How Have Health Workers Won Improvements to Patient Care? Strikes.

Suzanne Gordon September 30, 2019

(More than 2,200 nurses went on strike against University of Chicago Medical Center on September 20. (Photo: National Nurses United)

On Sep­tem­ber 20, 2,200 nurs­es rep­re­sent­ed by the Nation­al Nurs­es Unit­ed (NNU) went on a one-day strike at the Uni­ver­si­ty of Chica­go Med­ical Cen­ter. The Chica­go nurs­es were protest­ing unsafe work­ing con­di­tions and forced over­time — and had been in con­tract nego­ti­a­tions with the hos­pi­tal for months. The Med­ical Cen­ter has just spent $269 mil­lion on a hos­pi­tal expan­sion that it, insists, rep­re­sents an “ invest­ment to improve our com­mu­ni­ty’s health.”

In response to the strike, the Med­ical Center’s top offi­cials went on a P.R. offen­sive, accus­ing strik­ing nurs­es of engag­ing in shame­less behav­ior,” and insist­ing they are reck­less­ly endan­ger­ing their patients. 

Noth­ing could be fur­ther from the truth, says Astria John­son, an Emer­gency Room nurse who has worked for the hos­pi­tal for 10 years. This strike is about pro­vid­ing safe patient care. I can’t do that when I am assigned four patients, two of whom are inten­sive care (ICU) patients and two of whom are very sick. Some­one may be on a ven­ti­la­tor to breathe for them. Some­one may be sep­tic and require intra­venous antibi­otics and require con­stant mon­i­tor­ing. Some peo­ple are get­ting their first diag­no­sis in the ER and I can’t edu­cate them about their dis­ease or medication.”

In response to the strike, man­age­ment locked nurs­es out of the hos­pi­tal for four days. The nurs­es went back to work Wednes­day morn­ing, and bar­gain­ing is expect­ed to con­tin­ue now that they’re back on the job.

Health­care pro­fes­sion­als like John­son do not view strik­ing as their first option. Most spend years going through the prop­er chan­nels,” speak­ing with man­age­ment, and engag­ing in end­less inter­nal nego­ti­at­ing ses­sions to resolve patient care prob­lems. When they do final­ly go pub­lic with their con­cerns, their actions often result in improve­ments to patient care.

In Cal­i­for­nia for exam­ple, the Cal­i­for­nia Nurs­es Asso­ci­a­tion (CNA), the orga­ni­za­tion that was the found­ing mem­ber of NNU, spent 13 years fight­ing and win­ning the first — and thus far only — leg­is­lat­ed safe nurse-to-patient staffing ratios in the coun­try: In 1998, Cal­i­for­nia Gov­ern­ment Pete Wil­son vetoed a safe staffing bill that was passed by the leg­is­la­ture. In 1999, after more intense lob­by­ing and activ­i­ty by the CNA, leg­is­la­tion was passed and signed into law by Gov­er­nor Gray Davis. Ratios were final­ly imple­ment­ed in 2004. Accord­ing to one study, in Cal­i­for­nia, man­dat­ed ratios had a pos­i­tive impact on patient deaths as well as nurse burnout.

Oth­er health­care work­ers have gone on strike to address vex­ing patient care issues. Since 2010, the Nation­al Union of Health­care Work­ers (NUHW), which rep­re­sents 4,000 psy­chol­o­gists, social work­ers, and oth­er men­tal health clin­i­cians at Kaiser Per­ma­nente in Cal­i­for­nia, has mount­ed a cam­paign to pub­li­cize and rem­e­dy a crit­i­cal short­age of men­tal health work­ers at the state’s largest HMO. In 2011, the NUHW filed com­plaints to the Cal­i­for­nia Depart­ment of Man­aged Health Care (DMHC) charg­ing Kaiser was vio­lat­ing a reg­u­la­tion that requires that HMOs must see men­tal health patients with­in 10 busi­ness or 14 cal­en­dar days of their request for an appoint­ment. The com­plaint was accom­pa­nied by a 34 page report enti­tled Care Delayed, Care Denied.”

In 2012, the NUHW went on strike to expose Kaiser’s fail­ure to hire suf­fi­cient men­tal staff and give patients access to time­ly care. These men­tal health work­ers pushed the DMHC to take action to ful­fill its man­dates to pro­tect patients. In March of 2013, the DMHC released the results of its inves­ti­ga­tion. It found that up to 40 per­cent of patients at var­i­ous Kaiser facil­i­ties expe­ri­enced appoint­ment delays that vio­lat­ed Cal­i­for­nia law. In June of 2013, the state of Cal­i­for­nia fined the sys­tem $4 mil­lion, issued a cease-and-desist order against Kaiser, and ordered the HMO to cor­rect the prob­lems. In 2015, a fol­low up sur­vey by the DMHC, based on a sam­pling of hun­dreds of indi­vid­ual patient charts, revealed that, in North­ern Cal­i­for­nia alone, 22 per­cent of patients suf­fered exces­sive appoint­ment delays. The DMHC called the vio­la­tions seri­ous.”

In 2015, one of these seri­ous vio­la­tions result­ed in the death of, 83-year-old Bar­bara Ragan, accord­ing to her hus­band Den­ny Ragan. Bar­bara had worked for Kaiser her­self for more than two decades. She’d been seek­ing men­tal health care from Kaiser and, accord­ing to her hus­band, faced lengthy delays for treat­ment and ulti­mate­ly died by sui­cide. Kaiser has said it is not respon­si­ble for Ragan’s death and insist­ed that she had received ade­quate care.

In 2017, the state ordered fol­low-up inspec­tions to make sure Kaiser was in com­pli­ance with state laws and reg­u­la­tions. As a result, Kaiser has also hired hun­dreds more therapists. 

Even though the union’s actions have played a role in forc­ing Kaiser to improve patients’ access to an ini­tial vis­it or assess­ment, work­ers say prob­lems con­tin­ue when it comes to pro­vid­ing fol­low-up care. Kaiser has not hired enough staff so that, after an ini­tial tele­phone appoint­ment, patients get need­ed fol­low-up care. Today patients have to wait up to two months for a fol­low up in per­son vis­it,” says Kirstin Quinn Siegel a Licensed Mar­riage and Fam­i­ly Ther­a­pist at Kaiser Rich­mond. Peo­ple who have been suf­fer­ing in silence, per­haps for years, and final­ly call to get help should be seen imme­di­ate­ly not in two months.” 

After expe­ri­enc­ing delayed care, anoth­er Kaiser patient, 19-year-old Eliz­a­beth Brown, died by sui­cide in 2018. Kaiser has declined to com­ment to the press about Brown’s care.

Peter Ly, a psy­chol­o­gist on the Child Team at San Jose Kaiser, says that A teenag­er strug­gling with depres­sion, or who is self ‑harm­ing or has sui­ci­dal thoughts needs to be seen right away and then con­sis­tent­ly every week or two. We can’t do it. We are asked to put peo­ple into groups when what they need is indi­vid­ual one-on-one therapy.”

That’s why he and rough­ly 4,000 oth­er work­ers went on a five-day strike in Decem­ber 2018. For­mer Con­gress­man Patrick Kennedy (D, RI) the spon­sor of the men­tal health par­i­ty and addic­tion Equi­ty Act flew to Cal­i­for­nia to join strik­ing ther­a­pists on the pick­et line.

We do not go into this work to make mon­ey,” says Susan Whit­ney, a mar­riage and fam­i­ly ther­a­pist at Kaiser in Bak­ers­field. There is no cap on our case­load. In order to help patients we keep accept­ing more and more of them. We can’t take lunch or even bath­room breaks. We don’t act until we and our patients are at the break­ing point. And our num­ber one con­cern is how will this affect patient care?”

In a response to union alle­ga­tions, Kaiser has issued a pub­lic state­ment insist­ing that, Kaiser Per­ma­nente is com­mit­ted to find­ing solu­tions and cre­at­ing a mod­el for men­tal health care that meets the grow­ing demand for men­tal health care and responds to the short­age of qual­i­fied professionals.”

But accord­ing to Whit­ney, We’ve been going through offi­cial Kaiser chan­nels for years and the only way we’ve seen any enforce­ment or improve­ment is when we go pub­lic and enlist the sup­port of patients, com­mu­ni­ty lead­ers and polit­i­cal representatives.”

In July of 2019, Kaiser announced that it had added 300 more men­tal health staff statewide and was con­tin­u­ing to recruit staff. NUHW mem­bers have pro­posed that they par­tic­i­pate in deci­sions about where new staff are assigned both geo­graph­i­cal­ly and to which clin­i­cal teams.

In 2004, two researchers inves­ti­gat­ed man­age­ment claims that health­care work­ers rep­re­sent­ed by unions jeop­ar­dize patient care. Michael Ash and Jean Ann Sea­go found instead that patients on car­diac units in hos­pi­tals where RNs were rep­re­sent­ed by labor unions had a reduced car­diac mor­tal­i­ty rate. They con­clud­ed that, The pro­tec­tions offered by union­iza­tion may encour­age nurs­es to speak up in ways that improve patient out­comes but might be con­sid­ered insub­or­di­nate and, hence, career-jeop­ar­diz­ing with­out union protections.”

What was true 15 years ago is even more so today as health­care cor­po­ra­tions con­sol­i­date through hos­pi­tal merg­ers and acqui­si­tions, gain more pow­er, and act to pro­tect the bot­tom-line rather than patient care.

Suzanne Gor­don is a health­care jour­nal­ist and researcher.  She is the co-author of Safe­ty in Num­bers: Nurse to Patient Ratios and the Future of Health­care (Cor­nell Uni­ver­si­ty Press) and most recent­ly, Wounds of War: How the VA Deliv­ers Health Heal­ing and Hope to the Nation’s Vet­er­ans (Cor­nell Uni­ver­si­ty Press).
Limited Time:

SUBSCRIBE TO IN THESE TIMES MAGAZINE FOR JUST $1 A MONTH