In the past couple years, more and more nurse unions have been successful in negotiating better contracts with their hospital employers. These contracts typically include provisions for improved unit staffing levels and higher pay.

Nurse unions and labor experts agree that the pandemic was a turning point that catalyzed nurses to fight for improved working conditions and overall better treatment from their employers. By negotiating new contracts with their employers, unions say they are working hard to both uphold patient safety and mitigate the nursing field’s debilitating workforce shortage.

“The pandemic really peeled back the onion across the nation. Nurses were seeing that their employers weren’t doing the right thing. And so they have to fight. It’s evidenced by the amount of union organizing that’s happening across the U.S., as well as nurses that are striking for better contract language. We know what we need to not only protect ourselves, but to care for our patients and our communities,” Catherine Kennedy said in a recent interview.

Kennedy is the president of the California Nurses Association and a nurse in the neonatal intensive care unit at Kaiser Permanente’s medical center in Roseville, California. In December, her union ratified a new contract with Kaiser, averting what would have been the biggest private sector nurses strike in American history.

There have been at least 13 notable instances of nurses voting to strike so far in 2023. This is compared to the 14 notable nurse strikes that took place during the entirety of 2019, a year when mainstream media outlets were already noting an uptick in nurses’ organizing activity. 

Data from the Bureau of Labor Statistics shows that nurses organize at a higher rate than other workers — more than 20% of U.S. nurses belong to a collective bargaining unit, compared to the national average of 13% across other professions.

Why the pandemic was a turning point 

The recent wave of nurses demanding better contracts and voting to go on strike is a result of how abysmal their working conditions got during the pandemic.

“We were so disrespected. We lost nurses. We saw death every day. We were told to reuse N95s for days. I mean, even now when I talk to nurses, they’re just fearful,” Kennedy charged. “But a lot of nurses are rising up and saying enough is enough. We’re seeing nurses organizing in places where we never thought would happen, like red states and right-to-work states.”

Carie Babcock, a nurse employed by Michigan-based McLaren Health Care, agreed with Kennedy. Babcock is a nurse at McLaren’s hospital in Lapeer, Michigan, as well as the president of its local Michigan Nurses Association bargaining unit. Earlier this month, her union, which represents about 250 nurses at the Lapeer hospital, voted to ratify a new three-year contract with better pay and staffing levels.

Babcock pointed out that nurses have always known their worth as the backbone of a hospital. However, when the pandemic hit, “it was finally like the world knew our worth,” she said.

In her view, the collective power demonstrated by nurses across the country — who are demanding fair working conditions and compensation for their vital role in maintaining the nation’s health — helped her union reach its new contract.

Gerald Friedman, a labor union expert and economics professor at the University of Massachusetts, said that the recent organizing power flexed by nurses is reflective of an overall “revival of the labor movement” across various industries. He pointed to several companies in different industries that saw its workers go on strike in the last year or so — including SAG-AFTRA, Amazon, Starbucks and UPS.

What makes the nurses’ labor movement different is that the country could probably survive without Starbucks or new movies, Friedman said. You can’t say the same about nurses — hospitals wouldn’t be able to operate without them, and hospitals are a civil necessity.

Because of this, nurses’ labor movement has more of a moral angle to it than other union efforts, Friedman pointed out. Another thing that makes nurses’ organizing efforts stand out is the fact that nursing is a predominantly female profession, he noted. Women have historically taken on more family responsibilities than men, so being overworked and asked to stay for longer shifts is “even more of a problem for them.”

While more and more nurse unions are becoming successful in negotiating better contracts, the mass exodus from the profession still remains a major problem, Friedman said. A May survey showed that 60% of nurses have plans to change their job status in the coming year.

“Everybody who exits makes it harder for the people that remain. You can’t just create nurses out of thin air,” Friedman declared.

What health system employers had to agree to 

California Nurses Association represents about 22,000 nurses at 22 Kaiser facilities. Its new contract with Kaiser includes provisions to retain experienced nurses and hire new ones to provide much-needed relief for nurses amid staffing shortages. The contract also increased wages for Kaiser’s Northern California nurses by 22.5% over four years, boosted tuition reimbursement for nurses’ continuing education, ensured a three-month stockpile of personal protective equipment, and scaled workplace violence prevention plans to all facilities.

Additionally, California Nurses Association’s new contract asserts that healthcare is a human right. It states that the U.S. healthcare system must eliminate racial and ethnic disparities in patient outcomes, promote culturally competent care delivery and expand the diversity of its workforce. In the new contract, Kaiser has also promised to create a new regional committee for equity, diversity and inclusion at each of its Northern California medical centers.

Nurses across all of the union’s 22 facilities helped create the new contract, Kennedy said. declared. One of the most impactful parts of the bargaining process is that nurses give presentations about what it looks like to work a day in their unit, she pointed out. 

Giving health system leaders a detailed view into nurses’ seemingly unbearable workloads is important because most hospital executives have never been in the trenches like nurses have, Kennedy noted. Hospital leaders sometimes lack an understanding of all the tasks that are involved with caring for a single patient — let alone a dozen or more patients, which nurses are now tasked with caring for during a single shift. Many leaders also aren’t fully aware of all the things that could potentially go wrong while a nurse is providing care, Kennedy said. 

Toby Marsh, chief nursing executive for Kaiser’s Northern California region, told MedCity News that the health system’s leadership approach ensures its nurses are fully engaged at every level.

“We work together to help identify and implement ways to advance nursing practice through new ideas, research and technology. Our facilities have established care and quality committees where nurses sit at the table and contribute to ideas and policies to ensure our nurses’ voices are reflected in our care delivery. Our nursing leaders are often themselves nurses and bring extensive, first-hand experience to their work,” he said.

As for the new contract won by the Michigan Nurses Association, it includes a 19% wage increase, and it gives nurses the power to fine their employer for noncompliance with established nurse-to-patient staffing ratios. The contract also includes provisions to improve emergency department staffing, given the hospital’s emergency department is the only level 2 trauma center in the area. 

McLaren told MedCity News that its leadership works closely with its staff to “not only understand the impact of a high patient caseload on staff and patients but ensure that we have the resources and support structure in place to prevent burdensome caseloads.” The health system added that contract negotiations are nuanced and go beyond the concept of winning and losing.

“Employer and union contracts are reached through dialogue, hard work and compromise by both sides at the table, rather than either party flexing their power,” McLaren said in a statement.

The decision to strike

The decision to go on strike is a hard one for nurses to make — Babcock and Kennedy agreed that nurses only strike when they feel like they have no other option to address low staffing levels.

Understaffing obviously causes burnout that harms nurses’ mental health and wellbeing, but those problems aren’t really what drives nurses to go on strike. It’s the well-documented fact that understaffing has a dangerous and sometimes fatal effect on patient care. When nurses are assigned more patients than they can handle, patients die who wouldn’t have otherwise, they said. Patients also tend to suffer more adverse events, such as urinary tract infections and central line infections, when units are understaffed. 

To bring attention to this problem, the Michigan Nurses Association conducted a survey involving 400 nurses in January. The survey found that the percentage of respondents who knew of a patient’s death being caused by nurse understaffing nearly doubled in the past seven years. It grew from 22% in 2016 to 42% in 2023.

Hospitals need adequate staffing levels so that nurses can be there to check in on their patients and notice when something goes wrong — which is impossible if a nurse is juggling a dozen patients — but Babcock and Kennedy said that hospitals often fail to recognize how vital this is. When MedCity News asked the American Hospital Association to respond to this charge, the group declined to comment.

Walking out on patients is something that nurses really want to avoid, but sometimes they have to do it in order to protect patient safety in the long term, Kennedy explained. She pointed out that when a nurse union authorizes a strike, it continues to come to the bargaining table day after day to try and reach an agreement. 

“That’s what happened with us here at Kaiser. We bargained all night until we finally came to an agreement that morning,” Kennedy declared.

Getting 100% approval on a strike vote gives the nurse union “a lot of power” at the bargaining table, Babcock added. When her union’s members voted to authorize a strike, McLaren finally knew they were serious, she said. 

“They knew we were a united front in our demand. We dealt with so much during Covid. We’ve watched nurses leave the profession just because of the way that hospitals are run. We fear for our license when we cannot take great care of our patients, and patient outcomes suffer as well. That strike vote is really what turned the tables and enabled us to negotiate the major things that we needed to make us feel able to deliver the best patient care to our community,” Babcock explained.

It’s unfortunate, but sometimes striking is “the only way to gain the attention of the employer,” she added.

Not all employers will come to an agreement with nurses after they threaten a strike, though — several nurse unions have gone on strike in protest of inadequate staffing levels in the past year. For example, nurse strikes have occurred this year at three Ascension hospitals, three Providence facilities and Mount Sinai’s flagship hospital.

When it comes to the power dynamics between nurses and their employers, the industry will have to wait and see whether this a permanent shift or if the tables will turn on unions — especially if nursing AI gets implemented and proves its safety and reliability. However, one thing remains abundantly clear: amidst high demand for their labor, nurses are becoming less hesitant to advocate for better working conditions.

Photo: Irina Devaeva, Getty Images