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Administrators at Minneapolis-based Fairview Health Services, like other hospital leaders in the Twin Cities region, were suspended in contract-negotiation limbo for months last year. They hoped to avoid a nursing strike but couldn't assume that it wouldn't happen.

So Fairview leaders began to develop a strike operation plan roughly six months prior to the first of two threatened work stoppages, a one-day walkout involving 14 hospitals and more than 12,000 nurses. Over time, and continuing through the contract negotiations that started in March, they talked to temporary nurse agencies and hammered out strategy, including whether to dial back on noncritical services.

But administrators didn't shift into high gear until the union provided the 10-day notice of its intention to strike as specified by the National Labor Relations Act. Fairview officials finalized logistics, including confirming qualifications and providing on-site orientation for the 432 temporary nurses brought in from all over the country for the two impacted hospitals.

"The planning is ultimately about patient care and making sure that you can serve your community through a strike," says Paula Phillippe, chief human resources officer at the seven-hospital nonprofit system. "For so many [patients], it's not a choice to be here on any given day."

The Twin Cities strike, which ultimately was limited to June 10, is only one of a number of nursing strikes that have occurred at hospitals in the last several years, including at Philadelphia's Temple University Hospital and Northern California's Sutter Health system. And last June, Dameron Hospital in Stockton, Calif., narrowly avoided a one-day strike after administrators there decided to shut down all nonemergency treatment until a nursing contract could be reached.

During months of contract uncertainty, trustees and administrators walk a fine line figuring out how to treat patients in the event of a strike without aggravating ongoing negotiations. In the process, they must handle such basic logistics as providing additional security and finding temporary housing for traveling nurses, as well as resolve broader and more fundamental questions as whether to reduce medical services during the strike period. "It is a tense situation and a tense time," Phillippe says.

Hospital strikes potentially can jeopardize patient care, according to an analysis of New York State's experience published in a National Bureau of Economic Research working paper. The analysis, which studied nurses' strikes from 1984 to 2004, identified a 19.4 percent increase in mortality and a 6.5 percent increase in readmissions for patients admitted during the strike period. One researcher involved cautioned that the findings most directly pertained to that time period in New York State.

Other research has been limited. A Canadian study looking at the impact of a 1980s nurses' strike in Calgary didn't find any significant difference between the medical care provided before and after the strike versus during the strike itself. But the more recent findings, which translate to 138 deaths and 344 readmissions, do remind all contract parties "that the consequences of a strike are such that it has to be avoided at all possible costs," says Jim Conway, a senior fellow at the Institute for Healthcare Improvement.

If a strike does occur, trustees can play a role in reducing the impact on patients, Conway says. They can make sure additional staff is mobilized to support temporary nurses and establish measures in advance to monitor readmissions, medication errors and other red flags, ideally on a daily basis. "So [hospital leaders] know if they are getting into trouble, when they are getting into trouble," he says. "What you are trying to do is be nimble in response to the environment."

Gearing Up

Hospital leaders should develop their plan before they sit down at the negotiating table, even if a strike doesn't appear likely at that point, says Curt Kirschner Jr., a San Francisco-based partner for Jones Day who provides outside legal counsel for the American Hospital Association on labor issues. "You don't want lack of preparation for a strike to be the reason why you settle a contract," he says. "Then set it aside, know that it's there. And hopefully, you never have to turn to it."

To draft that plan, hospital administrators should work their way through a series of interrelated decisions, starting with whether and to what extent to reduce patient treatment services, according to Kirschner and others interviewed. Before making any decisions in that regard, they should conduct a detailed, unit-by-unit analysis of which clinicians and other personnel they can tap during a strike.

Count how many nonunion clinicians can step in, including nurse managers, suggests Connie Curran, R.N., chief executive of Best on Board, a Chicago-based health care consulting group. Also consider, based on your own hospital's history, how many patients could be discharged to nursing homes, home care and other settings, she says. "Can you, on a given day, discharge 20 to 25 percent of your patients?"

In the Twin Cities, hospital leaders were faced with two possible strikes and related coverage decisions, starting with the one-day strike on June 10. The following month a more open-ended strike was announced for early July. A contract agreement was reached less than a week before the second strike took place.

For the one-day strike, Fairview leaders decided to keep essentially normal operations and to hire temporary nurses to provide care, Phillippe says. Not all impacted hospitals took that route. At least one facility told a local newspaper that it was postponing all elective surgeries for June 10.

For the more open-ended strike, some medical services at the two Fairview hospitals might have been reduced slightly at the beginning, depending on the availability of some specialty nurses, Phillippe says. "It was a large number of nurses that the Twin Cities needed to have available," she says.

Fairview administrators kept board members updated as both the contract negotiations and the strike preparation unfolded, says Joanell Dyrstad, a Fairview Health Services board member. "I think our biggest concern, of course, is for the patients who are there and making sure that we have adequate coverage for them."

Preparing for the one-day strike, as well as the possibility of a second, proved to be costly. The price tag totaled nearly $24 million for the 14 hospitals involved, according to an analysis of financial statements by the St. Paul Pioneer Press.

The one-day strike "was a great way for each side to show that they have their ducks in a row," says Aaron Sojourner, an assistant professor in the department of human resources and industrial relations at the University of Minnesota.

The union leaders saw that the hospitals kept treating patients, he says. Meanwhile, hospital leaders saw "that the union pulled the strike off relatively well. And they saw that it is expensive. But I think they knew that," Sojourner adds.

Services vs. Staff

Rather than hire temporary staff to replace striking workers, administrators at Dameron Hospital last year opted for a different approach when their unionized nurses announced a one-day strike.

It would cost the 202-bed hospital roughly $1 million to continue at full operations during the strike, including bringing in about 80 temporary nurses, says Nicholas Arismendi, the hospital's chief operating officer. "That's a million dollars cash that goes out of the coffers of the hospital versus we just scale the hospital down and call their bluff," he says. "A million dollars is real dollars, and we were not willing to spend it in this manner."

So administrators at the nonprofit hospital, in consultation with the board, began to scale back hospital services June 1, including stopping all hospital admissions. Their goal was to provide, by strike day, only the bare minimum of services required by law, including emergency-department admissions, emergency surgeries and imminent baby deliveries.

The patient census, typically about 165, was projected to shrink to 30 to 40, Arismendi says. Roughly three-fourths of the hospital's 1,300 employees would be temporarily laid off by strike day. Services would continue to be scaled back until a contract agreement was reached, he says.

The hospital took out full-page advertisements in the local newspaper, explaining administrators' rationale for the service reduction, as well as what salary and other terms they had offered the nurses during contract negotiations. By June 4, when the nurses called off the strike, the hospital census was down to 110 patients, Arismendi says.

Arismendi acknowledges that Dameron's status as an independent hospital—one that has been operated by his family since 1924—gave administrators some autonomy that might not be available at a larger hospital system. Another advantage was the close family ties of employees at Dameron. Some of the nurses were related to other Dameron employees who would be laid off during the service reduction.

In the end, he estimates that Dam-eron lost about $300,000 in patient revenue as it scaled back services, compared with the $1 million in direct costs to provide strike coverage. Would he do it again? "Absolutely," he says.

The Final Stretch

A lot of the strike preparation won't be "visible to the rank-and-file employees, and it doesn't need to be," says Kirschner, who cautions against too public a preparation as it will send "a tough-guy signal that perhaps should not be communicated."

But at some point, planning can spill out into the open, straining ongoing negotiations. In May 2010, as a possible strike loomed in the Twin Cities area, a newspaper article reported that the Minnesota Board of Nursing had received a flood of licensure applications, more than 10 times the number it receives in a typical month. "It certainly makes the union suspicious—why are you spending resources on this?" Sojourner says. "Why don't you just come and talk to us and work it out?"

Contracting with temporary agencies can be costly. For such specialties as nursing, the agencies may require a minimum commitment of several days, according to Curran and Kirschner. Dameron Hospital's Arismendi said his $1 million cost estimate was based partly on the agencies' requirement that nurses be hired for a five-day minimum.

As part of the hiring package, the nursing agencies may handle other details beyond travel, including related certification, requisite vaccinations and other state requirements, Kirschner says. Still, he cautions hospital leaders from becoming too reliant on these firms and says they should verify key requirements themselves, because it's not unusual for state agencies to send out inspectors during a strike. "In the end, the hospital is going to be on the hook if that person providing care at the hospital isn't competent or qualified to do so," he notes.

In the final weeks leading up to the strike, it's crucial to convey to doctors and other clinicians the roles they will play, with no job being too small, Curran says. She was the chief nursing officer at New York City's Montefiore Medical Center when thousands of workers—housekeepers, dietary aids, social workers and security guards— went on strike in the 1980s. Everyone chipped in, Curran says, including the physicians who carried food trays to patients and kept the floors clean.

During a nursing strike, physicians can be pivotal, deferring some hospital admissions and preparing their patients for long emergency-department waits, Curran says. A physician's own staff also can assist with such basic tasks as admitting. Other clinicians also can step in. Social workers might be able to assist with discharge planning or provide support in some areas of the hospital like the geriatric units, Curran says.

At Fairview Health Services, the 432 temporary nurses arrived two and three days before the strike to complete an orientation process, including training on the hospitals' electronic medical record systems, and a review of policies and procedures. Managers and other supervisors also were stationed on the units during the strike day to answer questions and provide any necessary backup, Phillippe says. "We had a positive experience with our nurses. They were very committed caregivers. And they did good work."

As contract negotiations persist, trustees and administrators should strive to maintain a generosity of spirit when talking about the unionized employees, regardless of what's occurring at the negotiating table, Curran says. "You've got to live with these people when they come back in," she says. "And you can't destroy your community's trust in these caregivers."

Dyrstad said that Fairview board members reassured members of their community in informal conversations that hospital leaders had planned far in advance for any patient treatment contingency. "You express to them that, 'Yes, if the strike should happen, we are well-prepared. We have professionals coming in to cover those positions and health care will not be adversely impacted for our patients.'"

Charlotte Huff is a writer in Fort Worth, Texas.

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