Why VA Nurses Around the U.S. Are Not Striking
Private sector nurses have been striking more in recent years, exposing hospitals for its poor staffing, supply shortages, and workplace violence. Despite shared concerns, Veterans Affairs (VA) nurses across the country are unable to strike alongside private sector nurses. The most they can do is protest.
Without full collective bargaining rights, VA nurses are forced to demonstrate after work or on their lunch breaks. And their employers have no obligation to listen to many of their grievances.
While VA nurses are known to occasionally demonstrate to raise awareness about local issues, unionized VA nurses are protesting in Atlanta, Cincinnati, and Las Vegas. This country-wide string of protests is out of the norm, however.
"If you ask our nurses, they'll say, 'Yeah, it's about collective bargaining, but that's not really why we're doing this. We're doing this because we want more of a say in how we treat our patients and we feel like if we speak up, we're going to be singled out,'" says Steve Lenkart, the executive director of the National Federation of Federal Employees (NFFE), a union representing over 100,000 federal workers.
In recent years, VA nurses have endured worsening short-staffed conditions, resource shortages, and repeated accusations of substandard care. Now, many are reaching their breaking points.
The Move to Change VA Workers' Rights
Unlike private sector nurses, VA nurses are prohibited from collective bargaining and striking. A specific provision within Title 38 (section 7422) dictates that certain VA health professionals, including nurses, cannot bargain over "nongrievable" issues.
This means they can join unions and host informal demonstrations, but they have limited rights when it comes to compensation, staffing, scheduling, and patient care issues.
"Those clinicians' rights to full collective bargaining have been infringed upon," Ken Zinn says, the director of government relations at National Nurses United (NNU).
"Unless you have a union – a collective way of dealing with this to put pressure on management – nurses are just left out in the cold … at the mercy of employers," he says.
Because section 7422 leaves room for interpretation, the VA secretary – whoever it may be at the time – has the authority to deem which issues are off-limits.
"How we provide care should not be held captive based on who's in the White House and who's in the secretary's seat," Irma Westmoreland says, registered nurse (RN) and vice president of NNU.
One of the most commonly abused terms in the provision is direct patient care. If a nurse raises an issue that can somehow be linked to patient care, it's stamped as nongrievable.
"They widen the definition saying that almost every single thing that nurses do is related to patient care," Westmoreland says. "We can't even bargain over safe nurse-to-patient ratios … because under 7422, management can say, 'Oh, well this is direct patient care.'"
VA healthcare workers were especially frustrated by the law during Trump's presidency – when staffing shortages were reaching dangerous levels and criticism of VA healthcare was at an all-time high.
According to Linda Ward Smith, RN, who is president of the American Federation of Government Employees (AFGE) local 1224 in Las Vegas, morale among nurses was lower than ever at that time.
"Pretty much everybody just walked with their heads down," she says. "We had a lot of members that left the union because they felt like they didn't even have a voice anyway, so why bother?"
VA nurses are not just leaving their unions. Many are leaving the VA entirely, looking for work at private hospitals because of their inability to speak up for patients. Veterans advocates believe the law is a major contributor to nurse retention problems that perpetuate nurse staffing shortages at VA hospitals.
Studies on the private sector show that hospitals with successful unionization have improved patient outcomes, lower readmission rates, greater satisfaction among employees, and lower turnover rates. This is largely thanks to their ability to collectively bargain.
That's why unions that represent VA nurses – such as the NNU, the NFFE, and the AFGE – want to see this law changed.
Every few years, legislation to change Title 38 is proposed, but it rarely advances to the Senate floor. When Smith has met with congressional members and encouraged them to sign and cosponsor previous bills, they balk, arguing that veterans care might be compromised as a result.
"To say that veteran[s] care might be compromised because you're giving us a voice – it makes no sense," Smith says.
Because Democrats hold the majority in the House and Senate this year, there is a stronger push to finally pass the legislation. But there are parties that don't want to see government healthcare workers gain these rights.
Staffing Issues Plague VA Hospitals While Patient Influx Looms
The VA has not been immune to the nursing shortage ravaging private-sector healthcare systems. In July, the organization released its annual report on staffing. Every single facility surveyed reported at least one occupational staffing shortage. And 91% of its facilities reported severe shortages of nurses, specifically.
Understaffing, burnout, and moral injury are driving many nurses to look for other jobs, inflating turnover rates at many hospitals. Some are even considering leaving the nursing profession entirely.
Healthcare employers, both public and private, are finally acknowledging the scope of the problem. But at this point they are having difficulty attracting nurses to their struggling hospitals.
And with the passage of the PACT Act, a huge expansion of VA healthcare, hundreds of thousands more veterans will be seeking care at VA hospitals and clinics, putting further pressure on an already stressed healthcare system.
Zinn says PACT is a huge win for veterans and is overwhelmingly supported by government worker unions. But there is serious concern that the VA system isn't prepared for an influx of new patients.
"The reality is that the VA needs to step up and work on recruitment and retention of RNs," he says. " ... That's essential."
But lagging funding for VA hospitals has prevented facilities from making necessary investments in staffing, capacity, and updates to facilities. This would make conditions safer and more hospitable for healthcare workers and for veterans.
The Push to Privatize
The PACT Act harkens back to 1996 when Congress passed the Veterans Healthcare Reform Act, which vastly expanded VA eligibility. Over the next seven years, enrollment in VA healthcare nearly tripled, from 2.9 million to 7.5 million in 2003.
While expansion of VA services was celebrated by many, funding didn't keep up with increased demand. Over the next decade, VA centers had to ration their funding, leading to capacity issues, longer wait times, and poor conditions inside facilities.
It's become a trend among Republican presidents to neglect investing in the VA program and use the worsening conditions at VA hospitals to justify reliance on private healthcare.
"If they really cared about the veterans, then they would staff our VAs a little bit better so [veterans] can get the proper care that they need," Smith says.
She continues, "But what happens is our doctors and our nurses, they get overworked. So that means we have our current employees doing the work of many."
Criticism of federal healthcare workers surged in 2014, when the VA became wrapped up in a scandal about lengthy wait times that led to preventable deaths. That year, John McCain published an article for the Wall Street Journal, writing: "Veterans have earned the right to choose where and when they get their medical care, and it is our responsibility to afford them this option."
The idea was to increase veterans' healthcare coverage to include private clinics, so they weren't forced to seek care at overburdened VA facilities. While the criticism of unreasonable wait times was valid, not all supporters of McCain's proposal were motivated by improving care for veterans.
"What campaign donors on the Republican side see is a lot of dollar signs in the VA – that every vet has a dollar sign [attached]," Lenkart says.
While giving veterans more options for where they can receive healthcare may be well intentioned, it also means that funding is taken away from an underfunded VA.
"There are profit-driven forces at work in this country who would like nothing better than to get their hands on taxpayer money to finance veteran care at their private facilities," Lenkart says.
Escalation Under Trump Presidency
In response to the 2014 scandal, then-President Obama passed the Veterans' Access to Care through Choice, Accountability, and Transparency Act – commonly known as the Choice Act.
To the joy of Democrats, the bill increased funding to the VA to help with capacity and retention issues. It also pleased Republican politicians, who had been pushing to include private providers in the VA system for years.
Despite bipartisan support, veterans advocacy groups were concerned that the changes would increase reliance on the private sector. They were right.
When Trump took office, he made reforming VA healthcare a priority. In 2018, he fired David Shulkin, Obama's Secretary of Veterans Affairs who opposed privatization, and brought in Robert Wilkie, a longtime Republican congressional staffer.
The same year, Trump also signed the VA Mission Act. It is an alteration to the Choice Act, which further outsourced veterans care to private providers.
Trump justified these steps toward privatization by reviving the 2014 scandal, pedaling a false statistic that more than 300,000 veterans died waiting for healthcare during Obama's presidency. The Washington Post debunked the widespread figure, but Trump's condemnation of VAs revived the vitriol against government healthcare workers.
"VA employees in particular were brutalized under Trump," Lenkart says. "A lot of our members were accused of malpractice and negligence and so forth. It was all nonsense. It was simply a campaign to make these doctors, nurses, and other medical staff look bad, to say, 'Look, the VA can't handle this. Our best choice is to privatize.'"
When COVID hit, and hospitals began to overflow, another opportunity to undermine the VA's quality of care presented itself. And while there was – unsurprisingly – an increase in medical errors and patient deaths during COVID, Trump's targeted criticism of VA hospitals was unfounded.
A study from the Lancet Regional Health - Americas found that VA patients actually fared better than the general population during the virus' surges. This occurred despite the fact that many VA recipients are at a greater risk of developing severe COVID-19 due to their higher age and increased risk for underlying health conditions.
And long before COVID, VA hospitals have been proving their ability to provide quality care comparable to private hospitals. A study from 2016 that reviewed VA systems over a 10-year period found that they perform just as well and often better than other healthcare facilities in terms of safety and effectiveness of care.
While outsourcing to private clinics has become common, VA healthcare workers worry that veterans aren't getting the specialized care they need.
This isn't to say that VA centers can't be improved. In fact, VA nurses have a lot to say when it comes to why and how changes need to be made, which is why they are increasingly protesting.
But these studies demonstrate the point that VA nurses have been trying to make: that problems within VA hospitals aren't about poor quality of care. They are about funding, retention, and staffing.
At present, VA nurses' voices are being stifled, limiting their ability to advocate for necessary changes. Government worker unions are trying to change that.
The Fight for VA Nurses' Rights
Federal employee unions and veterans' advocates have been fighting for VA nurses' bargaining rights for years. But they've been met with opposition.
"If you don't allow collective bargaining rights for upper-level care providers, doctors and nurses… they have less of a voice, and you can control them more," Lenkart says.
The most recent version of legislation, the VA Employee Fairness Act, was introduced in March 2021 by Senator Sherrod Brown of Ohio and Mark Takano, chairman of the House Veterans' Affairs Committee. It would remove the direct patient care and clinical competency exceptions from Title 38 and allow VA healthcare workers to negotiate issues like nurse-to-patient ratios.
The House Veterans Affairs Committee voted to advance the bill to the floor in May 2021. Since then, support within Congress for the bill has slowly gained traction.
At present, advocates of the legislation are waiting for it to receive 218 cosponsors, which is the point at which the bill will reach a majority in the House. As of October 2022, it has 212. With two Republican cosponsors so far, the bill is officially bipartisan. Now, supporters are currently waiting in anticipation to see if it will reach the Senate.
In the meantime, VA nurses are forced to continue advocating for staffing improvements and hosting informal demonstrations on their own time. They hope that if the VA Employee Fairness Act passes, they will finally have the power to influence conditions within their hospitals to make sure they are able to provide the highest level of care to veterans.
Fact sheet: President Biden signs the PACT Act and delivers on his promise to America's veterans. (2022). https://www.whitehouse.gov/briefing-room/statements-releases/2022/08/10/fact-sheet-president-biden-signs-the-pact-act-and-delivers-on-his-promise-to-americas-veterans/
Feyman Y, et al. (2022). County-level impact of the COVID-19 pandemic on excess mortality among U.S. veterans: A population-based study.
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Gordon S, et al. (2019). The Trump administration is sabotaging veterans' access to health care
Legal information institute. (n.d.). https://www.law.cornell.edu/uscode/text/38/7422
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O'Hanlon C. et al. (2016). Comparing VA and non-VA quality of care: A systematic review.
OIG determination of veterans health administration's occupational staffing shortages fiscal year 2022. (2022). https://www.oversight.gov/report/VA/OIG-Determination-Veterans-Health-Administration%E2%80%99s-Occupational-Staffing-Shortages-1
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VA health care: Progress and challenges in providing care to veterans. (1999). https://www.gao.gov/assets/t-hehs-99-158.pdf
Wagner E. (2021). House panel advances legislation to expand VA medical employee bargaining rights. https://www.govexec.com/management/2021/05/house-panel-advances-legislation-expand-va-medical-employee-bargaining-rights/173868/
Wamsley L, et al. (2018). Fired VA secretary says White House muzzled him.
Ye Hee Lee M. (2015). Donald Trump repeats inaccurate figure that 'over 300,000 veterans died waiting for care.' https://www.washingtonpost.com/news/fact-checker/wp/2015/11/17/donald-trump-repeats-inaccurate-figure-that-over-300000-veterans-died-waiting-for-care/
Meet Our Contributors
Steve Lenkart, Executive Director of the National Federation of Federal Employees
Steve Lenkart has two decades of experience working in Washington D.C., on behalf of federal employees. Before joining the NFFE, Lenkart held senior leadership positions under Democratic and Republican presidential administrations, developing strong bipartisan relationships within Congress.
Ken Zinn, Director of Government Relations at NNU
Ken Zinn is the director of government relations at NNU. Prior to joining the union and professional organization, he worked at United Mine Workers of America, AFL-CIO, and the International Federation of Chemical, Energy, Mine and General Workers' Unions.
Irma Westmoreland, RN, Vice President and Veterans Affairs Chair of NNU
Irma Westmoreland has been a nurse for 36 years. She currently works as an RN at the Charlie Norwood VA Medical Center in Augusta, Georgia. Westmoreland became involved with the union in 2000 and entered leadership about two years later.
Linda Ward Smith, MSN, RN, AFGE Local 1224 President
Linda Smith has been a nurse for over 25 years. She started out working in the private sector in pediatric nursing and transferred to working at the VA in 2007, where she has been ever since. She has been the president of the American Federation of Government Employees local 1224 in Las Vegas since 2017.
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