IRI Intelligence Briefing

News and Developments Affecting the Workplace

Volume Number & Date: 
Vol. 1 No. 4 - August 2008

Divergent Agendas Create Turmoil Among Nurses Unions

At the American Nurses Association (ANA) House of Delegates meeting in June, Michigan Nurses Association (MNA) leadership announced that the union was withdrawing immediately as a constituent member of the national group.

For any one unit," ANA argues. "ANA's proposal is not a "one size fits all" approach to staffing. Instead, it tailors nurse staffing to the specific needs of each unit…this approach treats nurses as professionals and empowers them at "The health care industry is changing, and ANA's stance on issues does little or nothing to address the crisis that nurses and the profession face," John Karebian, MNA's executive director of labor, explained in a press release. "It's clear that ANA has no interest in supporting in a meaningful way the staff nurse performing essential bedside care," added Diane Goddeeris, MNA president. MNA's move reveals a power struggle among nurses unions - and one of the primary issues is being couched in terms of patient safety.

Federal regulation requires hospitals certified to participate in Medicare "have adequate numbers of licensed registered nurses, licensed practical nurses, and other personnel to provide nursing care to all patients as needed." The vague federal code gives states the responsibility to ensure that staffing meets patient needs. Unions are manipulating public perception about patient safety and influencing state and federal legislators to address alleged staffing deficiencies.

Nurse-Staffing: Who Decides?

There are differing philosophies about nurse staffing legislation - and the conflicting views have widened a division among nurses associations. The distinction is who determines adequate nurse-staffing levels: healthcare executives familiar with their organizations' strengths and market demands for care or union leaders seeking to prove value and clout to members.

ANA has launched a Safe Staffing Campaign and is advocating for federal legislation that promotes nurse-staffing plans developed by hospital committees comprised of executives and staff nurses. "Many factors including acuity of patients, level of experience of nursing staff, layout of the unit, level of ancillary support-are key to establishing the "right" nurse-patient ratio last to have a decision-making role in the care they provide."

ANA has worked with Congressional representatives to draft and introduce the Registered Nurse Safe Staffing Act. If passed, the legislation would hold hospitals accountable for the development and implementation of nurse-staffing plans.

More aggressive unions, like the MNA, challenge the staffing plan approach. Their argument: unless healthcare executives are mandated to comply with specific, mandatory nurse-to-patient staffing ratios, budget-conscious hospitals will sacrifice patient care for profits.

Yet, after years of federally sponsored research, no direct correlation can be drawn to prove that nursing ratios lead to improved patient outcomes. That hasn't stopped the California Nurses Association (CNA), which successfully advocated for ratio legislation in California, from continuing to press for ratios and lend its support through its National Nurses Organizing Committee (NNOC) to state nurses associations lobbying for them in other states, including in Ohio and Massachusetts.

NNOC's Ohio chapter scoffed at the state's recently passed staffing legislation."It's a joke," Katrina Howard, an NNOC organizer, complained to the Columbus Dispatch. The legislation requires hospitals to develop an in-house committee to determine registered nurse staffing plans but permits healthcare executives the flexibility to adjust staffing based on patient volume and acuity.

The Massachusetts Nurses Association cried foul when the state senate passed a staffing bill in July that would require hospitals to develop a plan with input from nurses. The union called the bill a "travesty." President Beth Piknick claimed that "thousands of patients each year will continue to be harmed by avoidable medical errors and hospital infections, and too many of them will die."

While the CNA is advocating in state capitals, the United American Nurses (UAN) is lobbying in Washington for federal legislation regarding nurse-to-patient ratios. It argues that other public service industries, such as airlines, are government-regulated to ensure there "is adequate staffing for safe operations."

Changes in Affiliation

As with most political issues, sides have been taken, relationships severed and new alliances formed. MNA, the third largest ANA affiliate, was not the first to break ranks from the ANA. In 1995, the CNA ended its relationship with ANA. Then in 1998, the Pennsylvania Nurses Association left ANA to form the Pennsylvania Association of Staff Nurses and Allied Professionals (PASNAP). Within the next few years, the state nurses associations for Maine and Massachusetts also terminated their affiliation with the ANA.

Concurrently, activist nurses within ANA, a traditional professional organization best known for Magnet Status credentialing, founded a labor arm called the UAN in 1999. Two years later the new organization was brought under the AFL-CIO umbrella as a chartered affiliate. In 2002, the CNA, Massachusetts Nurses Association, Maine Nurses Association, PASNAP and United Health Care Workers of Missouri formed the American Association of Registered Nurses (AARN).

AARN appears defunct as a formal organization, replaced instead by strengthening relationships between state nurses associations, the CNA and NNOC. In 2006, the Maine State Nurses Association affiliated with the CNA/NNOC. In 2007, CNA joined the AFL-CIO, replacing the void created when the SEIU left with other unions to form Change to Win. PASNAP announced in early 2008 that it also affiliated with CNA/NNOC. Rumors abound about MNA partnering with the California nurses union as well, which certainly would help CNA/NNOC's endeavor to build a "National RN Movement."

While AFL-CIO sister unions CNA and UAN agree about staffing ratios, they may butt heads about organizing strategy. UAN engaged CNA-rival Service Employees International Union (SEIU) in an agreement to "divide and organize." UAN will recruit nurses while SEIU will focus on organizing remaining healthcare workers. This agreement, as well as other issues, led to an exodus from UAN last December when the state nurses associations in New York, Ohio, Oregon and Washington announced their disaffiliation. About two weeks later, the ANA announced that too it would sever its relationship with UAN within six months.

Issues Management

Alliances, defections and turmoil among and within unions only will continue as they battle for revenue and market share. The challenge for today's healthcare executive is in understanding who is promoting a legislative agenda, what the true motivation is and then to develop a plan of action. Essential aspects of such issue management are strong communications programs and relationship-development and maintenance with internal and external stake-holders. They need to be aware of your contributions to the community and understand your organization's position on respective issues so they are willing and able to help when you ask for support.

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