How Nursing Strikes Impact Patient Care
Within the last couple years, nurses have gone on strike in Massachusetts, California, Oregon, Washington, Illinois, New York, and Pennsylvania. In other cases, strikes have been narrowly avoided with last-minute contract negotiations.
A strike in Worcester, Massachusetts, lasted nearly 10 months, making it the longest nursing strike in the state's history. And more recently, a strike in Minnesota was attended by 15,000 Minnesota Nurses Association (MNA) members, making it the largest private nurse strike ever seen in the country.
Healthcare workers often face a higher degree of criticism for striking than workers in other professions. When manufacturing workers strike, supply chains are temporarily disrupted. But when healthcare workers strike, patients' lives are on the line. That's why hospitals were excluded from collective bargaining rights until the 1970s — almost three decades after other sectors were allowed to unionize.
Some hospitals like to harp on research demonstrating that in-hospital patient deaths increase during strikes, painting nurses as greedy and careless when talks of strikes arise to win public sympathy.
But contrary to what healthcare employers want the public to believe, nurses don't protest in spite of patient well-being, but because of it.
"The single issue that moves nurses to this difficult decision [to strike] is their ability to provide safe patient care," says Julie Pinkham, executive director at Massachusetts Nurses Association, who has been involved in every strike and every strike vote taken by the association over the last 30 years.
Many communities in the U.S. look down upon striking, but in the end, it may actually be the saving grace for patients. It's not striking which puts patients at risk. It's the lack of continuity in care and the unsafe conditions under which nurses work that puts patients at risk.
Do Inpatient Mortalities Increase During Strikes?
First, let's look at how strikes really impact patient health. The 2010 publication from the National Bureau of Economic Research has caused many to believe that strikes are incredibly dangerous to patients. It found that in-hospital mortalities increased by 20% during strikes. But more recent research has questioned these findings.
A review from 2022 on healthcare worker walkouts found that strikes do not significantly change rates of in-hospital patient mortality.
This is not to say that strikes don't compromise the quality of care that patients receive. And it doesn't mean that patients never die as a result of inadequate care during strikes. Both studies noted variables that may impact results, which makes a true percentage increase of mortalities difficult to quantify. But the idea that patient deaths skyrocket during strikes — or even marginally increase — isn't supported.
A 2015 study on doctor strikes, which found that patient death rates remained the same during walkouts, said that "continued provision of emergency care" makes a significant difference when it comes to mortality rates. In other words, as long as patients in urgent need are taken care of, mortality rates aren't signicantly affected.
Hospitals today also have detailed contingency plans to prepare for work stoppages. They bring in temporary or travel workers, local registered nurses (RNs) who are not currently employed or retired, and nurses from out of state, made possible by temporary licensing permits.
And despite what some hospitals portray to the public, they have plenty of time to prepare.
"There is never an instance where management is surprised a strike is happening," Pinkham says. "Generally, six months to a year of time has elapsed where the issues have been escalating, culminating in a vote, and ultimately, as required by law, a 10-day notice to the employer allowing them a final chance to reach a resolution."
Knowing how much time and foresight hospitals typically have before a strike, which is a last resort, the suggestion that nurses are the ones ignoring patient care becomes ironic, according to Mary Turner, president of the MNA.
But in the case that negotiations fail and hospitals can't find enough temporary workers, they have a couple of options:
- They may shift outpatient clinical staff into inpatient roles and reschedule nonurgent appointments to later dates.
- In the worst case scenario, hospitals can shut down nonemergency units in an effort to triage.
These contingency plans make disaster scenarios, like preventable patient deaths, much less likely to occur during strikes.
Still, hiring temporary workers and limiting hospital services should never be the first courses of action. Temporary workers don't perform as well as permanent staff because they aren't used to the work environment or the hospital's protocols. So, there's a higher chance that operational efficiency will suffer and that quality of care will be compromised.
More to the point, these studies focus on in-hospital mortalities, not patients' satisfaction with their experience or even their long-term health complications and outcomes.
If hospitals want to demonstrate concern for patient health, they should be less worried about patient deaths during strikes and more concerned with how well their patients are being cared for the rest of the time.
The Real Issues Affecting Patient Health
The larger factors of nurses strikes undermining patient health outcomes are continuity of care and safe staffing.
Continuity of Care
Continuity of care describes when patients receive consistent care by the same team of healthcare professionals throughout their time in a hospital or when dealing with a long-term health condition as an outpatient. It allows healthcare professionals to make better insights about patients' health and promotes trust between provider and patient.
Many studies have proven the benefits of continuity of care. A study from 2020 that aimed to measure ischemic stroke patient outcomes during COVID found that patients who received more cohesive care had a reduced risk for rehospitalization and went home sooner.
Other studies have examined it from the opposite end: by looking at the relationship between discontinuous care and the likelihood of medical errors. Expectedly, more errors happen and risk of rehospitalization is heightened when care is fragmented.
Nurses know this, which is why they are so hesitant to leave the bedside to strike. But simultaneously, they want healthcare employers to pay attention to the more common disruptors to continuity of care, such as high rates of nurse turnover.
In 2021, nursing turnover increased by 8%, bringing the national average up to a staggering 27%. And the average hospital turned over 96% of their RN workforce between 2018 and 2022. As a result, hospitals have been incorporating travel nurses into everyday operations more and more, which hampers continuity of care and ultimately hurts patients. This is why nurses are asking hospitals to fix the root of the problem: nurses' working conditions.
"This whole concept of 'doing more with less,' the lean model that [hospitals] like to use … they want to treat patients like they are on an assembly line and [nurses] are a bunch of machines," Turner says. Turner recently led the three-day strike of 15,000 nurses from 15 hospitals in Minnesota.
"It doesn't work that way when you're dealing with people," Turner says. "The corporate healthcare business model, what they're trying to do to our profession, is driving nurses away."
In the last three years, the hospital has seen 500 bedside nurses leave, according to the MNA, largely because nurses don't feel comfortable giving patients anything less than their full attention.
Turner believes more nurses will soon do the same.
Inadequate pay, unsafe working conditions for nurses, and mandatory overtime are just some of the issues that are adding up to a mass exodus of nurses from the profession and an increased reliance on travel nurses. But one of the most significant factors — which is also another major threat to patient health — is unsafe staffing ratios.
Improving staffing ratios has been a major talking point of nursing unions across the country for years. It's not only because short-staffing of nurses leads to stress and burnout, but because of its direct effect on patient health outcomes.
The MNA has been pushing regional hospitals to do something about unsafe staffing for over a decade. More than 3,500 concerns for safe-staffing reports have been filed by nurses at Children's Minnesota Hospital — St. Paul over the last two years.
"It's well documented that one to two patients [per ICU nurse] is what is categorized as safe," Turner says. "We can find reams of literature on what best practice is. And so every time they want us to take three or four patients in the ICU, they are putting the patients at risk."
In other areas of the hospital, such as general medical-surgical wards and labor and delivery units, nurses can handle more patients during shifts. But when overloaded, the risk of patient complications increases.
"All the adverse events will go away [with safer staffing]. Patients will be turned when they're supposed to be turned and given pain medications when they're supposed to be … And you won't have as many medical errors," Turner says. "All those little events … are caused when they're short-staffed."
Studies have confirmed that higher rates of staffing lead to lower levels of patient mortality.
As Pamela Chandran, labor counsel for the Washington State Nurses Association (WSNA) explains, patients are seen by nurses more than any other healthcare professional during hospital stays. But nurses can only provide the best care if they have enough time and resources.
"If a nurse has worked four 12 [hour shifts] in a week and has taken call and worked overtime, that nurse has attenuated resources. Multiply that by months on end," she says.
Progress Is Slow
Like many states, Washington nurses have been working in short-staffed conditions for decades. The WSNA began talks with Seattle Children's Hospital in April.
After 12 bargaining sessions and hundreds of hours of negotiations, a strike was narrowly avoided. In September 2022, they secured a new contract in which all 1,700 WSNA nurses working at the hospital will receive a $10 per hour raise over the next year.
Chandran says the victory will "keep and bring in more nurses which will inevitably lead to better patient care."
Across the country, the strike at St. Vincent Hospital in Massachusetts lasted a record-breaking 301 days, finally ending in January of 2022 with changes to staffing practices. But soon after, tensions between the union and St. Vincent began to build again when the hospital lengthened nurses' shifts without sufficient notice.
Pinkham says that the staffing situation at St. Vincent isn't necessarily "safer" since the strike, "but [nurses] feel not having fought to assure staffing would have resulted in [an] even worse situation."
In Minnesota, nurses are still vying for hospitals to listen to them. Their three-day strike has not resulted in any progress in negotiations yet, although the union is far from giving up.
Short-staffing has a profound effect on nurses' ability to do their jobs, increases rates of medical error, and leads to preventable patient deaths. Knowing this, hospitals miss the mark when they criticize the effects of strikes on patient care instead of looking at what's derailing healthcare long-term.
"The underlying reasons [to strike] may vary, but ultimately, the inability to deliver care safely and effectively is where nurses will ultimately draw the line," Pinkham says.
Hospitals often say that they are trying to address staffing ratio issues, but they claim that there's a shortage of qualified nurses. However, Turner and many other nurses disagree.
"We have plenty of nurses. What we don't have is nurses willing to work in the current conditions," she says. "That's what we say over and over again … If we can improve the conditions, they would come flocking back to the bedside."
One in five healthcare workers left their jobs between the beginning of 2020 and the end of 2021. More recently, an alarming 47% of working nurses and physicians reported that they also intend to leave the profession, according to a 2022 report from Elsevier Health.
"That is a public health crisis. Unless somebody's going to magically change how we do healthcare in one year, that is a huge public health crisis," Turner says.
If hospitals don't start listening to nurses soon, the problem will go beyond bargaining with employees and become an issue of whether or not there are enough nurses available to keep hospitals running at capacity.
"Leaving a patient's bedside would have been a wrenching decision and the last thing they wanted to do — but as the picket signs say, 'If a nurse is outside, there’s something wrong inside,'" Chandran says. "If a nurse won’t stand up for patient care, who will?"
Meet Our Contributors
Mary Turner, RN
Mary Turner is the president of the Minnesota Nurses Association. She is an active intensive care unit (ICU) nurse at North Memorial Medical Center in Robbinsdale, Minnesota. During the COVID-19 pandemic, Turner worked in the COVID ICU at North Memorial. In 2021, she was selected by President Biden to serve as the only frontline healthcare worker on his COVID-19 Health Equity Task Force.
Julie Pinkham, RN
Julie Pinkham is the executive director of the Massachusetts Nurses Association. She has been involved in every strike put forth by the association in the last 30 years and has been executive director since 2000. Between 1982 and 1996, she worked as an RN. Pinkham also founded the Northeast Nurses Association, which was created to provide affiliate members organizing support in the Northeast United States.
Pamela Chandran, J.D.
Pamela Chandran, labor counsel for Washington State Nurses Association, was the chief negotiator for the union for the Seattle Children’s Hospital collective bargaining agreement. Chandran's expertise is in representing registered nurses. She worked as a union organizer and representative for healthcare workers unions before attending UCLA School of Law.
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