Last Updated 27 Mar 2020

Labor Unions in Hospitals

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Organizing and other labor union activity in the hospitals has drawn increasing attention for many years. The American Nurses Association (ANA) is the largest and oldest professional association of registered nurses in the USA (Martin, 2001). The ANA and state nurses associations are committed to the rights of registered nurses (RN), the largest group of health professionals.

The ANA represents registered nurses through organizing and bargaining collectively. The ANA is definitely for creation of labor unions in hospitals ("Physicians and Unions: Implications for Registered Nurses", 1998). This paper focuses on the development of these unions and outlines that union activity has an important role for nurses in addressing the benefits and salaries and in providing the appropriate care for patients.

Labor Unions in Hospitals

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The leadership of formal nursing organizations historically reviewed labor unions and labor legislation with suspicion, if not with direct distaste. In the early of the 20th century, the American Nurses Association (ANA) did not consider the nursing discipline as a profession and its practitioners as professionals (D'Antonio, n.d.).

On the contrary, practicing clinical nurses were somewhat more receptive to the idea of unions. The Nurses Associated Alumnae, founded in 1896, became the American Nurses Association in 1911, and nurses successfully lobbied for strict registration credentials. (“United American Nurses, AFL-CIO”, n.d.)  But the initial registration laws were voluntary (D'Antonio, n.d.).  Nurses joined together at the end of century to fight the lack of standardization among quickly development of nursing schools, hard working conditions and exploitation of nursing students.

Nurses also sought a means to work together in a professional organization to establish a code of ethics, elevate nursing standards and promote the nurses interests. The first nurse staffing ratios were set by the Continental Congress during the Revolutionary War. The first permanent hospitals were established during that war—but it wasn't until 1872 that America could boast its first professionally trained nurse, Linda Richards. (“United American Nurses, AFL-CIO”, n.d.)

During the early 20th century, nurses joined other workers looking for such benefits as an eight-hour workday and paid vacations. By the 1930s, ANA and state nurses associations were considering the question of unionization for nurses — a responsibility ANA confirmed in 1946.

During the 1920s and 1930s many nurses left the private-duty labor market to work in hospitals (D'Antonio, n.d.) They saw that the professionalization rhetoric did not forward their fight to control the quality as well as the conditions of their day-to-day work. Gradually the unionization idea helped to some hospitals' nursing staffs to secure contracts that improved wages and hours worked.

In the early 1940s state nurses' associations, without the support of the ANA that was opposed to formal organizing, began their own collective bargaining units (D'Antonio, n.d.).  But in 1946 the ANA formally sanctioned the idea of "professional" collective bargaining by its constituent state nurses' associations (D'Antonio, n.d.). In the post-World War II era nurses gained contract after contract.  Also in 1946 the ANA began the establishment of its Economic and General Welfare Program (“The Role of Collective Bargaining and Unions in Advancing the Profession of Nursing”, 1998).

That decision was made because of some of the same problems that nurses and nursing continue to face and from a desire to use collective wisdom and strength to effect necessary change. Nurses were represented on a national level as well, including a decades-long battle against the 1947 Taft-Hartley Act that left private RNs without coverage under the National Labor Relations Act. Since then, collective bargaining has provided for significant accomplishments in salaries, benefits, and the professional practice of nurses.

Historically, the nursing profession has worked to assure the public of  its commitment to their health needs through the establishment of professional licensure, practice standards and guidelines, and a code of ethics. Nurses have moved from the hospital into academe, research, long-term care, community and home health, school systems, the legislature, the military, law, and entrepreneurial enterprise.  Each avenue broadens professional perspective and adds value to the body of expertise and influence.

By the late 1960s the trade union movement had again resurfaced as a strategy for professional autonomy and economic security (D'Antonio, n.d.). Unions such as Local 1199 of the Hospital Workers Union reorganized to allow nurses separate guilds; and strikes, although deeply regretted, were no longer unthinkable tactics (D'Antonio, n.d.).


Labor unions representing nurses

In the past 20 years, nurses in hospitals and health care agencies all over the world have unionized in an effort to achieve  appropriate wages and benefits based upon the skill level and risk involved in successfully fulfilling their job responsibilities (Klein, n.d.). There are some examples of active unions representing nurses. The UFCW (United Food and Commercial Workers Union)  represents nearly 40,000 working men and women in the health care profession in the North America who work in hospitals, nursing homes, medical and dental laboratories, and home health care (Klein, n.d.).

Members include registered nurses, licensed practical nurses, unit assistants, certified nursing assistants, pharmacists, technicians, and caretakers. This union claims to have improved safety in the workplace and tackled a myriad of important issues, including restructurings, staffing levels, and compensation. Additionally, to being committed to workplace issues, the UFCW periodically sponsors training and education seminars to promote professional development among health care employees.

The United Nurses of America represents 45,000 registered and licensed practical nurses and is an AFSCME affiliate (Klein, n.d.). AFSCME is the voice for 360,000 health care employees, 76,000 of whom are nurses  (Klein, n.d.).  For its members, AFSCME provides training programs, information on workplace violence, a health and safety newsletter and fact sheets, and updates on union actions.

The ANA has also created the new United American Nurses (UAN) to strengthen collective bargaining states' efforts to retain and recruit members. Now, according to the ANA, 24 states or U.S. territories have collective bargaining for nurses; 29 do not (the total of 53 includes Guam, the U.S. Virgin Islands, and the District of Columbia) (Hellinghausen, 1999).  Today's  UAN, the nation's largest union of staff RNs, began from the nurse unionization movement before World War II. (“United American Nurses, AFL-CIO”, n.d.)

For more than 50 years, nurses, through their state nurses associations, have organized to advocate for fair wages, good working conditions and staffing levels that ensure patient safety. State nurses associations struggled for state measures to pick up the slack, and the 1974 health care amendments to the NLRA finally extended such protections. Amendments to the NLRA passed in 1983 extended Social Security coverage to non-profit workers.

The United American Nurses' forerunner, the Institute of Constituent Member Collective Bargaining Programs, met for the first time in September 1990. Nurses' efforts through the Institute to find the solutions of workplace problems led to the organisation of a separate labor arm of ANA—the United American Nurses—in 1999.

The UAN held its first National Labor Assembly in June 2000, as representatives of 100,000 nurses working under collective bargaining agreements elected Cheryl Johnson as the union's first president and Ann Converso as the union's first vice president. UAN affiliated with the AFL-CIO in 2001.

With the addition of the UAN, the AFL-CIO represent now 1.2 million health care workers. (Martin, 2001) AFL-CIO unions bargain to provide health insurance for more than 40 million workers and family members -  accounting for one out of every four Americans with employment-based coverage. Johnson of the UAN said nurses are organizing into unions at an increased pace to gain a voice on the job and on behalf of quality patient care, and that giving nurses a voice can address the nationwide staffing crisis.

Now the UAN has offered strike support on a national level to nurses on the picket line; provided media training, organizing assistance and collective bargaining help through the annual Labor Leader Institute; provided a massive and meticulous contract information database to state nurses associations and nurse leaders; and provided testimony to national leaders on patient care, staffing and other issues.

Problems of nursing unions

In fact, the American Nurses Association (ANA) is "wed" to organized labor and in some states, such as California and Michigan, the state Nurses Associations act as labor unions. (“Subject:Union Debate”, 2003)

Most labor unions and Nurses' Associations claim that by organizing nurses, they can increase salaries, improve benefits and working conditions, and draw more nurses into the profession. It sounds plausible, but a union cannot address the real underlying problem: Money. Unions cannot produce revenue. They can only extract dollars from the healthcare system.

Nurses' salaries and benefits are typically a hospital's greatest expense. A hospital's primary source of revenue is from reimbursement for patient services. While hospital operating costs have steadily gone up, reimbursement for patient services by Medicare, Medicaid, and insurance have not kept up with increased operating costs. In a February 13, 2003 Press Release by the American Hospital Association (AHA), entitled "Rising Demand, Increasing Costs of Caring Fuel Hospital Spending," rising hospital cost is cited as one the primary drivers of an increase in hospitals' spending (“Subject: Union Debate”, 2003).

While organized labor would lead to believe there is an increased need for unionization, their popularity has declined. In our nation's past history, organized labor played an important role in ensuring employee safety in the workplace. Currently, standards for employee safety have been established by Occupational Safety & Hazard Association (OSHA), Joint Commission for Accreditation of Healthcare Organizations (JCAHO), American Osteopathic Association (AOA), and other regulatory and accrediting bodies.

Therefore, the need for unions has declined. Especially because recent changes in healthcare have subjected nurses to the effects of cost cutting, shuffled duties and reorganization, not to mention a chronic nursing shortage. Just 17% of the nation’s 2.2 million RNs belong to unions, and labor groups are looking to nursing to boost their dwindling ranks (Salcedo, n.d.). Two AFL-CIO affiliated unions actively pursuing nurses are the Service Employees International Union (SEIU) and the United Food and Commercial Workers Union (UFCW).

There have been several instances of already formed collective bargaining units represented by the state nurses’ association switching to AFL-CIO affiliated unions. The American Nurses Association is reeling from the defections, including the defection of the 20,000 member CNA from the ANA in 1995 (Salcedo, n.d.). The California affiliate complained that the national leadership wasn’t doing enough to combat layoffs and staff shortages. (Jaklevic, 1999)

Each state nurses association (except now California) is a member of the ANA. Each state nurses association is divided into two branches, a policy branch and a collective bargaining branch. The ANA is loudly protesting that “only nurses should represent nurses”, however, unions such as the SEIU charge that the associations are much more geared toward policy making and academic issues than collective bargaining.

So, there is currently a critical shortage of nurses in USA. As long as nurses continue to feel disenfranchised, unprotected and under siege by doctors and health care administrators, interest in unions will grow stronger. Nurses organize not only to protect themselves, but also to protect the patients under their care, as evidenced by the recent activity regarding staffing levels and acuity systems.

As an example, nurses, traditionally uninterested in the distractions of organized labor, are showing new eagerness to embrace unions (Seeman, 2000). But rather than objecting to pay scales or benefits plans, experts say, they are aiming more often at working conditions - depleted staffs, reduced time with patients, jobs that increasingly intrude upon their personal lives.

Union membership is rising. The string of strikes in 1999 - 21 - was five times the number just four years earlier. (Seeman, 2000). More than 1,000 nurses are currently off the job. (Seeman, 2000). In California, union nurses have pushed lawmakers to guarantee more nurses on hospital floors.

Hospital officials and insurers characterized the grievances as understandable but difficult to assuage. Current health care dynamics, they said, are testing the limits of all segments of the industry.

What's unknown is whether nurses' relationship with labor will gain more momentum, and what long-term effects that might have on the nation's medical network.

In the early part of the decade, with the price of health care soaring, managed care gained currency as a strategy to encourage competition and control costs. Insurers notified hospitals that reimbursements for medical treatments would decline. That prompted hospitals to squeeze budgets, including the money spent on nurses, who typically represent about a quarter of a hospital's work force.

Hospital patients, meanwhile, grew sicker. Diseases that might have been fatal in an earlier age now left patients alive but ailing. Hospitals, under pressure to save money, discharged the less sick patients to focus on the direly ill. Technology made nursing much more complicated.

In the past three years, about 15,000 nurses have become unionized by joining the Service Employees International Union. (Seeman, 2000).  About 105,000 nurses now belong. (Seeman, 2000).

Another 170,00 belong to the American Nurses Association (Seeman, 2000).  Of those, about 60 percent use the organization for collective bargaining, according to the ANA. (Seeman, 2000).

The overall numbers remain relatively small. Only about 15 percent of America's 2.6 million nurses are unionized, according to government and industry estimates. (Seeman, 2000).

The BNA, echoing the nurses unions, said that walk-outs are more likely rooted in complaints about mandatory overtime, inadequate staffing and worries about patient care.

In California, the new law supported by union nurses requires the state to set nurse-to-patient ratio standards for general, psychiatric and special hospitals. Hospitals will also be banned from requiring unlicensed employees from performing traditional nursing duties such as giving medicine or assessing treatment. The bill was signed in October by Gov. Gray Davis. Its requirements were phased in through 2002. (Seeman, 2000).

Massachusetts, meanwhile, has become very important for union activity. The Massachusetts Nurses Association persuaded about 1,550 nurses at five hospitals to unionize in a 12-month period in 1997-'98, according to Judith Shindul-Rothschild, associate professor at the Boston College School of Nursing. (Seeman, 2000).

So, administrators should try to understand nurses. If to give the possibility to nurses to effectively care for their patients, half the battle is won. Better healthcare would mean better labor management relationships.


So, the American Nurses Association (ANA), along with its constituent state nurses associations, has a decades-long responsibility to the right of registered nurses, the largest group of health professionals, to represent through organizing and bargaining collectively, in labor unions ("Physicians and Unions: Implications for Registered Nurses", 1998).

Such activity can play an important role in addressing wages as well as benefits, and the many employment conditions that have a direct bearing on nurses' ability to practice their profession and to grant the highest quality care for their patients.

One of the most essential problems of unions is that there are no "guarantees" as to what will be included in a contract between management and the bargaining unit. Everything depends on contract negotiations. In other words, nurses may achieve less salary and/or benefits than before unionization.

Still, unionism is only one of some options to ensure nurses' control over their practice. For nursing always has and always will need different organizing alternatives, whether through unions or specialized practice associations.

1. D'Antonio, P.  (n.d.). Labor Unions: Nurses' Unions. Retrieved July 10, 2004, from

2. Hellinghausen, M. A. (1999, August 9) ANA's creation of labor entity worried the TNA. Retrieved July 10, 2004, from

3.Jaklevic, M. (1999, July 5). Associations join pro-union ranks’ Doc, nurse organizations want to give their members a stronger voice, new services. Modern Healthcare, 6.

4. Klein, J. A. (n.d.). Unions in Nursing. Retrieved July 10, 2004, from

5. Martin, S. (2001, June 28) Largest Independent Nurses Union Votes to Affiliate with the AFL-CIO. Retrieved July 10, 2004, from

6. Physicians and Unions: Implications for Registered Nurses. (1998, September) Vol. 3, No. 9. Retrieved July 10, 2004, from © 2004 The American Nurses Association, Inc. All Rights Reserved

7. Salcedo, K. (n.d.). Labor Unions and Nursing. Retrieved July 10, 2004, from;idenc=KxyHiuJa

8. Seeman, B. T. (2000) Working Conditions Drive Hospital Nurses Toward Unions. Newhouse News Service. Retrieved July 10, 2004, from

9. Subject: Union Debate. (2003, February 24) Nurses for Preservation of Professional Ethics (NPPE). Retrieved July 10, 2004, from

10.The Role of Collective Bargaining and Unions in Advancing the Profession of Nursing. (1998, February)  Vol. 3, No. 2. Retrieved July 10, 2004, from © 2004 The American Nurses Association, Inc. All Rights Reserved

United American Nurses, AFL-CIO. (n.d.) Retrieved July 10, 2004, from © 2004 The United American Nurses and The

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