Why Nurses Strike And What Needs To Change

The eight-hour workday, weekends, and child labor laws all came out of unions and strikes. Nursing is no different.

A strike happens when negotiations between a union and an employer stall and workers refuse to work. It is risky. Historically, strikers have lost their jobs, and some died in violent clashes with police. Nurse unions gained prominence in the 1940s with the same goals as unions in other industries: regulate the profession, raise wages, improve conditions. They have won real gains, but today's nurses are still fighting for the originals and some new ones.

"The complaints they hear from nurses at the bedside have to do with the conditions they're working under, the lack of power to speak up, and the lack of autonomy to make more meaningful decisions," says Denise Duncan, RN, president of the United Nurses Associations of California (UNAC).

Union membership across U.S. industries has been declining for years. But labor experts believe COVID-19 reignited interest, especially among healthcare workers. Strikes had become rare before the pandemic. In 2021 and 2022, nurses struck in New York, Massachusetts, California, and Oregon, and many others came close.

3 Reasons Nurses Strike

Concerns vary by region, but three problems come up everywhere.

1. Inadequate Staffing

Nurse-to-patient ratios top the list. COVID-19 intensified it, but understaffing has been a problem for over a decade. When a hospital is short, nurses absorb the slack, and stress and burnout follow. In a 2020 survey of healthcare workers, nearly half of 20,000 respondents reported burnout.

"We've been talking about it for so long, and nobody wants to listen," says Theresa Brown, PhD, BSN, RN, and a New York Times contributor. Brown came to nursing later in life and was struck by how overworked her colleagues were, sometimes covering for nurse aides on top of their own duties. "Nobody can keep doing the jobs of two people over and over and not have it wear on them."

Nurses say an ideal ratio is 1:1 or 1:2. In practice it runs 1:3 to 1:5 and can reach 1:10 in some hospitals. Understaffing and burnout are the biggest causes of turnover. In November 2021, one-third of RNs surveyed said they were considering leaving direct patient care.

Ratios aren't only about nurse well-being. Studies show inadequate staffing is linked to higher patient mortality. The shorter-staffed the hospital, the more likely a fatal medical error.

Brown compares it to cooking dinner. "If you're hurrying around slicing and dicing, you're much more likely to make a mistake than if you have a calm environment and enough time." But a mistake in a hospital isn't a burnt entrée. It can be life or death. In spring 2022, Tennessee nurse RaDonda Vaught was convicted of negligent homicide and gross neglect of an impaired adult after a fatal drug error killed a patient. The case amplified the conversation around understaffing and preventable hospital deaths.

Hospitals often argue they can't find enough nurses. In many states the issue is less a true shortage than an unwillingness to staff adequately. In Massachusetts, the number of licensed RNs rose 24% between June 2019 and February 2022, yet many hospitals stayed short-staffed. A 2018 state ballot measure to improve staffing was defeated over fears it would hurt hospital operations. Congress has reviewed a federal bill requiring minimum ratios, which drew the same opposition. California is the only state that has carried out such a law, passed more than 20 years ago.

2. Nurses' Safety

From 2015 to 2019, RNs missing work for illness or injury held steady at 19,000 to 21,000 a year. In 2020 it nearly quadrupled to over 78,000, likely from COVID-19. A spring 2020 study found frontline workers who reused personal protective equipment (PPE) were more likely to catch the virus than those with sufficient access. Some deaths could have been prevented.

Marie Ritacco, vice president of the Massachusetts Nurses Association (MNA), said nurses at St. Vincent Hospital in Worcester were asked to reuse masks for 6 to 8 shifts and wash plastic gowns between patients early in the pandemic. It happened across the country. In New York, nurses at Albany Medical Center reported reusing masks up to 20 times. The MNA struck for 10 months, partly over PPE, the longest strike in Massachusetts history. Ritacco says nurses raised the issue with the chief nursing officer and chief executive officer, and nothing changed.

The PPE crisis eased, but workplace hazards at hospitals didn't begin or end with COVID. Even in calmer times, hospital workers face higher health risks than the general population, and not only from disease. On the job, nurses face physical assaults, threats, harassment, and in the worst cases homicide. According to the American Nurses Association, 1 in 4 nurses are assaulted at work, double the rate of assaults on police officers reported by the FBI.

"Those of us in healthcare feel very vulnerable," Duncan says. "There are no metal detectors. There are open doors, and people can just walk in." Unions have pushed for better safety measures for years. The PPE failures during COVID were, for many, the last straw.

3. Mandatory Overtime

Many states bar healthcare centers from forcing overtime on nurses, but most of those laws have emergency carveouts. New York suspended its mandatory overtime law during the pandemic without saying when it would return, and legislation is underway to cap how long the state can pause those protections. Michigan's proposed Safe Patient Care Act would limit mandatory overtime but hasn't passed. In Nevada, the University Medical Center of Southern Nevada floated March 2022 plans to activate mandatory overtime, then delayed them after backlash.

It all circles back to staffing. Hire enough nurses, and mandatory overtime mostly disappears.

Pushback Against Strikes

The main arguments against striking come from hospitals, and they are predictable. Private institutions in particular want to cut costs and return money to shareholders, and most union demands work against that.

"There's this corporate mantra we've heard for years, 'let's do more with less,' but you can't slice people that thin," Brown says.

Employers point to a 2012 study showing patient mortality and readmissions can rise during a strike, since disrupting continuity of care, even with temporary nurses, lowers quality. But other research shows mortality also rises when hospitals are understaffed, and a 2020 study found COVID mortality in nursing homes was lowest in unionized facilities.

Deciding to strike is not easy. It is usually a last resort. The MNA negotiated with St. Vincent Hospital for 16 to 18 months before the pandemic and didn't strike until March 2021, after COVID numbers came down.

"If nurses don't stand up and say, 'No, it's not good enough for our patients,' who will?" Ritacco says. "It's a lot of work to get there. That being said, the effort is so necessary and totally worth it."