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How Have Health Workers Won Improvements to Patient Care? Strikes.

In California for example, the California Nurses Association (CNA) spent 13 years fighting and winning the first—and thus far only—legislated safe nurse-to-patient staffing ratios in the country.

More than 2,200 nurses went on strike against University of Chicago Medical Center on September 20. ,(Photo: National Nurses United)

On September 20, 2,200 nurses represented by the National Nurses United (NNU) went on a one-day strike at the University of Chicago Medical Center. The Chicago nurses were protesting unsafe working conditions and forced overtime—and had been in contract negotiations with the hospital for months. The Medical Center has just spent $269 million on a hospital expansion that it, insists, represents an “ investment to improve our community's health.”

In response to the strike, the Medical Center’s top officials went on a P.R. offensive, accusing  striking nurses of engaging in “shameless behavior,” and insisting they are recklessly endangering their patients. 

Nothing could be further from the truth, says Astria Johnson, an Emergency Room nurse who has worked for the hospital for 10 years. “This strike is about providing safe patient care. I can’t do that when I am assigned four patients, two of whom are intensive care (ICU) patients and two of whom are very sick. Someone may be on a ventilator to breathe for them.  Someone may be septic and require intravenous antibiotics and require constant monitoring.  Some people are getting their first diagnosis in the ER and I can’t educate them about their disease or medication.”

In response to the strike, management locked nurses out of the hospital for four days. The nurses went back to work Wednesday morning, and bargaining is expected to continue now that they’re back on the job.

Healthcare professionals like Johnson do not view striking as their first option.  Most spend years going through “the proper channels,” speaking with management, and engaging in endless internal negotiating sessions to resolve patient care problems.  When they do finally go public with their concerns, their actions often result in improvements to patient care.

In California for example, the California Nurses Association (CNA), the organization that was the founding member of NNU, spent 13 years fighting and winning the first—and thus far only—legislated safe nurse-to-patient staffing ratios in the country: In 1998, California Government Pete Wilson vetoed a safe staffing bill that was passed by the legislature.  In 1999, after more intense lobbying and activity by the CNA, legislation was passed and signed into law by Governor Gray Davis. Ratios were finally implemented in 2004. According to one study, in California, mandated ratios had a positive impact on patient deaths as well as nurse burnout.

Other healthcare workers have gone on strike to address vexing patient care issues. Since 2010, the National Union of Healthcare Workers (NUHW), which represents 4,000 psychologists, social workers, and other mental health clinicians at Kaiser Permanente in California, has mounted a campaign to publicize and remedy a critical shortage of mental health workers at the state’s largest HMO.  In 2011, the NUHW filed complaints to the California Department of Managed Health Care (DMHC) charging Kaiser was violating a regulation that requires that HMOs must see mental health patients within 10 business or 14 calendar days of their request for an appointment. The complaint was accompanied by a 34 page report entitled “Care Delayed, Care Denied.”

In 2012, the NUHW went on strike to expose Kaiser’s failure to hire sufficient mental staff and give patients access to timely care.  These mental health workers pushed the DMHC to take action to fulfill its mandates to protect patients.  In March of 2013, the DMHC released the results of its investigation. It found that up to 40 percent of patients at various Kaiser facilities experienced appointment delays that violated California law. In June of 2013, the state of California fined the system $4 million, issued a cease-and-desist order against Kaiser, and ordered the HMO to correct the problems. In 2015, a follow up survey by the DMHC, based on a sampling of hundreds of individual patient charts, revealed that, in Northern California alone, 22 percent of patients suffered excessive appointment delays. The DMHC called the violations “serious.”

In 2015, one of these serious violations resulted in the death of, 83-year-old Barbara Ragan, according to her husband Denny Ragan. Barbara had worked for Kaiser herself for more than two decades. She’d been seeking mental health care from Kaiser and, according to her husband, faced lengthy delays for treatment and ultimately died by suicide.  Kaiser has said it is not responsible for Ragan’s death and insisted that she had received adequate care.

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In 2017, the state ordered follow-up inspections to make sure Kaiser was in compliance with state laws and regulations. As a result, Kaiser has also hired hundreds more therapists. 

Even though the union’s actions have played a role in forcing Kaiser to improve patients’ access to an initial visit or assessment, workers say problems continue when it comes to providing follow-up care. “Kaiser has not hired enough staff so that, after an initial telephone appointment, patients get needed follow-up care.  Today patients have to wait up to two months for a follow up in person visit,” says Kirstin Quinn Siegel a Licensed Marriage and Family Therapist at Kaiser Richmond. “People who have been suffering in silence, perhaps for years, and finally call to get help should be seen immediately not in two months.” 

After experiencing delayed care, another Kaiser patient, 19-year-old Elizabeth Brown, died by suicide in 2018. Kaiser has declined to comment to the press about Brown’s care.

Peter Ly, a psychologist on the Child Team at San Jose Kaiser, says that “A teenager struggling with depression, or who is self -harming or has suicidal thoughts needs to be seen right away and then consistently every week or two.  We can’t do it.  We are asked to put people into groups when what they need is individual one-on-one therapy.”

That’s why he and roughly 4,000 other workers went on a five-day strike in December 2018.  Former Congressman Patrick Kennedy (D, RI) the sponsor of the mental health parity and addiction Equity Act flew to California to join striking therapists on the picket line.

 “We do not go into this work to make money,” says Susan Whitney, a marriage and family therapist at Kaiser in Bakersfield. “There is no cap on our caseload.  In order to help patients we keep accepting more and more of them. We can’t take lunch or even bathroom breaks.  We don’t act until we and our patients are at the breaking point.  And our number one concern is “how will this affect patient care?”

In a response to union allegations, Kaiser has issued a public statement insisting that, “Kaiser Permanente is committed to finding solutions and creating a model for mental health care that meets the growing demand for mental health care and responds to the shortage of qualified professionals.”

But according to Whitney, “We’ve been going through official Kaiser channels for years and the only way we’ve seen any enforcement or improvement is when we go public and enlist the support of patients, community leaders and political representatives.”

In July of 2019, Kaiser  announced that it had added 300 more mental health staff statewide and was continuing to recruit staff. NUHW members have proposed that they participate in decisions about where new staff are assigned both geographically and to which clinical teams.

In 2004, two researchers investigated management claims that healthcare workers represented by unions jeopardize patient care.  Michael Ash and Jean Ann Seago found instead that patients on cardiac units in hospitals where RNs were represented by labor unions had a reduced cardiac mortality rate.  They concluded that, “The protections offered by unionization may encourage nurses to speak up in ways that improve patient outcomes but might be considered insubordinate and, hence, career-jeopardizing without union protections.”

What was true 15 years ago is even more so today as healthcare corporations consolidate through hospital mergers and acquisitions, gain more power, and act to protect the bottom-line rather than patient care.