At Mission Hospital in Asheville, North Carolina, nurses won their first contract in July 2021, with language guaranteeing sufficient staffing in each unit based on the number of patients, additional pay for nurses working overtime and extra shifts, and adequate personal protective equipment meeting federal, state and local guidelines. The contract also states nurses can’t be floated to units where they haven't been trained.
Since then, the union has worked to sustain the contract's provisions, said Claire Siegel, a registered nurse in the adult medical surgical unit at Mission Hospital and organizer with National Nurses United.
“Our contract is as strong as the nurses that are willing to uphold it,” Siegel said.
Mission, which is part of HCA Healthcare, has a different perspective. “We do not believe having a labor union benefits our hospital and our colleagues, nor do they help us in advancing the delivery of quality care for our patients,” said Nancy Lindell, spokesperson for Mission Health.
Tens of thousands of healthcare workers went on strike in 2022, and some of the contracts hammered out at the negotiating table produced significant wins for unions. Emboldened by those victories, nurses are using a variety of methods to ensure the promises made on paper are put into practice on subjects including staffing, safety issues and worker benefits.
After their previous three-year contract expired in March, nurses at Three Rivers Health Hospital in Michigan ratified a contract in June, which included language to improve paid time off policies and increased wages by an average of 12% the first year and 3% the next two years. Though the hospital in the city of Three Rivers has generally followed the agreement, some disagreements have surfaced, said Brandy Shoup, an emergency room nurse and president of the local union, which is part of the Michigan Nurses Association.
To address issues, nurses typically talk with their department manager and the matter often can be resolved fairly quickly, she said. If not, Shoup said she helps employees fill out grievance forms to send to the manager and, later, to hospital administrators for the necessary response.
Union members have filed grievances to ensure nurses were put on the right pay scale and given at least four days' notice before being called in to work mandatory overtime, she said.
Beacon Health System, which owns Three Rivers Health Hospital, did not respond to requests for comment.
Sometimes enforcing contract terms requires more of a push.
Right after mental health clinicians in Northern California ratified a contract in October with Kaiser Permanente that called for the health system to change its behavioral health program to better recruit and retain employees, they were met with resistance from the health system, said Sal Rosselli, president of the National Union of Healthcare Workers.
In addition to being slow to implement increased time for therapists to complete patient care tasks, Kaiser Permanente disagreed with union members on contract language surrounding the length of child intake appointments, Rosselli said.
Union members brought in Sacramento Mayor Darrell Steinberg, who had acted as a mediator during contract negotiations, to clarify the agreed-upon language, he said. The mayor has had several follow-up discussions with Kaiser Permanente and union leadership.
While the health system has made progress on allowing therapists more time for indirect patient care time, the issue of whether Kaiser Permanente should continue to offer longer mental health intake sessions while committees determine best practices remains unresolved, Rosselli said.
At Fountain Valley Regional Hospital and Medical Center in California, a unit of more than 900 clinicians found that the health system was not following a provision in the contract to create a process for nurses to take on more responsibilities and get higher compensation, he said.
“We filed a grievance but more importantly we met with management, including leaders of this registered nurse unit that’s become radicalized during this bargaining process, and threatened to hold massive actions” such as strikes if the hospital didn’t honor the contract, Rosselli said.
The hospital then began implementing the process agreed to in the contract, he said.
Tenet Healthcare, which owns Fountain Valley Regional Hospital and Medical Center, did not respond to requests for comment.
Regular communication is becoming more essential to ensure contract terms are followed.
Kaiser Permanente's contract terms stipulate monthly meetings where union members share information on nurses’ recommendations and needs with system leadership, said Catherine Kennedy, a registered nurse in the neonatal intensive care unit at Kaiser Permanente Roseville Medical Center in Roseville, California, and president of the California Nurses Association.
Nurses can also fill out an Assignment Despite Objection form to notify management if there are not enough staff to safely care for patients at the beginning of a shift, said Kennedy, who is also vice president of National Nurses United. Kaiser Permanente has a week to respond to the form, and then union members can question unit leadership about how they plan to provide the necessary staffing and resources, she said.
“It's really important for nurses to actually understand the content of the contract and then when there is any type of violation, to know what to do about it,” she said. “They need to speak up and advocate to make sure that they have the appropriate number of ancillary support staff so that nurses can do their jobs.”
Kaiser Permanente's contract with its facilities in Northern California, ratified in December, guaranteed a 22.5% raise to more than 21,000 workers over four years as well as increased tuition reimbursement, a three-month stockpile of personal protective equipment and the hiring of 2,000 additional registered nurse and nurse practitioner positions.
The health system works to uphold contracts, collaborating with union members on areas of mutual interest such as patient and healthcare worker experience, said Steve Shields, senior vice president of national labor relations and the office of labor management partnership at Kaiser Permanente.
“We take those obligations very seriously and with such a rich, long-standing relationship with labor, our absolute duty is to stand behind those agreements and ensure we're implementing those terms exactly as they were intended,” he said.
Having a contract with language focusing on creating a better workplace—outside of wages, hours and other terms and conditions of employment—is a good way to show potential employees they will have a voice in decision-making and that labor relations don’t have to be contentious, Shields said.
“We've got to find new and creative ways to attract people into the industry, and some of these agreements help enable that,” he said.
However, not all health systems see partnerships with labor groups as necessary for improved employee experiences or patient care.
Even without the presence of a union, Mission Health would still provide the benefits it offers employees outside of contracts, such as student loan repayment, tuition reimbursement, sign-on bonuses and scholarships, Lindell said.
In 2022, the system provided more than $22 million in pay increases to all clinicians, exceeding the amounts negotiated under the union contract, she said.
Typically, experts advise that clinicians and system leadership try to find common ground, regardless of whether a union is involved.
The best practice is for labor and management to come together to discuss underlying issues behind burnout and vacancies and address areas that speak to one another’s interests, said John August, director of healthcare labor relations at Cornell’s School of Industrial and Labor Relations. Having these in-depth discussions instead of filing grievances and striking can be a more effective way to bring about change in the long run, he said.
Similarly, before turning to legal processes like documenting violations of law, filing complaints with the Labor Department or unfair labor practice charges with the National Labor Relations Board to force systems to adhere to a contract, union members should first try to collaborate with management to come to a resolution, Rosselli said.
Not only do legal tactics take more time and resources, but they also run counter to union culture, which is to organize members to direct action, August said.
Union members should be prepared to take collective action as the first line of defense for upholding contracts, while also keeping up-to-date with labor relations at other health systems so they know what to aim for at their own hospitals, Shoup said.
“The more people you have in the union, the more people who are invested in it, the more people who are willing to fight for what they want, the better outcomes you're going to have,” she said.
The pandemic has taught clinicians that employers lack regard for patient and worker, Rosselli said, meaning the impetus is on union members to advocate for their interests.
"Now that healthcare workers feel less threatened by COVID-19, they are fighting harder than ever to make employers improve conditions for themselves and their patients, and that includes enforcing the improvements they have won in contract negotiations," he said.