One Year After the New York Nurses’ Strike, What Comes Next?
This article is from Dollars & Sense: Real World Economics, available at http://www.dollarsandsense.org
This article is from the
May/June 2024 issue.
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Chronic short staffing is a common complaint of nurses working in U.S. hospitals—one that reflects a dangerous problem, as short-staffed hospitals pose a grave risk to the health and safety of patients and health care workers alike. Short staffing, the practice of burdening nurses with an excessive number of patients per shift, means nurses often don’t have time to take breaks and struggle to attend to all of their patients. It is burning out health care workers and potentially worsening a nationwide shortage of nurses, as many are unwilling to continue to work under such brutal conditions.
“When we have too many patients, the dilemma is that we can only be in one place at once. Therefore, if more than one of our patients require intervention, we have to choose which patient has a higher priority,” Michelle Gonzalez, an ICU nurse at Montefiore Medical Center in the Bronx said. “When nurses are short on a unit, it affects our ability to give care because patients require timely assessments and intervention—if not, patients can worsen, or even die.”
In 2021, New York State passed legislation that required hospitals to form committees of nurses and administrators to deliberate over staffing ratios. But the law didn’t mandate any particular ratios, and by January 2023, 57 hospitals in the state still hadn’t reached an agreement. By then, continued disputes over staffing levels helped provoke 7,000 nurses at Montefiore as well as Mount Sinai Hospital in Manhattan into a three-day strike. Nurses at both hospitals are members of the New York State Nurses Association (NYSNA), a 42,000-member union representing nurses across the state.
As a result of the strike, nurses at Mount Sinai won patient-staffing ratios for the first time, while nurses at Montefiore won improved staffing numbers in the labor and delivery department and established them in the hospital’s emergency department, where they hadn’t existed before. Both won a unique enforcement mechanism: If the employer is found to be violating the agreed-upon ratio, it will be hit with a fine that goes directly into nurses’ pockets.
A little over a year since the strike, nurses at Montefiore and Mount Sinai have collectively been awarded nearly $4 million in fines, and nurses report that management has made much more of an effort to maintain adequate staffing levels. Although the enforcement mechanism has limitations, the historic victory—the result of a strike led by rank-and-file nurses—suggests a path forward for nurses elsewhere struggling to address the crisis of short staffing.
What Is a Grievance? What Is Arbitration?
A grievance is a complaint filed by a union alleging that an employer has violated the terms of their collective bargaining agreement, or otherwise violated a worker’s rights under the law. In many workplaces, the employer and the union agree that, if a dispute stemming from a grievance cannot be resolved informally, it will go to arbitration, a form of dispute-resolution in which a private third-party hears from both sides and issues a final, binding decision. It often takes months, or even years, for a grievance to make its way to arbitration and receive a verdict.
An Historic Win
What makes the enforcement language unique is that arbitration is set up to happen quickly in response to ratio violations, and it explicitly empowers arbitrators to penalize employers with fines. In general, any violation of contract language can eventually wind up at arbitration through the grievance procedure, if a hospital staffing committee comes to an impasse. But at Montefiore and Mount Sinai, the hospitals and unions have a monthly arbitrator scheduled to quickly hear staffing disputes if the internal hospital staffing committee doesn’t fix the issue within a few days. Then, if they find that the hospital engaged in a pattern of staffing violations, arbitrators award the cost of a nurse’s salary for the understaffed shifts, multiplied by the number of additional nurses that the hospital should have had working, which is then divided and distributed to the nurses who worked those shifts. In theory, this removes the financial incentive for hospitals to short staff nursing shifts.
At other hospitals, even if an arbitrator finds the hospital guilty of violating staffing ratios, they won’t necessarily assess a fine. On the other hand, the normalization of penalties at Montefiore and Mount Sinai has, in some cases, encouraged arbitrators elsewhere to impose fines where they never had before. This is the case, for instance, at the Mount Sinai West and Morningside Hospital, which won much weaker enforcement language that did not explicitly call for fines. Arbitrators at those facilities have nevertheless begun more often assessing financial penalties because of the practices established by Montefiore and Mount Sinai. (As of press time, there aren’t any hospitals where nurses have won the penalty language in contracts settled since the strike.)
In the year since the new contract provision went into effect, Mount Sinai has racked up $3 million in penalties, Politico reported in February. This figure represents penalties imposed at Mount Sinai Hospital as well as at Mount Sinai West and Morningside. Since that report, according to Matt Allen, a clinical nurse in labor and delivery who was vice president of NYSNA’s bargaining unit at Mount Sinai during the strike, nurses there on a high-acuity oncology and transplant unit were awarded $700,000 for a short-staffing violation on March 12. Meanwhile, nurses at Montefiore have won a total of $155,000 in fines since the new enforcement language went into effect.
Nurses at each hospital say that the penalties are working—not just in compensating nurses for working understaffed shifts, but in actually improving staffing ratios. Allen said that where Mount Sinai had over 700 open positions for nurses and nurse practitioners in January of 2023, they are down to below 300 vacancies now.
“All the major departments where we were having issues in the past have improved a ton,” Montefiore’s Gonzalez said. “When we went on strike, there were 100 nurses staffing the ED [emergency department] per month; now our numbers are up to 200.” She continued: “We’ve noticed that there’s an improvement in staffing with all of the units that we’ve brought to arbitration—the moment we brought them to arbitration, their staffing was up within about two weeks.”
What Is a Strike Authorization Vote?
During union contract negotiations, unions will often hold votes of their membership to determine whether members are willing to go on strike; this is a strike authorization vote. Such a vote does not mean the union necessarily will go on strike; instead, if a sufficient proportion of members vote to authorize a strike, that empowers the bargaining committee—the union committee tasked with negotiating a new contract with the employer—to declare a walkout if it sees fit.
A Failure of Coordination?
Montefiore and Mount Sinai were two of 12 private-sector New York City hospitals represented by NYSNA whose contracts expired in December 2022, most of which had authorized strikes. But Montefiore and Mount Sinai were the only two to walk out. Bargaining committees at the two hospitals called the strike after another hospital, New-York Presbyterian (NYP), became the first to settle its contract with the union. The January 7 agreement at NYP failed to include significant staffing language of the kind later won at the two striking hospitals.
The strikes at Mount Sinai and Montefiore followed years of growing frustration with short staffing. “In 2019, nurses throughout New York City were in a contract fight together, and we were close to potentially going out on strike for staffing ratios,” Montefiore’s Gonzalez said. “That didn’t happen, but it did spur some very intense emotions in our membership. Because after 2019, we didn’t see improvements in our staffing, and then we were hit with the Covid-19 pandemic, which further exacerbated staffing issues.” This made staffing a major priority for members in contract negotiations in 2022, according to Gonzalez.
The strike began on Monday, January 9, after nurses bargained late into the evening the day before without reaching an agreement. “We felt strongly that striking was what our colleagues wanted based on the response, or lack of response, we got from management. It was an incredible experience,” said Johnaira Dilone-Florian, a bargaining committee member at Montefiore. Nurses at Montefiore and Mount Sinai say the picket lines were electric, rippling with bottled-up anger from the caregivers who put their lives on the line during the worst of Covid-19 while their supervisors and administrators worked from home. The union and the hospitals came to an agreement with the new staffing language after just three days, on January 12.
Some nurses suggested that NYSNA leadership hoped to settle with the hospital companies fast and head off the walkouts. Ninety-nine percent of NYSNA members at NYP voted to authorize a strike in the lead-up to bargaining, with over 90% of members there participating in the vote. But the bargaining committee ended up recommending an agreement without striking, which was ratified by membership with a 57% yes vote. The contract secured salary increases of 7%, 6%, and 5% over three years; it also increased nurse staffing in some units, but without the ratio-enforcement mechanisms eventually won by Montefiore and Mount Sinai.
The settlement left nurses at other hospitals still in the bargaining process confused. “I felt those wage increases were suddenly the ceiling for us, which was surprising because we were still asking for 10% a year at that time, if I remember correctly. Nothing was communicated with us on our city-wide bargaining calls to indicate they were going to settle; it came out of nowhere,” Jillian Primiano, a nurse and member of the bargaining team at Wyckoff Heights Medical Center in Brooklyn, said. “Even after the wage was settled, Monte[fiore] and Mount Sinai still were rallying around enforceable staffing language with monetary penalties. Our NYSNA rep discouraged me from putting monetary penalties on the table, saying that they would be impossible to get. So basically, after NYP settled, it felt like we had no rallying point and just had to accept the baseline set by NYP.”
“We as a bargaining unit and we as an executive committee never really felt supported by the upper leadership of this union,” Gonzalez said of her experience bargaining at Montefiore. “If anything, they wanted us to settle that evening [before the strike].”
The way bargaining unfolded also seemed to some nurses to undermine the idea, promoted by NYSNA officials prior to bargaining, that nurses at the different hospitals should coordinate their negotiations. The year before the contracts expired, NYSNA held a bargaining conference. “Coordinated communication was a core ask coming out of the kickoff conference, to keep ahead of the hospital alliance [representing the hospitals at the bargaining table],” Mount Sinai’s Allen recalled. “We knew they were in constant communication to enforce pattern bargaining [on their end].”
To build strike readiness, nurses at the 12 hospitals had set up Contract Action Teams that held unit meetings to report on bargaining, had one-on-one conversations about impending possible strikes, and turned out their coworkers for union sticker days, open bargaining sessions, and other actions.
Yet Allen reported that bargaining teams were discouraged from sharing contract language or from coordinating demands. “From the beginning of the contract campaign, it was agreed that all the bargaining teams be in constant communication with each other, because it was understood the bosses were all communicating in real time so we should be doing it also,” he said. “But when I actually tried to do this, I was discouraged from doing so [by top union leaders].”
Allen, along with other Mount Sinai bargaining team members, eventually made contact with bargaining team members at Montefiore. They learned Montefiore administrators had agreed to the arbitration language for staffing enforcement and used that to win it in the Mount Sinai contract too. Nurses at Mount Sinai and Montefiore both ratified their contracts with 98% yes votes.
When asked about the contract negotiations for this story, NYSNA declined to comment.
The Taylor Law: No Empty Threat
In New York State, public-sector workers’ collective bargaining rights are governed by the 1967 Public Employees Fair Employment Act—popularly known as the Taylor Law—which prohibits public-sector employees from engaging in work stoppages. The law has been used to fiercely prosecute public-sector unions that go on strike. It was deployed, for instance, against Transport Workers Union (TWU) Local 100, representing New York City public transit workers, in the wake of a 60-hour strike in late December 2005. A New York State Supreme Court judge fined the union $2.5 million and ordered the local’s president, Roger Toussaint, to jail for 10 days.
Impact of the Strike Victory in New York
These contract victories were obviously significant for the nurses at New York City’s private- sector hospitals. But they also boosted the campaign that year for pay parity at the city hospitals, which disproportionately provide care to the poor and uninsured. Public-sector nurses are covered by New York State’s Taylor Law, which imposes harsh sanctions for public-sector unions that strike—including steep fines for workers and union officers, loss of dues check-off, and even imprisonment for union officials.
Pay rates for the 8,000 nurses in the public system lagged behind the private sector by 16%, contributing to high turnover as new nursing graduates often leave for the private sector after gaining a few years of experience. In the 2023 contract campaign, NYSNA framed the parity fight as health care equity for low-income people of color, as many of the nurses who work in the public hospitals are immigrants and women of color, and low retention threatens the quality of care for the poorer and more racially diverse patient population that the public system serves.
After months of escalating rallies and protests by nurses, the city eventually gave in in July 2023. Among other gains, public-sector nurses won pay increases of $16,006 in the first year and $5,551 in the second year of the contract, bringing them up to parity with pay for nurses in the private New York City hospitals. Though the public contract won new language around enforcing staffing ratios, nurses say it establishes a long, complicated process that could take up to a year to reach a binding decision. Nor does the contract provide for penalties to threaten employers into complying with agreed-upon ratios.
“We don’t have anything about penalties spelled out like they do in the private-sector contract; ours is much weaker. We’d love to have language like they won at Monte and Mount Sinai in our contract,” said Sarah Dowd, an ICU nurse practitioner at the public Kings County hospital. “One of my hopes for this next contract cycle is that we’ve educated nurses about what’s going on in private sector staffing enforcement so we have a standard to aspire to. With nearly five years before our contract expires we’ve got some time to get that done—but it’s going to take a lot of shop-floor organizing.”
The arbitration-penalty mechanism won by Sinai and Montefiore is not without its limitations. For instance, it means a large investment on the part of the union to pay for lawyers to pursue the staffing arbitration cases; also, arbitration can be atomizing for members as they go through the testifying and cross-examining required by the process. Still, it represents an important challenge to the state’s existing procedure for ensuring safe staffing levels, which employers have violated rather freely, and the new contract language already appears to be paying off.
The enforcement mechanism, then, might provide a model for nurses throughout the country who are struggling with staffing shortages. But just as important as the victory was how it was won—through an energetic strike led by rank-and-file nurses, which secured a historic win that non- striking hospitals did not.
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