The rising power of nurses is on display in a flurry of strikes

Preparing for 2,200 nurses to walk off the job, the University of Chicago Medical Center decided to move some critical patients to other hospitals in the week leading up to a one-day strike on Sept. 20. 

While nurses like Danielle Bergman, a pediatric ICU nurse at Comer Children’s Hospital, worried about their patients, they also felt that the strike was necessary. They say the University of Chicago chronically understaffs its nursing floors, nurses are forced to work overtime and don’t always have time to take bathroom or lunch breaks, and crucial supplies like infusion pumps, used to deliver nutrition or medication intravenously, are often in short supply or lacking altogether. 

“This really isn't about money,” Bergman said. “Nurses have been, over the years, told to do more with less, and it's just getting worse and worse.”

University of Chicago nurses went on strike the same day that nearly 8,200 nurses in four states represented by the same union walked off the job for 24 hours, citing staffing ratios, wages, and employee medical debt among their concerns. 

While the number of strikes varies year to year, this year’s strike activity indicates that change is afoot among health care workers. Nurses, in particular, are no longer willing to shake off their concerns about staffing levels and are instead becoming increasingly vocal about the growing number of patients they are expected to care for, their stagnant wages and rising health care costs, and what they say is a lack of support from the organizations that employ them. 

They are now using their influence and size — there are 4 million nurses in the U.S. — to push for change. And in the current labor market, in which nurses are in short supply, they are largely winning those battles. 

An estimated 80,000 health care workers at Kaiser Permanente just called off a seven-day strike scheduled for October. So did 650 nurses at St. Luke’s Hospital in Duluth, Minn., who planned to go on strike this week. This spring, 1,200 nurses and health care workers at Mercy Health's St. Vincent Medical Center in Ohio went on strike for 38 days, demanding a solution to overtime policies and what they say are unsafe on-call policies. 

“Executive pay is high, the role of private equity is growing and patient care seems to be at the bottom of the priority list,” said Rebecca Givan, associate professor of labor studies and employment relations at Rutgers University. “All those changes have led to massive frustration among nurses. We're also in a moment of increased strikes and increased protests across the economy.”

A lack of resources 

Strikes among health care workers in the U.S. ebb and flow depending on the year. About 8,200 health care workers went on strike in 2018, up from 1,200 in 2017, but far below the 25,000 health care workers who walked off the job in 2014, according to a Bureau of Labor Statistics report examining work stoppages involving at least 1,000 workers. 

The majority of large health care strikes over the last decade have primarily taken place in California, Massachusetts, and Minnesota. But in 2018 and 2019, workers have gone on strike in seven states, including first-time nurse strikes in Arizona and Florida that occurred last month, based on an analysis of work stoppage data compiled by the Federal Mediation and Conciliation Service and the BLS report.

Experts say the recent strikes and threats to strike have been driven in part by the shift toward a profit-focused health care system that is now dominated by major hospital systems. Nurses read news stories about million-dollar pay packages for executives, new construction on administrative buildings, and record-making margins at the not-for-profit hospitals where they work, and they are then angered by a lack of lunch breaks, basic supplies, and pay raises. 

“There's so much to our job that's more than just giving meds and doing the task,” Bergman said. “And when you see how much money the hospital and these people are making, and then we don't have the time to do the basic things that we got into health care for is absolutely heartbreaking.”

In the week leading up to the strike at the University of Chicago, talks between striking nurses and administrators became contentious. (The nurses’ contract has been in negotiations since it expired in April.) The Intercept, an investigative news site, published an internal hospital memo that told managers to “use the transferring of critically-ill premature infants as the ‘shameless’ example” of nurses when they talked about the strike. 

“We’re disheartened that we had to get to this point,” Sharon O’Keefe, president of the University of Chicago Medical Center, said in a statement leading up to the strike. “We worked long and hard negotiating with the help of a federal mediator and had hoped union leadership would meet us halfway.”

While hospitals have generally written off the strikes and threats to strike as bargaining tactics in contract negotiations, questions about staffing ratios have become an increasingly common complaint among striking nurses. 

California is the only state to mandate patient-to-nurse staffing ratios despite efforts by other states to get similar laws passed. Last year, voters in Massachusetts nixed a ballot measure that would have required nurse-to-patient staffing ratios, following a $25 million opposition campaign by hospitals.

Ratios have been cited by nurses striking or threatening to strike this year at hospitals owned by Tenet Health, one of the largest for-profit hospital companies in the U.S.; Mercy Health, the largest health system in Ohio; and three of New York City’s largest hospital systems — Montefiore Health System, Mount Sinai Health System, and the NewYork-Presbyterian Hospital system. In New York, in order to prevent a strike of more than 10,000 nurses, the hospitals agreed to set a minimum nurse-to-patient ratio and hire an additional 1,500 nurses. 

However, staffing isn’t the only issue top of mind for nurses. After Starlette Robinson gave birth to twin sons in 2017, the registered nurse was dismayed to realize she owed $6,300 in out-of-pocket costs, to the same hospital where she works. 

Robinson’s story isn’t unique among the nurses at Barton Health hospital in Lake Tahoe, Calif. The union that represents nurses there estimates that 20% of them owe medical debt to the hospital for medical care they or their families received. While the hospital disagrees “with the union’s characterization of Barton’s health plans,” a spokeswoman for the hospital confirmed it sent, on average, 13 nurses a year to collections for medical debt they accrued there between 2014 and 2018. 

Medical debt is increasingly common these days, and it’s one reason why Barton’s 180 nurses went on strike in September for the second time this year. “We are wondering why such a wealthy corporation is treating their employees with such disrespect and medical billing and some people are going into collections,” Robinson said. “If the nurses can't afford their health care⁠ — imagine the janitors.”

The ethics of striking

Nursing is one of the most respected professions in the U.S., and much of the messaging behind the strikes has sought to reinforce the idea that nurses are advocating not just for themselves but also for their patients and other hospital workers. But that doesn’t mean that strikes don’t raise complicated questions for nurses and nurse managers. 

One study, which was published in 2010 and looked at two decades of nurse strikes in New York, discovered that strikes increased in-patient mortality by 19% and 30-day readmission rates rose 6.5% for patients admitted during a strike. (“Unfortunately, solutions aren’t easy,” Jonathan Gruber, the study’s co-author and a professor of economics at the Massachusetts Institute of Technology, told me.) Another study, published this year, found that nurse managers (who don’t go on strike) often feel betrayed when union nurses strike. 

“As the presence of nursing union activity grows in California and elsewhere in the United States, hospitals and nursing staff must learn how to examine and discern ethical dilemmas associated with collective bargaining strategies such as the threat of strikes,” Roxanne O'Brien, a registered nurse, wrote in 2016. 

Strikes tend to occur at large not-for-profit hospitals. This includes Kaiser Permanente and Providence St. Joseph Health System in 2018. Rhode Island Hospital and the University of Vermont Medical Center, both not-for-profits and the largest acute-care hospitals in their respective states, also had large strikes last year, with 2,400 and 1,800 workers, respectively.

“Strikes are expensive,” Givan said. “Hospitals need to really understand that the threat to strike is a credible threat and if they want to avoid a strike they need to deliver more at the bargaining table.”

Strikes are on the rise in the U.S. In fact, 2018 had the most number of workers involved in a strike since 1986, despite the fact that union participation in the U.S. has generally been declining. The number of registered nurses who are union members (and the number of nurses in general) has gone up and down in recent years. The number of registered nurses who are members in unions dropped off last year, falling to 487,000 members in 2018 from 527,000 in 2017. About 17% of the roughly 3 million RNs in the U.S. are union members.  

What’s driving this trend?

As the U.S. population both ages and gets sicker, demand for nurses has soared, and that need has led to some growing pains for the nursing profession. 

It’s a predominantly female workforce — about 85% of nurses are women — that regularly has to face off with limiting stereotypes that nurses are assistants to doctors and less able to take on the leadership roles in health care that they already do. 

That shift has been evident this year. Nurses showed up in droves on social media to demand an apology from Washington state Senator Maureen Walsh, who had said she wouldn’t support state legislation that would require meal and rest breaks because “nurses probably play cards” at work. (She apologized.) In recent weeks, a petition started by a nurse to reopen a leadership appointment at the National Institute of Nursing Research that went to a dentist was successful. The National Institutes of Health said they are now searching for a new candidate. 

“There is a push for that, nurses having more of a voice and speaking up if they are concerned about safety,” said Anthony Young, an assistant nurse manager for Mount Sinai. “It’s an effort of having nurses working together with their unified voice to be more politically active, speak up more within their organizations if they aren't satisfied with, for example, the nurse-patient ratio or the work environment.”

What’s your take on this trend? Will more nurses and health care workers go on strike this year? How are strikes impacting hospitals? Are nurses becoming a more powerful voice within the U.S. health care system? 

[Animation by Greg Lee. Data support from Weng Cheong.]