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Nurses and health care workers across the country are finding strength in numbers and with labor actions not seen in years.

In California, which has a strong union tradition, Kaiser Permanente management misjudged workplace tensions during the covid-19 crisis and risked a walkout of thousands when union nurses balked at signing a four-year contract that would have slashed pay for new hires. In Colorado, Pennsylvania, North Carolina and Massachusetts, nurses have been embroiled in union battles over staffing and work conditions.

As deadly coronavirus cases spiked this year, daily pressures intensified on hospital floors. Some nurses retired; some became travel nurses, hired by agencies that advertised more than double, even triple, the day rates for intensive care unit, telemetry and emergency room nurses. Others gave up their jobs to avoid possibly carrying the covid virus home to their families.

“Things had gotten particularly stark for nurses,” said Rebecca Kolins Givan, an associate professor of labor studies at Rutgers University.

‘They Can Make More at McDonald’s’

It was so grim in Pittsburgh that registered nurses at West Penn Hospital, part of the Allegheny Health Network, voted this year to authorize a strike — less than a year after they unionized with SEIU Healthcare Pennsylvania. Chief among their complaints: The hospital system had balked at improving staff ratios even as it offered bonuses, up to $15,000 for some, to hire registered nurses to fill vacancies.

Kathleen Jae, a member of the bargaining team that reached a pact without a work stoppage, said nurses wanted management to work harder to retain veteran staff members: “We had to face the fact that nurses are retiring, nurses are leaving the bedside out of frustration, and, in certain instances this year, nurses had more patients than they felt comfortable taking care of.”

Allegheny Health Network said the first-ever pact with RNs at West Penn provides “competitive wages and benefits” to help it “recruit and retain talented, experienced nurses.”

Liz Soriano-Clark, a teacher-turned-nurse on the bargaining team, said the pandemic had made workers across the health sector more careful and choosier about what jobs they’ll take.

“There’s a nursing shortage and a shortage of nursing instructors, nationwide. They’ve seen aides leave. They’ve seen cleaners leave,” Soriano-Clark said. “Why is that? Because they can make more at McDonald’s and not have to clean up vomit.”

In September, the alerted the Biden administration to an “unsustainable nurse staffing shortage facing our country” in a . The ANA said a “crisis-level human resource shortage” was evident: Mississippi had 2,000 fewer nurses than it did at the beginning of 2021. Tennessee called on its National Guard to reinforce hospital staffs. Texas was recruiting 2,500 nurses from outside the state.

Union membership among U.S. nurses has inched up over the past 15 years and held steady, , for five years, according to , an academic website. But 2021, a year of union organizing and holdouts in such disparate workplaces as Starbucks cafes and John Deere tractor plants, might well be a turning point for essential workers in health care.

“If you ask nurses what they want,” said Givan, who interviewed dozens of nurses on health care workers, “they want working conditions where they can provide a high level of care. They don’t want appreciation that is lip service. They don’t want marketing campaigns. They don’t want shiny new buildings.”

Still, Givan noted, the health care sector has spent handsomely to fight unions.

After years of staff retention issues at Longmont United Hospital in Colorado, nurses are awaiting the results of a vote on whether to join National Nurses United, the largest union of registered nurses in the U.S.

Stephanie Chrisley, a registered nurse in the hospital’s ICU, said nurses are regularly caring for double the number of patients — often three to four “ventilated, sedated, critically ill patients.”

She and others protested outside the hospital in early December. They said the company that runs the hospital, Centura Health, this year had employed aggressive union-busting tactics, including disputing a handful of votes, which dragged out the union election for about five months. In another instance, her colleague Kris Kloster said, Centura, , issued company-wide emails announcing raises and retention bonuses for everyone except nurses at her hospital.

“Where there should have been newly hired nurses, there were anti-union consultants roaming around the hospital,” Chrisley said. Since July, she added, the hospital has lost nearly 80 RNs, “nearly a third of our nursing staff.” Longmont United Hospital Interim CEO Kristi Olson said in a statement that the hospital “will remain open and fully operational” and that “we are committed to making sure that all voices were heard” in the union election.

Organizing can take a long time, Givan said, pointing to tense labor negotiations in Massachusetts, North Carolina and Pennsylvania. “But when there is a crisis — what we call a hot shop — you can get workers to organize quite quickly.” Nurses represented by the Massachusetts Nurses Association walked off the job March 8 in Worcester. A chance to break the bitter impasse collapsed when management, Tenet Healthcare, refused to allow some nurses to return to their original jobs. In North Carolina, registered nurses at Mission Hospital in Asheville ratified a contract with the HCA management that locked in 17% raises over three years and set up a committee to review patient care conditions.

A recent poll by Gallup, the global analytics firm, found that the share of Americans who say they approved of unions was at 68%, its since 1965.

Sal Rosselli, president of the National Union of Healthcare Workers, said that in the past year “there has just been an explosion of leads,” queries from health workers exploring how to unionize.

Rosselli, whose organization represents about 15,000 health workers, said the pandemic exposed practices that had long antagonized employees. Too many hospitals scrambled for masks, gloves and gowns, he said, and front-line workers were on round-the-clock schedules and facing ghastly daily deaths. “They weren’t keeping their employees and their patients safe,” Rosselli said, “and all because these systems were focused on profit over anything else. That has been coming on for a long, long time.”

Registered nursing is among the U.S. occupations expected to experience the greatest levels of job growth in the next decade, according to the Bureau of Labor Statistics’ . Also among the are nurse practitioners, home health care aides and assistants. Shortages of RNs and other health care workers are expected to be the most intense in the South and West.

Some of the most powerful nursing unions in the nation operate out of California, representing employees in Western states. “The nurses in California have the hours they have, the care they have, the protections they have because of the union,” said Soriano-Clark, who has worked at hospitals in California and Pennsylvania.

Ready to Picket in a Pandemic

Douglas Wong, a physician assistant, never imagined hoisting a “strike” sign outside Riverside Medical Center. But that nearly happened after a sobering breakdown in talks between Kaiser Permanente and a top nurses union at the facility, part of the KP system. Nurses, pharmacists and operations staffers are among the insurers’ 160,000-plus unionized employees, according to KP spokesperson Marc Brown.

The California-based health system giant tried to force a two-tier pay schedule that would have cut wages for new nurses by 26%. Wong and thousands of allies — many who dryly noted they had been heralded as “heroes” in the covid crisis — prepared to picket in the middle of a pandemic. Kaiser Permanente’s demands crumbled when dozens of affiliated unions threatened one-day sympathy strikes.

The tiered-pay demand and an attempt to lower wages in some markets were dropped. Staffing ratios were adjusted to ease safety concerns. Wong said that, despite the pact, the bruising negotiations “felt like a betrayal.”

“Make no mistake: This was an enormous win for labor, especially pushing back on the two-tier. At the end of the day, they pulled back. And we made huge strides toward improvement in our staffing,” said Wong, a six-year KP employee and an official with the United Nurses Associations of California/Union of Health Care Professionals.

The negotiations were a marked shift for Kaiser Permanente, which for most of three decades has relied on a labor-management partnership with its unions, emphasizing cooperative decision-making and robust discussions. Talks were held with teams, set around circular tables, hashing out concerns. KP was known for much of the past decade as a market leader in wages and quality of care, and the labor-management partnership was received by academics and labor experts as an innovative, successful approach to managing a workforce.

The health system recently hired new top executives, and, to the surprise of the unions, Kaiser Permanente used negotiations this year to offer the two-tier pay regimen, a tactic used by auto- and steel-makers during economic downturns in the 1980s. The union negotiators noted this: The health care giant’s management wanted to scale back wages after notching $6.8 billion in net revenue from 2018 to 2020.

On Thursday, workers voted to ratify a four-year contract with KP. The company declined to comment for this article. , Christian Meisner, KP’s chief human resources officer, said: “This contract reflects our deep appreciation for the extraordinary commitment and dedication of our employees” during the pandemic. “We look forward to working together with our labor partners,” he said, to “further our mission of providing high-quality, affordable care.”

that nurses’ pay was sweetened in 2021 by thousands of dollars in raises — handed out without union wrangling — as hospitals competed for workers. Premier, a health care consultancy hired by the Journal, analyzed 60,000 registered nurses’ salaries and found that average annual pay, not including overtime or bonuses, grew about 4% in the first nine months of the year, to more than $81,000. That compares with a 2.6% rise in 2019, according to federal data.

Raises don’t necessarily mean retention.

“There always seems to be a shortage of nurses,” said professor Paul Clark, who is a former director of Penn State University’s School of Labor and Employment Relations and has studied nursing and labor organizing. “But it’s important to realize there’s not a shortage of RNs. There’s a shortage of RNs willing to work under the conditions they’ve been asked to work.”

Aya Healthcare, a national travel nurse provider, has found that the pandemic aggravated historical understaffing at hospitals, spokesperson Lisa Park said in an email. “There were over 100,000 vacancies at the start of the pandemic. And now, that number has increased to over 195,000,” Park said. Travel nurses account for fewer than 2% of the nursing workforce, she added, but “with the increase in permanent vacancies due to burnout/resignations, the demand for temporary healthcare workers has increased.”

David Zonderman, a professor of labor history at North Carolina State University, noted that nurses unions have grown more political and more outspoken — in Washington, D.C., and their home states. Nurses on the hospital floor lived through a crisis — fearing for their lives amid shortages of protective equipment — much like the trials of American workers in the mining and manufacturing industries in decades past.

“This may sound weird,” Zonderman said, “but nurses are a little like coal miners. They tend to help each other. They are watching each other’s back. They have solidarity.”

“And,” he said, “if you treat people badly long enough, they finally say, ‘I’m done.’”

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