directs its Center for Work and Democracy, to explain why this strike is happening now and how labor actions like this can affect patient care.

1. Why is this historic strike happening now?

The two main reasons are concerns over staffing levels and practices and dissatisfaction with pay that hasn’t kept up with inflation and was too low to begin with.

Kaiser says its options are limited due to a national shortfall in all sorts of health care workers^[10], including home health aides and nurse practitioners. Workers counter that higher pay and better working conditions would attract more applicants.

Health care workers have long worried that inadequate staffing is undercutting the quality of care^[11] for patients – this has been a central issue in contract negotiations and strikes for years. But the COVID-19 pandemic greatly exacerbated^[12] the problem.

At the same time, inflation has outstripped negotiated wage increases for Kaiser workers. Kaiser is currently offering some workers in Northern California and Washington state 4% annual raises^[13] for the four years covered by the new contract and lower raises for everyone else. The unions have rejected^[14] this offer, which they say would not make up for past inflation and would unnecessarily create different wage scales based on the region where workers are located.

2. Has Kaiser’s financial management played a role too?

Kaiser, which provides health care for 12.7 million Americans, took in US$95.4 billion in revenue^[15] in 2022 but ran a $1.2 billion operating loss^[16] that it attributed to “strong economic headwinds in the financial markets” – suggesting that its investments were to blame rather than its health care operations.

For 2021, Kaiser reported that it had about $56 billion in unrestricted cash^[17] and investments^[18], excluding assets tied to employee and retiree pensions.

Kaiser’s profits in the first half of 2023 totaled about $3.4 billion^[19], however. And with the exception of its losses in 2022, Kaiser has been consistently profitable for years^[20].

Concerns over low worker pay are growing while Kaiser’s executive compensation^[21] is increasing. As of 2021, its CEO Gregory Adams was making more than $15.5 million^[22] a year in pay and “other” compensation.

3. But isn’t Kaiser a nonprofit – and does that mean it has any special obligations?

Like many health care systems, Kaiser is a nonprofit^[23]. This means it pays very little in taxes. In exchange for their special tax status, nonprofits are supposed to provide public benefits^[24].

Nonprofits may make more money than they spend, but they can’t distribute profits to its shareholders^[25]. Nonprofit executive compensation must be “reasonable,” according to the Internal Revenue Service^[26] – although it can be hard to determine how much is too much.

4. Are there any precedents for this strike?

Health care strikes are not unusual, with more than 40 occurring^[27] in the past two years. However, the industry and the workforce are heavily fragmented, which means that these strikes tend to be relatively small.

In September 2022, the Minnesota Nurses Association took 15,000 members^[28] on strike over many of the same issues, such as staffing and inflation. That strike, which lasted three days, was the largest health care strike in U.S. history by that point in terms the number of workers involved.

Prior to that, the largest was probably another Minnesota strike in 2010^[29], in which about 12,000 nurses walked off the job for 24 hours.

Kaiser has experienced much smaller strikes in the past, such as a walkout in 2015^[30] of about 75 mental health clinicians.

5. How much are patients harmed during health care strikes?

It depends on the strike, but usually not much.

Critical care Kaiser facilities will remain open, though the strike will likely cause some delays in care due to short staffing and long lines.

Some appointments and elective procedures at the affected hospitals are being postponed, and nonessential functions like labs and radiology departments are temporarily closed or their hours are being reduced.

Nurses, who are very important bedside caregivers, are part of a different coalition of Kaiser unions. While they won’t be on strike, they may have to help cover work^[31] not being done by aides and other support staff who are on the picket lines.

The COVID-19 pandemic ushered in a new era of digital connection: In the absence of in-person gatherings, many people instead found themselves face-to-face with their co-workers and loved ones on a screen.

Videoconferencing has provided many benefits and conveniences. However, it isn’t surprising that constantly seeing ourselves on screens might come with some downsides as well.

Prior to the pandemic, studies showed that surgeons were seeing increasing numbers of patients requesting alterations of their image^[1] to match filtered or doctored photos from social media apps. Now, several years into the pandemic, surgeons are seeing a new boom of cosmetic surgical requests related to videoconferencing. In one study of cosmetic procedures during the pandemic, 86% of cosmetic surgeons reported videoconferencing as the most common reason for cosmetic concerns^[2] among their patients.

Despite the fact that many aspects of life have returned to some version of pre-pandemic normal, it’s clear that videoconferencing and social media will be with us for the foreseeable future. So what does that mean when it comes to appearance satisfaction and making peace with the image that’s reflected back at us?

For the past 10 years, I have worked as a specialist in obsessive-compulsive disorders, eating disorders and anxiety^[3]. Since the pandemic, I, too, have seen increasing numbers of therapy clients reporting that they struggle with appearance concerns related to videochatting and social media^[4].

Zooming in on image and appearance dissatisfaction

Every person has perceptions and thoughts about their appearance. These can be neutral, negative or positive. We all look at ourselves in the mirror^[5] and may have even experienced distress while looking at our reflection.

There are a number of factors that may lead to appearance dissatisfaction. A preoccupation with thoughts, feelings or images of one’s own appearance is linked to the action of “mirror gazing,”^[6] or staring at one’s reflection. Researchers suggest that this type of selective self-focused attention and mirror gazing can lead to negative fixations^[7] on specific attributes or minor flaws, which in turn intensify the preoccupation with these attributes.

Other factors that can contribute to appearance dissatisfaction include low self-esteem^[8], societal beliefs^[9] around appearance, peer^[10] and parental influences^[11], temperament^[12] and genetic predispositions to mental health conditions^[13].

Appearance dissatisfaction and negative evaluations of self are associated with depression, lower self-esteem^[14], habitual negative thinking^[15] and increased social anxiety^[16]. What’s more, research suggests that these preoccupations can contribute to the development of eating disorders^[17] and disordered eating behaviors, such as frequently restricting food intake or exercising without refueling.

The ‘Zoom’ effect

With the ubiquity of Zoom meetings, FaceTime calls, selfies and the constancy of documenting our lives on social media, access to our own image can often feel inescapable. And for some people, this can magnify feelings of appearance dissatisfaction that may have been more fleeting before the Zoom era.

Since the pandemic, screen time has increased for both adults^[18] and children^[19]. What’s worse, recent research suggests that the video and photo reflections^[20] we see of ourselves are distorted^[21].

Videoconferencing, taking selfies and posting on social media are visually based activities where appearance is often the primary focus^[22]. All of them have in common the fact that a person’s image is either live or shared in an immediate manner. Perhaps not surprisingly, these image-based platforms have been significantly associated with appearance dissatisfaction, anxiety, depression and eating disorders^[23].

One study found that those who engaged in more videochatting appearance comparisons, meaning those who looked at others’ appearance during a video call and sized up their own appearance in comparison, experienced lower appearance satisfaction^[24]. This study also found that people who used more photo-editing features on videochat platforms were more likely to compare themselves with others and spend more time looking at themselves on video calls^[25].

One thing that is unique to videoconferencing is that it allows people to easily compare themselves with others^[26] and watch themselves sharing and speaking in real time. A 2023 study found that discomfort with one’s appearance during videoconferencing led to an increased fixation on appearance, which in turn led to impaired work performance^[27].

Researchers also suggest that appearance dissatisfaction is associated with virtual-meeting fatigue^[28]. The research reports that this could be due to negative self-focused attention, cognitive overload^[29] and anxiety around being stared at or being negatively evaluated based on appearance^[30].

This last point is notable because of the difficulty videochatters have determining where other users are looking. Using the concept of the “spotlight effect^[31]” − our tendency as humans to overestimate how much others are judging our appearance − this difficulty may lead to more anxiety and individuals believing that others are evaluating their appearance during a video call.

How to combat appearance dissatisfaction in the digital age

If you find yourself criticizing your appearance every time you hop onto a videoconference call, it may be time to evaluate your relationship with your appearance and seek out help from a qualified therapist.

Here are some questions to consider to help determine whether your thought patterns or behaviors are problematic^[32]:

− How much of my day is spent thinking about my appearance?

− What sort of behaviors am I doing around my appearance?

− Do I feel distressed if I do not perform these behaviors?

− Does this behavior align with my values and how I want to be spending my time?

Another strategy is to be intentional about focusing on what other people are saying in a videoconference instead of peering at your own face.

When it comes to helping others who might be struggling with appearance dissatisfaction, it is important to focus on the person’s innate qualities beyond appearance. People should be conscious of their comments, no matter how well intentioned. Negative comments about appearance have been linked to worsened self-esteem and mental health^[33]. When viewing yourself or your peers on video and social media, try focusing on the person as a whole and not as parts of a body.

Reducing screen time can make a difference as well. Research shows that reducing social media use by 50%^[34] can improve appearance satisfaction in both teens and adults.

When used in moderation, videoconferencing and social media are tools to connect us with others, which ultimately is a key piece in satisfaction and well-being.