UNIONIZING NURSES: WILL IT CHANGE THE FUTURE FOR PATIENTS?
Kandy K. DeWitt
University of North Carolina at Pembroke
in partial fulfillment of the requirement for the
degree of
MASTERS OF PUBLIC ADMINISTRATION
2
TABLE OF CONTENTS
LIST OF TABLES ………………………………………………………………......3
LIST OF FIGURES………………………………………………………………….4
ABSTRACT………………………………………………………………….………5
PURPOSE …………………………………………………………………………..7
INTRODUCTION…………………………………………………………………...8
NURSING…………………………………………………………………………..11
NURSE TO PATIENT RATIOS…………………………………………………...16
MANDATORY OVERTIME………………………………………………………19
PURPOSE OF UNIONS……………………………………………………………22
LEGISLATURE…………………………………………………………………….28
UNIONS IN HEALTHCARE………………………………………………………31
IMPACT ON BENEFITS…………………………………………………………...36
PATIENT OUTCOMES…………………………………………………………….37
REFERENCES……………………………………………………………...………41
3
LIST OF TABLES
TABLE 1………………………………………………………..……………… 13
4
LIST OF FIGURES
FIGURE 1…………………………………………………………..…………..23 FIGURE 2…………………………………………………………………..…..25 FIGURE 3………………………………………………………………………35
5
ABSTRACT
UNIONIZING NURSES: WILL IT CHANGE THE FUTURE FOR PATIENTS?
By Kandy K. DeWitt
Masters of Public Administration
University of North Carolina at Pembroke
November 27, 2007
The nursing profession is under fire by the very people who
entered the field to become nurses. As we see patient to nurse ratios rising
and reimbursements for healthcare services falling, nurses across the
country are rethinking their career choice. Because of these changes many
nurses are leaving the workforce which is leading to a nursing shortage
across the nation.
As the demand on nursing continues to escalate they are seeking
union support to help lobby their needs with hospitals to increase salaries,
impose nurse to patient ratio standards, and control overtime. In 2002,
California law mandated that staffing ratios be capped in an attempt to
improve patient care and increase nursing satisfaction.
6
As nurses search for answers many are turning to unions for help.
This paper looks at the history and structure of nursing, why unions came
about, their relationship with nursing, and the impact the nursing
shortage is having on patient care across America. What is the impact
unions are having on nursing, hospitals, and legislation? Finally, does
unionizing nurses change the outcomes for patients?
7
PURPOSE OF THE PROFESSIONAL PAPER
I have been a nurse for many years in both staff nurse and
management roles. I have witnessed first hand the impact that rules and
regulations have on hospitals. This also influences the downstream effect
on the nurse’s role and career contentment as well as patient satisfaction
and outcomes. Most of my knowledge of nursing and unions were only
perceptions and I had very little actual knowledge based on data and
research.
I have been aware of heightened union activity nationally in
nursing but I had not been sure of what was best for nurses and patients.
The purpose of my professional paper is to expose readers to a brief
history of nursing describing some nursing models and historical nurse to
patient ratios. I will also touch on the history of labor unions and how and
why they came to intersect with nursing.
Finally, what have these unlikely relationships done for the nurses
and more importantly for patients. I will show what impact unions have
on nursing that led to positive patient outcomes.
8
INTRODUCTION
The profession of nursing has been around since the 14th century
with nurses caring for the infirmed. When patients are sick and admitted
to hospitals they typically spend the majority of their time with nurses.
Doctors admit patients to hospitals and prescribe care but it is in fact
nurses staffing hospitals that carry out most physician orders and
facilitate patient care.
Changes in Medicare, Medicaid, and increased unemployment
have caused a rise in the uninsured patient population. This uninsured
patient population is affecting the financial state of healthcare providers
and hospitals. Many hospitals are looking for opportunities to cut back
expenses and save money on capital, operational, and human capital
expenses.
The Centers for Medicare and Medicaid Services (CMS) continue to
reduce reimbursements and make disease processes fall into cookie cutter
diagnosis related codes (DRG’s). This puts a tremendous amount of
pressure on hospitals to figure out how to pay for the care of patients that
fall outside of their prescribed guidelines.
Some patients develop complications that do not follow the
schedule of this prescribed care and recently the federal government has
9
announced some illnesses will no longer be eligible for coverage
(Medicare Fee, 2007).
These changes leave healthcare facilities in a quandary because
they must continue to care for these patients plus continue to pay the care
givers salaries and benefits regardless of the patient’s reimbursement
status.
The federal government has created a list of events they believe
should never happen to patients in healthcare facilities. They call these
conditions “preventable complications” and by federal mandate the
government will no longer pay for them. This new rule which becomes
law on October 1, 2008 will no longer include payment for any of the
listed conditions (Rosenthal, Oct 18, 2007).
Historically, when a complication or nosocomial acquired disease
process occurs insurance companies and federal programs have paid for
the continued care needed to support and sustain the patient. This new
program entitled the “never events” will no longer reimburse healthcare
providers for treatment and charges for any of the occurrences on the list.
Many of the items on the list are significant and justifiable why they have
been identified, such as wrong site surgery. But, the list also includes
conditions such as the development of stage 3 or 4 pressure ulcers and
urinary tract infections in patients with catheters which in reality, is going
10
to occasionally happen. The bottom line is in-patients are sicker and
statistically some complications are going to occur (The National Quality,
2006).
As the pressure mounts on hospitals to reduce their costs changes
in healthcare like the “never events” are impacting the nurse’s role. Some
of these changes are affecting the way patients are cared for, the way
nurses feel about their role, and this is leading to negative changes in
patient outcomes, and ultimately nursing dissatisfaction.
This dissatisfaction will cause some nurses to leave healthcare to
pursue other career opportunities further contributing to the critical
nursing shortage which is projected to worsen in the future. They
anticipate the demand for nurses will continue to rise and as work
environment dissatisfaction increases the gap in the need for nurses and
the availability will continue to widen (Biviano, Tise, 2004).
As frustration mounts nurses are looking for help from outside
sources because they are losing confidence in hospital administration
(Welch, 2005).
Labor unions have been in existence since the mid 1800’s to
counterbalance wealth and power of employers and to represent workers.
Unions have historically worked to negotiate the terms of collective
11
bargaining for their members and represent their best interests (United
Steelworkers, 2007).
Nurses in greater numbers are turning to unions for help in
representing their best interests in areas of work environment, benefits,
wages, and staffing. After joining unions many nurses claim they are more
professionally satisfied stating the benefits they reap by unionizing have
contributed to better patient outcomes in morbidity and mortality (Seago
& Ash, March 2002).
NURSING
Nursing has undergone major changes over the years. Nursing has
been described by many great nursing leaders but to this author it is
somewhere between a science and art. Nurses not only focus on numbers
and values but they learn to develop a sixth sense when caring for patients
and recovering them back to optimal health. Nurses have concern for
patients as individuals and they have concern for their families and social
situations. It is a profession that transcends a traditional eight to five work
mentality.
A survey of over 700 nurses reported they planned to leave direct
patient care sometime in the next five years for reasons other than
retirement. They cited their current jobs were too stressful and the work
12
requirements too physically demanding. They also reported that their
current patient to nurse ratios was the single most important factor that
could be changed to influence them from leaving the nursing profession.
In North Carolina, 324 nurses were randomly surveyed and 60
percent reported they remained in their positions for five years longer
than they had planned. They said the reason was mainly out of loyalty to
their coworkers and factors such as pay, benefits, and flexible scheduling
were only secondary influences (Lacey, Feb 2003).
It is essential that we act now rather than react later to address
today’s nursing shortage because it is different from those in the past.
Until real changes are made within the nursing profession nurses will
continue to become dissastisfied, frustrated, and then quietly leave the
nursing profession.
In the current shortage we have experienced high vacancy rates for
longer periods of time. In table 1, The Department of Health and Human
Services has projected the supply, demand, and shortage of RN’s will rise
over time and they predict we will fall short by over one million nurses in
the year 2020.
13
Table 1: Projected U.S. Full Time Equivalent RN Supply. Projection of how many nurses will be needed, how many nurses are projected to be in the workforce, and what the projected shortfall will be.
2000 2005 2010 2014 2020
Supply 1,890,700 1,942,500 1,941,200 1,886,100 1,808,000
Demand 2,001,500 2,161,300 2,347,000 2,569,800 2,824,900
Shortage (110,800) (218,800) (405,800) 683,700) (1,016,900)
Supply/Demand 94% 90% 83% 73% 64%
Demand Shortfall 6% 10% 17% 27% 36%
Note. From “What is Behind HRSA’S Projected Supply, Demand, and
Shortage of Registered Nurses?”, by Biviano, M., Tise, S., Fritz, M., &
Spencer, W., 2004, U.S. Department of Health and Human Services,
p. 27. Washington, D. C.
14
Nursing makes up 25 percent of the work force in the United States
with nursing vacancy increasing at high rates (Garretson, 2004).
Nurses are being challenged in how they care for patients and are
being tasked to do more with less, work harder, and work faster. But the
reality is, not much is being done to fix the problem. Healthcare facilities
seem to be in crisis management and reacting to situations instead of
taking a proactive approach to address the problems. Nurses are
frustrated and feel they need to take serious measures to change the future
forecast.
Historically, hospitals have tried many different techniques in how
they assign nurses to attend to patient care needs. Two of the most
popular models of care have surfaced to the top and describe how nurses
administer care for patients. The models most commonly practiced are
team nursing and primary care nursing.
Team nursing which is still practiced today was popular in the
1970’s and 1980’s and refers to the delivery of care done by a team of staff.
It is led by a registered nurse (RN) who has a team of licensed practical
nurses (LPN’s), certified nursing assistants (CNA’s), and technicians. The
RN delegates the plan of care to the team members and has oversight of
those activities. This model has lost favor because the staff mix is
unpredictable and the demands on the team leading RN are immense.
15
Often the RN is unable to make ongoing rounds and physical assessments
on patients which lowers safe and quality bedside care (Potter & Perry,
2005).
Another model of nursing practice is primary care nursing which
places an RN at every bedside. The primary nurse assesses the patient’s
condition, develops a care plan with interventions, and delivers care
based on the patients needs. The primary nurse will be assigned a number
of patients and typically has the same patient load during the week to
increase familiarity and continuity of care. This model has been supported
by data to show quality is better with primary care nursing (Potter &
Perry, 2005).
As the focus shifts from patient centered to financial centered care
and to combat the nursing shortage nationally, healthcare facilities are
making decisions that are impacting how nurses care for patients.
Hospitals are changing nurse to patient ratios to lower costs and to reduce
the nursing vacancy rate.
Healthcare facilities are able to improve their nurse vacancy rate by
increasing the number of patients any one nurse is assigned to care for.
Nurses are not only being overwhelmed with greater numbers of patients
but they are concerned for patient safety. As the ratios are increased it
decreases the amount of time nurses can spend with their patients.
16
Ratios are regulated in many other areas such as day care centers
and airlines so it would only make sense that safety standards for patients
should be regulated (Bangor Daily News Staff, 2007).
Nurses feel they are being stretched so thin they do not have the
time to spend with patients to give them adequate patient care. They are
rushing from patient to patient and report they are often late
administering medications and delivering timed treatments (Garretson,
2004). This leads to frustration and dissatisfaction for the patients,
families, and staff.
An important key to improving patient care, patient outcomes, staff
and patient satisfaction is how well the nurses know their patients. Some
of the factors affecting this are staffing ratios, how much time nurses are
able to spend with their patients, the nursing model, and the work
environment (Potter & Mueller, 2007).
NURSE TO PATIENT RATIOS
Nursing salaries are the number one staffing expense for hospitals
in America. When hospitals began looking for ways to cut costs they
realized they had a potential to save a substantial amount of money by
reducing the number of nurses on staff by changing nurse to patient ratios
(Garretson, 2004).
17
Hospitals realized they could reduce their overall nursing vacancy
rate by reducing the number of nurses they need by increasing patient to
nurse ratios. They began to take on a greater business sense and make
decisions based on financial outcomes instead of patient focused
outcomes. Because managers spend over fifty percent of their budget
dollars on nursing positions it made sense to hospital administrators to
change the way they had historically staffed patient care units (Garretson,
2004).
As hospitals changed staffing models and required nurses to take
care of more patients’, reports began to surface indicating patient care was
being compromised. The Institute of Medicine of the National Academies
of Science reported that low nurse staffing levels was a key cause in nearly
100,000 deaths annually (National Consumers, May, 2004).
There was also evidence to support that same study showed that 45
percent of in-patients reported that they felt their care was compromised
because a nurse was not available in a timely fashion (National
Consumers, May, 2004).
The Journal of the American Medical Association (JAMA)
published a study showing that as a nurse’s workload increased so does
the risk of death for patients. The rise in workload also increased the
nurses’ burnout rate and job dissatisfaction which could lead to job
18
turnover. The study by JAMA revealed that a nurse caring for four to six
patients had a 14 percent increase in death and a nurse caring for four to
eight patients mortality probability rose to 31 percent (New Jersey State
Nurses Association, Dec 2002).
Nurses report they took their concerns and fears to their managers
and nursing administrators to be addressed with variable results. There
have been some actions whereby some states have adopted controlled
nurse to patient ratios and some hospitals have lowered their staffing
ratios as a recruitment and retention tactic (Maine State Nurses
Association, Feb-Apr 2002). But in reality most hospitals have continued
to ask their nurses to work harder and faster and adjust to the greater
demands of the nurse to patient ratios.
A report by the Joint Commission Accreditation of Healthcare
Organizations (JCAHO) recognized when nurses are spread too thin by
high patient ratios there is a higher incidence of overlooking early
warning signs of a more serious problem. They cite that there is a 3-12
percent reduction in certain adverse outcomes with lower nursing staff
ratios (Joint Commission, 2002).
In a study of nurse to patient ratios it was found that fewer patients
died at one to six versus one to ten nurses to patient ratio (Joint
Commission, 2002). The ongoing pressure of the increased patient load,
19
less patient contact, and unresponsiveness by the administration leads to
job dissatisfaction. Frustrated nurses are seeking help from
administration, leaving their profession, or getting help from labor unions.
MANDATORY OVERTIME
As the nurse to patient ratios were increasing some nurses left their
profession causing a larger gap in the national nursing shortage. As
healthcare facilities found gaps in their nurse staffing schedules they had
to find a way to cover the shifts so many institutions began to require
mandatory overtime.
Mandatory overtime has become a routine part of a nurse’s
workload. Mandatory overtime is commonly defined as any hours
worked in excess over and above their predetermined, regular schedule
for both part and full time employees. There are many reports that
support the error rate markedly increases when shifts are greater than
12 hours or when staff are required to work more than 40 hours in one
week (The American Nurses, 2007).
Scheduling of mandatory overtime is another source of concern for
nursing that contributes to both dissatisfaction and frustration and also
negative patient outcomes by forcing nurses to work extra shifts. Data
supports that nurses who volunteered to work overtime prepared for the
20
extra shift work. These nurses allowed for enough rest time between
assigned work assignments and they delivered better nursing care than
nurses who were mandated to work extra shifts (Facts on Mandatory,
2007).
Healthcare decision makers for hospitals had already increased
nurse to patient ratios stretching nurses to maximize their work abilities
but now these same hospitals are mandating overtime. This was not a
good message to the nurses or patients.
Nurses reported that it was a requirement to work overtime and it
is a common expectation for managers to mandate nurses to pick up the
unassigned shifts. Many nurses also reported they felt that they would
face disciplinary action or retaliation if they did not cover the open
vacancies (The American Nurses, 2007).
Data suggests that mandatory overtime adversely affects patient
care and increases the probability of nursing errors (Facts on Mandatory,
2007). In a report by the Institute of Medicine they clearly show a
correlation between mandatory overtime and patient safety because of
fatigue, decreased energy levels, and slow reaction times (The American
Nurses, 2007).
Nurse’s work under the rules of their state regulated Nurse Practice
Act. It is the nurse’s responsibility regardless of nurse to patient ratios or
21
mandatory overtime that the nurse will be held accountable and liable for
the safety of their patients. Once a nurse accepts the patient assignment
their license could be in jeopardy if their care results in a negative patient
care outcome regardless of unsafe working conditions.
Congressman Pete Stark from California reminds us that we limit
overtime for truck drivers and pilots to improve public safety yet we do
not impose limitations on the time nurses must work (California Political
Desk, 2007).
Witnessing a first hand account on Capital Hill in July 2007 of
Congressman Stark discussing the upcoming changes affecting hospital
reimbursements resulting from the “never events”. Stark is an advocate
for nurses and is very passionate in his approach. He has been an
outspoken supporter for the regulation of nurse to patient ratios and
regulating the number of hour’s nurses can be required to work.
Just as in the case of nurse to patient ratios similar actions are being
introduced at the state level and by individual healthcare organizations
for mandatory overtime. Nurses continue to leave their profession out of
frustration and dissatisfaction, turn to their managers and supervisor for
help, or look for outside sources such as labor unions for answers.
22
PURPOSE OF UNIONS
Unions have had a presence in the United States since the mid to
late 1800’s representing the interests of the working class people. Their
original inception was out of a need to represent the injustices done to the
working class. Unions fought to end the use of child labor, the forty hour
work week, mandatory overtime, equal pay for women, and retirement
security for all members. Unions evolved out of a need for safety and
security for workers (United Steelworkers, 2007).
In the United States there are approximately 20 million employees
working in the public sector with more than eight million of these workers
being represented by labor unions (Adler, Win 2006).
Government agencies have approximately 42 percent of their staff
represented by union agencies while the private sector has approximately
8 percent. Healthcare agencies staffed with union RN’s make up
approximately 19 percent of their workforce as shown in figure 1.
23
Figure 1: Union Density by Various Categories
This represents categories of workers that belong to unions.
05
1015202530354045
% o
f al
l em
ploy
ees
Men Women Private Sector Government RN's
Categories of Workers
Note: From “RN Unionization in Comparison”, by the Bureau of the Census Population Survey (CPS)., 2005, United American Nurses., Silver Springs, MD.
24
There has been a steady increase in RN union membership with a
17.9 percent rise in union membership from 2002-2003 and an 83 percent
increase since 1983 as demonstrated in figure 2.
RN’s have a greater percentage of union workers than the overall
U.S. workforce; RN’s have 19.5 percent as compared to 14.3 percent
(Bureau of National, 2005).
25
Figure 2: RN Union Membership Growth 1983-2003
Union membership of registered nurses has increased since 1983. From 2002-2003 there has been a significant rise of 62,000 nurses or a 17.9 percent increase.
0
10
20
30
40
5019
8319
8519
8719
8919
9119
9319
9519
9719
9920
0120
03
Years
num
ber o
f mem
bers
X's
100
,000
____ All Represented by Unions _____Union Members
Note: From “Employment and RN Union Density”, by the Bureau of National
Affairs. 2005, United American Nurses., Silver Springs, M.D..
26
Today it seems unlikely nurses would be faced with similar labor
issues as in the 1800’s but with the frustration and dissatisfaction that
nurses are facing they feel they are working in unsafe environments.
Nurses are turning to unions because they feel their voices go
unheard as individuals but when represented by a union they can speak
with a unified voice. Nurses want to have a voice in the decisions that
positively affect patient outcomes and they want to be assured that these
same principles of safety and security for workers are upheld.
In the United States today there are predominately two large labor
union organizations. They are the American Federation of Labor Congress
of the Industrial Organizations (AFL-CIO) and the newly formed Change
to Win Federation which broke away from the AFL-CIO in 2005.
One of the largest nursing unions in the country is the California
Nursing Association that has been in existence for over 100 years with a
membership of over 66,000 Registered Nurses. This union is now reaching
out across the country to recruit new members. They have launched a
campaign to encourage direct care patient care givers to seek national
support to address issues they describe as nursing crisis. They call the
crisis issues those of staffing ratios, mandatory overtime, patient care
protections, wages, benefits, and retirement (California Nurses, 2007).
27
The process to join a union remains similar as in the past as there
must be a majority of the workers in favor to begin the process. When
there is enough support the union provides authorization cards that
require interested nurses to sign stating they have inquired and had their
questions answered and they desire to join the union.
The number of signed cards returned by the nurses determines the
level of union interest. If there is a majority the union representatives give
the signed cards to the National Labor Relations Board (NLRB), the
federal agency that governs union elections and they conduct the formal
election. The election is done by secret ballot in which the hospital is not a
part of the process and has no knowledge of how staff votes. The votes are
tallied and the final result is simply majority rules.
Once a decision has been made to unionize the hospital cannot
change any practices without a collective bargaining process with the
union (California Nurses, 2007). By law once the workers have voted the
government must certify the newly formed union. It then becomes the sole
responsibility of the union to negotiate the terms of the workers
employment (United Steelworkers, 2007).
Collective bargaining is the terminology used to describe the
process of negotiating that the union representatives conduct with
28
hospital representatives. The union bargains for the nurses with the
hospital regarding all employment issues, wages, hours of work, and
other work related topics.
LEGISLATURE
It is a difficult concept to understand when data clearly shows that
patients have better outcomes with lower patient to nurse ratios why
states continue to support the higher patient staffing assignments
(Gonzales, 2007).
While some states ignore the poor statistical patient outcomes data
many states are introducing and supporting laws that protect patients and
nurses in safer practices. California has set the bar for staffing ratios by
attaining legislative support mandating a maximum assignment of five
medical-surgical patients to one nurse. This action of support has
encouraged nurses who left their profession to re-enter the work force
increasing California’s nursing workforce by the thousands (Gonzales,
2007).
Currently California remains the only state to have this legislation
that was passed in 2004. Illinois recently introduced a bill that would
regulate nursing ratios in the emergency department, operating room,
medical surgical rooms, and intensive care units. If passed they would
29
become number two in the nation to have this written support
(Department, March 2007).
Medicare has introduced language in the form of 42 Code of
Federal Regulations (42CFR 482.23(b) that requires hospitals that receive
Medicare reimbursement to, “have adequate numbers of licensed
registered nurses, licensed practical (vocations) nurses, and other
personnel to provide nursing care to all patients as needed” (Nurse
Staffing Plans, 2007). While the regulation sounds good it does little to
improve actual staffing conditions and does not impact staffing ratios
which are left for hospitals to figure out.
The American Nurses Association and the State Nurses Association
have joined forces to support legislation that would require hospitals to
design and implement appropriate staffing models of care. Currently to
date there are nine states plus the District of Columbia (DC) that have
passed some kind of staffing plan to regulate nurse staffing.
These states are Illinois, California, Maine, DC, Florida, New Jersey,
Oregon, Rhode Island, Texas, and Vermont. While California remains the
only state to actually mandate patient to nurse ratios the other states have
attempted to place requirements by developing written staffing plans and
numbers of direct patient care givers (Nurse Staffing Plans, 2007).
30
The American Nurses Association has developed a position
statement that charges the RN to consider their level of fatigue when
accepting overtime. It is common for nurses to be assigned mandatory
overtime to compensate for inadequate RN staffing (The American
Nurses, 2007).
There are thirteen states to date that have enacted legislation that
imposes restrictions or limitations on the use of mandatory overtime for
nurse staffing. Connecticut, Illinois, Maine, Maryland, Minnesota, New
Jersey, New Hampshire, Oregon, Washington, and West Virginia all have
legislation that prohibits mandatory overtime. California, Missouri, and
Texas have provisional regulations that restrict the mandating of overtime
for nurses (Nurse Staffing Plans, 2007).
The state of Michigan has also joined the ranks in their efforts by
trying to get support in the passage of Senate Bill 169 and House Bill 4101
and 4216 to promote safe patient care and to they add “save money”.
These bills support regulations for mandatory overtime and support nurse
to patient ratios (Johnson & Bissonnette, 2005).
A House bill 2122 (H.R. 2122) entitled, “The Safe Nursing and
Patient Care Act” has been introduced in the House for the 110th Congress
by Pete Stark, (D-CA) and Steven LaTourette (R-OH). If passed H.R. 2122
would place strict guidelines on mandatory overtime practices nationally.
31
The passage would prohibit hospitals from receiving Medicare funding if
they required registered nurses or licensed practical nurses to work
beyond their scheduled shift. It is believed that by limiting the practice of
mandatory overtime by supporting it with a bill like H.R. 2122 it will send
a powerful message to nurses who left the field and encourage them to
return to a culture that is safer and offers more quality to patient care
(Artz, Oct 2007).
UNIONS IN HEALTHCARE
There are more than 500,000 nurses that have opted to join unions
in America today. These nurses made the decision to unify with other
nurses to work together as a group to address issues that were important
to them. These nurses feel that by having a union voice it allows them to
have input into hospital policies and patient care decisions. They also feel
that the union will negotiate for higher salaries, better benefits, and safer
staffing ratios. The nurses also have confidence that the union will stand
by the agreements and hold hospitals accountable to uphold the mutually
agreed upon commitments (Service Employees, 2007).
Unions are able to offer nurses the courage to demand that
something be done to improve patient care, and to give the nursing
profession respect and support they need to stand up for their rights.
32
Union representation gives nursing a bigger voice in Washington
and helps to lobby for legislative and regulatory support. Unions give
nurses political clout to promote patient care through legislative changes
that hold hospitals accountable in not assigning mandatory overtime and
limiting patient to nurse ratios (Seago & Ash, March 2002).
In the 1990’s there were approximately 600,000 to one million
needlesticks annually causing serious illness to about 1,000 healthcare
providers injured. A study by the Centers for Disease Control concluded
that about 76 percent of the sticks could be prevented with a safer system.
It was through the pressure of the Nurse Alliance Union that spearheaded
the effort to get federal regulations for safer needles. The federal
government enacted the Needlestick Safety and Prevention Act of 2000
that serves as a layer of protection against needle sticks (Service
Employees, 2007).
Unions offer nurses the ability to demand, “that the standards of
their profession be respected and enforced. When (nurses) do not have the
protection to speak out on behalf of patients, the patient care provided
and the patients lose” (Budd, Warino, & Patton, 2004).
The process of collective bargaining through union support offer
nurses the chance to regain some of the control back over nursing practice
33
issues such as the number of patients they can care for safely and
effectively and the amount of overtime they must cover.
A nursing journal supported publishing a series of articles written
to report on the perception of nurses on nursing from 2002 to 2004. Nurses
were surveyed in a national study on a variety of topics to include nursing
unions. They reported the number of union nurses increased from twenty
one percent in 2002 to twenty seven percent in 2004. Nurses were asked in
both surveys how they perceived the effect of unions on the nursing
profession and how they thought it related to patient care. In both 2002
and 2004 nurses felt that unions had a mostly or somewhat positive effect
on the nursing profession and had a positive effect on the quality of
patient care (Buerhaus, Donelan, Ulrich, Kirby, Norman, & Dittus, June
2005).
California introduced nursing to unions in the early 1960’s and in
an interview with United Nurses Association President, Kathy Sackman,
RN; she chronicled how she became interested in working for a union. In
1964 she was called into work early one day because the ancillary support
staff from the steelworkers union called a strike. The nurses hurried to the
hospital to pick up the workload of the support staff before getting to their
job duties of patient care. But before they could start their shift they had to
34
wash and clean the hospital departments, stock supplies, and wash and
fold laundry.
The ancillary staff came back to work four days later after
successfully holding out for a dental plan. When the nurses heard about
the ancillary staff getting a dental plan it rung a chord because they had
asked for one and had been told they didn’t need one. This was the
tipping point for these nurses and they decided it was time to organize at
work to get better benefits.
The group formally decided to associate with the California Nurses
Association (CAN) and they began their campaign in California. In 1989,
CAN merged with the American Federation of State, County, and
Municipal Employees (AFSCME) and affiliated with the AFL-CIO and
today they are over 13 million members strong (Sackman, 2003).
The top fifteen states with the greatest number of nurses
represented by unions are displayed in figure 3. Kansas (not displayed)
has the lowest number of union RN’s at 2 percent and North Carolina
precedes them with a 3 percent RN union population.
35
Figure3: Union Represented RN’s by State
This chart shows the top fifteen states by the number of RN’s that are represented by unions plus I have displayed NC. North Carolina is the second from the last in union represented RN’s only surpassing last place Kansas by 1 percent.
0
10
20
30
40
50
60
70
80
RN
's in
100
,000
's
CA NY WA MI MN MA PA NJ OH IL FL MD OR GA IA NCStates
Note: From “Registered Nurse Unionization”, by the Bureau of
National Affairs. 2005, United American Nurses, Silver Springs, MD
36
IMPACT ON BENEFITS
In general there are numerous examples of better benefits for union
nurses in almost every area of a benefit package over non union nurses.
Over a ten year period there has been consistently higher wages paid to
union nurses as compared to non union nurses averaging approximately
15.6 percent higher (Bureau of National, 2005).
Some of the areas that unions have focused on with success is to
upgrade pension plans to nearly double monthly benefits and increase
health insurance benefits for full and part time employees. Unions have
negotiated for nurses that want to retire at 55 to have guaranteed health
benefits, an increase in paid time off programs, continuing education
support, and allowing staff to cash out vacation time at some union
facilities (Service Employees, 2007).
A benefit that is difficult to measure is RN job satisfaction.
Hospitals that have collective bargaining units for nurses work under
contracts that describe patient assignments, assignment of overtime,
wages and future pay raises, and terms of employment. Studies has
suggested that nurses that work in predictable settings that include
collective bargaining units have higher job satisfaction and better nurse
recruitment and retention (Pittman, Oct 2007).
37
PATIENT OUTCOMES
Research from a study in California conclusively showed that
patients treated in hospitals with union nurses do indeed have a better
chance of survival. The hospitals that employed union nurses had a 5.7
percent lower mortality rate for myocardial infarctions (Seago & Ash,
March 2002).
This study found that the hospitals that were staffed with union
nurses had “significantly predicted lower risk-adjusted acute myocardial
infarction (AMI) mortality”. In a joint statement at the conclusion of the
study Jean Ann Seago, PhD, RN and Michael Ash, PhD summarized, “this
study demonstrates that there is a positive relationship between patient
outcomes and RN unions” (Seago & Ash, March 2002).
While not all hospitals that assign lower patient to nurse ratios are
filled with union nurses the vast majority of the hospitals that impose
them do so because of union influence and bargaining. Research supports
that with each additional patient assignment over four patients there is
proportionality a 7 percent increase in the likelihood of a patient dying
within 30 minutes of admission (Mueller & Potter, 2007).
This was again supported in another study that showed with each
additional patient assigned to a single nurse the complication rate
increased significantly. This study went on to report that with this
38
additional patient the nurse had a 23 percent increase in burnout and a 15
percent increase in overall job dissatisfaction (Aiken, Clarke, Sloane,
Sochalski, & Silber, Oct 2002).
As the patient load for a nurse is increased so goes the stress level
to be able to prioritize all of the patients needs all of the time. The nurse
must be able to recognize clinical changes as they happen and respond
appropriately to them. If the nurse is assigned ten patients it is unlikely
close ongoing monitoring can be achieved (Mueller & Potter, 2007).
It is estimated that patients that are cared for at a one to four ratio
could result in 72,000 lives saved annually. Furthermore, by improving
the nurse to patient ratios the New England Journal of Medicine reports
the complication rates are reduced for pneumonia, urinary tract infections,
shock, cardiac arrest, and gastrointestinal bleeding (National Nurses, Jan
2005).
In a study to support patient outcomes when the typical patient
load was reduced by one patient per nurse and it led to a decrease in
length of stay and lowered the risk of adverse outcomes by 3 to 12 percent
(Hershbein, July 2005).
39
The American Cancer Society reports that cancer surgery patients
who are cared for by nurses with lower patient ratios cut their mortality
rates by more than 50 percent (National Nurses, Jan 2005).
Unions have an impact on the quality of nursing care because they
are able to negotiate increased staffing levels which are linked to better
patient outcomes. It is theorized that higher wages attract better nurses
and decrease turnover rates making staffing more stable which is linked to
improved patient care and outcomes (Seago & Ash, March 2002).
Hospitals that do not require higher RN staffing ratios and
assigned patient care to LPN’s and nursing assistants found that
preventable deaths and patient complications were up to nine times
higher (Johnson, 2004).
Nursing unions promote the standards and quality that hold
hospital administrators accountable to make sound patient care focused
decisions. The restriction of mandatory overtime and requiring nurses to
care for high numbers of patients creates an environment for nurses to
thrive and increase their professional job satisfaction.
The truth is that most of the issues that nurses find unacceptable
should be able to be resolved by healthcare facilities without the influence
of unions if the hospitals listened to key stakeholders. If healthcare
40
organizations take the necessary actions to keep patients safe, nurse to
patient ratios reasonable, and lines of communication open they do not
need the intervention of nursing unions and can achieve quality patient
outcomes.
But, when reviewing the data the ultimate result for patients is that
unionization of nurses does increase the probability that patients will
receive better nursing care and enjoy improved patient outcomes.
41
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