Nurses striking: is it effective?

As many of you have likely heard, the nurses employed by Sutter Health in Northern California staged a strike on Thursday September 22, 2011 in protest over an increase in benefits costs and decreases to sick and vacation leave. of

While the non-profit Sutter Health has real profits in the near billion dollar range, we are left wondering why it is the nurses’ benefits are being cut even as the heads of the organization walk home with millions of dollars of “bonuses” each year.

I think the nurses are in some respects justified in taking this stance and going on strike; they are working together to stand in solidarity (though up to 40% of the nurses at the various hospitals crossed the picket lines and reported to work). On the other hand, I feel that the strike does not create an atmosphere for discussion and dialogue that might be meaningful. This action in and of itself seems unlikely to create a path for communication between administrators, decision makers, and the nurses. The union itself also prevents much of this direct communication and may prevent the working nurses from communicating their concerns outside of the union’s presence.The strike does create some obstacles and safety concerns for patients, administrators, nurses crossing the strike line, and the replacement nurses.

I have thought a mass exodus of the nurses, or many immediate resignations, would be more effective, though highly unlikely to happen for obvious financial reasons. For each nurse who quit, Sutter would lose at least $60, 000 in training a new nurse to replace them. These expenses could add up very quickly if a good chunk of the nurses walked away from their positions. Sutter may have problems with hiring new nurses in relation to the higher costs of benefits, the reduction in vacation pay, and the elimination of paid sick leave. Paid sick leave can help to stop the spread of illnesses like the flu (have we already forgotten H1N1?), but perhaps I am digressing a bit here.

It would be interesting to poll the public and get their perception of striking nurses, professionalism, empowerment, and the image of nurses. From the current state of the media coverage, it is difficult to tell where the public stands on this.

We do know that the nurses have now been locked out until Tuesday, as at least two of the hospitals have a minimum contract of five days for their temporary staff contracts. These contracts are likely very expensive and in no way are saving Sutter any money, which was the reason given for changes in the benefits.

The issue of unions, strikes and walk-outs is prime for nursing researchers to continue to explore: what are the outcomes of strikes, do the nurses feel or experience a sense of empowerment through the process, what is the public’s perception of nurses’ unions and strikes, and so on.



4 thoughts on “Nurses striking: is it effective?

  1. Hi Carey,

    Great post!

    Worker’s strikes, like wars, are the consequence of communications breakdowns, not their cause. That is not to say that there are never any “bad” strikes, conducted for venal or self-serving motives, but it is easy to forget that strikes could often be avoided if the relationships between workers and employers were better on a day today basis. In our age there are people who control the manufacture of the resources needed to produce goods and services and there are others who control the human labor. Health care executives run health facilities and labor union executives control labor supplies. It isn’t such a bad system. Both tend to be large enough to have some counter-balancing effect on the other, though I think the writing is clearly on the wall – labor’s influence is declining, management’s influence is rising.

    The issue here is that nurses and management st Sutter Health are likely not even remotely on the same page. Nurses are seeking to maintain or advance their net salaries and benefits and management is trying to reduce costs. The idea that Sutter will lose $60,000 in value if nurses leave, which I agree is unlikely, is likely incorrect. Most nurses are fairly productive within days of hire, and to be totally frank, most management executives see little or no difference between a nurse with 20 years experience and a nurse with 2 weeks experience, nor unfortunately do most patients. In fact, many patients cannot tell the difference between a hospital trained patient care assistant and a registered nurse.

    So, let me sound a note of what I see as realism. We have been increasing the numbers of nursing programs and their graduates for a decade. We are also the worlds largest net importer of foreign nursing school graduates. At the same time we are also seeing the greatest consolidation of the health care system due to thousands of bankruptcies of health care providers from individual solo practitioners to group practices, hospitals, and health provider consortia. Most of this has passed relatively unseen as group practices have been sold, taken over, or closed, as have hospitals, nursing homes, and home health agencies.

    This is only going to increase because one of the major factors in these financial failures has been been the four decades of transferring health insurance risks to health care providers that I rail on about all the time. This is only going to get worse as Medicare finds it impossible to avoid cutting payments for care.

    The large health empires are acting in a totally predictable and rational manner given one crystal clear reality: The health care finance system is in its death throes. Everyone is out to get as much as they can before the gravy train comes runs off the washed out bridge. Far from producing the kind of health care system the world will admire, our health care (finance) systems are dying. As I look forward I see a system in which many Medicare recipients will find it hard to find any providers who will see them, or when they are seen, the quality and quantity of care they will get will be far below the standards in place in non-Medicare certified facilities.

    Worse still, for nursing, the largest health chains are developing the critical mass needed to effect the biggest push back against nursing and patient care ever. What will it look like? In return for slightly lower payments under Medicare and Medicaid, large national health chains will ask for, and get, massive reductions in nurse-patient staffing ratios. The argument will be simple and the bargaining chip blunt – either allow us to reduce costs by using substitutes for high cost nurses or we will start closing our doors.

    This, coupled with large numbers of new nursing programs, and scads of new nursing program graduates, and record numbers of foreign nursing graduates will create one of the darkest periods for nursing in history. Too many nurses for the way health care facilities operate, too many nurses competing for scarce jobs, and many nurses willing to work for sharply reduced salaries, and willing to accept any corporate imperatives.

    While this will certainly have dire consequences for our beloved profession, it will not necessarily reduce the quality of care for patients (Sorry Linda Aiken). New ways of monitoring patients, more use of computers, and more narrowly focused staff activities could actually lead to higher quality care at lower cost.

    So, are strikes inevitable in the current environment? Absolutely. Are they likely to be effective considering the fact that nurses and health care executives are not even remotely on the same pages? Probably not. Will there be some wins? Yes, but they will be few and far between, and even after the wins, there are likely to be reduced needs for nursing staff and I’ll give anyone at all 4 free guesses as to which nurses are most likely to be released after a successful strike.

    For far too long nurses have been looking through rose colored glasses. If you consider the concerns of nurse and the concerns of health care executives it is more than a little like the relationship between Linda Rosa and the Therapeutic Touch community. To really be effective in the future, nurses need to understand that the profits that have been made, in the past as health care providers managed insurance risk portfolios are about to dry up. Executives are already focusing on the costs of nursing staffing over the next 5-10 years. The costs of hiring scabs, potentially for only a few weeks, to break a strike, are insignificant when compared with the costs for nursing salaries and benefits over a 5 – 10 year period. A 10 – 20% reduction in registered nurses, and 10 – 20% reductions in nursing salaries and benefits over a 5 – 10 year period of time are measured, in the aggregate, in billions of dollars. The costs for a few hundred strikebreakers for a few months are measured in millions of dollars. Guess which one wins in the Executive lounge.

    We are well past the point where nurses can ignore the financial context of care – but that does not mean nurses are paying attention – trust me, I know how hard it is to get people’s attention and to get people to focus on what is actually happening in health care finance.

    Sadly, most nurses will wake up one day, not understanding quite how it is that the profession went from the best times ever: High salaries, High sign on bonuses, Great benefits and working conditions to meeting fellow nurses at unemployment offices, seeing 20 – 30 nurses applying for a single job, and a reversion to some of the worst working conditions ever, as the roles of nurses in health care facilities are subordinated to non-nursing care managers who are acutely well tuned to the financial consequences of patient care.

    Is it inevitable? Gut feeling – It is already way too late to stop the worst of what is coming. Nurses have been sleeping at the watch and we are already surrounded, our enemies attacks are coordinated, sharp, and focused and our response is diffuse, scattered, and chaotic. The supply lines are closed, the food, water and ammunition is running out, and surrender is all but inevitable.

    Sorry for the pessimism but I have been watching this whole thing play out, like running a movie in slow motion, wondering why almost nobody has been concerned since I was in nursing school in 97-99. Now, 12 – 14 years later, I just don’t think most nurses are going to know what hit them when it all comes together.


  2. Thomas, thanks for your post; simply said, I appreciate your scholarly opinion and the research you have done in this area. You are a great educator on this topic! I agree there is a dismal lack of emphasis in nursing and nursing education on the finances of healthcare.

    I think the eventual demise of our relationship with hospitals may actually be a good thing for some of us, in particular those of us who are interested in enacting caring-healing practices. In my research with the nurse manifest project, the story that emerged from my perspective is called nurse65x89:

    In the story, I portray 2 different types of futures for the nursing profession. One is pretty much as you have detailed here, with nurses being in charge of large volumes of technologically managed patients; the other future has a more holistic and healing slant. My hope would be that if nurses end up leaving the hospital environment as the opportunities decrease, they will move toward the healing professions within communities. There will likely not be as much money involved, but I strongly believe that patients and nurses can work together to create healing communities.


  3. 🙂

    I think there will be some such opportunities. It reminds me of one of the conversations I had with someone at my first Rogerian Dialogue back in 2000.

    I do anticipate some problems however:

    First, we are already living in a dark age of scarcity for 16% of Americans whose income is below the poverty line.

    So, do I see a role for concierge nurses? Absolutely. The rich will indeed hire a few nurses to be available 24/7. Will this type of nursing practice address the needs of the overwhelming majority of patients – not likely. Reduced salaries at other facilities will drive the costs of concierge nursing down, but the demand among the wealthy will soon take the best, brightest, and most caring nurses willing to do what some will find to be too ethically challenged. Some will not mind driving in their patient’s limos, through streets crowded with the un-cared for old and young, middle and lower income people, but some of the most compassionate nurses will indeed find such practice unacceptable.

    Second, the needs of many, potentially most people, will simply go unmet, much like the situation for most people currently on Medicaid: Medical, Dental, Nursing, and Mental Health providers will deliver services at a fraction of what most of us currently consider to be minimal care. People will die and be debilitated from diagnosable, treatable, even curable conditions from which they can heal, but these patients will not be diagnosed, treated, cured, and healed because they simply cannot afford the entry costs, transportation costs, or time off from work.

    So, will there be a Prospective Payment System out of CMS for nurses in independent practice? Well yes, there are already two in place – the Prospective Payment System for long term health care and rehab facilities and the Prospective Payment System for Home Health Agencies. But the core problem will not change. The risk transferring systems that are bringing down our health care (finance) systems now, will bring down whatever replaces our current set of providers. Nurses will either seek CMS certification or rule out caring for most of the elderly and disabled population. If they become certified they have to deal with the same economic and financial forces that are bringing down Physicians, Nurse Practitioners, Hospitals, Nursing Homes, and Home Health Agencies right now. If they elect not to become certified they watch as others step in and perform less well than they think they could.

    In essence, if you change the risk transferring finance mechanisms most of the current system can be salvaged, if you don’t change the risk transferring finance mechanisms most of the new system will look like the current system after a few years of operations.

    Third, while most of this will be simple economics – a peripheral war between medical device manufacturers, pharmaceutical companies, hospitals, nursing homes, third party intermediaries between all these entities, and independent practitioners, the issue, as always, is going to be who pays, who gets, and who cares? I think there will always be caring nurses and patients who value that, but in many cases it will be quite simple. The caring nurses will increasingly work in hospice roles for patients with diagnosable, treatable, even curable conditions from which they can heal, but these patients will not be diagnosed, treated, cured, and healed because they simply cannot afford the entry costs, transportation costs, or time off from work.

    Oooops, got to get back to my paper submission from Joint Statistical Meetings in July. Have to submit it tomorrow. Was an interesting panel and unusually highly correlated with my work – Made me re-think what case mix adjustment is all about. In essence, much like our shared vision for future nursing practice, case mix adjusts the average cost of care – it does not adjust for the risk of higher than expected costs. Nurses will be faced with a fee for service model few patients can afford or a capitated model which guarantees that 5 – 20% will fail financially each year, more if they fail to cut services below what they consider to be minimally acceptable care.

    I always enjoy your posts – you make me think and re-think…


  4. One thing I worry about, is that those who do the striking are looked down upon. I’m referring to those who are thinking, “how could they walk out and leave their patients ‘unattended’?” We all know the patients won’t be unattended, but still, this sheds bad light on nurses and the nursing profession. Just a thought and not a scholarly one at that. 🙂


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