Nursing Unions: A Still Undecided Controversy

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January 6th, 2012

By , BSN, RN

As we come to the end of this first week of 2012 nursing is looking strong for the future. It's not to say there won't be tough times; new grads may have trouble getting jobs immediately but the economy is already turning around and positions and internships will open. Hospital cutbacks are happening, worries about Medicare/Medicaid reimbursement are keeping hospitals from hiring and some healthcare systems are closing non-profitable hospitals. However, healthcare is still one of the largest industries in this country and the need does not lessen.

In 2010/2011 we saw nurses striking in several areas of the country, most recently in California, Washington, D.C., and one of the largest nursing strikes ever in Minnesota in 2010. The union-based actions were not long, usually only 24-hours, but they did disrupt normal business and they did garner national attention. At the forefront of strikers' concerns were nurse-to-patient staffing ratios, benefit cuts, and of course, salaries.

Nursing Unions

Unionization is an interesting topic when it comes to nursing. ”It is well known that large unions have been targeting the growing health care sector to offset the loss of union members throughout the private economy. In 1980, 20% of all U.S. private workers belonged to unions, whereas today the percent is only 7.2," writes Peter Buerhaus, PhD, RN, FAAN, and chair of the National Health Care Work-force Commission, in an article for Nursing Economics, in 2010. Using data from the 2004 and 2008 National Sample Surveys of Registered Nurses, Buerhaus notes approximately 23% of RNs report belonging to a union. "Because the health care industry accounts for nearly one-fifth of the U.S. economy, and because the industry added jobs every month of the recession, unions are seeking to increase their presence in health care. Of particular interest are registered nurses, and unions have vigorously advocated mandatory nurse staffing ratios to attract them," he says. Approximately 21% of US hospitals have unionized nurses.

Nurse-to-Patient Ratios

An absolute answer to the question of do nurse-to-patient staffing ratios really affect patient care, is it better or worse, are there fewer adverse events or shorter stays, has not really been found. Advocates say patient satisfaction is up, there are fewer medications errors and there is improved retention of nurses. Opponents say ratios are hard for hospitals to enforce, that it is the enforcing of those ratios that builds the long lines in emergency rooms as patients wait for care and while hospitals can use historical information as predictors for nursing needs, it leaves very little flexibility for unexpected circumstances like surges in patients from large scale accidents or flu epidemics.

In April of 2005 California became the only state to enact legislation imposing minimum patient-to-nurse ratios for hospitals. About a dozen other states have tried to copy California's blueprint, but have either given up or settled for compromises requiring reporting and public disclosure of staffing levels, or increasing the number of nurses sitting on hospital staffing committees.

Many experts, including Buerhaus, believe staffing ratios ultimately result in inefficient nursing care and increased hospital costs. According to Buerhaus, "The half dozen published reports that have examined ratios in California show that the costs of care have increased and patient outcomes have not improved."

What Else Do Nurse's Unions Do?

Besides pushing for smaller nurse-to-patient ratios the nursing unions allow for collective bargaining for salaries, healthcare and other benefits. But does their presence improve nurse satisfaction or patient outcomes?

In a study published in 2008, out of Clark University, researchers examined the impact of RN unions on whether bargaining paid off in terms of better patient care. "Unionized hospitals have 9.1 percent lower heart-attack mortality but 5.3 percent and 33 percent higher rates of failure-to-rescue and pressure ulcer, respectively," said Maggie Cole Beebe, PhD. " The results indicate that nurses successfully bargain as professionals, both for wages and other traditional goals as well as for goals chosen to uphold the standards of the profession. While unionized hospitals are more likely to have conditions associated with better patient care, the resulting patient outcomes are mixed." Again, there is no absolute answer to the benefits or detriment of belonging to a union.

Nurse Satisfaction

And the lack of answers continues. Are nurses who belong to unions happier in their jobs? It's hard to say. In fact, it seems to be a paradox of sorts. In two different studies on the topic, hospitals with RN unions had higher job dissatisfaction but greater nurse retention. When researchers more closely examined the association between unionization and job satisfaction they came to a couple of conclusions.

The first conclusion authors Jean Ann Seago, PhD, RN, FAAN; Joanne Spetz, PhD, and Michael Ash, PhD arrived at was the likelihood that lower levels of job satisfaction didn't result from unionization but that dissatisfied employees seek out union representation, hoping for better conditions. They also concluded that unionized nurses were more apt to complain, which has been proposed in other studies as well. It's not necessarily that union nurses are any less satisfied than non-union nurses but they feel freer to voice their unhappiness because the union has their backs.

"Generally, union nurses know they have a specific advocate when discussing negative workplace issues; however, nurses who are not union members may be less secure about whether someone will advocate on their behalf when discussing those same issues," it says in the Journal of Nursing Administration article. "Because union negotiations occur regularly and may break down with disagreeable outcomes, there may be an adversarial relationship that exists between staff nurses and managers in a union environment."

What this all says to me is, union or not, if managers have a strong rapport with their nursing staff and the staff believes management is their advocate with the union or hospital administration, nursing job satisfaction will be higher.

Unions are not everyone's cup of tea. They serve a purpose and there will never be agreement on whether they help or hinder. In fact, that seems to be the only conclusion all these union studies have been able to agree on.

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