Nurses on Strike: How CNOs Can Meet in the Middle

By G Hatfield

Nurses everywhere are going on strike.

Right now, it seems like every day there are new cases of nurses striking or unionizing at health systems all across the country.

Nurses are frustrated, and the recent union activity is indicative of large, widespread problems in the nursing industry with staffing, work environment, and nurse wellbeing. While it is the CNO’s responsibility to address those issues and to facilitate those conversations, it can be quite difficult.

Underlying causes

According to Katie Boston-Leary, Director of Nursing Programs at the American Nurses Association, there are several reasons that nurses have been going on strike, starting with the staffing crisis and its impact on overall nurse wellbeing. Workplace violence, unmanageable workloads, exhaustion, and the feeling of not being heard are also contributing factors.

“There is a generalized dissatisfaction of the current state [of the industry] from nurses,” Boston-Leary says, “and I think that the phenomenon that’s happening right now is nurses are really saying ‘no more.’”

Due to staffing shortages and heavy workloads, nurses are not able to spend as much time with their patients as they want to, and according to Boston-Leary, they often leave work feeling like they did not provide the best possible care.

“We have unintentionally set up a system that pulls nurses away from what matters most to them,” Boston-Leary says, “which is spending time with their patients.”

COVID-19 exacerbated the issue. It forced nurses and other healthcare professionals to be introspective, and to reassess what their priorities were in terms of job structure and how work should balance with their personal lives.

“I think COVID is an accelerator and illuminator,” Boston-Leary says, “and it just adds fuel to everything that we [already] knew.”

Boston-Leary believes that nurses are using unions as a last resort to find their voices in health systems, and that they are voting to make sure that things are changed for the better, for themselves and for new nurses. If they do not see the issues being addressed, nurses might feel a need to turn toward the more compulsory, structured approach.

Boston-Leary also states that in all her experience leading and working in unionized hospitals, the unionized environment does not impact the dedication that nurses have to their profession.

“Nurses have a right to voice their concerns,” Boston-Leary says, “and [they] find a number of different ways to do that through shared governance, through leadership, and in some cases through unions.”

Are strikes avoidable?

Last year, Temple Health was close to a nursing strike, and the issue up for negotiation was staffing. According to Chaudron Carter, Executive Vice President and Chief Nurse Executive at Temple Health, they were able to avert the strike by sitting down with the nurses and adjusting staffing based on acuity and many other criteria.

Temple implemented a new set of staffing guidelines that do not include ratios, and they developed a process where the guidelines are looked at on a monthly basis, and any necessary adjustments are made. Leadership focuses on a different unit each month, and they provide the union with updates about new staff and other information. The meetings last for eight hours, four are dedicated to discussing topics on a shared agenda, and the other four are spent assessing the staffing guidelines and making changes if needed.

To Carter, it is crucial that the nursing staff show up for these discussions, and that they continue to deliver on quality of care, as part of the effort to foster shared governance.

“Leadership can make decisions,” Carter says, “however, if it is not the right decision to drive the change that we want, it won’t work.”

Communication and action

With the principles of shared governance in mind, the responsibility falls on CNOs and other nurse leaders to be able to strike a balance between the unions and health systems in a way that is beneficial for everyone.

According to Boston-Leary, the nurses will know that the CNO is listening when their questions and concerns are answered and addressed.

CNOs can find out what their nurses are going through by asking them directly. Boston-Leary recommends setting up a shadow board in the department so that nurses can give feedback in a structured way. It is also vital that leaders give feedback to nurses about actions being taken to make progress and to keep them updated on that progress.

“We have to get to a point of resolving a lot of these issues and managing these pain points, because it’s at the point of being unbearable for nurses,” Boston-Leary says, “which is why we’re seeing all the [union] activity that we’re seeing.”

Additionally, CNOs can maintain relationships with their nurses without always involving the unions. Boston-Leary states that nurses are a part of a CNO’s team regardless of union presence, and it’s important to still have conversations with them.

“You should have relationships with the people that are under your leadership because those relationships are important,” Boston-Leary says, “and the unions don’t necessarily have to come between [those] relationships.”

For Carter, communication is also key. She recommends stepping onto the hospital floor and spending time listening and talking to staff to better understand the pain points that might arise in union discussions. That way, CNOs can get ahead of the curve and develop strategies before negotiations that will help move the problem-solving process along.

“If you could develop a strategy before you get to go into negotiations around what those topics may be, and the organization develops a strategy on how to combat those issues,” Carter says, “I think you’ll position the organization better as it relates to going into negotiations and averting a strike.”

Trust is another important ingredient. Carter believes that open dialogue and transparency can help create a trusting relationship between the two parties, so that even when there are disagreements on approach, there are still shared goals.

“We don’t always see eye to eye,” Carter says, “[but] we’re here for the same reason, we’re here for safe patient care, [and] to make sure that the staff is taken care of as well.”

Have a contingency plan

For CNOs working in union environments, preparation is essential.

Carter highly recommends that any organization embarking on contract negotiations should have a contingency operations plan in place. The plan should detail how to continue operations at the hospital if the nurses go on strike.

Carter suggests that this could involve pulling from other departments within the health system, such as housekeeping or radiology, or hiring an agency to bring in a contingency workforce. CNOs should determine where and how to downsize and distribute staff so that they can still provide the same quality patient care.

“The plan is huge because nursing touches all aspects of an organization,” Carter says, “and so you have to think of the most minute things to the larger scale items.”

At the end of the day, unions are an inevitable part of dealing with the workforce.

In her time leading in a unionized environment, Boston-Leary took the approach of enlisting the support of the unions and keeping them informed in order to help tackle nursing issues. She found it important for nurses to see their leaders working together for their benefit, rather than an adversarial relationship where no progress is made.

“I learned that I cannot treat unions as if they were the bad guys, because that was a non-starter,” Boston-Leary says. “If they’re here, they’re here, and you have to work with them and partner with them.”

G Hatfield is the nursing editor for HealthLeaders.