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by David Gaynor, Elinor Blake, Thomas Bodenheimer, & Carol Mermey
This article originally appeared in HEALTH/PAC BULLETIN #60, Sept./Oct. 1974.
As this issue was going to press, we received further communication from a member of the Bay Area Negotiating Council. This article (which will hopefully appear in a later issue) tells of the solidarity, trust, and collective effort that grew during the strike last year. Since then, organizing has continued around the contradictions that emerged in the final days of the strike.
By June 1974 the paid CNA (not working nurses) had taken over the negotiations; they refused to meet with the nurses-elected Negotiating Council, to release a copy of the proposed contract in advance of the ratification meeting, to recognize the dissenting voices of one third of the staff nurses. Since then, the Negotiating Council and rank-and-file nurses have worked together to reassert the power of their elected leadership. The CNA people are now the advisors, whereas in June the Negotiating Council was advisory. Shop stewards, rank-and-file staff nurses, have formed a council, elected their own officers, organized their own training programs, and contacted active labor lawyers for advice and support. All of this has been done outside the formal CNA structure. The stewards have also been filing grievances at the request of the staff nurses against the advice of the CNA.
Since the strike, organizing efforts have also been centered around the basic problems which arise from the nature of the class backgrounds and professional orientation of the RN’s. While the RN’s had the sympathy of some other workers, they were the only ones on strike, a situation which exacerbated the already existing tensions between the RN’s and other workers. RN’s are now in a position somewhere between management and workers. One of the questions being asked now is, “Which way will they go, with management or their fellow workers?.”
On June 7, 1974, 4,400 registered nurses struck 41 hospitals and clinics in the San Francisco Bay area. The RN’s, all members of the California Nurses’ Association (CNA), remained on the picket lines for 21 days. With the American Nurses’ Association holding its annual national convention in San Francisco during the strike, the issues were discussed and brought back to every state in the nation.
On one level the RN strike differed from typical management-labor disputes. The central demands were not for increased wages and other bread-and-butter gains. Rather, RN’s posed their fight in terms of control over working conditions and the quality of patient care. In addition, RN’s and their professional association, the CNA, displayed a new level of militancy in their willingness to confront the administration on the picket line.
On the other hand, the strike poses many problems and contradictions with far-reaching relevance for future struggles by hospital workers. Given the existing hierarchical division of labor within the hospital, will bargaining along narrow skill lines by a relatively privileged group of professional nurses serve to create even more tension and divisions? And what is the meaning of the demand for workers’ control when that demand is made for the sole benefit of a narrowly defined group? On a more pragmatic level, can any single classification of hospital workers win its demands without uniting with others – that is, can any one group muster enough clout to shut the hospital down and force the administration to capitulate?
No Ordinary Demands
In 1970 the CNA won a clause in its contract with Bay Area hospitals giving RN’s the right to help determine how wards are staffed. The clause called for “participation of Staff Nurses in the assessment of patients’ daily needs for nursing care and the basis upon which nursing personnel are assigned… ” By the time the contract expired on December 31, 1973, neither the hospitals nor the CNA had moved in a significant way to implement this clause. When negotiations for the 1974 contract opened, management’s position on the staffing issue became unequivocal-delete the clause and deny RN’s any participation in staffing matters.
The staffing clause became the core of the strike: Who decides how many and what type of personnel should work on each unit? This issue is central to both hospital workers and patients. Understaffing makes workers unable to perform all necessary tasks. Patients find that their needs are ignored for hours, and even then are met in a brusque and hurried manner.
Administration, through the director of nursing, distributes RN’s, LVN’s (licensed vocational nurses, also called licensed practical nurses in some states) and aides around the hospital according to the number of patients on each floor. Some hospitals use the more sophisticated “acuity” method of staffing, which takes into account that some patients are sicker than others and need more staff time. But in all cases, the number of workers is determined bv administration, and if the fiscal picture looks bad, staff can be cut back no matter how full or how busy the wards become.
One RN, for example, tells of working a night on a floor with 30 patients, many acutely ill, staffed with one RN, one LVN and one aide. Thirteen patients had intravenous solution bottles running. Each bottle had to be changed at different times, requiring close watching to prevent bottles from running dry. In addition one patient needed irrigation of the bladder with multiple bottles of fluid. After continued pleas from the beleaguered RN, the nursing office offered only one extra LVN – this despite the fact that hospital regulations do not allow LVN’s to perform these tasks.
Management was steadfast in its refusal to allow an RN voice in staffing. Hospital negotiator Arthur Mendelson warned physicians: “If we accede to the demands of the registered staff nurses and the California Nurses’ Association in this connection it is only one step away for the registered staff nurses to demand a voice in the way you treat your patients with respect to admissions, discharge, treatment and length of stay.” The American Hospital Association, in an alarmist statement, took up the cudgels: “An issue with national implications is at stake here. Under the banner·of an interest in the quality of care, the striking nurses are attempting to gain control over the number of nurses employed by each hospital…”
In truth, the staffing demand was not nearly as threatening as Mendelson described it. The CNA was merely asking for participation in deciding staffing levels, not control over staffing. Some RN’s defined the strike as a worker control struggle but the demands were not in fact that progressive.
The staffing issue did, however, have implications for other hospital workers. Why shouldn’t all personnel on a unit – including LVN’s, orderlies and aides – be involved in staffing decisions? The strike could not deal with this question since the CNA is a professional association separate from the union of other hospital workers, and as such can bargain only on behalf of RN’s. Thus the demand for some control.over staffing by RN’s missed the mark of what real worker control might mean – teams composed of all workers on a floor deciding staffing patterns, division of labor between workers, and patient diagnosis and treatment.
A second strike demand was that administration not assign RN’s without appropriate training to specialty units. The technological explosion in health care has brought with it increased specialization. Doctors carve out an organ or two as their exclusive area of concern. Technicians are increasingly split up into narrow functions. And with RN’s operating complex devices in intensive care units, coronary care units, renal dialysis, emergency rooms and other specialized areas of the hospital, nursing is following suit.
RN’s at Bay Area hospitals flatly stated that administrators were staffing specialty units with unqualified “floating” nurses – nurses who spend different days on different floors. At Mt. Zion Hospital in San Francisco, administration first denied the charge of improper staffing, but later reluctantly admitted to such staffing in case of “emergency.” An intensive care unit nurse responded, “If Mt. Zion does indeed assign untrained nurses to specialty care areas only in emergency situations, then these areas are in a constant state of emergency.”
Not only is this practice dangerous to patients, but it is intolerable to hospital workers. One RN told of an orderly sent to a pediatric unit where he had never been trained to work. The orderly accidentally disconnected a life-supporting device. After some tense moments, the child’s condition was restored, but the orderly was distraught by what he had nearly done. Nevertheless, the specialty staffing demand would do nothing for this situation since it applies only to RN’s.
Bread-and-butter demands were not altogether ignored. These included demands for every other weekend off for all RN’s, a 5.5 percent pay increase and a cost-of-living escalator clause. The CNA also asked for a pension plan separate from other workers and portable from one hospital to another. Pensions were an issue because RN’s frequently change jobs and do not benefit from the money they place into hospital-wide pension plans. The demand reflects the high degree of job mobility of RN’s vis-a-vis other less mobile and less privileged hospital workers.
Why a Strike?
The precipitating cause of the strike was the hospitals’ complete intransigence on the staffing issue. Hospital management had refused to negotiate until a few days before the contract expired at the end of 1973, and had failed to budge during the five months of talks in 1974. Administration not only wanted to delete the gains won by the CNA regarding participation in staffing in the 1971–3 contract, but pushed to include a management’s rights clause. According to Burton White, CNA Director of Economic and General Welfare, “Management was trying to turn back the clock. That was too much.” The CNA had no choice but to give in or strike.
Woven into the strike decision were several underlying threads. Staffing conditions in hospitals have tightened due to the excess of hospital beds and the federal wage-price controls, both of which have hurt the hospitals’ economic position. From management’s point of view, there is a critical need to limit staffing – after all, each additional worker costs money. For management it would be unthinkable to allow hospital workers – who have no responsibility for keeping the hospital in the black – to control levels of expenditure. From the workers’ point of view, the economic pinch means speed-up- more work for each person to do – and wages that fail to keep up with the rising cost of living. Two other Bay Area hospital strikes in the past year – at Kaiser and San Francisco General hospitals – reflect the workers’ refusal to bear the brunt of the economic situation.
At the same time, many RN’s have been influenced by the women’s liberation movement, acquiring a new self-respect and militancy. Traditionally nursing has been women’s work – an extension of their caring, cleaning and serving roles as mothers and housewives (see Health/Pac Bulletin, March, 1970, September, 1970, and April, 1972). Socialized to be passive and to accept the devaluation of their contributions as workers, women have been reticent to speak up for their rights and push forth their demands at the workplace. Although feminist issues were not at the forefront of this strike, women asserted leadership, self-reliance and self-confidence, taking themselves and their jobs seriously. A Kaiser RN stated, “If it weren’t for women’s lib, we wouldn’t have been striking.” Another went on to say, “It definitely gave us the courage to speak up and express our opinions.”
Also underlying the strike was the CNA’s response to the new militancy of the rank-and-file RN’s. In Los Angeles, 600 public hospital RN’s recently switched from the CNA to representation by the Service Employees International Union (AFL-CIO). In San Francisco, the AFL-CIO and the Teamsters are the collective bargaining agents for increasing numbers of public hospital RN’s. This year seemed like the CNA’s last chance to prevent widespread defection of RN’s into labor unions.
A final condition underlying the strike was the fact that the RN’s didn’t know what they were getting into. The CNA had little experience in conducting strikes and the RN’s shared a widespread feeling that “We’ll go out for a few days, win and be back on the job next Monday.”
Prelude to the Picket Line
In December 1973 the CNA entered into contract negotiations with three groups on northern California hospitals: Affiliated Hospitals (most of San Francisco’s private hospitals, banded together solely for the purposes of collective bargaining), Associated Hospitals (a similar grouping mainly in Oakland and Berkeley) and the Kaiser hospitals and clinics.
In January, 1974, the Bay Area Negotiating Council was created to represent the RN’s with each hospital electing two representatives to serve on it. The Council in turn selected 12 RN’s to sit in on the negotiating team. These 12 joined five paid CNA staff members, led by Burton White, a non-RN and experienced labor negotiator. Thus the CNA leadership (staff plus elected officials) was under the surveillance of rank-and-file RN’s at the bargaining table.
During the five months of weekly bargaining sessions, the Negotiating Council served as a communications link between the RN’s and the CNA. Information about negotiations and strategies passed from the negotiating team to the Council, and the Council brought questions and concerns from RN’s at the individual facilities.
In May, mass meetings attended by 1,300 RN’s rejected a management proposal by a 95 percent vote and authorized strike action. On June 7, Negotiation Council member Joyce Boone declared, “We are a new breed of nurses, fighting for our rights and those of our patients.” The same day RN’s set up picket lines around over 40 health facilities.
Meanwhile, contracts for LVN’s, aides, housekeeping and dietary workers, represented by Local 250 of the Service Employees International Union (AFL-CIO), had also expired January 1, 1974. Negotiations dragged on for the first five months of the year. As the CNA prepared for strike action, management became increasingly anxious to settle with Local 250. Hospitals can manage without RN’s; after all, LVN’s do many RN tasks anyway (even though they are paid much less). But a simultaneous walkout by RN’s and other hospital workers would be devastating.
So shortly before the anticipated RN strike, management offered a 40 cent per hour (9–12 percent) across-the-board increase to Local 250 members. The union, which had negotiated without rank-and-file participation, recommended acceptance of the offer. Withholding the terms of the agreement from its members until 45 minutes before the vote, the union achieved ratification and thereby helped management avert a combined strike. No attempts had been made by the CNA and Local 250 to coordinate or combine their strategies. Hospital administrators heaved a sigh of relief: Divide and conquer had worked again.
Going It Alone
Unaware of the import of the Local 250 settlement on their own struggle, the RN’s went it alone. Bearing signs declaring, “Patients are our business,” “We want to serve what you deserve,” “Qualified nurses for specialty units,” and “Better staffing equals better patient care,” the RN’s picketed the entrances to their hospitals. Some SO to 95 percent of RN’s participated in the strike, varying from hospital to hospital, a response far better than expected. The RN’s encouraged other workers to wear blue armbands in support of the strike but not to leave their jobs.
The CNA hoped to exert financial pressure on the hospitals by eliminating the profitable elective surgery and non-emergency admissions. But not forgetting the patients, the RN’s initially maintained staffing of emergency and intensive care areas. Hospitals reported occupancies running 40 to 50 percent of normal levels. Though these occupancy levels clearly hurt the hospitals financially, they were not low enough to bring the institutions to their knees.
Three days after the strike began, 8,000 RN’s gathered in San Francisco for the annual American Nurses’ Association (ANA) convention. ANA delegates joined the picket line, raised funds and overwhelmingly passed a resolution in support of the strike.
On June 12, 200 Kaiser RN’s rallied at the Kaiser Center in Oakland, and the following day several hundred RN’s held a spirited demonstration in San Francisco. A week later, a march picking up RN’s at each hospital converged on San Francisco’s Civic Center Plaza for another major rally. Day after day, the strike was the leading story on local TV news broadcasts, with charges and countercharges flying between the CNA and the hospitals.
On June 20, with negotiations at an impasse, the RN’s upped the ante – they withdrew from the emergency and intensive care areas. Irene Pope, President and Acting Executive Director of the CNA, charged that hospitals were assigning supervisory personnel to non-critical care areas because they had strikers available to staff emergency units. Others observed that patients who did not need critical care were kept in the critical care area.
The pull-out from emergency units was the only tactic available to a professional association that bargains for only a limited number of workers in an institution. Strikes by all workers- closing down profitable but not emergency areas of hospitals – would have been more effective in advancing the RN cause than the emergency unit pull-out. But the CNA did not want support strikes by other workers. At least one group, the X-ray technicians at Herrick Hospital, members of the International Longshoremen’s and Warehousemen’s Union, were on the verge of a sympathy strike when word came from Herrick RN’s that the CNA had rejected the support offer, not wishing to be obligated to honor future X-ray technician strikes. One Herrick X-ray technician said, “We wanted to go out — there was sympathy with the RN’s standing up to the doctors and administration. But when the RN’s told me they didn’t want our strike, I pulled my blue armband right off.”
The RN’s did gain substantial public support from other groups during the strike. Unable to unite with Local 250 in their own workplaces, the RN’s did receive verbal backing from Local 1199 of the National Union of Hospital and Health Care Employees in New York City. The interns and residents organization at San Francisco’s Children’s Hospital issued a statement of support, as did 63 members of Mt. Zion’s house staff. Over 100 unit clerks, lab techs, LVN’s, social workers and housekeeping personnel at Mt. Zion Hospital signed a petition of support.
But in several hospitals, the atmosphere was hostile toward non-RN staff who supported the strike. Many workers feel that RN’s are the supervisors or the “fore-men” on the floor, and the strike demands were seen as potentially increasing RN’s power over other workers. Thus workers who donned blue armbands soon began to feel isolated. In fact, one Local 250 representative even threatened to fine armband wearers $50.
As the strike wore on, RN’s began to feel acutely the absence of their paychecks. The CNA leadership, fearing that RN’s would straggle back to work, tried to hasten the bargaining process by edging the 12 elected RN’s off the negotiating team. Told that they were too inexperienced to participate in this stage of the negotiations, the elected team members were forced to wait outside the negotiating room. CNA staff negotiators justified their moves by instilling a Henry Kissinger aura upon the delicate sessions and convinced the team not to speak with their rank-and-file peers.
|TOO MANY BEDS SPOIL THE BUDGET
Why are Bay Area hospitals so insistent on understaffing in order to keep their costs down? The reason is that the hospitals have gotten themselves into financial trouble by overbuilding. As the San Francisco Examiner (June 9, 1974) editorialized, “San Francisco has too many hsopitals [sic] occupying too much land, filled with too many beds, loaded with too many expensive medical devices and – partly as a result of all these excesses – charging too much for medical care.”
According to the Bay Area Comprehensive Health Planning Council, San Francisco and Oakland hospitals have occupancy rates around 65 percent. By 1978, San Francisco will have 1,412 unneeded beds. With an unoccupied bed costing $50,000 to build and $20,000 per year to maintain (see HEALTH/PAC Bulletin, March/ April, 1974), these excess beds are costing $28 million per year plus the initial construction cost of $70 million. Since empty beds bring in no revenue, hospital management must make up the lost money by charging patients more and/or spending less on employees. The most effective way to save is to cut back the total number of workers.
With the empty bed crisis worsening, competition among hospital managements is intensifying. Already one San Francisco hospital, Harkness, is closing down. To make sure his hospital won’t be next, each administrator must look for new and better ways to admit more patients, charge them more, hire fewer workers and increase their productivity.
On June 23, after several attempts to force management to sit down with third-party mediators, the CNA finally succeeded in securing the services of William J. Usery, Jr., chief federal negotiator and personal labor troubleshooter for then-President Nixon. Usery immediately called for around-the-clock negotiations and a news blackout that extended to the striking RN’s. With the breakdown of the democratic process, some RN’s began to shift their anger from management to the CNA.
On June 26 a settlement was announced. At 7 p.m. on June 27 the striking RN’s, without having been allowed to see the settlement, assembled at San Fransisco’s giant Cow Palace. Some of them angrily demanded individual hospital caucuses to discuss the agreement before voting on it. But after a short period of confused debate, a vote was forced. The RN’s accepted the package by a vote of 1,670 to 494.
Victory or Holding Action?
The CNA leadership touted the strike settlement as a major victory for RN’s. Most importantly, management failed to delete the key staffing clause from the existing contract. Concerning the specialty units, the new agreement provides that “Except in case of emergency, nurses without appropriate training and/or experience shall not be assigned to such areas.” The first five words are those of management, and whether this clause is a victory or defeat for the RN’s depends on how “emergency” is defined. Management decides what is an emergency unless the CNA can overturn their definition by filing and winning grievances. The hospitals also agree to provide training for specialty care.
The RN’ s won a whopping 11 percent pay boost, felt by some to be an overt attempt to buy them off. In fact, the figure represents the 5.5 percent raise asked for plus a one-shot 5.5 percent cost-of-living adjustment to cover inflation since January 1. The RN’s failed to win a continuing cost-of-living escalator clause. The demand for alternate weekends off was compromised, and the portable pension plan was not granted but was submitted for study. Management conceded to the opening of certain issues for renegotiation on January 1, 1975.
Rather than a victory, the settlement is actually closer to a successful holding action. With the economy in decline, hospitals, like all industries, are trying to squeeze more work out of their employees at lower cost to themselves. The retention of the staffing clause provides the RN’s with at least some leverage to fight against understaffing and speed-up. The pay increase slows the rate at which RN’s incomes fall behind inflation. The specialty staffing clause, provided that the RN’s fight for its implementation, is the only substantial move ahead. Given management’s refusal to yield the slightest decision-making authority to the RN’s, the staffing portions of the new contract are of little use without constant grievances and battles for enforcement by the RN’s at each hospital.
The New Consciousness
After five months of negotiating and 21 days of striking, the RN’s won a holding action but made few advances in changing their objective conditions of work. RN’s have returned to find the wards still understaffed and themselves still overworked. And the tensions manifested during the strike between RN’s and those who take orders from them, such as LVN’s, orderlies and aides, have not magically disappeared.
Nevertheless, for the RN’s the strike had significance that went past the bargaining table and changes in objective conditions of work. The most marked achievement was the mobilization of the RN’s from the wards to the picket lines and the development of a sense of unity, militancy and self-reliance — the antitheses of the passive role women are socialized into in nursing school.
Equally important was the way the strike served to break down the isolation among RN’s. There are many structural organizational reasons for hospital workers to be isolated from one another: Wards are physically separate, some jobs are more prestigious than others, some pay more and people on different shifts seldom see each other. Moreover, the assigned workloads are often so heavy that merely getting one’s work done is difficult. Working together during the strike gave RN’s a chance to get to know and trust on another as well as to develop collective strategies and solutions. An obstetrics nurse at Alameda Hospital stated, “The strike has given us a new sense of unity.”
The strike also served to show the true face of the CNA. Throughout the five months of negotiations and for the first part of the strike the CNA was remarkably democratic, allowing for participation by rank-and-file RN’s. RN’s were represented on both the negotiating team and the Negotiating Council, bringing the latest developments and management offers back to RN’s at the hospitals they represented. In the last week of the strike, however, the CNA reverted to top-down, heavy-handed tactics, which many RN’s found infuriating. Refleeting this anger, a committee of RN’s at Mt. Zion Hospital sent the following letter to the CNA:
We at Mt. Zion feel that we were sold out…. The most charitable view expressed has been that the team members had hit a low point in their motivation and energy and that they were afraid to let Usery leave without a settlement…. The other, less charitable opinion is that the strike was, from the first, a grandstanding maneuver by the paid officials of the CNA; a tactic to tighten their hold on jurisdiction over RN’s in the Bay Area…
We feel that these questions must be spoken to by the leadership of CNA. We ask for the support of all CNA members in working to ensure that this betrayal of democratic principles in our organization does not repeat itself. We are willing to work within CNA to make the leadership more responsive to our needs and to strengthend their commitment to the democratic process. We are willing to work to use the contract to make whatever progress is possible on the issues of staffing, patient care, and professioinal self-determination. We hope that our analysis of the situation will provide food for thought for all CNA mambers returning to work under this contract.
Democracy, however, is far from the central issue regarding the CNA. What is at question is the difference between a professional association and a non-hierarchial anti-professional organization of workers fighting for their own power and interests. Historically the CNA, while making minimal support gestures in other hospital workers’ struggles, has not even honored picket lines during their strikes. By choosing to go it alone, the CNA not only loses a powerful bargaining weapon, but keeps RN’s separated from the majority of hospital workers.
The Old Contradictions
While on the one hand the strike raised the level of consciousness of the RN’s, on the other hand it manifested and exacerbated the existing tensions and contradictions found in the hospital workforce-namely the race, class and sex antagonisms upon which the hierarchical division of labor rests. At the top of this hierarchy are the male administrators and physicians, enjoying high status, income and power. Next come RN’s, predominantly white female professionals, who in this case were demanding a piece of the pie. Beneath them are LVN’s, aides, orderlies and other low-paid, predominantly Third World workers who make up the majority of the workforce and take their orders from the RN’s.
While RN’s are in supervisory roles and make more money than other hospital employees, they are still wage workers and are exploited as such. The ideology of professionalism promotes elitism on the part of RN’s, but in fact they have more in common with other workers than with doctors or administrators. The RN’s are pawns in the hospital hierarchy, placed in positions in which they must assume responsibility for running a floor and give orders to other: workers. They are forced to act as a buffer for the doctors and administrators, becoming, whether they like it or not, the most visible authority figures, who do the dirty work of the administrators and boss other workers around.
Reactions of other workers during the strike underscore these tensions and hostilities. A worker at Children’s Hospital in San Francisco said, “We’re better off without them here.” Another worker characterized the strike, “The attitudes of the nurses during the strike seem to have been taken over from doctors- anti-union, pro-professional, pro-specialization. They were competing with doctors to gain more decisions over patient care by raising their level of professionalism to that of doctors.”
In the final analysis, RN’s alone cannot shut hospitals down and bring significant change to their workplaces. In the long run, demands for professional upgrading by RN’s are made at the expense not only of other workers but of the RN’s themselves. The RN strike has made clear the tremendous obstacles to success that exist when different hospital workers’ groups fight their own battles in isolation and even opposition to those of other health workers.