Nurses' strikes: a profession maturing.

Nurses' Strikes: A Profession Maturing

Very few metropolitan areas have experienced nurses' strikes. Even fewer have contended with a second potential strike and averted it. The Twin Cities experienced a nurses' strike in 1984. In May 1989, a similar strike was threatened. An agreement was reached less than 48 hours before the strike vote. This article analyzes the changes that occurred between the two strikes.

The health care environment has seen sweeping changes in the 1980s. Government agencies have adopted policies to significantly reduce health care expenditures. The private sector has supported this goal. Cost reduction demands have put great financial stress on hospitals. The past five years have seen dramatic increases in the acuity of hospital patients because of increases in outpatient and home health care delivery for the less seriously ill. This increase in acuity requires greater knowledge and technical sophistication. Nurses are doing more physical assessment and diagnosis and are partners with physicians in the care of patients. We see nurse clinicians and practitioners taking larger shares of medical practices than ever before. The challenges of the health care environment and role changes for all health care professionals have placed significant stress on everyone. Nurses are the group of professionals who are with the acutely ill, hospitalized patient 24-hours a day, 7 days a week. They are care giver, advocate, educator, and coordinator of care. Most hospitals in the Twin Cities are unionized under the Minnesota Nurses Association (MNA). Multihospital bargaining is done through MNA and Health Employers, Inc. (HEI), the hospital representative. These two organizations represent 17 nursing departments and hospitals, respectively. In 1974, MNA and the hospitals agreed to arbitration to resolve disputes and prevent strikes. In 1980, MNA rescinded its agreement to arbitrate contract settlements. In 1982, MNA issued a 10-day strike notice. The issues were salary and benefits. A last-minute settlement prevented the strike. There had been a great deal of planning by hospitals and patients for the strike. Although all were glad that a strike had not occurred, there was some resentment that the nurses had created chaos for the community. The next round of negotiations was in 1984. In that year, MNA led a 39-day strike of the 17 hospitals. The strike was the culmination of nurses' quest for power and responsibility. The 1989 negotiations reflected evidence of further maturation in the nursing profession in seeking control of nursing practice and in the response by hospitals to that maturing process.

The 1984 Strike: Strategies and Issues

The history of negotiations, particularly the 1982 experience, had significance in the labor strategies of 1984. Both parties approached the table with tentative hopes for a settlement. Wages, fulltime work, and job security were the overt issues for the union. The nurses' power and strength in collective bargaining were covert issues. The revolution in nursing and collective bargaining over the previous 5 to 10 years made a strike a likely occurrence. The sentiment of the community was with the nurses, and they used the media to build support. The hospitals chose to negotiate from a traditional stance. They attempted to remain issue oriented and to prioritize key factors. They focused on the cost constraints under which they were operating. At that time there was excess hospital capacity and nurses were not in short supply. Hospitals did not address the power issues, nor did they acknowledge that changes in the nursing role had occurred and required new management strategies. Male-female issues served to intensify the power issues and polarize the parties into traditionalist and feminist orientations, although those terms were never used. Each hospital implemented its own plan for a reduction of services. Physicians offered to mediate. When one looks at the power issues, it is obvious that the physician's offer would be considered by MNA as paternalism. MNA rejected the offer. At this point, public sentiment began to shift to the hospital's position. The public saw physicians as deserving the power of mediation. Patients were discharged from hospitals, elective admissions were postponed, and a central clearing house was established through the medical societies. The clearing house maintained ongoing bed counts. Physicians used it to find beds for patients who truly needed hospitalization. Nonnursing employees were laid off in the hospitals as capacity was restricted. Nurses were surprised that hospitals would institute contingency plans. In many instances, they did not comprehend that they had voted to bring about a work stoppage with far-reaching effects on other hospital employees. They were forced to make a decision whether to continue patient care or walk a picket line. The strike began on June 1, 1984, and the hospitals responded by providing urgent and emergency services to the community. The nurses and hospitals settled this strike 39 days later--for the same package offered before the strike. In those 39 days, major shifts occurred in the hospital industry. The nurses suffered many tangible losses, but made many intangible gains. Metropolitan health care would not return to prestrike practice.

Outcomes

While it is difficult to point to the strike as the cause of changes in the hospital environment in the two years after the strike, its impact is definitely significant. A survey by employers indicated an increase in the percentage of part-time nurses from 65 percent in 1984 to 75 percent in 1985. While this may be due to demand by nurses for part-time and job-sharing positions, guarantees for more full-time positions had been a strong strike issue. In the Twin Cities from 1984 to 1986, hospital days dropped 20 percent, compared to the national average of 10 percent. Only 14 hospitals in the Twin Cities were able to maintain an occupancy level above 50%, and only 3 had an occupancy level above 60 percent.[1][2] The primary causes of this statistic were reduced admissions and shorter stays. Physicians changed practice patterns in ways that they had previously resisted. They began to do many procedures as outpatients, at first out of necessity. As they saw that it worked well, and the patients and insurance companies liked it, they continued after the strike. During the strike, they discharged patients earlier, did more work in their offices, and did more therapies at home. After the strike, they continued these practice patterns. This reduced hospital days, thus reducing jobs for nurses. Other outcomes were less tangible: * The recall agreement with the MNA

required job rebidding and disrupted

many work groups. * Many previously harmonious nursing

units became hostile as nurses who

crossed the picket lines were forced to

work with pro-union RNs and RNs

who had not crossed the picket lines.

In some settings these hostilities

resulted in permanent division. * Some nurses were angry that the

"system" worked well without them for

the five weeks of the strike. * Physicians were angry about the

disruption of their work and reduction in

their income by the strike. * The net loss of RN wages during the

strike was larger than the net wage

increase for 1984 and 1985 combined. There were some positive outcomes. * The nurses received increases in wages

and benefits. * Nurses received lay-off concessions,

although the language adopted had

been proposed by some hospitals

before the strike. * Nurse-managers and nurse executives

experienced a renewal of clinical skills

and a comfortable flexibility of roles. * When RN managers became involved

in providing patient care, they made

long-needed adjustments in procedures

and equipment. * Hospital administrators were forced

out of their offices and into the roles of

the nurse managers, giving them new

perspectives on the hospital's

activities and mission. The corporate culture during the strike shifted from one based on structural authority to one that required situational competence, openness, and acceptance. Trust surfaced on the basis of reliability and congruence of goals. Several characteristics emerged as hallmarks of a future culture, including the value of constructively challenging the status quo and an emphasis on process management as well as bottom line management. Communication became important for recognition, as well as for information sharing. A person who could identify the key questions became as important as those who could answer them. There was a strong diverse work force emerging that demanded to be heard. Members of that work force spoke clearly on the need to understand the values, directions, and authority of the health care organizations. The organization's leaders were ready to hear them.

1989 Negotiations

In 1989, a major issue again was wages. The negotiations were strengthened by the shortage of nurses. They were also intensified by current feminist issues regarding raising pay for predominantly female professions of great value to society. An equally strong issue was involvement in decision making by nurses and control of the practice of nursing by nurses. The hospitals were facing bleak economic times. One large system was facing bankruptcy. The nursing shortage was sure to drive up salaries. Hospitals wanted to be seen as supporting nurses and as having moved to participatory decision making. Many of the hospital negotiators had participated in the improvements in the work environment in the preceding five years. These were leaders who had heard the voices demanding acceptance of the direction the nursing profession was taking and participation in the decisions leading to changes in the workplace. Hospitals began strike planning several months before the anticipated strike. Twenty-four hours before the vote, the hospitals reached an agreement with the nurses. The nurses voted to accept it.

Comparisons

How was 1989 different from 1984? To be sure, the economic situation was worse. Three of the potential strike hospitals would likely have declared bankruptcy with a strike. Their RNs had a good chance of being ordered back to work after judicial review through bankruptcy law. Beds were in much shorter supply than in 1984. In addition, most hospitals had streamlined their administrative staffs through mergers and cutbacks, leaving fewer management personnel to fill in for striking RNs. Shortages would have required critically ill newborns to be transferred as far away as Cincinnati. Patients with myocardial infarctions would have been transferred as far away as South Dakota and Iowa, most of them by ground ambulance. Lives could have been lost. The 1984 strike seemed an inevitable event in the maturation of the union and the nurses. It was a powerful statement against past paternalism and parochialism, a statement regarding women's issues, and a protest of the instability of the health care environment. Employees asked to be treated as partners. Nurses asked for words and actions conveying trust. Hospitals learned in the ensuing five years that nonadversarial relationships with labor are developed through frequent sharing of issues and conflicts. Problem solving cannot occur if the only meetings are at the bargaining table. Management started to study style, philosophy, and leadership. Training for expanded job roles was instituted, with interdependence of departments, incentives for change, and reward systems. Hospitals looked ahead and learned that leadership in their environments could not be based on past values. The 1984 negotiations were characterized by a struggle of the nurses for power and recognition as a maturing profession, with the hospitals focused on financial issues. The 1989 negotiations saw more equality and more awareness and acceptance of the consequences of their actions by the nurses. Communication over the five years was the key variable. A position paper written for the American Nurses' Association identified several important reasons that nurses strike.[2] * Increased demand for professional

control of nursing practice by nurses. * The "professional collectivism"

ideology that emphasizes the responsibility

of a profession to ensure high-quality

care. Provision of such care depends

on satisfactory work conditions and

satisfaction with the work itself. * Successful collective bargaining in

teaching, social work, and medicine. * The motivation and the self-esteem to

seek to resolve years of inequalities in

respect, wages, and decision-making

authority that has come from the

feminist movement. * Growing discontent with working

conditions--i.e., limited staffing,

unscheduled floating, nonnursing tasks,

and unacceptable work schedules. * Negotiation of contract provisions

addressing such professional concerns

as standards of practice, staffing, roles,

performance evaluations, practice

committees, and professional growth.

Summary

All parties in health care seem to focus on external factors as the reason for perceived powerlessness. Professionals feel manipulated and tend to blame another group for whatever they don't like. No group is willing to be the first to step back, take a risk, and say, "What's my piece in this and how should I work with my colleagues in medicine, nursing, and administration?" As both physicians and administrators, physician executives have the opportunity to assist in the revolution in nursing roles. The nursing profession is defining its authority, accountability, and responsibility. The changes should come before there is a strike. Physician and hospital leadership must be proactive. It is our responsibility to create an atmosphere of respect for the role of nurses. We must ensure that nurses are involved in professional decision-making in an active and supportive way. The climate in the hospital must be one of empowerment. If the true issues of collective bargaining and strikes relate to respect for nurses and their roles, and power and control by them of their own professional needs, nurses must be involved at every level in making the professional decisions that affect their delivery of high-quality care. We will not only avert strikes by empowering them; we will create professional liaisons and interdependence among nurses, physicians, and administrators. It is this teamwork that should become the trend of the '90s.

References

[1].Yearly Health Care Statistics, Metropolitan Health Planning Board, St. Paul, Minn., 1985. [2].Duffy, J. Presentation at 1985 annual meeting of the Texas Hospital Association.

Barbara Le Tourneau MD, MBA, is Medical Director, Emergency Department, Unity Medical Center, Fridley, Minn. Lois Hybben, RN, MA, MBA, is Vice President and Chief Nurse Executive, Metropolitan-Mount Sinai Medical Center, Minneapolis, Minn. The authors are especially grateful for the contributions to this article of Janice Duffy, Vice President of Mercy Hospital, Bakersfield, Calif. (formerly with Mercy Medical Center, Minneapolis), and William MacNally, CEO of Unity Medical Center, Fridley, and of Mercy Medical Center, Anoka, Minn.