The acrimonious withdrawal of the California Nurses Association from the American Nurses Association on Oct. 1 exposed the tensions inside nursing.
Should nurses organizations be primarily professional associations or collective-bargaining units? How should they address their employers and the public? Having reached different conclusions, the CNA and the ANA will go their separate ways (Oct. 9, p. 42).
The Californians' secession could have wider and deeper implications. What may have looked like only a shootout at the Left Coast Corral may have been the start of a trend in the industry, observers say.
To be sure, the CNA is the most vocal exponent of a healthcare work force that refuses to go along quietly with the new script the industry is writing. Instead, the California nurses are speaking out, buying advertisements, recruiting consumer advocates, staging demonstrations, suing hospitals, sponsoring legislation and going on strike.
All these efforts are designed to draw attention to what nurses assert is a willful disregard for standards of patient care perpetrated by a money-mad medical-industrial complex.
The nurses' counterparts in the nonprofessional healthcare work force are using many of the same tactics. The Service Employees International Union Local 250, the Health Care Workers Union, which represents some 35,000 non-nurse personnel in California, is the CNA's closest ally. They collaborate on many public ventures and organize jointly when possible.
CNA and SEIU Local 250 leaders make no secret of the fact that they intend to attack the very premises on which the market-based reforms in healthcare are founded.
It's tempting to dismiss the San Francisco-based leadership of these unions as hopelessly out of touch with the political direction of the rest of the country. Yet what happens in California always bears watching. This is the state that originated the property-tax rebellion almost 20 years ago, and that recently voted to roll back automobile insurance rates. Last summer it abolished affirmative action in its state universities.
If the CNA and its allies succeed on their home turf at halting healthcare restructuring, then the counter-revolution against managed care, for-profit care and patient-focused care could gain a beachhead.
At the same time, events on the national level promise heightened union activity, especially in healthcare. The AFL-CIO will elect a new president Oct. 25. Both candidates for the job, Thomas Donahue and John Sweeney, have pledged to step up organizing in all settings.
Since 1980 Sweeney has been president of the SEIU, one of the few labor unions to show membership growth. The SEIU now has 450,000 healthcare workers, more than any other union. Donahue is interim president of the AFL-CIO and the protege of its recently retired president, Lane Kirkland. Sweeney holds a substantial lead over Donahue in preliminary counts of expected votes.
A new day for labor?
Could the CNA's militancy and the SEIU's organizing efforts among service employees coalesce to forge a new momentum for labor in healthcare?
"I'm watching it very closely," said Ken McDonald, president of Management Science Associates, an Independence, Mo., labor relations and healthcare employee consultant.
"I think we're seeing several things coming together simultaneously," McDonald said. "The AFL-CIO, whether Sweeney or Donahue (wins), has committed to a rejuvenation. Their platforms are very, very similar. Both emphasize the need to increase organizing if the labor movement is to stay alive. They are talking about $20 million in funds for organizing.
"Sweeney is targeting women and lower-paid workers, which obviously focuses in on healthcare. Healthcare has a high percentage of females. And the lower-paid are the service component of hospitals and the whole long-term-care industry," McDonald said.
Sweeney's track record is impressive. In the 15 years since he became president, the SEIU's membership has risen to 1.1 million from 625,000.
The SEIU has found its greatest success organizing women, minorities and low-status workers. The union's Justice for Janitors campaign has signed up 35,000 members since 1985. Its Dignity Campaign is targeting nursing home workers across the country. As part of the latter effort, the SEIU has launched public relations campaigns against Hillhaven Corp. in California and Sun Healthcare Group in Connecticut to force those nursing home companies to come to terms on contracts and to adhere to certain standards of patient care and staffing.
These campaigns are effectively radicalizing the workers involved. In August SEIU Local 250 and the CNA put on a rally and conference in San Francisco to talk about how to oppose what they see as the decline in patient-care standards. The conference drew some 900 nurses from around the country, along with less-skilled SEIU healthcare members and other union stalwarts.
"What I saw were nurses from all over the country who have never identified as leftists or political activists or leaders in their facilities," said Nora Roman, a triage nurse for the San Francisco County Department of Public Health and a member of SEIU Local 790. "Now that healthcare has become more commoditized, nurses are working with their hands tied behind their backs. You start to question what's going on here."
Roman said the CNA has become the leader nationwide in attacking what it believes to be the root cause of nurses' plight: the introduction of the profit motive into healthcare.
"The focus of this healthcare industry seems to be on garnering market share, expansion, shifting capital into those areas, instead of delivering patient care," CNA President Kit Costello said. "We're the first organization to question the financial need for restructuring."
At the CNA's House of Delegates meeting, members voted 200 to 20 to change their bylaws and disaffiliate from the ANA. Declaring independence allows the CNA to retain $1.8 million in dues it formerly paid the national association. The CNA intends to devote those resources to organizing new bargaining units in California and raising the consciousness of nurses around the country.
"At this point," Costello said, "we've had a lot of interest expressed by activists in other state nursing organizations liking the work we do, the advocacy, consumer outreach, the approach that we're taking." The CNA's new bylaws redefine it as a collective-bargaining group for nurses and other healthcare workers, which should free it of the shackles of being a professional organization.
"We need to be out there with other consumer groups helping to frame the public debate," Costello said. "We'll be able to work actively in coalition with other unions, (which) has the effect of developing a national strategy." As part of that public outreach, Costello appeared recently on the CBS television news show "60 Minutes" in a segment about HMOs.
While the CNA will strategize nationally, it will organize locally. Costello said it has a full plate in its home state and won't seek to organize units elsewhere.
CNA Executive Director Rose Ann DeMoro cast the conflict in terms of "two different ideologies, not only in terms of labor but in terms of public health. The ANA has taken the position that restructuring is inevitable, that managed care is the future and that essentially we have to work in ways to accommodate a corporate agenda to accomplish those goals.
"We see things quite the opposite," DeMoro said. "We don't think that corporatization and the profit motive in healthcare is inevitable."
The CNA has doubled the amount of money that will go into its political action committee. It also will use the public initiative mechanism. In 1996 it plans to sponsor a statewide initiative to guarantee healthcare access to the insured (not the uninsured).
"Right now the insured are denied access (by managed-care companies)," DeMoro said. "We're going to address the middle class. Pretty radical, huh?"
The ANA way.
To hear the CNA tell it, the ANA sounds like a bunch of ladies sipping tea with their corporate oppressors. That's hardly the case, said ANA President Virginia Trotter Betts.
The ANA is working very hard to sound the alarm, both publicly and within nursing, on the dangers of inappropriate work redesign, she said.
Consultant McDonald agreed. "For the first time, what's happening in hospitals is finally giving the ANA a rallying point for RNs," he said. "Patient-focused care, or job reassignment-whatever you want to call it-affects job security, and the ANA has really picked up on that right now."
Nurses are distributing the ANA's pamphlet Every Patient Deserves a Nurse and going on local television to talk about patient care in their communities, McDonald said. They are giving patients surveys to fill out. They've bought billboard space.
"It's selling well, very honestly," McDonald said. And it's causing headaches for some of his hospital clients. "The evening news at 6 and 10 was patient care at this hospital. If you're in a multihospital town, and you're getting a lot of radio and television about quality of care at your hospital, it's got to be tough. People do believe what they see on TV."
Public suasion is one thing; belligerent, confrontational tactics are another, the ANA believes. "I don't think that's the way you solve problems in today's America," the ANA's Betts said. "In today's America you make new relationships and you transcend the problem. It has to be a talking relationship, a win-win solution.
"But when your leaders are vilified because they try new strategies.....I met with (AHA President) Dick Davidson; (AHA officials) think I'm the devil incarnate," she said.
The CNA is mimicking "industrial-model union thinking," Betts said. "I don't believe that's the solution that's going to save healthcare."
Besides, what works for the CNA in California might not be appropriate for other parts of the country. The ANA is a big-tent organization that has to represent the many points of view held by nurses across America. Betts fought to persuade the California delegates to stick with the rest of the ANA for the sake of unity.
Anna Gilmore, director of the ANA's labor relations program, predicted the CNA will try to recruit some state nurses associations but won't succeed. "The rest of the state nurses associations are anxious to work with us to address the needs of all nurses in all settings," she said.
"There is a lot going on in restructuring that is bad for patients and bad for nurses," Gilmore said. "I think there is a variety of tactics we should be using. Frankly, (the CNA's) is one, and there it seems to be working well. Other places it does not work well."
Lorraine Freitas, an associate director of the school of nursing at San Diego State University, is working with the ANA to set up a new state nursing association in California to replace the CNA.
The CNA, she said, is "one-focused. They've made it very clear that unionization of staff nurses is their agenda. Although I believe in collective bargaining for nurses, I don't believe that a single focus is best for nurses or for nursing. What they're doing is for their own job security and not care of patients."
The nursing profession, she said, encompasses education, research and practice. "Practice is a primary issue of what nurses are all about. The CNA has chosen not to be in a position to address that," Freitas said.
Connie R. Curran, editor of Nursing Economics, wrote recently that if she had sponsored the conference and rally in San Francisco, she'd have invited union leaders from Chrysler and Eastern Airlines, the former to tell how new models of collective bargaining can transform an industry and enhance workers' rewards, the latter to tell how union intransigence can wipe out an employer.
"It's time for nursing unions to lead the way with innovative contracts that share in the responsibilities and rewards of change. It's time to stop the name-calling and picketing," she wrote.
Of course, the nurse executives who read that magazine are exactly the people the CNA accuses of deserting the fight for patient care.
Likewise, the California Association of Hospitals and Health Systems is watching the situation closely. The CNA's stridency, said Susan Harris, vice president for clinical services, "is very wearing on the public. It's becoming evident now that this is a very self-interested campaign. I'm hoping this blows up in their face."
She expects the CNA to work hard at organizing parts of the state that aren't heavily penetrated with unions, particularly Southern California. But she believes the effort will falter, succeeding in turning off the public along the way. "The public said last year, `We want less expensive healthcare, but maintain quality.' At hospitals that's what we're trying to do. And we're doing it."
DeMoro isn't fazed by that point of view. "I think a lot of the nurses across the country are going to be joining with us," she said.
"The industry may have a trillion dollars, but we've got the patients with us, the consumers with us and the healthcare workers with us. They've got the money, but we've got the numbers."