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Are Nurse Unions Needed to Fight Obamacare?
Recently, I uttered words that I swore would never escape my lips: “I think, maybe, it’s time that the nurses come together and do something. Like … make a union.”
I have been vehemently and rabidly anti-union all my voting life. The daughter of a member of the California Teachers Association, I was introduced at a tender age to the many evils of unions. I was taught the different ways that unions manipulate members, abuse their dues, provide money to pet political causes, and make life difficult for the teachers. In public school, however, I was taught all of the ways that the teachers’ union was magnanimous, benevolent, and essential to a Good Education.
The hospital I work for has tried very hard to ensure that no unions take hold here. In conservative Orange County, this has not been too difficult: We are all afraid of the overreaching sight of Big Brother. We have rallied together to proclaim our independence from unions, our ability to directly negotiate with our managers, and to voice our happiness that we do not pay dues for services that we do not receive.
But new pressures mount on nurses in California on a daily basis. Standards of care are rapidly changing. While the state leads others in mandated nurse-to-patient ratios — one place I excuse governmental interference — this has not evolved with the healthcare landscape: Acute patients have more chronic illnesses with serious monitoring needs, and nurses are required to stay within ratio or lose their license.
One way that employers avoid passing the nursing ratio numbers is by manipulating the nurses aide (Clinical Nursing Assistant) to patient ratio. There may be one nurse for four patients, but an aide on that floor may be responsible for twelve patients. There are no laws, policies, or consequences for overburdening the clinical staff. With government emphasizing Value Based Purchasing, everything comes down to patient satisfaction and numbers.
It is only logical that number-crunching leads to pressure on the nurses. Looming costs, threat of non-repayment for Medicare patients, limits on what insurance will pay, reduction of MediCal patients — all pressure upper management to create catch-phrases and scripts for the nurses. When patients receive surveys such as HCAHPS, they can can answer questions about “hourly rounding” and “patient education” because the nurses have constantly reminded them of these terms.
But when patient satisfaction is key, patient safety is reduced. Studies are beginning to confirm that patient satisfaction actually coincides in a drop in patient outcomes, because patients receive the medication they want, rather than the medication they need. Hospitals rigidly deny these studies and affirm meaningless phrases such as “cost excellence,” repeatedly thrown at nursing staff for overuse of patient safety companions or patient care associates. Break nurses are treated as a luxury rather than a necessity, and staff nurses are burning out at an unprecedented rate, changing careers from healthcare shortly after their hospital care experiences.
Yet the safety measures that nurses ask for — beg for — are constantly denied. Those who seek these measures are pinpointed and maligned as troublemakers who aren’t part of the solution. Nurses who complain are scapegoated, and over time, the faces change. The number of those who were present before the ACA was enacted and Meaningful Use became a part of hospital life wanes. Nurses simply give up rather than risk their health and licenses to care for patients. “RN” is not meant to stand for “Refreshments & Narcotics,” no matter what the comics say.
The ultimate goal of hospital nurses is to provide compassionate, skilled, scientific, evidence-based care to their community, to educate their patients and their families, and to provide comfort for those during their most desperate times of need.
The government has been a hurdle to providing competent care. While increasing tracking and reporting, the outcomes have only increased government interference, reducing genuine care to care-by-the-numbers, the antithesis of the “individualized care” we are taught is the ideal. The only feasible hope for nurses appears to be to unionize down to the local, hospital level. In protecting nurses who complain, there is hope for change.
How else do we protect our patients and our nurses from Executive Administrators? How else do we ensure excellent care and — more importantly — safe care?
It is not the conservative way to want to limit the administrators who seek to keep the business afloat so it can continue to serve people. But surely there must be a limit to the unsafe practices that force nurses into the dark, protect dangerous work practices, and prevent patients from receiving care from healthy, educated, prepared nurses. There must be consequences for these actions and there must be a balance.
Unions were once needed to prevent gross negligence and abuse. Health care may again find a real and desperate need for them, not only to preserve the American quality of care, but to preserve the health of the American nursing force.
Editor’s Note: The published version of this piece erroneously stated that there was an aide-to-patient ratio. This was a confusion by the editor, not the author and has since been corrected.
Published in Domestic Policy
A final thought: I toyed with the idea of creating a political action committee for right leaning nurses a few years ago while in grad school, but never had the time to work to actualization or really knew where to start. Maybe this could be the instrument you are looking for.
It’s not just nurses, it’s also physicians who have become overpaid data entry clerks.
The “overpaid” part is being rapidly corrected.
Back to unions/whistleblowers – unions will merely engage in power struggles regarding how well a given rule is being followed. What they will not do is stand up and say NO! That rule is absurd, unnecessary and will actually impede our ability to render competent services. Such rules are already many layers thick. In anesthesia, for example, the mandated record keeping is the greatest distraction we face. Distraction from essential monitoring is the single greatest cause of error. No matter. Hardly a week goes by without additional data entry becoming required. If pilots were similarly burdened, the accident rate would increase.
Believe me, I know. I took pay cuts three years in a row, after which my income has been flat for, I think, an additional three years. I meant, of course, overpaid for the job of data entry, not overpaid for the skill and training we have.
Let me answer you point for point: I shudder to leave CA to do bedside nursing in another state specifically because of the ratios mandated. Evidence-based practice and research shows that when nurses can focus on care, patients do better. In CA, the law is based on patient acuity which, generally, works except with complex med/surg patients (which are a 5:1). Getting technical: Tele is 4:1, Sub-ICU is 3:1, ICU is 2:1 or 1:1 (depending on patient, some hospitals will even go 1:2!). But only for nurses. Our aides are anywhere from 6:1 to 20:1 (when things really are busy and at their most dangerous). Support staff is eliminated because reimbursement is down, because that is how Medicare is designed to work now. They cannot scrimp on licensed staff (except Respiratory and doctors), so they scrimp where they can.
We do not need more people taking out trash. We need more people taking care of a patient’s basic and skilled needs, which are complex for complex patients.
Super Nurse:
*continued*
On #2, nurses and support staff build the hospital. If patients are aging with more serious and chronic illnesses, they have more needs. This translates to ambulation, basic toileting, frequent and skilled vital signs. With the patient population I serve, vitals are frequent, patients have serious movement issues and compromised skin. There is of course more room for our support staff!
This is part of the reason for unions. Nurses need support staff so they can continue safely care for patients. If nurses are performing these tasks, this is less time devoted to critical analysis of the patient’s needs during hospitalization as well as discharge.
There are a few studies that bear out this assertion, but the reason that there are not more hospitals and states with mandated ratios is that this has been really difficult to replicate. Linda Aiken’s work is most often cited, but many researchers have failed to find similar evidence. Because ratios are really complicated.
Yes, these are the ratios typical in IL. Tele may have 5 patients overnight. I was an ICU nurse for 11 years, and have been 2:1 on several occasions.
Not in IL, but nothing to do with Medicare. This is in part a response to rigid adherence to the above staffing ratios.
But staffing ratios dictate where the scrimping occurs and sometimes mean that more resources are devoted to a nurse when others might be more cost effective and equally matched to the task.
Basic needs could be unlicensed personnel. Have you ever worked in a place that eliminated secretaries, techs, and stripped EVS to discharge rooms only? How do you take care of patient needs when you’re emptying garbages, answering phones, passing meal trays, and feeding people?
You cannot squeeze blood out of a turnip. If your work rules prohibit a nurse taking out garbage, but the hospital cannot afford EVS personnel or yours called in sick or what have you, and your patient’s garbage is overflowing, are you going to just leave it? Unions make answering this question “yes” more palatable to even really good people. It’s truly an awful work environment.
EVERYTHING is about what’s right for the nurse, not the patient in the union organization. In addition, the work rules essentially prohibit lots of really good things like shared decision making. There are, last I knew, zero Magnet union hospitals. it pits workers against management when we should be collaborating on how to best take care of patients given the reality of finite resources.
It sounds like you’ve identified unions as a solution to your issue. I would really encourage you to look for avenues you can take without going down that path. Do you have shared governance? Do you have a CNO or CNE with an open door policy you can schedule an appointment with? Go and talk to someone about your concerns. Ask lots of questions about why and get some real understanding of the issues your hospital faces. I would really recommend finding a different hospital before going union.
Because unions cannot address some of the issues we’ve talked about here (support staff, etc.), they end up serving nurses at the expense of everyone else in healthcare, including patients. They cannot help create a safer working environment, and they aren’t intended to. From an ethical perspective, I have a really hard time with nurses’s unions.
This is why I had said that it is the concept of unions, not the established ones as they currently exist. Historically, unions were present to prevent abuses and to prevent unsafe practices.
I do not think that current unions are the solution at all.
If working with the Nursing Executives worked, I think things would already be solved. As it is though, there is a saying at my hospital: “Nothing will change until someone sues or someone dies.”
I’m sorry to say that every time it has proven right.
We put on a great show. We are nationally recognized, we have been published as a receiving center of excellence for stroke, cardiovascular surgery, orthopedics. We are Magnet certified. Those who have put in notice have been fired before their leave date because it looks better for Magnet. We have wonderful posters. The pictures are great.
In practice, those who speak up get fired. You get with the program or you get fired. Join a council, have a voice, but that voice only means something when the voice has weight. We decide what chair alarms to pilot; we do not decide whether our tele techs watch 60 patients or 30. We are appeased, not valued.
My hospital is not the only one.
BTW, our techs now watch 30 patients despite multiple complaints. Because someone died.
That’s a stretch.
Assuming that the resources exist and are simply misdirected.
That is a shame, and it sounds like your hospital is run by unethical people. Honestly, you should probably report the data maneuvering to Magnet.
Let’s take a step back and think about the goal first, and then what strategies could be created to achieve that goal. Obviously, unions aren’t the answer. What might be? If the goal is safer care for all patients, it seems like the answer is some organization that incorporates ALL healthcare workers, maybe even patients and families, to pressure administrations to prioritize patient care resources over everything else. An organization that targets hospital boards?
Super Nurse: Obviously, unions aren’t the answer. What might be? If the goal is safer care for all patients, it seems like the answer is some organization that incorporates ALL healthcare workers, maybe even patients and families, to pressure administrations to prioritize patient care resources over everything else.
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Unions as they exist are not the answer, sure. What might be? Well, in this day of healthcare monopolies (think HMOs, now ACOs too), there needs to be some organization that holds people accountable and has some sort of power over the unethical decision makers. It is illegal for Physicians to unionize anyway, so that will not be it.
The current problem is that administrators tell themselves that they are transparent, that these councils that “listen to concerns” mean shared governance (and other Magnet catch phrases!), and that some must suffer so that the organization can continue to provide services. Hospitals that have unions have survived just fine, so clearly unions are not causing the doom of all hospitals. Clearly, fiscal accountability has not prevented hospitals from performing some pretty egregious offenses on behalf of Cost Excellence…
So what is the answer? My experience is that people listen when they have some skin in the game. How do we peons and workers find a way to put the executives skin in the game? How do we make their current position untenable without violating law?
Most offenses are protected by HIPAA, so how do we hold executives accountable?
Yep. I am right in terms of abuse protection. I have seen good nurses receive written warnings over minor things and have actually heard from long-term doctors that this is a hospital practice to keep the nurses in line. Everyone gets written up for something so that there is leverage. Really sick.
Patient satisfaction is brilliant, really. Social security is running out. Payment is a huge problem. How do we stop paying for genuine services? Make payment contingent upon objective AND subjective reviews. Then make standards difficult to reach… viola! Hospitals everywhere start taking on costs until they become insolvent, get bailed out by the government, become further beholden to The Man and it’s a short walk toward a single payer system. Brilliant, really.
Administrators are people, too, who chose healthcare (often nursing) as a profession likely for an altruistic reason. I have to believe that some of that is them self-protecting from the cognitive dissonance.
Don’t think this has something to do with mergers?
Executives are employees of the board. The boards are highly protected, cosseted, and spoon fed only positive information or heavily redacted negative info, IMO.
Board is exempted from HIPAA. What if an organization, such as NPSF, called for regulatory changes to require regular, random sampling of MDs and nurses, techs, etc to talk to board members about specific hot-button topics like staffing, safety, and quality? Would not help in your apparent tinpot dictator/ banana republic model hospital, but for most places…?