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Lessons of the 2001 Fairview Nurses Strike
Headings:  The One-at-a-Time Strategy - The Scab Nurse Shortage - The Public Relations Front - The HealthEast Settlement - The Domino Effect - Ratification of a Rejected Contract - The Formation of RNs for Change - The Legacy of Win-Win Bargaining - No Confidence in Management to Voluntarily Reduce RN Workloads - Nursing Shortage or Staffing Crisis?

Doug Mann, LPN -- 9 July 2001

On June 25, registered nurses at 2 Twin Cities area hospitals approved a collective bargaining agreement with Fairview Health Systems, ending a strike that began 3 June 2001.  The RNs are represented by the Minnesota Nurses Association (MNA).

Reportedly approved by "a wide margin," the new Fairview contract is similar to the contracts ratified by MNA members at 11 other hospitals in the Twin Cities area during a period from May 17 to June 3, 2001.  Most of the contracts were approved by narrow margins. One contract, rejected by a one-vote margin, was imposed because of a miscount and an announcement by the MNA leadership that it had been ratified .    

Understaffing was a key issue in the Fairview strike and the negotiations that preceded it. A majority of hospital nurses surveyed by the MNA report that they are generally unable to adequately monitor medically unstable patients, administer medications safely and do the basic care their patients need in a timely manner. All of the new collective bargaining agreements say that nurses will have some "input" on staffing issues, but none actually commits management to reduce patient-to-caregiver ratios.

The One-at-a-Time Strategy

Prior to 17 May, 8900 RNs represented by the MNA at 13 Twin Cities area hospitals were poised to strike after their contracts expired on May 31.  However, the MNA leadership failed to preserve a united front and effectively represent the interests of the nurses.  By the 3rd of June, only the 1350 Fairview nurses did not have a new contract.

On May 17, MNA members at 13 Twin Cities area hospitals voted on their employers' first offers.  More than 85% of the members at 12 of the 13 hospitals rejected the first offer.  MNA bargaining committees have the authority to call a strike if a two-thirds supermajority votes to reject a contract offer.

MNA members at North Memorial Medical Center reportedly approved their employer's first offer by a very narrow margin, according to the official tabulation.  Opponents of the contract were reportedly more vocal, and later requested a recount (request denied).  The original vote totals were never made available to the MNA membership and the general public.

With 1100 RNs in staff nurse positions, North Memorial is 1 of 3 Level One trauma centers in the greater Twin Cities Metropolitan Area.  It is the only Level One trauma center in the Twin Cities area where RNs are unionized.

The MNA leadership urged the North Memorial nurses' bargaining committee to recommend the contract offer for approval, as it did. North Memorial's first offer included a 19.8% across-the-board wage increase over 3 years.  The rest of the hospitals offered 18%.

A big selling point for the North Memorial contract was an "equalizer clause," a stipulation that if nurses at another hospital ratified a contract with higher wages, improved benefits, and so forth, North Memorial would match it. The MNA leadership warned that North Memorial would withdraw the equalizer clause from subsequent offers.  However, the equalizer clause was never put in writing.  It was a non-binding promise.

The bargaining committee for nurses at 3 HealthEast hospitals also recommended approval of the employers' first offer on May 17 due to the "fragile financial state" of HealthEast, but the membership rejected it by a huge margin.  

MNA bargaining committees representing a total of 7800 nurses at 12 hospitals then gave their 10 day strike notice. The strike date was set for 1 June 2001.

The Scab Nurse Shortage

According to an article in the May 16 Star-Tribune, the hospital owners claimed they could manage quite well in the event of a strike by 7800 nurses. They expected to hire about 4,000 replacement nurses, also known as scabs or nursenaries. This prediction, however, turned out to be overly optimistic. The employers were bluffing.

An article in the Minneapolis Star-Tribune of May 25 reported that the Minnesota Board of Nursing had received only 2,700 RN license applications from other states during the Month of May.  Only 1,700 applications were eventually approved.  
A strike by 7,800 MNA members would have forced the struck hospitals to severely cut, and possibly eliminate all non-emergency admissions and divert some emergency admissions to other hospitals. The entire health care delivery system would have been under tremendous stress in the event of a strike of that magnitude.

As the strike date drew near, the Minneapolis Star-Tribune published at least one letter-to-the-editor that denounced the MNA membership for threatening to abandon their patients. The strikers would have blood on their hands, didn't care, and so forth.

The Governor of Minnesota, Jesse Ventura started talking about the duty of the state government to outlaw strikes that could interfere with the delivery of essential services, but didn't mention the impending nurses strike.  Instead, he argued that public school teachers should not be allowed to strike because, by doing so, they prevent children from getting an adequate education, which is guaranteed by the Minnesota Constitution.

 It should be noted that in June 2001, citing the absence of a realistic plan to provide labor needed for emergency services during a strike, the government of Nova Scotia moved to outlaw a strike by allied health care workers with a piece of legislation called "Bill 68."  Jesse Ventura signaled his willingness to do the same thing on the same pretext.

An effective response to the threat of government intervention was made by nurses during a 1970s hospital strike in San Francisco.  They proposed the creation of  a union hiring hall where striking nurses could sign up for work at the struck hospitals.  This would ensure that essential emergency services could be provided. The nurses would get premium pay rates, just like scabs, and the hospitals would pay the same rates they were paying for scab nurses, with the fees going into the strike fund. The union would monitor how the nurses' labor was being utilized, and employment contracts with the scab nurses would have to be terminated. Obviously, the hospitals didn't agree to the proposal for a union hiring hall as described above.

The Public Relations Front

It was certainly hard for the news media to cast hospital management, insurance companies, and HMOs as downtrodden victims of a bunch of greedy, heartless nurses, especially when the story got out that the hospitals were hiring scab nurses at a cost of  $1,000 per 12-hour shift.  But that was not the only public relations nightmare that hospital management had to contend with.
Long before the eve of the strike, the MNA had launched its "start hearing nurses campaign."  It was helping to raise awareness of unsafe staffing conditions and reinforcing the position of nurses who are demanding better working conditions.  The most effective slogan put forward was "I believe nurses, safe care now," which was printed on the thousands of lawn signs that were planted across the Twin Cities area just prior to and during the Fairview strike.

Hospital spokespersons deny that the quality of patient care in hospitals has been seriously compromised by short-staffing, and assert that the ratio of patients-to-caregivers is generally within acceptable limits. However, on the basis of first hand experience, too many people have formed the opinion that nurses have a legitimate beef about being overworked and that patient-to-caregiver ratios should be reduced.

The HealthEast Settlement

Soon after the May 17 contract ratification vote, HealthEast management begin to send out layoff notices.  In the event of a layoff, many of the nurses employed at HealthEast would probably have to make do without a wage increase, or even take a
pay cut in order to land a job at another hospital.  This is due to a differential in pay of several dollars between new hires and someone employed for 10 to 15 years with the same hospital.  For nurses, the average length of service with a particular hospital is generally between 10 to 15 years.

HealthEast also raised its across-the-board wage offer from 18% to 20.8%. However,  the pay scale for RNs at HealthEast was much lower than the scale at the other hospitals, so a 20.8% wage hike at HealthEast is really less than an 18% wage increase elsewhere.  The nurses' bargaining committee recommended approval of the new offer and scheduled a vote on May 31.  The new offer was reportedly approved by a narrow margin.

Just after the HealthEast contract was approved, an article in one of the Twin Cities daily newspapers quoted Peter Rachlef, a professor at Macalaster College, as saying something to the effect that by reaching a settlement with HealthEast, the MNA had cleverly divided the bosses.

In reality, the HealthEast settlement weakened the bargaining units that were still bargaining. That's because, in the event of a strike, fewer patients would have to be diverted from struck hospitals, and fewer scabs would be needed to run the struck hospitals.

The Domino Effect

On the morning of June 1, an MNA spokesperson announced that the membership would vote on slightly improved contract offers from Allina, Fairview, and Park Nicollet Methodist Hospital. Union bargaining committees at the Fairview hospitals and two of the Allina hospitals, Abbott-Northwestern hospital and Phillips Eye Institute, recommended approval.  The union bargaining committee at the other Allina hospitals, United Hospital in St. Paul and Mercy Hospital in Coon Rapids were submitting an offer to the membership for a vote without a recommendation.

The bargaining committee for nurses at the 2 Children's hospitals reached a tentative agreement with their employer on May 31 and scheduled a vote on June 1.  The Contract was reportedly approved on a close vote.

Nurses at the Children's hospitals were certainly influenced by the ratification of contracts for nurses at North Memorial and HealthEast, and the recommendations of the other bargaining committees. The recommendation of the bargaining committee at Abbott-Northwestern hospital had the strongest impact on nurses at other hospitals because Abbott-Northwestern is the biggest hospital in the Twin Cities Metropolitan area.  As of March 2001, ANH employed about 1700 RNs in staff nurse positions, and had 140 vacant positions for RNs.

At the meetings on June 2nd where nurses from Abbott Northwestern and Philips Eye Institute voted on their employer's contract offer, bargaining committee members reported they had taken a neutral stance: no recommendation for or against.  However, the MNA leadership did not correct the error they had made in announcing the ANH/PEI bargaining committee's recommendation on the morning of June 1.   Several nurses reported that bargaining committee members argued that the employer's latest offer was as good as anything they could hope to get if they went on strike.          

At least a couple members of the Fairview nurses bargaining committee claimed that they didn't like what was being offered to them, but the MNA leadership explained that the employers' last, best offer couldn't be submitted to the membership for a vote without a recommendation to approve it.  However, the bargaining committee did, in fact, have the right to submit the employers' "last, best" contract offer to the membership for a vote without a recommendation to approve.  They could have adopted a neutral stance or recommended that the employer's offer be rejected.

On Sunday, June 3 at 5:30 AM the Fairview strike began. Later that day, nurses at Methodist Hospital reportedly approved the contract offered to them by a narrow margin.

Ratification of a Rejected Contract

Then came an announcement from the MNA leadership that the outcome of the contract ratification vote by nurses at Abbott-Northwestern was "in doubt."  The results of a  recount, held on Sunday June 3, were not revealed to the membership and the general public until the evening of Tuesday, 5 June 2001

MNA officers and staff met with Allina management behind closed doors on June 4th and 5th, then announced that the ANW/PEI contract had been rejected, with 620 "yes" votes and 621 "no" votes.  The original tally was 645 to 596 in favor of ratification (the ballots were reportedly recounted once on June 2).  Three additional recounts on Sunday, June 3 revealed that a bundle of 25 "no" votes had been put in the "yes" pile. There were also 5 more ballots cast than there were nurses who had signed in to vote.

The MNA leadership urged the membership to accept the new contract because Allina's management threatened to go to court in order to enforce it. Allina claimed that the new contract was legally enforceable because, ten minutes after the votes were originally counted, a representative of the MNA informed Allina management that the contract had been ratified.

The MNA leadership set up special meetings for the membership at Abbott-Northwestern to discuss the miscounted ballots and the imposition of a rejected contract. The MNA leadership understood that the outcome of these meetings depended a great deal on how the issues to be discussed would be framed.  The idea was to give the membership an opportunity to vent their anger at the leadership without opening the door to seriously questioning, and reversing the decision to accept the new contract.  

The Formation of RNs for Change

The stated goal of the MNA bargaining teams was to obtain collective bargaining agreements that would make bedside nursing a more attractive option to RNs, and the nursing profession a more attractive career choice.  In an exceptionally favorable situation, the MNA leadership clearly failed to effectively represent the interests of bedside nurses at the bargaining table.

One would think that the aim of the MNA leadership should have been to keep the pressure on hospital management to make an offer that would be acceptable to a large majority of the membership.  However, the actions of the MNA leadership had the opposite effect.

Soon after the May 17 contract ratification vote, a group of MNA members at North Memorial Medical Center began to discuss their concerns about the approval of North Memorial's first contract offer and the failure of the MNA leadership to keep the membership at all 13 hospitals united and hold out for a better contract. This group adopted the name "RNs for Change."

In the wake of revelations about the ratification of a contract rejected by nurses at Abbott-Northwestern Hospital, RNs for Change attracted a lot of attention by demanding the resignation of the MNA leadership.  However, putting new people in leadership positions, by itself, will not solve the MNA's leadership crisis.  RNs for Change should also play an independent role in leading the fight of MNA members for better working conditions.  That's the best way for the membership to test and select a new leadership.    

In my opinion, the main problem with the MNA and its leadership is an infection of company unionism. Far from being inept bunglers, the MNA leadership did a highly effective job of selling collective bargaining agreements patterned after the North Memorial settlement. What is involved here isn't necessarily a conscious betrayal of the interests of the membership, but the legacy of "win-win" bargaining and a widely held assumption that the fundamental interests of health care workers and their patients can be reconciled with a for-profit health care system.

The Legacy of Win-Win Bargaining          

Since the late 1970's and early 1980's, most labor unions have been engaged in what is know as "win-win" bargaining.  However, it would be more accurately described as a strategy of retreat-along-the-path-of-least-resistance from union members.

One "win-win" stratagem is to hold down the pay rate for new hires and increase the number of steps on the pay scale.  There is an emphasis on increasing the difference in pay between steps rather than on across-the-board pay raises.  The greater the difference between the top and bottom of the pay scale, the more effectively the threat of a layoff can be used to blackmail workers at the top of the pay scale.  

Another "win-win" stratagem that is popular in the health care industry is linking wage increases with staffing cuts.  The people who do the direct patient care get a tiny pay increase, Congress cuts appropriations for Medicare and Medicaid, and the amount of money on the bottom line increases for health care facilities, insurance companies, and HMOs.   

No Confidence in Management to Voluntarily Reduce RN Workloads

The reduction of  patient-to-caregiver ratios was near the top of  the MNA membership's wish list, but the MNA leadership didn't put it forward as a demand at the bargaining table.  Opening statements by the bargaining committees in March 2001 complained of excessive workloads, but didn't explicitly propose a reduction of patient-to-caregiver ratios. The opening statement of the MNA bargaining committee at Children's Hospitals and Clinics said,

"...We ask that the management team keep some key points in mind over the next few months. Think: Safe patient care, not profit margins. Nursing productivity based on quality patient outcomes, not low RN/patient ratios..."
The MNA leadership asserts that RNs and hospital management have a mutual interest in reducing the workload of RNs. The formula is: increased staffing = better patient care = lower costs = higher profits. In theory, the cost of increased staffing could be offset by a reduction of costs associated with better patient outcomes, including fewer medical and nursing malpractice lawsuits.

On the June 1 Mid-Morning Show on Minnesota Public Radio, Diane O'Conner, an official of the Minnesota Nurses Association asserted that hospitals, health insurance companies and HMOs could actually cut health care costs by increasing staffing levels. Studies show that increasing a nurse's workload has an adverse effect on patient care. When you increase a nurse's workload beyond a certain point, you see a big increase in complications like pneumonia, pressure sores, urinary tract infections, more medication errors, and less effective monitoring of medically unstable patients. What hospitals save on staffing is offset by longer and/or more frequent hospital stays for many patients.

On the same Mid-Morning Show, Roger Feldman, a U of MN health economist disputed O'Conner's assertion that hospitals could cut their costs by reducing RN/patient ratios. The health care industry has a lot of  people like Roger Feldman on the payroll to figure out what happens to the bottom line when RN/patient ratios are increased or decreased.

Evidently, some of the adverse patient outcomes associated with low-quality health care actually save the HMOs and insurance companies some money.  For example, money is saved by shortening the lives of patients who need round-the-clock nursing care on a long term basis.  That might explain why staffing cuts have been particularly savage at nursing homes.

No confidence should be placed in hospital management to voluntarily reduce the workload of RNs who do the bedside care. If they could improve their bottom line by doing so, they would have done so by now.

Nursing Shortage or Staffing Crisis?

The current shortage of RN's willing to apply for vacant staff nurse positions is the result of a mass defection of RNs from bedside nursing due to unacceptable working conditions rather than being the result of a generalized shortage of RNs.  During the 1990s, the number of RNs and nursing school graduates steadily increased as the number of bedside nursing positions in hospitals sharply declined.  [To this writing I have appended excerpts from an article posted at the Ohio Nurses Association web site and a table posted at The Nurse Voice web site.]

An understaffing crisis came about after politicians legislated away minimum staffing requirements and massively cut appropriations for health care during the 1980's and 1990's.  For example, in 1985 the Minnesota legislature repealed minimum staffing requirements for nursing homes, and in 1993 the US Congress approved cuts in the Medicare and Medicaid budgets totaling $200 billion.  Health care facility managers responded to this situation by massively cutting positions for health care workers.

Hospital and nursing home owners assert that the quality of patient care has not been compromised by "lean staffing." Evidence of patient neglect is explained away or the blame is shifted to health care workers and patients.  For example, pressure sores (bed sores) rarely or never occurred at most nursing homes 25 to 30 years ago, but are now commonplace.  The standard explanation is that pressure sores are no longer preventable because nursing home residents are generally older and sicker than they used to be.

For several years, hospital and nursing home mangers could ignore complaints about understaffing because there were more nurses than nursing jobs.  Nurses had no choice but to go along with lean staffing policies or quit doing bedside nursing care.  But that situation has changed in recent years because so many nurses have opted to quit doing bedside care.

There can be no solution to the current nurses shortage unless we demand and agitate for better conditions of employment, especially a big reduction of patient/care-giver ratios and a ban on forced overtime.  Hospitals and nursing homes that are forced to comply with those demands will not face a shortage of job applicants.  Other Health Care Facilities will then have to adopt the same standards in order to recruit and retain health care workers.

To address "the economic realities of managed care," unions representing health care workers should demand that health care facilities open their books, both sets. Proposals to change the economic realities of managed care should include the creation of a single payer system, which would massively reduce administrative costs. The profit motive could be taken out of the health care industry by taking the health care industry into public ownership.

Demands should be placed on the government to ban mandatory overtime and impose staffing requirements on hospitals and nursing homes that would substantially lower patient to care-giver ratios.  However, no confidence should be placed in capitalist politicians, including Democrats, to solve the "nursing shortage."  The current shortage is directly attributable to the health care reform agenda of the Clinton administration, which enjoyed broad bi-partisan support in Congress.

The California Nurses Association had the right idea when it affiliated to the Labor Party as a charter member in 1996.  The Democratic and Republican Parties are really two wings of the same party, both represent the interests of the capitalist class. If the employers can have two parties, why can't we have one of our own?

From The Nurse Voice,  issue #3, January 30, 2001
Minnesota Registered Nurse supply shows steady growth.
The question is why aren't more RNs choosing hospital-based practice settings?
RN's licensed in Minnesota by Year
2000: 60,732
1999: 59,271
1998: 56,731
1997: 55,471
1996: 54,500
1995: 53,166
1994: 52,293
Source: Minnesota Board of Nursing
The number of Licensed RNs increased 35% during the 1980's and 25% during the 1990's.
Excerpts from
Congressional research agrees with ONA; concludes its a "staffing crisis" and there is no true nursing shortage [from Ohio Nurses Association web site]
Healthcare facility associations in opposition to legislation calling for safe staffing and prohibitions against mandatory overtime have been decrying a nursing shortage as the reason why such drastic measures as mandatory overtime are a necessary "tool"...
The Congressional Research Service (CRS), at the request of the 107th Congress, recently released a report echoing what ONA has been stating all along: that a maldistribution of labor, rather than an actual shortage, is pinpointed as the likely culprit behind the nation's nurse staffing crisis. For many months now, after having extensively studied the nursing bedside shortage crisis, ONA has concluded and claimed that numerically there is no shortage of nurses in Ohio, rather, there is a mass defection of nurses from bedside nursing into other areas of healthcare, or leaving nursing altogether. The true culprit - unacceptable work environment conditions.

The report, which was released to Congress May 18, noted that available labor market indicators do not indicate "conclusively" that there is "an across-the-board shortage of RNs at the present time." The document further blames "poor personnel decisions" for any spot shortages of nurses that have occurred, rather than a simple lack of available nurse recruits. However, again echoing the sentiments of ONA, the report also warns that facilities could face a shortage of nurses by 2010 if "ameliorative actions" are not undertaken.

Highlighting Health Resources & Services Administration (HRSA) data, the report notes that graduations from nursing education programs will increase between 1998 and 2020 by 13%, compared to 10% between 1976 and 1998....