Registered nurses, already pursued by competing hospitals and aggressive recruiters, now face an increasingly crowded field of unions vying for their time, money and loyalty.
The California Nurses Association won its first election outside its home state on May 13, officially joining two powerful, well-established national nurses' unions and a handful of smaller ones already crossing state lines to bring nurses into the rank-and-file.
Competition for the U.S.'s 2.3 million registered nurses may weaken unions and aid hospitals and health systems, say labor insiders and experts, especially when unions target the same employer. That happened in Cook County, Ill., this month, when 1,800 nurses voted to leave the Illinois Nurses Association, an affiliate of the American Nurses Association, and join the National Nurses Organizing Committee, or NNOC, the CNA's national organizing arm.
The election has underscored the competing ambitions and divergent strategies of labor unions that are organizing healthcare's largest and fastest-growing occupation, which remains largely nonunionized, according to organizers.
With 60,700 members and another 1,800 organized under the NNOC, the Oakland, Calif.-based CNA is not the nation's largest RN union. The Service Employees International Union counts 80,000 registered nurses among its 900,000 healthcare members. The United American Nurses, a union affiliated with the American Nurses Association and the AFL-CIO, represents 104,000 registered nurses.
In launching a national campaign, the CNA has aimed squarely at the ANA and UAN, arguing neither aggressively promotes the interests of nurses. The California union withdrew from the ANA a decade ago-the first state affiliate to do so, followed by Massachusetts, Maine and Pennsylvania-and CNA officials are unapologetic about nabbing nurses from their rival.
"This is a victory with national significance," said CNA President Deborah Burger. "We think it's important that we have a union that represents nurses strictly and can then really speak to nurses' issues, which are patient advocacy, workplace safety and improving the healthcare system."
Outside of California, nurses in 40 states have signed on to join the NNOC, although they are not officially organized, said Rose Ann DeMoro, executive director of the CNA. To date, 2,200 such members have joined, according to the CNA.
In its meetings and classes across the U.S., the union's board and members tout the NNOC and California's groundbreaking 1999 law limiting the number of hospital patients per nurse. "We're an activist organization," DeMoro said. "This is not your staid, grandmother's organization, like the ANA."
It's not much of a national organization at all, fired back Susan Bianchi-Sand, national executive director for the Silver Spring, Md.-based UAN. "From our perspective, there is no national in the National Nurses Organizing Committee," she said. "It's just rhetoric."
The UAN operates in 27 states with its own budget, staff and a constitution that gives its members a voice in governance, she said. The CNA operates in two states and is raiding other unions to grow, she said.
"Of course, the more unions there are, the more it weakens the solidarity and the focus, I think, the focus on the workplace and safe patient care," Bianchi-Sand said. "But the problem with the California nurses' approach is that they are organizing the already organized. That really is an enormous step backwards for registered nurses." Bianchi-Sand questioned how well-prepared the California union is to accommodate rank-and-file members in a second state. "We are the biggest union and the most well-positioned," she said. "We are the best choice for registered nurses."
A third significant healthcare union, the SEIU, is actively pursuing consolidation of organized labor's RNs, said Mary Kay Henry, an executive vice president for the Washington-based union. The SEIU is among a handful of AFL-CIO unions pushing for an overhaul of the labor federation that would significantly boost spending on organizing and merge unions.
The SEIU approached RN unions in October and March with plans to either build a coalition with a common agenda or merge organized nurses under one union-either a newly formed one or, ideally, the SEIU, Henry said.
The union represents nurses in 21 states and is organizing in nine others. "We think we've got the infrastructure to do right by our members," Henry said. The crisis in healthcare may prompt labor leaders to seriously consider such an option, Henry said.
SEIU vs. CNA
The SEIU and the CNA wrangled in California over nurses before reaching a truce that Henry and Burger said might be a model for how the pair of aggressive unions may work together nationally. However, each said their union was the best suited to represent RNs. The SEIU gains clout for all healthcare workers by organizing across various sectors of the industry, Henry said. The CNA's Burger countered that the CNA's efforts on behalf of nurses focus solely on bedside RNs' professional and public policy concerns and not the entire industry.
Burger said her national union will grow from its grass-roots effort without a top-down imposition of organization. She bristled at the charge that the NNOC, which is wholly supported and sponsored by the CNA, couldn't democratically represent nurses in Illinois. "It's a continuous, participatory democracy," she said.
The NNOC is an unincorporated association without its own budget, Burger said. Its 20 employees are paid by the CNA, and Burger said she "would not venture to guess" how much the union has spent organizing outside of California. DeMoro described the NNOC as "the CNA extended nationally."
The CNA's efforts won't compete with its partners in the American Association of Registered Nurses, a coalition formed by the California, Maine, Massachusetts and Pennsylvania unions that split from the ANA, Burger said.
In Illinois, its newly formed bargaining unit is electing leadership, and Burger said it's premature to answer questions about how much members will pay in dues. "Right now our focus, frankly, is on getting them a contract," she said. Once collected, dues from Cook County nurses will help organizing elsewhere in Illinois and the Midwest. "We're building a movement," she said. "We only want nurses in the NNOC who want to build a movement."
In its disputes with hospitals and lawmakers, notably California Gov. Arnold Schwarzenegger, the California nurses union has gained a reputation for tenacious, sometimes flashy protests. In recent months, the union used television and print ads, marches and protests to target Schwarzenegger for his push to relax the state's landmark nurse-to-patient ratios-and even hired a blimp to taunt the governor during the Academy Awards.
The state's precedent-setting nurse-to-patient ratios have been a strong selling point for the NNOC, said CNA spokesman Chuck Idelson. "Staffing is the No. 1 concern of nurses around the country," he said.
Jan Emerson, spokeswoman for the California Hospital Association, called the union's high-profile defense of California's ratios a bid to raise the union's national profile, not improve patient safety. The trade group joined Schwarzenegger in trying to loosen the ratios, which hospitals say cannot be enforced during a national nursing shortage.
Ruth Milkman, a sociology and labor professor at the University of California at Berkeley, described the California nurses' union as "super active both politically and as organizers."
The union's ratio of members to organizers-940-to-1-was the lowest of any California union in 2001 and 2002, said Milkman, who conducted the census of the state's unions. That's a significant investment for a small union, she said. By comparison, the SEIU, another aggressive union in the state, had a ratio of 4,500-to-1. "Having a lot of organizers means you're organizing," she said. In a national campaign, expect more of the same. "I think they'll be very aggressive," she said. "I think you can expect an aggressive drive all over the place."
San Francisco lawyer Greg McClune echoed Milkman's assessment. McClune, a partner with Foley & Lardner, has represented management at Northern California hospitals and health systems in collective bargaining and labor relations for 25 years. The California nurses' union became less willing to "sit back and wait" for organizing opportunities after bolting from the ANA, McClune said. "They became more interested in expanding their base," he said. "That was the most significant change."
Upheaval and uncertainty in California's healthcare market during the late 1990s created a climate ripe for organizing, McClune said. The chronic demand for nurses and turbulent healthcare markets could make for similarly ripe conditions outside the state today, he said.
In Illinois, Tom Renkes credited the CNA's win to its aggressive organizing and the Illinois Nurses Association's failure to connect with workers. Renkes, who became executive director of the INA roughly two weeks before the 1,800 nurses opted for the California union, vowed the INA would change. "We lost the unit," he said. "That's telling us something. We have to look at it as a message. The message is: `Guess what? You weren't here,' " he said.
The defection left the INA with 4,800 to 5,000 members and cut into its finances by an unknown amount, he said. "We have to energize the troops we have and do more," he said. The INA's strength is its ability to work with nurses employed at every level. "We can do it all," he said. "CNA can't. They're a one-tunnel-visioned union," he said. "We can do it all and we will."
Despite the CNA's bullish attitude, one nurse and union-avoidance consultant, Susan Harris, said she's not convinced one more union targeting nurses will make a difference for hospitals. Harris, president of the healthcare division for the Burke Group, was CNA president in 1981 and an ANA board member in the 1980s. Harris made the jump to consulting after she believed the California union no longer tried to solve workforce problems, she said. The CNA is one of many trying to woo nurses. "We'll just have one more player in many more places," she said. "In one way, it's good. The more players, the more they pick at each other."
What do you think?
Write us with your comments. Via e-mail, it?s [email protected]; by fax, 312-280-3183.