We know very little as to how union activities (negotiations, strike preparations, or actual strikes) affect the personal and professional experiences of nurse leaders. Little evidence exists in nursing and healthcare literature about nursing unions and their impact on patient outcomes, nurse leaders, Magnet® journeys or designation, nurse satisfaction, or other relative variables. Most articles regarding the union and patient, provider, or organizational outcomes have been published in non-peer-reviewed, labor relations, or union journals. Because of the paucity of previous literature on the topic, it seemed necessary to conduct an exploratory study to describe how union activities affect nurse leaders’ personal and professional work experiences. The purpose of this study was to explore the personal and professional experiences of nurse leaders during union negotiations and strike preparations and to understand the impact on lives of nurse leaders. There were 2 research questions for the study: 1) What are the perceptions of nurse leaders about union negotiations, strike preparation, or actual strikes on personal, professional, and organizational outcomes? And 2) what is the effect of union negotiations and strike preparations on nurse leaders in a healthcare system?
Review of the Literature
A literature search was conducted for the past 5 years using PubMed, CINAHL, and Google Scholar search engines. The following key words were used: strikes, labor disputes, labor relations, collective bargaining AND nurse administrator, nurse leaders, nurses, nursing administration, nursing management, nurse leaders, Magnet, or Magnet organizations. Very few peer review articles were retrieved, and most articles were published in prounion or labor journals and were not evidence-based.
The crisis of leadership in the context of the nursing shortage and the increasing prevalence of nursing unions was discussed from several perspectives. Balogh-Robinson1 discussed increased trends of nursing unionization and the lack of willingness of nurses to leave the union for nonunion leadership roles. The coexistence of unions and Magnet initiatives was also discussed by authors2,3 who described the importance of converging organizational goals, Magnet requirements, and union contract obligations. The authors’ indicated nursing unions and Magnet convergence was pivotal for the nursing care delivery and high quality patient care.2 Other authors3,4 discussed the need to mitigate conflict with union representation with proactive communication strategies and a partnership model with union representatives where the chief nursing officer (CNO) meets with frontline nurses without human resources and the union negotiators to enhance shared governance strategies. Topics for discussion with the CNO and frontline nurses should include staffing and scheduling, floating, technology, education, clinical ladder, and the charge nurse role but exclude the typical union compensation and benefits discussions. The interrelationship of service, quality, and price (the triple aim)5 should be discussed to provide a context about the evolving healthcare system. Keeping labor negotiations clinically or patient focused may decrease the “we-they” perspective.6
Despite union rhetoric about quality patient care, strikes were often about membership, compensation, benefits, working conditions, and power. When strikes ended, the rift between nurse leaders and striking nurses was deep and took time for recovery.7 Improved listening was recommended between nurse leaders and striking nurses with sensitivity to the ideas of informal leaders among frontline nurses to minimize negative feelings after the strike ended.
The literature is limited on the topics of nursing unions and their impact on patient outcomes, nursing leadership, and Magnet designation. We do know that union environments have fostered a “we versus them” mentality. After all, the National Labor Relations Board defines professional nursing and union membership as mutually exclusive categories.1
An exploratory, descriptive design was used. After approval was obtained from a hospital institutional review board and the research council for the Association of California Nurse Leaders (ACNL), an e-mail was sent to a convenience sample of ACNL members describing the study and how to participate if they had worked in a hospital or healthcare environment where union activities had occurred in the past 3 years. The convenience sample included nurse executives (chief operating officers, CNOs, and system nurse executives), nurse directors, nurse managers, clinical nurse specialists, and leads (shift, full-time, exempt charge nurses). An electronic link was provided to the online information letter, invitation to participate, and the survey questions if they were eligible to participate. A snowball sampling method was also used, and the nurse leaders were asked to provide the study website link to other nurse leaders who met the eligibility criteria within or outside of California. Nurse leaders who were involved in a union negotiation process more than 3 years before the study were excluded. There were no nurses in the sample who were dues paying members in a bargaining unit.
A self-developed survey with 86 questions was used to explore and describe nurse leaders’ perceptions of union activities on their professional and personal lives. The survey was not intended for instrument development or psychometric testing. The items in the survey (Supplemental Digital Content 1, http://links.lww.com/JONA/A664) were informed by anecdotal reports from nurse leaders experiencing union activity and from the clinical expertise of the authors. The survey includes 16 demographic questions used to describe the sample, 35 questions to measure respondent perceptions of the effect of union activities on their personal and professional work life and the organization, 30 questions to measure how the respondents felt during the union events, and 5 open-ended questions asking the respondents to describe how union activities affected: 1) their day-to-day work life responsibilities; 2) their thoughts about professional nursing; 3) the relationships between unionization and Magnet initiatives; 4) what more could have been done to alter union negotiations; and 5) to describe the biggest obstacles and challenges faced during the union events.
Of the 1,318 ACNL members at the time of data collection, there were 93 respondents who completed the electronic survey (7% response rate). Most of the respondents (89%) reported being involved in union activities within the past 3 years. Most respondents resided in California, and 67% were ACNL members. Non-ACNL respondents (33%) were recruited using the snowball sampling method. Most respondents were directors (20%), managers (19%), CNOs/nurse executives (18%), clinical nurse specialists (18%), leads/permanent charge nurses (7%), nurse educators (6%), and other (11%, not specified). The respondents had a mean of 27.4 years as a nurse and 59.3 direct reports, most of whom were RNs. Respondents were employed in hospitals ranging from 60 beds to 2,100 beds (mean [SD], 355.5 [264.5]). Surprisingly, 40% had been union members in the past but (76%) described themselves as not being very active in the union or somewhat active (21%).
Personal and Professional Effects of Union Activities
Three questions related to how the union negotiations and strike preparations affected the nurse leader personally and professionally. Most of the respondents indicated that the union activities had a moderate or major negative effect (90%) on them personally; 66% reported a negative effect on the family life at home; and 73% reported a negative effect on them professionally. With a response set of “major positive effect = 4, moderate positive effect = 3, moderate negative effect = 2, major negative effect = 1, no effect = 0,” the respondents indicated that the union activities mostly affected their relationships negatively with their peers (mean [SD], 1.78 [1.28]), those to whom they reported (mean [SD], 1.19 [1.30]), and their relationships with those who directly reported to them (mean [SD], 1.32 [1.12]). It should be noted that there were both positive and negative effects reported in these relationships. The more negative effects were felt between the nurse leaders and those who directly reported to them (49% moderate or major negative effect).
Five questions with a 4-point response set (strongly agree = 4, agree = 3, disagree = 2, strongly disagree = 1) focused on nurse leaders’ feelings of being betrayed by union nurses or surprised at some of the behaviors of union nurses. The highest means related to nurse leaders being surprised by some of the behaviors and tactics of the union nurses (mean [SD], 3.30 [0.81]) and feeling betrayed by union nurses who were behaving in ways the nurse leaders did not feel were consistent with professional behavior (mean [SD], 3.28 [0.89]). Nurse leaders reported (strongly agree = 4, agree = 3, disagree = 2, strongly disagree = 1) support extended by colleagues, supervisors, organizational executives, or leaders during the union activities. They felt supported by their supervisors during the union activities (mean [SD], 3.26 [0.74]), and they were appreciative of open communication from their organization’s leadership team about union negotiations (mean [SD], 3.12 [0.85]).
How nurse leaders viewed union nurses during the union activities was negatively affected (86%), and 85% of the nurse leaders indicated that their perspective or view of the professionalism of clinical nurses was negatively affected. Nurse leaders indicated that their work stress was higher during the union activity time as compared with their usual job duties (mean [SD], 3.33 [0.77]).
Effects on the Organization and Culture
The nurse leaders indicated that union activities affected the organization (work environment, organizational initiatives and priorities, and employee satisfaction), its organizational culture of safety, and overall culture (major positive effect = 4, moderate positive effect = 3, moderate negative effect = 2, major negative effect = 1, no effect = 0). The respondents (80%) reported a moderate to major negative effect on the work environment on patient care units and nonunion nurses reported that they felt pressure (strong = 46%, moderate = 24%) by their peers and/or union organizers to join the union (mean [SD], 2.83 [1.39]). Union activities were reported to negatively affect (73%) current and future initiatives such as Magnet designation or redesignation, certifications, and awards or recognition for excellence. Respondents indicated that it took approximately 6 to 9 months for the organization to return to “a normal state.” The organizations reputation in the community was viewed to be negatively affected (72%).
Nurse Leaders’ Personal Feelings About Union Activities
Nurse leaders reported some positive feelings about the union activities (range: 5 = always, 4 = most of the time, 3 = sometimes, 2 = rarely, 1 = never). The respondents reported feeling energized (mean [SD], 3.30 [0.92]), encouraged (mean [SD], 3.18 [0.90]), happy (mean [SD], 3.08 [0.93]), and proud of the nurses who worked at their hospital (mean [SD], 2.9 [0.93]). The top 10 mean scores for negative feelings are outlined in Table 1 and included feeling guilty, alone, violated, traumatized, and depressed. Other feelings were reported to have occurred less frequently (sometimes and rarely) are also included in Table 1.
More Insight Into the Nurse Leaders’ Experience
Five open-ended questions provided more insight into how union activities affected nurse leaders’ work life responsibilities, their thoughts about professional nursing, and the relationships between unionization and Magnet initiatives. Nurse leaders’ responses to the open-ended questions provided insight into the biggest obstacles and challenges experienced during the union events. It should be noted that the nurse leaders were eager to share their thoughts in the open-ended questions, with 68% of the respondents providing lengthy comments. Each author individually identified themes from the open-ended questions and then met as a group to affinitize the responses to reach consensus on common themes and categories.
When asked to describe how the union activities affected their work life responsibilities, the nurse leaders described an unsettled work environment where feelings were more intense, guarded, and deliberate communication between clinical nurses and the nurse leaders.
Fuses were short and tempers flared; it was an intense time prior to the union strike vote; I had to be more tolerant and avoid some discussions in the clinical area.
Nurse leaders assumed additional roles beyond their usual scope of work leading to long work hours and missed days off or holiday times with their families. In preparation for a potential or real strike, there was a rapid discharge of large numbers of patients, focused time to ensure the competencies of replacement workers hired to staff units during a strike, and education of nonclinical nurses or nurses who do not typically provide patient care every day. Usual work operations were interrupted with the immediate discharge of patients when strike threats were imminent. There was less time to focus on patient care quality.
Day-to-day activities were put on hold; all other projects came to a halt; nothing but union preparations got done.
The nurse leaders’ personal lives were also affected.
We were prepared to leave our families for days to live in hotels near the hospital; we missed weekends and special holidays such as Thanksgiving and Christmas; I was concerned personal property, cars, and selves would be threatened if the strike occurred.
The nurse leaders described how the union activities affected their thoughts about professional nursing, and many described disappointment with the profession (“Moved the profession to a technical realm”; “I do not believe in abandoning patients in a strike”), being shocked at the behaviors of union nurses (“A lack of professionalism”; “Disappointed in behaviors of union nurses who acted like blue-collar workers”; “Some union nurses were self-serving, dishonest, and manipulative”), and surprised to see nurses active in collaborative governance councils and Magnet now active in union activities. Some comments indicated the following: “Unions are a business and more interested in money than the quality of care.” “Professional nursing was reduced to monetary priorities.” “Nurses were whipped into a frenzy to demand more money and benefits.” “The contract focused on money.”
Many comments focused on the impact of social media and the effect on nurse leaders’ perceptions of professional nursing. Nurse leaders were shocked at some of the behaviors of the union nurses and their negative comments about their organizations.
I couldn’t believe the negativity of bedside nurses, I was disappointed to see the hateful and hurtful things posted for the world to see. What was being said in the media was not congruent with patient safety data, employee opinion surveys, or nurse satisfaction reports. The clinical nurses posted things on social media they would never say in person. I had a hard time understanding how clinical nurses active in Magnet activities were now carrying negative signs about the hospital or speaking badly about the quality of care at the hospital to the media.
Study findings reveal that the union negotiation process and preparing for an impending strike result in a wide range of both positive and negative emotions in nurse leaders. On the positive spectrum, the nurse leaders expressed feeling energized and encouraged. Negative emotions were more dominant with feelings described as guilty, alone, angry, sad, and overwhelmed. Data revealed an overall theme of 5 feeling states: disappointed, distressed, discouraged, demoralized, and disheartened, which the researchers labeled the “5 Ds.” Clearly, the results reflect that this process resulted in a professional and personal toll on the nurse leader respondents. Respondents were surprised at the negativity and incongruence of social media postings. Respondents discussed the disconnect between the union advocating for improved patient quality and safety, yet the negotiations and contract discussions were mainly focused on monetary topics.
Implications for Practice
The results of this study have organizational implications. Organization leaders may be surprised and have feelings of betrayal when hearing accusations of poor care quality and working conditions from union nurses who were previously supportive of the organization. During the union negotiation and strike preparation process, the executive and leadership team need to facilitate support for nurse leaders at all levels of the organization. Leaders with experience in union activities should mentor less experienced leaders in how to manage their own feelings and emotions, interact with hostile union nurses, diffuse conflictual situations, and refocus conversations to nursing practice and patient care quality issues. The executive leaders must realize the emotional impact on managers and provide opportunities to reflect on issues emerging from negotiations, comments in the media, or conversations on patient care units. Potentially contentious issues should be discussed with strategies developed for managing communications or unexpected behaviors in the clinical setting or public forums.
Despite best efforts in ensuring clinical nurses’ participation in collaborative governance and Magnet initiatives, nurse leaders must recognize the existence of parallel organizations influencing their direct nurse reports with their own information and agendas. Organizations should consider redesigning an improved partnership between union and hospital representatives. For example, include union representation in the collaborative governance committees with a focus on improving patient quality and safety. Mayes et al8 discussed the key factors in sustaining a long-term partnership between the union leaders and administration, including open communication, commitment to quality patient care, mutual trust and respect, and a spirit of innovation. Cullen and Donahue4 discussed the specific strategies that CNOs implemented to engage frontline nurses in nonunion topics.
This study indicated increased levels of work overload, role conflict, role ambiguity, and organizational constraints in terms of communicating with hostile and accusatory union nurses. The results support other studies’ findings of predictors and outcomes of nurse leaders’ stress9,10 and moderators of nurse leader stress.11 Reduced nurse leader job satisfaction, intent to quit, and mental health symptoms are reported outcomes of nurse leader stress.11-13 The ability of a nurse leader to cope with and manage his/her stress may be varied depending on experience, personal attributes, and personal and professional support systems. Anticipating and making additional supportive resources available to nurse leaders may be an important organizational strategy, because nurse leaders will be working longer work hours with increased emotional stress. Personal stress reduction strategies to help leaders express feelings and use appropriate coping mechanisms may be important.
The study illustrated the need to ensure transparency in all communications to ensure truthful facts as contrasted to emotional conjecture and reactions. Further exploration of the effect of union activities on organizations, nurse leaders, care providers, and patients is recommended. Most important is to know how union activities affect patients’ perceptions of care quality when they are exposed to public demonstrations and media reports of poor staffing and patient outcomes at the hospital where they are receiving care. The perspectives of nurses, other care professionals, and patients would be helpful for nurse leaders in planning future negotiation strategies. Additional research is needed to clarify the nurse leaders’ responses in this study about “feeling guilty” during the union activities.
The data in this study were collected through an e-mail to ACNL members, who were then invited to share the survey with other colleagues. The snowball sampling method could have created respondent bias, with more nurses responding who had experienced union activities and were interested in this topic, although the non-ACNL respondents were only 11% of the sample. This study has a small response rate, and it is unknown how the findings would have changed with respondent input from other nurse leaders who did not respond. The study is generalizable to nurse leaders working in California hospitals, and it is unknown if the findings apply to nurse leaders in other geographical locations.
The study used retrospective study design, with participants reflecting on their emotions/feelings over past 3 years. Memories may have diminished over time. The abundance of comments to the open-ended questions (in general, 65% of respondents made a comment) indicated nurse leaders’ need to share feelings and thoughts about the union activities. A psychometrically tested instrument was not available and the self-developed study questions (Supplemental Digital Content 1, http://links.lww.com/JONA/A664) were based on the literature review and experience of the authors. Content validity was enhanced when 3 members of the research committee within ACNL reviewed the questions and recommended changes.
Nurse leaders impact the nursing profession, clinical operations, and patient outcomes. This research adds to a body of knowledge where little has been reported about the effect of nursing unions on nurse leaders. Findings will help executive leaders in anticipating nurse leaders’ professional and personal responses to union activities and in planning organizational strategies for future union negations and strike preparations to neutralize the effect on providers, patients and families, and the organization as a whole.