Special report. The new hospital labor picture: More unions? More strikes? More problems for security directors?

A recent U.S. Supreme Court decision upholding National Labor Relations Board (NLRB) rules for hospital bargaining units appears to be fueling union efforts to organize hospitals nationwide. As unions gain more footholds in hospitals, the prospects for strikes and labor unrest increase. This expected surge in organizing may place hospital security departments in critical situations, whether they're the specific target of unions or not. This report reviews the implications of the new bargaining unit rules as they affect hospital security operations.     

Labor relations: an update

Preventive labor relations training for managers and supervisors is vital today. Management must take the necessary steps to prepare its leadership to face the reality of hospitals being a prime organization target in the 1990s. The U.S. Supreme Court ruling will undoubtedly result in increased union activity as was experienced following the enactment of the 1974 healthcare amendments. Because of the rapid changes taking place within the healthcare industry and these new bargaining unit rules, hospitals will be targeted by unions. Management must be prepared in order to remain union free. Employee opinion surveys and preventive labor relations training for managers and supervisors are positive steps to be considered for a union-free workplace.     

Preparing for increased union organizing. A commitment to deal justly with employees is the best response to the new bargaining unit rules

The U.S. Supreme Court recently upheld a National Labor Relations Board regulation giving unions of healthcare workers the right to organize as many as eight different kinds of hospital bargaining units. With the Court's decision, hospital administrators must prepare for increased union organizing by maintaining policies that evidence the institution's commitment to social justice in the workplace. Hospital administrators can reduce the potential for labor-management conflict by stressing the institution's commitment to social justice and establishing programs to educate managers and other employees about Catholic teaching on social justice. Facility administrators should also establish a written philosophy statement outlining the institution's position on unionization, institute labor relations training, survey employees' opinions of management and their work environment, conduct audits of managers' perceptions of the organization's effectiveness, and periodically review the state of labor relations in the organization.     

Bargaining unit rules having little effect on hospital union activity

The number of hospital union elections rose only slightly between 1990 and 1991, suggesting that the National Labor Relations Board's new hospital bargaining unit rules haven't had much impact on hospital organizing efforts. NLRB data appear to contradict the dire predictions of many hospitals and labor attorneys who said expanded bargaining unit categories would lead to unbridled union organizing efforts.     

Union elections and the NLRB. The healthcare industry continues to challenge bargaining unit determinations

In the healthcare industry today, unions and management must cope with a confused, contradictory, and often changeable body of law and National Labor Relations Board (NLRB) policy when unions attempt to establish themselves at a particular institution. More than 15 years ago, Congress amended the National Labor Relations Act to grant labor unions the right to organize employees of not-for-profit hospitals and other healthcare organizations. An election to form a union cannot be held, however, until the NLRB determines which employee classifications constitute an "appropriate" collective bargaining unit. Since 1974, labor and management have fought over this basic question before Congress, the NLRB, and the federal courts. One paragraph of congressional instruction to the NLRB, which stipulates that the board prevent "proliferation of bargaining units in the health care industry," has over the years been construed in widely varying ways by the board and the courts. Management has argued that two units should be the maximum number allowed as appropriate whereas unions have argued for more. Last April the NLRB established a rule allowing for as many as eight bargaining units at a particular institution, but three months later a federal district court issued a permanent injunction against the rule. The board has appealed the injunction, and as both sides await a ruling, dozens of pending hospital union election cases have mounted up. Nor does a decision by a court of appeals promise to resolve the issue.     

Physician unions: any doctor can join, but who can bargain collectively?

Employees in the health care industry, including physicians, have recently taken more interest in unions and collective bargaining. At the present time the health care industry is approximately 20 percent unionized. Labor leaders believe that existing conditions are fertile ground for significant union activity that has been on a recent upswing after a decline during the early 1980s. While current attention is being drawn to the shortage of and increased union organizational activities by nurses, physicians may not be far behind. It is conceivable that by the year 2000 the majority of physicians in the United States will work in full-time salaried positions. In addition, the antitrust laws that currently restrain independent physicians from collective bargaining are being challenged and are likely to change as more physicians become salaried and begin to resemble other professional employee groups. The ruling determining that interns and residents are students rather than hospital employees is also certain to be challenged and changed, especially as pressures on the National Labor Relations Board (NLRB) are brought by house staff union organizations. After a 1987 ruling that the NLRB had been improperly interpreting the 1974 amendments to the Taft-Hartley Act, the NLRB was ordered to exercise its rule-making power in defining bargaining units for health care workers in acute care hospitals. Physicians would then be one of eight occupations defined as a separate health care bargaining unit.     

NLRB's St. Francis decision signals broader-based bargaining units

The number of potentially appropriate bargaining units in a hospital has been sharply reduced by the National Labor Relations Board's recent St. Francis decision. Following a series of rejections by the U.S. Courts of Appeals, the NLRB has abandoned its previous position and adopted new standards that it believes are more in keeping with Congress' directive to prevent the proliferation of bargaining units in the health care industry. The new standards require that there be unusually sharp differences between the wages, hours, working conditions, etc., of employees requesting a separate bargaining unit and those in an overall professional or nonprofessional unit. As a result, hospital bargaining units will become much more broadly based. The St. Francis decision does not, however, invalidate previous NLRB certification or relieve a hospital of established bargaining obligations. To establish the appropriateness of broader based units, employers can ensure that employees in such a proposed unit are covered by a centrally administered wage and salary program with common wage scales, labor grades, pay increments, and job performance evaluation standards. Functional integration, continuing education and training, job transfers, shared facilities and activities, and centralized personnel policies and procedures are also areas in which employees' mutuality of interest can be established, thereby supporting the creation or maintenance of broad units.     

Collective bargaining practices in the health care industry: an empirical analysis

The study described in this article focuses on the effects of collective bargaining on the health care industry. Due to the wide range of bargaining groups authorized to become unionized in the health care industry, this study concentrates on how collective bargaining affects the nurses in hospitals. The authors also surveyed a number of administrators and nurses in several hospitals in the midwestern part of the United States to secure their opinions about the effect of the union on their profession. The results of the survey are presented. Finally, the authors summarize related themes and interesting points from the literature and the surveys and provide recommendations.     

Supreme Court to hear ADA suit involving arbitration clause

The U.S. Supreme Court agreed to review a third case under the Americans with Disabilities Act (ADA) this year. The Supreme Court previously agreed to hear Bragdon v. Abbott, involving a dentist who refused to treat an HIV-positive patient in his office. The second case is Pennsylvania Department of Corrections v. Yeskey, in which the State asserts that the ADA does not apply to prisons. The third involves whether an arbitration clause in a labor union's collective bargaining agreement prevents a court from hearing a union member's discrimination claim. South Carolina longshoreman Ceasar Wright alleges that the South Carolina Stevedore Association and several employers violated the ADA when they refused to help him for employment referral. Wright previously settled a workers' compensation disability claim with Stevens Shipping and Terminal Co., his employer. Three years later he applied for work at the International Longshoreman's Association hiring hall and was referred to four different employers. The employers discovered he had received a worker's compensation settlement and would no longer accept Wright for employment referral. The case is important because union members can continue to file ADA charges with the EEOC and the outcomes will vary depending on the circuit where the union member happens to file the claim.     

On evaluating the impact of flexibility enhancing strategies on the performance of nurse schedules

Hospitals develop nurse schedules that cover a period of 4–6 weeks and are posted several weeks in advance. Once posted, changes to the schedule require voluntary participation by the nurses, making it difficult for hospitals to respond to changes in nursing needs and availability of nurses. At the same time, nursing needs’ forecasts developed several weeks in advance are often wrong. In each hospital setting, there may exist several promising strategies to enhance scheduling flexibility and reduce the mismatch between the nursing needs and the availability of nurses. However, methodologies to evaluate such strategies, before testing them in expensive pilot implementation, do not exist. We demonstrate how such evaluations can be carried out using historical data. Furthermore, we demonstrate the use of our approach by evaluating the benefits of a strategy where nurses are divided into two cohorts and schedules are phase shifted for the two cohorts. Staggering schedules allows nursing unit managers to benefit from more frequent updating of needs’ assessments without having to change work rules. Upon applying our approach to data from a large urban hospital, we discovered that in this example staggering did not improve the performance of nurse schedules. We discuss possible reasons for this result, its implications for hospital managers, and other potential uses of our approach.     

NLRB rule making. The impact of regulatory reform on hospital unionization

Many hospital executives feared that the National Labor Relations Board's 1991 decision to recognize eight hospital employee bargaining units would lead to increased union activity. However, this study shows that union activity actually decreased after that decision.     

Collective bargaining with professionals: conflict, containment or accomodation?

The prospect of a collective bargaining unit in his institution sends shivers down the spine of the health care facility manager. What are the concerns--and are they warranted? This study of an actual situation at "Central Hospital" identifies those concerns and follows them over 10 years to point up some implications of the collective bargaining agreement for managers, the bargaining unit--and other professionals in the institution who might be affected.     

Physician collective bargaining in a U.S. public hospital.

In a study to investigate the factors that would drive attending physicians employed in a public hospital to seek collective bargaining with their employer, the authors developed an instrument to determine which variables and which hypotheses were predictive of union proneness. The findings reveal that a desire for voice was the number one reason for physicians' wanting to join a union. Union-prone physicians had a lower salary on average, were more dissatisfied with their income, were more likely to feel the effects of work "speed up" (too many patients and too little time), were less likely to have administrative functions (thus a larger patient care role), had a strong sense of entitlement to collective bargaining, believed that unions improve participation in decisions affecting their jobs (reinforcing their desire for voice), and had a sense that a union would improve their treatment by supervisors (reinforcing their desire for due process and equity).     

Supreme Court rejects longstanding labor rule for nurses. NLRB v. Health Care & Retirement Corp. of America

This past year, the Supreme Court significantly changed the rules regarding whether nurses are entitled to unionize, strike, and engage in other concerted activities under the National Labor Relations Act (NLRA). Health care employers may now lawfully deny NLRA rights to any nurse that assigns or responsibly directs the work of other employees in a manner that requires the use of independent judgment. Accordingly, health care employers will need to revise their labor relations policies and implement well-informed litigation strategies for defending their decision making in light of the Supreme Court's ruling.     

The paradoxical impact of health care restructuring in Canada on nursing as a profession.

This article draws on the concept of "countervailing powers" to explore some of the contradictory effects of Canadian health care restructuring on nursing. The main focus is on key institutional powers in the nursing field, the major individual and collective strategies nurses have adopted in response to restructuring, and the ways in which the interaction between global and national market forces and the aggregate responses of nurses has created a severe shortage of nurses. The global shortage has led to a global competition for nurses' labor. This, along with government budget surpluses, has increased nurses' bargaining power, forcing governments and hospital managers to reverse nursing spending cuts; to offer more secure professional jobs, as opposed to casual work; to engage in aggressive, bonuses-laden recruitment of nurses, both within Canada and abroad; and, more generally, to rethink some of their restructuring strategies. However, since the bargaining power of nurses is largely market dependent and, as such, highly variable, there does not seem to be much potential for a sustained increase in the institutionalized power of the nursing profession.     

Changing images of professionalism: the case of public health nurses.

A survey of 89 public health nurses in a California county explored factors that might account for the growing support of unions and subsequent militancy among nurses. As predicted, changes in the backgrounds of public health nurses have occurred over time: 1) older nurses are more likely to have graduated from a diploma program and to have parents of lower educational and occupational attainment than younger nurses; 2) older nurses are more likely to view nursing as a calling and less likely to desire representation in collective bargaining by the union or to believe striking professional; 3) older nurses and those from lower social class backgrounds were less likely to belong to the union and less likely to participate in a county-wide strike. Because age and parental background factors are independently related to our indicators of militancy--union membership and participation in a strike--the results are interpreted as a change in nurses' images of professionalism.     

Trends in hospital unionization and a predictive model for unionizing success

Between 1976 and 1980, the average annual increase in hospital expenses was 12.7%. Wages for employees accounted for approximately one-half of this increase. Because employee wages have such a great effect on hospital costs, it is important to study those factors that could curtail management's control over these expenses. One such factor is the establishment of labor unions. This study outlines the structural factors that encourage union activity, as well as the factors that contribute to its success. Variables studied include: the types of employees in the bargaining unit; the total number of employees in the bargaining unit; the number of hospitals in the same city; the control of the hospital and the presence of a profit motive; the number of beds in the hospital; the occupancy level of the hospital; and the region of the country in which the hospital is located.     

Physicians and collective bargaining

This article discusses both the history of physician collective bargaining and the applicability of the 1974 health amendments of the National Labor Relations Act to this subject. Gordon outlines the issues for housestaff programs as well as for hospital-based professionals. The scope of physician bargaining includes: wages, hours, working conditions and issues related to the quality of patient care. Housestaff collective bargaining often addresses the issues of on-duty meals, free laundry and uniforms, subsidized housing, parking facilities, and on-call rooms. The concerns of staff physicians include tenure, pensions, and insurance benefits. Gordon suggests that the difficulty and novelty of physician/ hospital collective bargaining will frequently result in an impasse. He states that the propriety or impropriety of a doctors' strike depends upon: (l) the patient-care implications of the grievance causing the strike; (2) the gravity of the grievance leading to work stoppage; (3) the consequences of the strike for patient care; and (4) the other alternatives available. In the view of the author, a doctors' strike may be justified when it arises from a grievance relating to patient care as well as to self-aggrandizement. He states,"...if the strike is the only effective method of making known conditions prejudicial to patient care, including conditions which regularly and systematically cause loss of health and life, the physician may be obliged to engage in such a strike, rather than desist from such action." He concludes that as professionals shift from being private entrepreneurs to salaried employees, they will be compelled to use a collective bargaining approach for professional as well as economic concerns.     

A profile of hospital union election activity, 1985--1994 NLRB rulemaking and results in right-to-work states

The authors present union election results in non-governmental, short-term hospitals for the 10-year period 1985--1994. The authors include profiles for the periods before (1985--1989) and after (1990--1994) the National Labor Relations Board (NLRB) rulemaking. When comparing the period data, they found that the impact of rulemaking was a reduction in mean bargaining unit size, an increase in the absolute number of elections in hospitals, and an increase in the percentage of union wins. Their examination of hospital union election results in right-to-work (RTW) versus non-RTW states revealed that unions did not aggressively try to organize workers in non-RTW states and, when they did, they were not very successful. When the authors examined only initial recognition elections during the periods before and after rulemaking, as well as the whole 10 years, regression analysis identified three variables significantly related to union wins: the 1989 NLRB rule change, bargaining unit size, and employee participation rates.     

The role of nursing in bridging the gap between managers and physicians in hospitals

Tension between hospital managers and physicians is at an all-time high. This article builds on a previous work on the culture of managers and physicians and suggests that nurses can play an instrumental role in bridging the gap between these 2 cultures. Several similarities appear between managers' and nurses' cultures, other similarities can be found between physicians' and nurses' cultures, whereas nurses' culture seems to fall somewhat in the middle of the continuum on some other cultural aspects. Therefore, we suggest that nursing can and should play a crucial role in bridging the gap between the worlds of management and medicine. In a way, nurses can act as "translators," who can explain physicians' views to managers and vice versa. Practically, this will mean a better-defined role for nurses in key hospital committees and task forces, a more active role of the chief nursing officer in the Chief Executive Officer-Chief Medical Officer, and, more importantly, better representation of nurses on hospital boards that already have physician members.