Albion Monitor /Commentary
[Editor's note: For more background on the crisis in nursing, see Stearley's "Nursing on the Edge" series in a previous issue.

Ralph Nader and the California's Nursing Association are currently collecting signatures for a November ballot item, "The Patient Protection Act of 1996." This proposal would regulate HMOs in a variety of ways, including new protections for whistleblowing nurses and doctors, minimum requirements for staffing levels, and removing incentives that actually reward doctors who turn away patients. The group has until April 19 to collect 700,000 signatures.]

The Rise and Fall of Nursing Unions

by Harold Stearley

As restructuring of our health care system continues, layoffs for nurses are at an all time high. While managers speak the psycho-babble of their armchair vocations, replacement of professional staff with unlicensed personnel is escalating. Elimination of professional staff nurses will, according to management, translate into an opportunity for advancing our professional role as "patient care coordinators."

A "patient care coordinator" still follows the nursing process to intervene in all aspects of patient care -- only now we will have more patients per nurse. We also know, if we direct all of the newly acquired unlicensed personnel, we will be held liable for their actions -- or inactions. In light of these recent developments, nurses have turned to professional associations and labor unions for support, only to find yet another rug pulled out from beneath their feet.

Who has fought nurses battling for decent wages, staffing, and benefits?

The Supreme Court ruling on May 23, 1994 effectively demolished the last staff nurse sanctuary which offered protection from abusive management practices. The Court upheld a ruling by the Sixth Circuit Court of Appeals, stating that the nurses fired from an Ohio Nursing Home were "supervisors" and were not entitled to protection under the National Labor Relations Act.

This ruling is far-reaching in its implications. At a time when staff nurses are being forced to direct an ever increasing number of unlicensed assistive personnel (UAP), they have been classified as supervisors and have lost all labor law protection because of their compulsory supervisory status.

This leaves staff nurses at the mercy of "termination-happy" administrators during the most wide-spread cycle of hospital redesign facing this nation. Is it a coincidence that this major court ruling occurred just when hospitals were restructuring, and desired unlimited ability to indiscriminately put us in the unemployment lines? Who knows?

At the exodus of this noble nursing institution, I think its appropriate to take a look back at nursing's labor movement. How did we arrive at today's impasse? Who has fought nurses battling for decent wages, staffing, and benefits?

Many nurses traditionally opposed unionizing. It was looked upon as being "blue collar", or "non-professional." There was always the fear that striking to obtain sane working conditions would remove nurses from the bedside

In addition, employees of many state institutions and hospitals were forbidden by law to strike, which undermined the power of unions to flex collective bargaining muscle. Labor laws, initially, were prohibitive and denied nurses the opportunity to form separate bargaining units. But nurses moved forward to consolidate their labor force and gain additional leverage.

In 1974, the Taft-Hartley Act was amended by Congress allowing non-governmental, not-for-profit, hospital employees the right to unionize. The National Labor Relations Board (NLRB) had fought hard for these changes, and continued to fight for nurses to have the right to form their own separate bargaining units. Having an independent bargaining unit would allow nurses to concentrate on issues specific to the their own profession -- as opposed to incorporating issues specific to other hospital departments such as clerical workers and housekeepers.

As of 1991, the Supreme Court affirmed eight bargaining units per hospital, allowing nurses to form separate units for collective action. Who do you suppose fought these changes which would favor nurses? The American Hospital Association (AHA), composed of administrators and physicians, have opposed any legal action which could possibly benefit nurses. This is why it took so many years -- and court battles -- for the NLRB to win us these rights. Why is the AHA so afraid of nurses organizing?

Arrogance became the management style of choice

With health care costs continuing to go off the scale and the public outcry for cost-cutting, hospitals want to be able to freely cut nurses and nursing wages. Labor traditionally accounted for at least 60 percent of hospital costs, and nurses make up almost half of a hospital's labor force. A study of current statistics show that labor costs actually dropped 13 percent between 1962 and 1992. In contrast, hospital administrative costs have risen by 180 percent, and capital expenditures have risen by 36 percent.

And while RNs are being laid off, hospital profits were up almost 20 percent last year alone, and hospital executives have experienced an average 12 percent raise every year for the past ten years.

So while it seems that hospitals are making plenty of money, and hospital administration is making plenty of money, hospitals are lowering expenses by eliminating those of us who provide the direct care for patients.

Eliminating expenses (nurses) has not translated into lower costs for consumers but rather, higher profits for hospital administration at the sacrifice of quality care for patients. And it would appear that hospital administrators have enormous resources from which to compensate nurses -- if they were willing to do so. Losing the power of organized labor will make just compensation a very difficult issue to press.

After the 1991 ruling on separate bargaining units -- and recognizing the growth in staff nurse resentment -- management journals began advocating ways to prevent nurses from organizing. Actually, most of the articles I read offered good suggestions. If you treated your employees with respect, open communication, retained your expert staff, provided nurses with the equipment and proper staffing ratios to care for their patients appropriately, and offered reasonable pay and benefits you would not have to worry about your nurses organizing and participating in collective bargaining. Not bad ideas: pay up now, or risk bargaining with a union later.

Despite these initial positive suggestions, nurses were becoming more interested in organizing than ever before. Why? While the journals were offering some positive strategies to eliminate the threat of unions, managers had been offering threats of their own.

Management turned its back on the front line of our patient care delivery system. Instead of support, as the journals suggested, nurses continued to be told to do more with less. I wasn't shocked to read all of the suggestions to bust unions provided in administrative journals, but I was shocked to observe that managers were doing exactly the opposite of what was recommended to prevent staff from organizing. Perhaps they foresaw our unions' demise, because arrogance became the management style of choice.

Apparently, administrators were not even concerned with the possibility that staff nurses could form a united front. They rarely, if ever, acknowledged that we could be strong enough to speak up for ourselves. Many nurses did mobilize to fight for better treatment, and for our patients' right to receive the care that only a nurse could provide.

So what did unionization produce for the nurses who successfully organized? Better salaries, wages, and benefits approximately 6 percent better when compared to non-unionized nurses. Hospital administrators not only feared organized nursing for this reason, but apparently some "spillover" occurred. Once a hospital unionized, and the nurses received better compensation, the nurses at other area hospitals would receive better compensation due to the increased competition to attract skilled nurses.

Firing nurses is a convenience hospitals wish to protect

It appeared that administrators had good reason to fear us organizing, as they actually had to treat us with a little bit of respect and dignity, as well as compensating us fairly for our services. Administrators are rejoicing the Supreme Court's ruling, and those gains in compensation, respect, and dignity have been shelved once again.

In all fairness, we must examine the AHA's position on collective bargaining for nurses. After all, they contested that there were other reasons -- other than maintaining the bottom line -- for opposing unionization.

The AHA points out that RNs with separate bargaining units tax the hospital system by demanding appropriate ratios between RNs, LPNs, assistive personnel, and patients. One argument put forward was that by allowing RNs to participate in such decisions, they would be defining professional responsibilities for the various categories of health care providers. Nursing administrators have always wished to reserve the right to dictate our professional roles, and further argue if RNs determined their own roles it would create "competitive loyalties" between the other collective bargaining units when overlapping functions were divided. Time, and discussion to resolve matters of importance between professional groups, costs money which administration has been unwilling to spend.

The AHA was also concerned that simply negotiating with another independent union would be costly. They have deduced that contracting with all of the various hospital unions (8 bargaining units as supported by the 1991 Supreme Court decision) would result in the cost of approximately $360,000 for just one round of negotiations.

Of more concern than this increased cost was the fear that RNs would demand some form of job security. This would eliminate management's ability to fire us at will, and it seems firing nurses is a convenience hospitals wish to protect -- how else do you maintain an average 12 percent salary increase for administrators every year for the past ten years?

While the AHA has maintained their concerns did not center around cost, it appears that cost was their sole interest, and with the current legal ruling they can take comfort with not having to negotiate with us "bottom of the food chain" RNs.

Hospital administrations immediately went on the offensive

Arguments concerning divisiveness among staff members never did hold up in light of actual events surrounding nursing strikes. In the Winter 1993 issue of Revolution, Dawn Chipman describes the nursing strike which occurred at St. Joseph's Medical Center in Joliet, Illinois. While there were many emotional issues involved and their final contract may not have achieved all which the nurses desired, the nurses emerged with great feelings of camaraderie and empowerment. Other local unions offered to intervene on the nurses' behalf, and although the nurses did not approve of the other unions' methods, or accept the additional support, it disproves the AHA's argument of divisiveness between labor groups. Labor supported labor.

It is more likely that the AHA was -- and is -- worried about dealing with a strong, united group of nurses who might actually demand what they deserve. The so-called high cost of negotiations was one reason unions worked -- bargaining takes time and money, and with the dollar-clock running decisions favorable to nurses were forced.

If we want to be treated like professionals, have a voice in directing our practice, earn better wages, receive better benefits, and foster camaraderie and empowerment, I would conclude we need some form of organized representation. Yet we have now come full circle. Nurses fought the battles for over thirty years to gain separate bargaining units. Nurses resisted great forces of opposition to achieve job security, better staffing ratios, and better wages and benefits. Yet, in one swift ruling, all of those hard earned benefits were lost. Hospital administrations have not stood by waiting for us to react; they immediately went on the offensive.

In Michigan, administrators simply canceled the union election

The nurses at DePaul Hospital in St. Louis finally attained a vote for a nurse's union in late 1994. Those ballots are now impounded awaiting a court decision on their right to unionize brought about by their "supportive" administration. It seems the management at DePaul spared no cost in fighting the union. They were willing to spend over $200,000 to produce a movie, which they required all of their nurses to view, showing the AFL-CIO to be a corrupt union. They were willing to lose a multi-million dollar contract, providing health care to members of the AFL-CIO in St. Louis, just to prevent their nurses from organizing.

Providence Hospital, in Anchorage, Alaska, has waged war against their nurses for trying to unionize. At last check, their ballots for a union remained impounded awaiting a decision from the NLRB. What ever the decision, you can be sure the administrators will pursue a conclusion in their favor.

Then we have Woodbury Nursing Home, in Nassau County, New York, where administrator Frederick White demanded his staff of twelve RNs quit their membership in the State Nursing Association or face dismissal. The nurses discontinued their membership in fear of losing their jobs.

At Michigan Capital Medical Center in Lansing, Michigan, administrators simply canceled the election being held on forming a nurses union. It takes a great deal of effort to organize a ballot for union formation. A vote must be obtained requiring at least 30 percent of the representative group (thus the nurses) to agree upon having an union election. The NLRB then monitors the election. With hospitals preventing elections, or impounding ballots, nurses are not even being allowed the right to consider joining organized labor.

These are a but a few examples of administration's response to the Supreme Court's ruling. It has become clear what their motives are, and now, more than ever, nurses need to stop infighting and come together on the issues shaping their future practice conditions. Nurses need to become vocal! How else will our concerns be heard? We must lobby for an amendment of the language defining supervisors in the National Labor Relations Act so we can regain our labor representation.

It is our job to inform the public they may no longer be receiving the services which only a nurse can provide. Once the consumers of health care learn administrators are more interested in profit than in providing them with quality treatment, pressure can be brought to bear on hospitals to provide adequate RN staffing. After so many years of fighting to achieve decent working conditions, let's not lay down our arms and give up the battle.

Harold Stearley, R.N., B.S.N., A.S.B., CCRN, has held various clinical and supervisory positions over his twenty-one year career, and has helped develop innovative programs for several hospitals. He is a member of Sigma Theta Tau, and was named in "Who's Who in Nursing" and "Who's Who in America." His freelance writing appears regularly in the local press in Missouri, and his articles have been featured in Nursing, Nursing Administrative Quarterly, Nursing Economics, and The Missouri Nurse. He holds positions on the Editorial Board of The Missouri Nurse and on the Staff Nurse Editorial Advisory Board for The American Nurse.

A version of this essay previously appeared in REVOLUTION, The Journal of Nurse Empowerment.

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Albion Monitor March 10, 1996 (

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