Improving Working Conditions in Turbulent Times

Expanding Unions’ Toolkits

By Peter Lazes, Marie G. Rudden

AFT Health Care, Spring 2022

In 2005, two staff nurses at Maimonides Medical Center in Brooklyn, New York, were on the verge of being fired. Six unexpected fatalities had occurred in the cardiology department over the previous 16 months. An initial investigation by hospital administration and risk management staff concluded that these two nurses were responsible for the deaths through lateness in responding to cardiac telemetry monitor alarms, and they were suspended without pay until the investigation was completed. Fortunately, they were not facing these accusations alone. Their unions (the Service Employees International Union’s Committee of Interns and Residents and the New York State Nurses Association) and hospital leadership had established labor-management committees in many of the hospital’s departments as part of their labor-management partnership. Members of the committee within cardiology, encouraged by union leaders, decided it was their responsibility to investigate the cause of the unexpected fatalities. After three months of research and analysis, the committee identified several issues that contributed to the fatalities, but these did not include inappropriate care by staff nurses. The two nurses who had been accused of causing the fatalities were reinstated with full back pay. In addition, the committee agreed to implement a series of interrelated solutions, including updated and standardized protocols for the care of all cardiac patients (which were agreed to by all physicians and nurses), investment in better cardiac monitoring equipment that could be easily adjusted, and training for staff on the new procedures and equipment. During the following two years, they tracked the result of these changes, finding no unexpected adverse events on their cardiac units.

This positive, proactive outcome likely would not have been possible had this situation been handled solely by a traditional grievance process. The partnership process enabled frontline staff to investigate the situation, devote work time to researching the problem, and access clinical data about the care of the patients who died. Union leaders played a crucial role in representing their members and in improving patient care; they had a strong voice and a structure for intervening with the well-established labor-management partnership. The cardiology labor-management committee’s problem-solving process was successful—for the providers and the patients—because it offered a comprehensive analysis from the standpoints of all stakeholders to get at the root causes of the problem.

What Is a Labor-Management Partnership?

Labor-management partnerships are different in every workplace, but fundamentally they establish structures and processes to address a wide range of issues, allowing unions greater influence in decision making. Unions have used labor-management partnerships since the 1970s to increase their power to improve working conditions for their members. When these partnerships are effective, unions have much greater access to patient and budget information, workarounds are eliminated, and members have more meaningful jobs (e.g., they have greater decision-making power about their working conditions, have input into how technology is used in their departments, and gain considerable respect for improving patient care). Importantly, unions still have all of their traditional sources of power when there is a partnership process.

We have been researching, helping create, and supporting labor-management partnerships for more than 40 years. Although we understand that the idea of partnering with management may be inconceivable—especially now, since so many hospital administrators have shown little regard for staff members’ safety during the pandemic—we have seen the power of partnerships to improve staff satisfaction and patient outcomes.2 Even if a partnership does not seem feasible for your local now, knowing about partnerships’ structures and processes may be beneficial in the future. When circumstances change or opportunities arise, being equipped to seize these opportunities can be useful.

In some cases, unions have used traditional tactics like negotiations, protests, walkouts, or strikes to initiate partnerships or to more forcefully press for changes in existing partnerships. For example, in July 2018, the Vermont Federation of Nurses and Health Professionals, AFT Local 5221, which had established a labor-management partnership more than a decade earlier, conducted a two-day strike over staffing levels and retention issues at the University of Vermont Medical Center.3 One result of the strike was the establishment of the Unit Staffing Collaboratives Project, a robust process for ensuring reasonable, safe staffing levels for all hospital units and outpatient clinics.4 This initiative involved intensive research and analysis to determine adequate staffing for nurses and support staff, unit by unit, with each one proposing a new staffing grid that had to be approved by both the chief nursing officer and the union president, Deb Snell. According to Snell, the project has resulted in the addition of 77 new positions, primarily in nursing roles, across all but two units in the hospital.5 (See “Boxing and Dancing at the Same Time: Finding Balance in a Labor-Management Partnership” for more.) While ongoing challenges in hiring and retaining nurses remain, greatly exacerbated by the COVID-19 pandemic, the new staffing levels are in the process of being implemented, based on the recommendations of frontline nurses.

Essential Elements

When labor-management partnerships are successful, they have a specific structure for their work that is agreed upon at its outset. Workgroups are created to make use of the collective knowledge and skills of frontline staff, who know the most about the working conditions in their units and departments, and staff members are given time to participate in workgroups. Lastly, union and management leaders support and provide a vision for this joint work.

Labor-management partnerships specifically provide frontline staff time to identify, research, and implement changes in targeted areas of the hospital to improve working conditions and patient care. This gives workers greater control over how they do their work, including the material and equipment they use and, in some cases, their actual clinical practice. Unlike traditional management-driven improvement processes, where management determines the issues to work on and the changes to enact, in a labor-management partnership the areas for improvement and the actions to take are determined by mutual agreements between frontline staff and management. When all stakeholders are truly engaged and the staff is not dictated to, these partnerships can be highly effective.6

Creating a labor-management partnership process requires establishing a social contract to set ground rules about who can participate and how decisions are made. This agreement clarifies the arrangement for establishing work teams and should state that no employee will lose their job as a result of worker involvement activities. Once a proposed change is accepted by labor and management leaders, frontline staff are provided time for implementation. A partnership process also establishes a budget so that staff time is allocated to participate in problem-solving activities during work hours and some members can be paid to serve as internal consultants to support the partnership process. In many hospitals, where wall-to-wall frontline staff are represented by unions, all frontline staff are encouraged to participate in partnership activities. In other hospitals, when only some staff are represented by a union, the partnerships process is focused on these unionized staff—although nonunion staff might be members of a specific workgroup.

In our experience, labor-management partnership processes are an important tool for unions because they create opportunities for frontline staff to improve their working conditions and to safeguard their own well-being and that of their patients. It is best for a new partnership to begin with areas for change that are fairly easy to improve and where there is a readiness of management and frontline staff to work together. This is particularly important if your organization hasn’t had much experience with labor and management working together. Over time, as worker involvement activities achieve positive outcomes, the process can be expanded to address more complex problems.

As a result of these cogenerated activities, frontline staff and their union often obtain access to budgets, patient satisfaction scores received by the hospital, and documentation of clinical outcomes. Having access to this critical information enables union members to understand the parameters within which they are working and to receive feedback on their performance. Without a worker involvement process, much of this information is usually not available to either frontline staff or their union leaders. For example, some unions only get access to basic budget and staffing information and have limited opportunities to engage in problem solving about work and patient care problems during contract negotiations. In our experience, increased access to information on an ongoing basis is one of the ways in which partnerships are valuable to unions and frontline staff. A partnership process is also useful to management because it can enhance management’s understanding of the union contract and how the union functions, which is much different than management. These understandings often improve labor relations and strengthen the ability of management to work with a union and its leadership.

The important outcomes achieved by recent healthcare labor-management partnerships have included reducing staff injuries by purchasing equipment to turn and transport patients safely, reducing emergency department visits for diabetic patients, reducing the turnaround time of test results between an emergency department and the lab, coordinating care for patients by creating patient-centered medical homes, improving hospital cleanliness, reducing the number of patients needing to return to ICUs, and increasing staffing ratios for registered nurses and their support staff.7

Establishing a labor-management partnership takes time: managers, staff, and their union need to determine an appropriate structure for supporting the new worker involvement activities. Although learning about existing partnerships is useful, each organization is unique in terms of its patient population, so the structures and processes for a particular partnership must be customized. Most critical to the success of the partnership is that union and management leaders are committed to and show support for these activities.

Why Are Labor-Management Partnerships Needed?

AFT Health Care, Spring 2022Long before the pandemic, nurses and other healthcare workers faced seriously deficient working conditions. Scholars such as Suzanne Gordon, a healthcare researcher and nursing professor, and Theresa Brown, a registered nurse and bestselling author, documented the dangers for patients and healthcare workers of staffing that focuses “more on costs than care.”8 Not long after COVID-19 arrived in the United States, what had already been long-term problems—especially with staffing and with the availability of equipment—became catastrophes. Connie M. Ulrich, a professor of medical and surgical nursing and bioethics, described how bad things became with COVID-19: “Many [nurses] have moral scars from ethical issues and trauma they experienced while trying to provide the best care to sick and dying COVID patients—lack of personal protective equipment and other supplies, inadequate staffing and poor leadership, bedside attendance at multiple deaths daily, and shifting messages on how to protect themselves and their patients.”9

AFT nurses have had similar experiences during the pandemic and have struggled to find ways to deal with the impacts of these issues. This has left many AFT healthcare leaders and members frustrated and angry. Many nurses feel abandoned and betrayed by their employers and now share a massive distrust of hospital management. Inadequate staffing, the lack of training for hastily arranged new assignments, the lack of PPE, and administrators’ physical absence on COVID-19 treatment units have been cited as deeply disturbing.10

Looking to the future, Linda H. Aiken, a professor of nursing and sociology, wrote, “We celebrate nurses now. We call them heroes. But if we value their sacrifices and want them to be there when we need them, we must prevent a return to the poor pre-pandemic working conditions that led to high nurse burnout and turnover rates even before COVID.”11 Aiken advocates for creating local and national initiatives to achieve better staff-to-patient ratios as a way to improve working conditions of nurses. Better staffing levels will indeed help to reduce some of the exhaustion frontline staff experience and will ensure better care for their patients. But increasing the number of nurses on a unit will not be sufficient to improve the compromised working conditions that nurses face, such as a lack of safety equipment or a lack of training on new equipment or on procedures for treating different patient populations as a result of being assigned to new departments. Nurses know that they can’t deliver good care to their patients when the time available to them is severely compromised. These situations have contributed to a sense of moral injury among many nurses.* Far too many nurses do not feel that their working conditions have allowed them to offer the ethical care they have been trained to provide.12 Bedside attendance at multiple deaths daily during the COVID-19 pandemic adds to their pain and trauma. Too few healthcare organizations have developed effective processes to help nurses process these stresses or provided them opportunities to improve these working conditions. In some hospital systems, however, labor-management partnerships have helped improve working conditions both before and during the pandemic.

During the pandemic, we have been in contact with many union leaders and members who are engaged in labor-management partnerships. Based on these conversations,13 we have learned that many hospitals with structures for involving frontline staff used these structures to help cope with significant issues caused by the overwhelming number of extremely sick patients. For example, in labor-management partnerships at Jackson Memorial Hospital (in Miami), Los Angeles County Health Services, and UMass Memorial Health, management, union leaders, and frontline staff worked together to create access to adequate protective equipment and to keep staff informed of updated protocols for caring for COVID-19 patients and safety procedures (many of which were changing daily). Some hospitals with labor-management partnerships increased compensation for nurses working during the pandemic and offered therapeutic support for them when needed. Healthcare workers still faced tragic circumstances, but these efforts, assisted by partnership structures and processes, have led to better working conditions during COVID-19. Further, many workers in these settings did not feel as betrayed by their managers as workers in hospitals without partnerships.14

Labor-Management Partnerships Are Not New

Giving workers a voice in decision making to improve their working conditions and the effectiveness of their organizations while also contributing to union building dates back to the end of World War II. After the war, union and political leaders in Scandinavia decided to develop specific structures through national legislation to ensure that frontline staff had opportunities to identify and solve working condition and production problems. They felt that these structures would strengthen their economy and create meaningful work for frontline staff. They also saw the value of worker participation, since those who had this experience tended to become active in civic life.15 Worker participation was viewed as a vital approach to retaining an active democracy.16 Worker participation continues to be an important focus of Scandinavian unions.

In the United States, union leaders of the Amalgamated Clothing and Textile Workers Union (ACTWU) and the United Auto Workers (UAW) started to think about potential ways to adapt worker participation strategies to American companies and the work culture of American workers after learning from the Scandinavian initiatives and understanding that an active role of unions was needed to increase worker participation activities.17 Their expanded vision for their unions was that in addition to securing wages and benefits, unions had a responsibility to find ways to work with management to improve the success and productivity of their organizations and to create opportunities for workers to have more meaningful work.18

Three significant partnerships created during the 1970s and 1980s were found in the General Motors (GM) North Tarrytown assembly plant with the UAW, the Xerox Corporation with the ACTWU, and the Saturn-GM assembly plant with the UAW.19 At the Tarrytown plant in New York state, worker involvement activities adapted the concept of quality control circles from Japan to create unit-based problem-solving teams. Initial work teams reduced damage to windshields and water leaks in cars’ front windows during the manufacturing process. The success of these initial teams resulted in workers being asked to tackle other problems with the quality of the newly assembled cars. In just four years, the worker participation process resulted in the Tarrytown site being rated the highest quality plant in GM’s car assembly division. Before this, it had been in the bottom tier of manufacturing quality ratings. The partnership also led to a radical reduction in grievances and arbitrations in the plant.

At the Xerox Corporation in Webster, New York, the worker participation process established problem-solving workgroups in all of their manufacturing plants to improve the quality of manufacturing Xerox machines. By late 1981, however, Xerox faced serious competition from Japanese copier companies. Xerox management’s response was to develop plans to move the manufacturing of subcomponent parts (the wire harness) of their machines to Mexico—which would save $3.2 million, in part by laying off 180 US-based employees. After learning of this potential layoff, the leadership of ACTWU, the union representing workers at Xerox, persuaded Xerox management to use a study action team process to identify other ways to reduce costs instead. A group of frontline manufacturing staff, a manager, and an engineer spent six months identifying ways to save the $3.2 million in operating costs. As a result of their solutions, $3.7 million was saved, as were all 180 jobs. In fact, these joint activities resulted in the creation of 150 jobs, on top of those saved, due to the development of a new, high-quality production process that included redesigning the flow of work, training employees to do multiple processes, and purchasing and using new equipment.

At the Saturn Corporation in Spring Hill, Tennessee, a partnership process was established to structure how the union and management would work together in this new car division of General Motors. Manufacturing staff, union leaders, and management made all decisions jointly from the inception, including designing the cars, choosing production equipment and suppliers, and licensing dealerships. This partnership resulted in the manufacturing of high-quality, affordable cars that successfully competed with the Honda Civic for many years.

The success of these worker involvement activities caught the interest of union leaders in both private and public healthcare organizations during the late 1990s. In 1997, one of the first healthcare labor-management partnerships was established at Kaiser Permanente, which has facilities in several states. At the same time, a partnership was also developed at Maimonides Medical Center in Brooklyn.

After a long history of strikes, labor leaders and managers at Kaiser Permanente decided to establish their partnership process to improve patient care, worker satisfaction, and labor relations.20 Most of the focus of this partnership has been on creating unit-based teams in both inpatient and outpatient departments to improve staff working conditions, staff and patient safety, and labor relations. For the most part, this partnership has been productive, thanks largely to the strength of the unions and to the commitment from the former CEOs.21 More recently, as discussed in “Partnership in Flux: The Importance of Strong Relationships,” labor and management have faced significant disagreements over management’s proposal for a two-tier wage system, insufficient staffing, and long-term problems with recruitment and retention, among other issues. The Alliance of Health Care Unions at Kaiser Permanente (representing 21 unions, including the Oregon Federation of Nurses and Health Professionals [OFNHP], AFT Local 5017) was prepared to go on strike in November 2021; that strike was narrowly averted in large part because management finally agreed to remove its demand for a two-tiered wage system.22 According to Jodi Barschow, president of OFNHP and a registered nurse, “The pressure our members, labor leaders, and community supporters put on Kaiser and the threat of a strike worked and moved Kaiser leadership to do the right thing and abandon the two-tier system.” She further explained that “Members of OFNHP were ready to go on strike over the persistent staffing issues. A two-tier system would have been disastrous and would have compromised Kaiser’s ability to attract, recruit, and retain labor—worsening the staffing crisis.”23 Other major wins in the new contract include staffing committees to address vacancies and travelers; safe staffing and workload requirements; across-the-board wage increases; a renewed commitment to patient safety; an organization-wide focus on equity, diversity, and inclusion; and a variety of educational, health, and retirement benefits.24

Although the partnership has been strained in recent years, there is value in the partnership’s long history and the hard-earned problem-solving abilities of its frontline unit-based teams.25 Explaining her commitment to the partnership, Barschow said, “Members want to have a voice in their workplace and in their care delivery because that’s how to achieve the best outcomes for the patients. When it is working well, the partnership helps build relationships and gives workers the stronger voice they deserve.”26 Still, this is a good example of the fact that having a labor-management partnership doesn’t take away the rights of either labor or management. Being able to cooperate as much as possible and confront each other when necessary are skills that labor and management leaders need to master to establish and sustain a labor-management partnership process.

At Maimonides Medical Center, a partnership grew out of an already strong and positive relationship between senior union and management leaders. This partnership was seen as an important process to deepen activities of the hospital for improving access and quality of care. After making a trip to the Saturn assembly plant to learn from its staff what was needed to create and sustain a labor-management partnership, union and management leaders at Maimonides established ground rules for their partnership process. The initial focus of worker participation activities was on unit-based teams to solve patient care issues identified by the staff on each unit. Based on the success of these teams, the process shifted to departmental initiatives that extended beyond individual units. It was a departmental team, for example, that addressed the significant problem of unexpected patient deaths on several cardiac units mentioned at the beginning of this article. That team was able to exonerate two nurses from being responsible for these deaths and to establish new processes to avoid such deaths in the future. As a result of the Maimonides partnership, significant changes were achieved: patient falls decreased significantly, a faster turnaround of lab and radiology reports was enacted, bedsores were reduced, and more meaningful jobs were created by the frontline staff themselves.

Thus, based on their different cultures, needs, and resources, these healthcare partnerships created unique structures and processes for engaging frontline workers in problem-solving and restructuring initiatives.

Today’s Partnerships Have Varied Approaches 

We have found that three approaches to change are typically used within labor-management partnerships: unit-based teams, departmental labor-management committees, and study action teams. Because we have already provided examples of unit- and department-based initiatives, we will briefly review their key features and then devote more attention to study action teams.

Unit-Based Teams

In our experience, unit-based teams are the most common method of worker involvement in healthcare organizations. This structure provides frontline staff a direct role in identifying and solving working-conditions and patient-care problems. Unit-based teams usually meet every other week. Once they solve a particular problem, the group selects another problem to work on.

Departmental Labor-Management Committees

Departmental labor-management committees usually meet monthly and serve as an oversight group to identify crucial patient care and staff satisfaction issues. Once a committee identifies a specific area of work, a small workgroup, composed of members from all units and all shifts in the department, begins to meet on a regular basis until a solution is determined. During this process, the members of the designated workgroup consult with staff on the relevant units of their department to obtain a comprehensive understanding of the circumstances of a particular problem or process and seek their advice about a potential solution. Once a solution is approved by the departmental labor-management committee, the workgroup is responsible for implementing the solution.

Study Action Teams

In addition to unit- and departmental-based teams, study action teams are a third approach used in some healthcare partnerships. This method is particularly helpful when extensive research and experimentation are needed to restructure a current service or to create an entirely new one. A study action team usually consists of six to nine frontline staff, union representatives, and managers. The group’s research is assisted by the hospital’s quality improvement, risk management, and financial departments.

Labor and management leaders on the hospital’s partnership council jointly identify areas for change that need intensive research and analysis. A team is then created by union and management leaders, with suggestions from frontline staff, recruiting volunteers for this work. Study action team members work full time, usually for three to four months, on the project. This approach enables staff and managers to have sufficient time to analyze a given system and to design effective approaches to solving what is not working adequately. If a new design involves changes in jobs and/or compensation, the bargaining committee of the union and management leaders need to approve the suggested changes. Outcomes of study action teams in healthcare organizations have included improving the cleanliness of a hospital by involving all departments and frontline staff, not just its housekeeping employees, resulting in higher patient satisfaction scores for cleanliness; reducing costs, usually by more than 30 percent, and creating new revenues; creating a centralized call center for setting up appointments effectively; transforming outpatient departments into coordinated patient-centered medical homes; and creating home dialysis services.27

Regardless of the worker involvement approach that is established, employees throughout an organization with a structured labor-management partnership process are encouraged to identify problems to work on. This becomes an ingrained aspect of the hospital’s culture.

The Need to Expand Collective Action

Nurses and other healthcare workers have suffered for years with poor working conditions and disrespect for their skills.28 It is important, therefore, to find effective ways to cope with and change these circumstances, now more than ever. Conditions have only gotten worse during the COVID-19 pandemic.29 Daily, the situation is driving increasing numbers of healthcare professionals to leave their essential and valuable work.30

Looking to the future, when we start to emerge from the desperate firefighting aspects of the pandemic, there will be an important opportunity for healthcare union leaders to push for worker involvement activities for their members. As the public is now more aware of how broken our healthcare system is, unions can make use of this awareness to build public support for initiating worker involvement activities. Relying solely on collective bargaining language within contracts and on established grievance processes will force nurses and other healthcare professionals to continue to create workarounds to simply do their jobs well.

As we emerge from the pandemic, it might be important to consider some nontraditional ways to provide members a direct voice in decision making to improve working conditions. Returning to the stressful pre-pandemic working conditions that led to high nurse burnout and turnover rates before COVID-19 should not happen. Maybe it’s time to consider adding new approaches to our toolkit?


Peter Lazes, PhD, founded the Healthcare Transformation Project in Cornell University’s School of Industrial and Labor Relations and is now a visiting professor at the School of Labor and Employment Relations at Penn State, where he is a co-coordinator of the Healthcare Labor-
Management Partnership Initiative. Marie G. Rudden, MD, is a psychiatrist and clinical assistant professor of psychiatry at Weill Cornell Medical College. Lazes and Rudden authored From the Ground Up: How Frontline Staff Can Save America’s Healthcare.

*To learn more, see “Moral Injury: From Understanding to Action” in the Spring 2021 issue of AFT Health Care. (return to article)

Endnotes

1. For more information about this and other partnerships, see P. Lazes and M. Rudden, From the Ground Up: How Frontline Staff Can Save America’s Healthcare (Oakland, CA: Berrett-Koehler, 2020).
2. P. Lazes, L. Katz, and M. Figueroa, How Labor-Management Partnerships Improve Patient Care, Cost Control, and Labor Relations (Washington, DC: Jobs with Justice, February 2012).
3. Lazes, Katz, and Figueroa, How Labor-Management Partnerships.
4. Deb Snell, president of the Vermont Federation of Nurses and Health Professionals, conference call with author, June 19, 2019, and contract language for the unit collaborative process at the University of Vermont Medical Center.
5. Snell, personal communication, January 10, 2022.
6. A. Avgar et al., “Labor-Management Partnership and Employee Voice: Evidence from the Healthcare Setting,” Industrial Relations 55, no. 4 (October 2016): 576–603; A. Eaton, R. Givan, and P. Lazes, “Labor-Management Partnerships in Health Care: Responding to the Evolving Landscape,” in The Evolving Healthcare Landscape: How Employees, Organizations, and Institutions Are Adapting and Innovating, ed. A. Avgar and T. Vogus (Ithaca, NY: Cornell University Press, Labor and Employment Research Association, 2016); and Lazes and Rudden, From the Ground Up.
7. Case studies with these outcomes are provided in Lazes and Rudden, From the Ground Up.
8. See, for example, S. Gordon, J. Buchanan, and T. Bretherton, Safety in Numbers: Nurse-to-Patient Ratios and the Future of Care (Ithaca, NY: Cornell University Press, ILR Press, 2008); S. Gordon, “How Have Health Workers Won Improvement to Patient Care? Strikes,” In These Times, September 30, 2019; and T. Brown, “When No One Is on Call,” New York Times, August 17, 2013.
9. J. Hagemann et al., “How Nurses Are Feeling: Tired, Angry, and Hopeless,” letter to the editor, New York Times, August 25, 2021.
10. B. Rosen, D. White, and A. Rean-Walker, “What Causes Moral Injury?: From Dangerous Conditions for Patients to Disregard for Providers, These Union Leaders Have Many Examples to Share,” AFT Health Care 2, no. 1 (Spring 2021): 14–17; A. Coles, “AFT’s Health Professionals Push OSHA for a COVID Standard,” American Federation of Teachers, May 4, 2021; A. Coles, “Backus Nurses Hold Two-Day Strike,” American Federation of Teachers, October 15, 2020; A. Coles, “Nurses Tell Hackensack Meridian: ‘Ignoring Your Nurses Is Bad Medicine,’ ” American Federation of Teachers, June 23, 2020; D. O’Toole, “I Don’t Want to Leave the Bedside,” AFT Voices, June 2, 2021; and K. Ross, “Safe Back Home,” AFT Voices, September 17, 2020.
11. L. Aiken, “Nurses Deserve Better. So Do Their Patients,” New York Times, August 12, 2021.
12. A. Jacobs, “ ‘Nursing Is in Crisis’: Staff Shortages Put Patients at Risk,” New York Times, August 21, 2022.
13. Janet Wilder, organizer for the SHARE Union, conversation with author, March 8, 2021.
14. Patricia Castillo, senior union representative for the Union of American Physicians and Dentists, conversation with author, February 26, 2021.
15. Worker-Participation.eu, “Workplace Representation: Sweden,” European Trade Union Institute, www.worker-participation.eu/National-Industrial-Relations/Countries/Swed... Worker-Participation.eu, “Workplace Representation: Finland,” European Trade Union Institute, www.worker-participation.eu/National-Industrial-Relations/Countries/Finl... and Lazes and Rudden, From the Ground Up.
16. R. Karasek, “Job Demands, Job Decision Latitude, and Mental Strain: Implications for Job Design,” Administrative Science Quarterly 24 (1979): 285–308; and M. Elden, “Political Efficacy at Work: The Connection Between More Autonomous Forms of Workplace Organization and More Participatory Politics,” American Political Science Review 75, no. 1 (March 1981): 54.
17. Douglas Fraser, former president of the United Auto Workers, conversation with author, June 20, 1990.
18. Wikipedia, “Sidney Hillman,” Wikimedia Foundation, en.wikipedia.org/wiki/Sidney_Hillman.
19. Details on each of these are in Lazes and Rudden, From the Ground Up.
20. S. Liss, “Kaiser Permanente’s Historic Labor-Management Deal Survives Again,” Healthcare Dive, November 23, 2021.
21. S. Greenhouse, “ ‘A Slap in the Face’: Nurses’ Strike Signals Kaiser’s End as a Union Haven,” The Guardian, November 13, 2021.
22. Katie Ekstrom, Northwest director for the Alliance of Health Care Unions, personal communication, January 14, 2022.
23. Jodi Barschow, president of the Oregon Federation of Nurses and Health Professionals, personal communication, February 3, 2022.
24. 2021 National Bargaining: Kaiser Permanente and the Alliance of Health Care Unions, “Highlights of the 2021 KP-Alliance National Agreement,” October 1, 2021, bargaining2021.org/tools/highlights-2021-kp-alliance-national-agreement.
25. Ekstrom, personal communication.
26. Barschow, personal communication.
27. Outcomes are documented in Lazes and Rudden, From the Ground Up.
28. Joint Commission, Improving Patient and Worker Safety: Opportunities for Synergy, Collaboration and Innovation (Oakbrook Terrace, IL: Joint Commission, November 2012).
29. B. Castillo, “ ‘Treat Us Better’: Nurses Flee Hospital Jobs Because Working Conditions Aren’t Safe,” National Nurses United, The Blog, October 11, 2011.
30. J. Lagasse, “Nurses Urge HHS to Declare the Staffing Shortage a National Crisis,” Healthcare Finance, September 2, 2021; and P. Boyle, “Hospitals Innovate Amid Dire Nursing Shortages,” Association of American Medical Colleges, September 7, 2021.

[Illustrations by Pep Montserrat]

AFT Health Care, Spring 2022
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