Nurses unions aren’t quite the same as other types of collective bargaining units. There’s a third stakeholder in health care – the patient.

St. Elizabeth Medical Center nurse Tosha Elseth said she thinks the nurses’ new contract agreement will keep her patients safer.

“My unit isn’t typically short-staffed on a regular basis, but when it is, it’s really, really seriously short-staffed," she said. "I work in cardiothoracic ICU so things can go sour quite quickly."

In the past, nurses could only document the problem, Elseth said. But a new pool of floating nurses in the contract, which was ratified last week, will bring immediate help, she said.

Elseth was skeptical of nurses unions when moving to this area from the Midwest six years ago, but now she’s a believer. “I can tell that it makes a difference. It has given me a renewed joy in my own job, to be a part of that,” she said.

Nurses unions aren’t quite the same as other types of collective bargaining units, said Ariel Avgar, an assistant professor specializing in employment relations in the health care industry at Cornell University’s School of Industrial and Labor Relations. There’s a third stakeholder in health care who is very much affected by what happens at the bargaining table – the patient.

Staffing has become a key issue in nurses contract negotiations around the country, including those just resolved with the New York State Nurses Association at St. Elizabeth, Samaritan Medical Center in Watertown and Nathan Littauer Hospital in Gloversville. It’s also been an issue in ongoing contract negotiations with two Buffalo-area health systems, said Debora M. Hayes, an area director for the Communications Workers of America in upstate New York, which represents Faxton St. Luke’s Healthcare’s nurses.

“The big issue for us in both health systems has been staffing,” Hayes said. “Nurses really are concerned about patient care delivery and the quality of care that’s delivered. Staffing has ranked as high on our bargaining surveys as wages and higher than all other benefits like retirement and paid time off and health insurance. It just is that important to people.”

Nurses also have lobbied hard for laws setting minimum staffing ratios in hospitals, although only California has passed minimum staffing legislation.

“Unions have been especially successful in improving staffing levels, which is a classic example of a way to address both working conditions and patient care with the same kind of action,” Avgar said.

But some of those successes come at the cost of strikes and threatened strikes. So are unions good or bad for patient care?


The nurses at St. Elizabeth, Samaritan and Nathan Littauer had all voted for one- or two-day strikes on Sept. 1 and Sept. 2 – with management then calling for subsequent lockouts – before they reached contract agreements in late August that canceled the strikes.

“There is a disconnect between saying that you are trying to improve patient care while engaging in strikes because you are removing nurses from providing care,” said Curt Kirschner, a partner in the San Francisco office of law firm Jones Day, who does a lot of work for health care systems.

But strikes are an important tool for improving working conditions, leaving nurses, who are also concerned with patient welfare, in a “bind,” Avgar said. “Strikes are not consistent with that. So I think there’s a tension in health care,” he said.

And strikes are bad for patient care, according to a 2010 study of hospital strikes in New York between 1984 and 2004. “We found that there’s these short-term declines in sort of quality of care as measured by mortality and readmissions during these strikes,” said co-author Samuel Kleiner, an assistant professor in the department of policy analysis and management at Cornell.

The study, the most in-depth Kleiner has seen, looked at more than 38,000 affected patients and found 138 more deaths and 344 more readmissions than there would have been without the strikes. But the average length of those strikes was 32 days, far longer than the recently threatened one- or two-day strikes even with the subsequent lockouts that were planned.


With or without strikes, unions have been successful, though, in their quest to increase R.N. staffing levels in hospitals, Avgar said. “I don’t know of data that directly links union fights for staffing levels to patient care. But I do know that there’s a growing body of research that suggests that unions are good for patient care … We know that where unions enter hospitals, quality of care goes up,” he said.

A recent study in the ILR Review published by Cornell looked at unionization efforts in California between 1996 and 2005. “Unionization was more likely to happen when quality was deteriorating in a hospital,” Avgar said.

The researchers found that most quality of care indicators improved at hospitals in the year after nurses voted in a union, but not at hospitals that voted down the union, he said.

And in a 2004 study of California hospitals, researchers found that hospitals with nurses unions had a 5.5 percent lower mortality rate from heart attacks and other cardiovascular issues, he said, calling the number “pretty staggering.”

Kirschner said he can’t offer an opinion on the impact of unionization on quality measures. “I think there are some fine performers who are unionized and there’s some very fine performers who are not unionized,” he said.


Unions and health care organizations do best when they understand that “nobody has absolute ownership on the issue of patient safety,” said A. Jack Davis, vice president human resources for the Mohawk Valley Health System, the parent organization of St. Elizabeth. “Of course, that’s a shared concern for all of us. That’s our accountability to our community to deliver that. And we consider that every single day.”

A non-contentious work environment — and a labor-management relationship without antagonism — is important in hospitals, Kirschner said. “Having a tranquil work environment is a positive thing for patient care. So the less disruptions and antagonism you can have with the hospital environment, the better it is for patients,” he said.

Avgar agreed that unions can accomplish more with a good relationship with management. “When relationships are positive … it’s more likely,” he said, “that unions are going to be able to have the positive effect on the quality of care that’s been documented.”

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