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Traditional and Non-traditional Collective Bargaining: Strategies to Improve the Patient Care Environment

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Karen W. Budd, PhD, RN, CNS
Linda S. Warino, BSN, RN, CPAN
Mary Ellen Patton, RN


Acquiring organizational autonomy and control over nursing practice, through a combination of traditional and non-traditional collective bargaining (CB) strategies, is emerging as an important solution to the nursing shortage crisis. For the past 60 years, nurses have improved their economic and general welfare by organizing through traditional CB, particularly during periods of nursing shortages. During the past decade, however, the downsizing of nursing staffs, systems redesign, and oppressive management practices have created such poor nursing practice environments that improvement in wages no longer is viewed as the primary purpose of CB. Much more essential to nurses is assuring they have a safe practice environment free of mandatory overtime and other work issues, and a voice in the resource allocation decisions that affect their ability to achieve quality health outcomes for patients. The thesis presented in this article is that traditional and non-traditional CB strategies empower nurses to find such a voice and gain control over nursing practice. This article describes the current shortage; discusses how CB can be used to help nurses find a voice to effect change; reviews the American Nurses Association’s (ANA's) history of collective action activities; explains differences between traditional and non-traditional CB strategies; and presents a case study in which both strategies were used to improve the present patient care environment.

Citation: Budd, K., Warino, L., Patton, M., (January 31, 2004). "Traditional and Non-traditional Collective Bargaining: Strategies to Improve the Patient Care Environment". Online Journal of Issues in Nursing. Vol. 9 No. 1, Manuscript 5.

DOI: 10.3912/OJIN.Vol9No01Man05

Key words: collective bargaining, control over nursing practice, organizational autonomy, professional autonomy, empowerment, National Labor Relations Act, interest-based bargaining, strikes, mandatory overtime, distrust of management, quality health outcomes, Magnet status, shared governance, unions.

What comes to mind when you read the words "collective bargaining" in the title of this article? If you are like many of the more than 80% of nurses (Carlson, 2003) who are not a part of a collective bargaining unit (CBU), you might respond with "strikes," and "aggressive, unprofessional behavior." While even CBU nurses might agree to a dislike for strikes and the accompanying picket lines (Fitzpatrick, 2001), these nurses certainly are not likely to agree that organizing for collective bargaining (CB), nor strikes for that matter, are unprofessional (Ketter, 1997). Rather, unionized nurses are likely to point out that in the current health care environment, CB strategies may be the only effective means for nurses to gain control over their practice and "attain professional as well as personal and economic goals" (Breda, 1997, p. 99).

Control over practice means nurses have "a voice in decisions that affect the patient care environment and their ability to deliver quality care" (Fitzpatrick, 2001, p. 41). Such control requires an organizational structure that promotes organizational autonomy, which is "the freedom to take the initiative in shaping unit and institutional policies required for patient care and accessing the organizational resources required for providing care" (Hinshaw, 2002, p.92). When organizational autonomy or control over practice is present in a practice setting, nurses feel respected and empowered to provide high quality patient care (Apfer, Zabava, Ford, & Fox, 2003; Kramer & Schmalenberg, 2003).

The ability to provide patient care of high quality is a core value of nurses (American Nurses Association, 2003; Breda, 1997; Darr, Schraeder, & Friedman, 2002), and therefore, controlling the availability of essential resources, including those affecting time and personal well-being, is a vital commitment for them. When such resources are threatened or are unavailable, and when nurses are not a part of the process of finding solutions, "they perceive a loss of control over something they value highly---an environment in which they can provide the highest quality care possible" (Clark, Clark, Day, & Shea, 2000, p. 95). Further, they feel disrespected, frustrated, and disillusioned (Breda); lacking needed resources, quality care outcomes decline (Carlson, 2003; Fitzpatrick, 2001; Needleman & Buerhaus, 2003; Sheridan, 2002). Unable to reverse a decline of healthy outcomes, nurses are either leaving the hospital practice setting or searching for a means of empowerment, such as that provided by unions, to find a collective voice.

Finding structures and methods, such as CB, that offer nurses the possibility of control over practice has never been more crucial to the survival of professional nursing than in the current patient care environment, which is in the midst of an acute nursing shortage crisis (Goodin, 2003; McClure, Poulin, Sovie, & Wandelt, 2002). Traditional CB has been used by constituent states of the American Nurses Association (ANA) for the past half-century, particularly during nursing shortages. Resolution of the present shortage, however, may require using both traditional and newer, non-traditional CB strategies to promote control over practice and improve the patient care environment. The thesis presented in this article is that traditional and non-traditional CB strategies empower nurses to find a voice and gain control over nursing practice. This thesis will be developed by describing the current shortage, discussing how CB can be used to help nurses find a voice to effect change, reviewing ANA’s history of collective action activities, explaining differences between traditional and non-traditional CB strategies, and presenting a case study in which traditional and non-traditional strategies were used to improve the present patient care environment.

Current Nursing Shortage

Analysts of the current shortage agree that this shortage is different from previous ones. At a time when there is an increased demand for nurses skilled in the use of sophisticated patient care technology, the nurse workforce is aging faster than replacements can be educated by a professoriate that is itself graying (Hinshaw, 2001). Nurses are leaving the workplace, and in many instances the profession, in protest that mandatory overtime and high patient-to-nurse ratios result in unsafe patient care environments (Burger, 2002).

In 2001, 21% of a sample of 700 nurses then in current practice expected to leave direct patient care within five years for reasons other than retirement (Peter D. Hart Research Associates, 2001). The main reason given was to find a job that was less stressful and physically demanding. Further, an improvement in staffing ratios was the most important change mentioned by these nurses that would keep them from leaving. Additionally, in another study of 324 randomly selected staff registered nurses (RNs) in North Carolina, the 171 RNs of the sample who had stayed longer than five years in their present position were asked why they had stayed. Their top reasons were having a collegial environment, satisfactory pay and benefits, and flexible scheduling (Lacey, 2003; Lacey & Shaver, 2002).

Sources of the Shortage: Restructuring and Redesign

Different from several previous shortages, which lasted only 12 to 18 months and were solved by raising wages (Phillips, 2003), the current shortage is more complicated. In an attempt to deal with prospective payment, managed care, and other cost issues in the nineties, hospitals restructured and redesigned health care delivery systems, and downsized nursing staffs. The results of such market-based "reform" initiatives for nurses were downsizing of staffs, increased supervision of lower-cost workers brought in to replace nurses, increases in workload and responsibilities, mandatory overtime requirements, distrust of management, and burnout (Clark et al., 2000; Clark, Clark, Day, & Shea, 2001; Gelinas & Bohlen, 2002). Continuing cost-reduction efforts have had disastrous effects on patient care quality, nurses’ morale, and nurses’ safety (Aiken, Clark, Sloane, Sochalski, & Silber, 2002; Clarke, Sloane, & Aiken, 2002; Needleman, Buerhaus, Mattke, Stewart, & Zelevinsky, 2002; Shumaker, 2003). In a survey conducted by Cornerstone Communications Group (2001) for the American Nurses Association, 75% of 7,299 respondents stated that due to inadequate staffing, nursing care quality had declined in their facilities in the past two years. Further, about half (3,617) said they were "exhausted and discouraged" when they left work, and 2,928 felt they were "powerless to affect change necessary for safe, quality patient care" (Report Appendix, Question 7). Similarly, Aiken et al. (2002) found in their study of 10,184 staff nurses and 232,342 discharged patients that high patient-to-nurse ratios were associated with increased risk of patient mortality within 30 days of admission, and increased nurse burnout and job dissatisfaction. In fact, adding one patient per each nurse workload increased the odds of the patient dying by 7%; increased the likelihood of nurse burnout by 23%, and increased the odds of job dissatisfaction by 15%. Aiken and her associates concluded, "Core problems in work design and workforce management threaten care provision. Resolving these issues, which are amenable to managerial intervention, is essential to preserve patient safety and provide care of consistently high quality" (Aiken, Clarke, Sloane, & Sochalski, 2001, p. 255).

Unionizing to Compel Systems Changes

Although recognizing that the nursing shortage is due to the interaction of many factors, Needleman and Buerhaus (2003) have concluded that resolution of the crisis must begin with systems-level change of the environment in which health care is provided. Gelinas and Bohlen (2002) have reached similar conclusions. Stating that "leaders must take systemic action" to promote a safer, more satisfying health care environment, they provide many suggestions for improving the culture, leadership, work design, and human resource processes (Gelinas & Bohlen, p. 11). "Only by changing the way that hospitals deliver, compensate and value the work of caring, can leaders eliminate the deficiencies embedded in the system" (p. 43). Unfortunately, such systemic changes are unlikely to occur rapidly, even when management is committed to taking action (Gavin, Ash, Wakefield, & Wroe, 1999). As nurses’ frustration and perceptions of being undervalued, disrespected, and helpless to effect change themselves grow (Goodin, 2003), they increasingly are turning to unions for help (Clark et al., 2001; Darr et al., 2002; Forman & Davis, 2002; Gelinas & Bohlen; Shindul-Rothschild, Byers, & Adams, 1999; Steltzer, 2001).

Unions appear to offer nurses protection to demand, "that the standards of their profession be respected and enforced. When [nurses] do not have the protection to speak out on behalf of patients, the patient care provided and the patients lose" (Clark et al., 2000, p.95). A recent study by Seago and Ash (2002) comparing patient outcomes of union and non-union hospitals in California supports Clark’s contention. A 5.7% lower risk-adjusted mortality was found among acute myocardial infarction patients in hospitals with unionized nurses compared to non-union hospitals even after controlling for wages and RN hours, which were higher in union hospitals. The authors speculated that possible factors for the better patient outcomes in union hospitals than in non-union hospitals were "stability in staff, autonomy, collaboration with MDs, and practice decisions that have…a positive influence on the work environment…" (p. 150).

Unions and CB represent a structure and method to at least begin to gain control over practice and combat management systems that "threaten the quality of care of patients and diminish the quality of nurses’ working conditions" (Darr et al., 2002, p. 21). The expectation of frustrated nurses is that constraints imposed by labor law will compel management to reduce the current high patient-to-nurse ratios, abolish mandatory overtime, increase the safety of the environment, and improve their general welfare (Clark et al., 2001). Based on a study of 940 nurses, Clark et al. concluded, "nurses who perceived problems with administrative support and voice in their hospitals were more likely to view unions as instrumental, or potentially effective, in dealing with the effects of healthcare reform than nurses who perceived [the] climate positively" (p. 140).

Finding a Voice to Effect Change Through the Power of Collective Bargaining

As a legally regulated negotiating tool, CB empowers nurses to find a voice for requiring change in their economic and general welfare and in the health care environment.

As a legally regulated negotiating tool, CB empowers nurses to find a voice for requiring change in their economic and general welfare and in the health care environment. By implication, the procedures established by the National Labor Relations Act (NLRA), and additional state laws, require employers to negotiate with their employees as equals. "While the typical workplace is built on principles of authority and subordination, the bargaining process is not. When union members [come to the bargaining table], they are no longer in a position of subordination to the managerial authority of the employer" (Rainsberger, n.d, "Control of the Agenda," para. 2).

Employers are obligated by the NLRA to bargain in good faith over issues of wages, hours, and other terms and conditions of employment (Szcepanski, 2003a). The latter bargaining focus, terms and conditions of employment, has taken on a prominence over the other two, however, in the current nursing shortage environment. Nurses are reporting that while wages and benefits are important, these are not the primary reasons for turning to unions and CB (McGrath, 1996; Steltzer, 2001). More important is the ability to ensure an environment that will allow nurses to practice in a manner conducive to achieving the best possible patient health outcomes (Darr et al., 2002). Consequently, in addition to wages and benefits, common subjects of agreements negotiated in CBAs include:

  • mandatory and voluntary overtime
  • acuity-based staffing systems
  • use of temporary nurses
  • protections from reassignments, work encroachment by non-nurses, and mandated non-nursing duties
  • provisions for work orientation and continuing education
  • whistleblower protection
  • health and safety provisions, such as free hepatitis B vaccine
  • "just cause" language for discipline and termination
  • provisions for nursing and multidisciplinary practice committees

("The Benefits of Collective Bargaining," 2001; Sheridan, 2001; Szcepanski, 2003b; "Using Collective Bargaining," 2003; "What Do Maine Nurses Bargain?," 2002).

The resulting contract or CB agreement (CBA) is enforced under federal and state law ("Collective Bargaining and Labor Arbitration," n.d.). Further, since the CBA is a legally binding contract, it prevents employers from making arbitrary decisions about changing the negotiated agreements of the contract. To insure recourse to nurses when they dispute employers’ interpretation of the contract, the CBA usually also will include grievance and arbitration procedures ("Collective Bargaining FAQs," n.d.; Troutman-Poole, 2002).

History of the American Nurses Association Collective Bargaining Efforts

Although nurse CBAs have been negotiated under the aegis of several national unions, the largest nurse union is the United American Nurses, which, as an affiliate of the ANA, is comprised of members of ANA’s constituent states’ local bargaining units. The ANA has more than a half-century of unionizing and traditional CB experience, which was acquired particularly during periods of nursing shortages. Calling upon such experience can be extremely useful to help nurses find their voice and change the health care environment during the current shortage. A summary of that experience follows.

The Post-World War II Shortage

Although the ANA had promoted the economic security and general welfare of nurses throughout the first half of the 20th century, it had not engaged in CB (Forman & Davis, 2002). This lack of CB involvement likely reflected the predominate view that nursing was a calling and not an occupation. In the post World War II years, however, poor working conditions, inadequate pay, and an increased demand for nurses resulted in an acute national shortage of nurses (Flanagan, 1986). Concern about the future of nursing was fueled by a report that had been prepared by Raymond Rich Associates, a consulting firm hired by ANA. The report stated, "….nursing could not hope to maintain high standards of practice, attract qualified recruits, or retain the best nurses unless the profession did everything in its power to gain for nurses a decent measure of social and economic security" (Ketter, 1996, p. 4).

In response to the report, a resolution was adopted at the 1946 ANA Convention to establish an economic and general welfare program. The program provided guidelines and assistance to State Nurses Associations (SNAs), now called Constituent Nurses Associations (CNAs), for promoting the economic security of nurses and engaging in CB. Subsequent certification of ANA as a labor organization in 1949 paved the way for SNAs to represent registered nurses as their bargaining agents.

Subsequent Shortages

According to Flanagan (1986), "by the early 1960s, nurses in SNA local units were successfully negotiating provisions for shortened hours of work, salary increases, shift differentials, shift rotation, overtime, length-of-service increments, sick leave, health benefits, retirement plans, grievance procedures, Social Security coverage, and more" (p. 16). Nevertheless, by the mid-1960s a critical shortage of nurses attributed to economic exploitations was occurring once again, which prompted the ANA in 1966 to adopt the Resolution on National Salary Goal. This resolution established the salary goal of not less than $6,500 for entry-level registered nurses, and called upon SNAs to use negotiation through CB to implement the goal (Ohio Nurses Association, n.d.). The establishment of a salary goal provided the impetus for many SNAs to secure higher entry-level salaries for nurses through CB. Not until 1974, however, were nurses in non-public hospitals offered protection under the NLRA. Therefore, before 1974, mass resignations were used as a collective action in lieu of strikes (Flanagan, 1986; Ketter, 1996; Patton, 1998).

In 1965, Patton (1998) used mass resignation as a method to change employment conditions following thwarted CB efforts. As a staff nurse in an Ohio hospital, she was part of a nursing staff that faced "staffing and scheduling problems, no input in decisions affecting nursing, physicians controlling promotions, a low starting wage, few benefits, and no pension" (p. 80). She recounted, "the final insult was management’s offer of a 10-cent-per-hour raise for full-time nurses, with only five cents per hour for part-time nurses, which were most of us. This was later called the most expensive nickel in hospital history because it galvanized us to…. organize [through the Ohio Nurses Association (ONA)] for [CB]" (p. 80). Unwillingness of an obdurate management to negotiate with ONA resulted in a mass resignation of 85% of the nursing staff. Assistance of a federal mediator was obtained, and thirteen days later, the nurses returned to work with "a contract in hand" (p. 80). Patton’s CBU was the first to be represented by ONA. Today ONA’s Economic and General Welfare program includes more than 5,500 registered nurses in 29 local units (ONA, personal communication, October 21, 2003).

Once or twice each decade throughout the next twenty-five years, cyclical, short-lived nursing shortages occurred primarily as a function of an economic supply and demand (Phillips, 2003). When the national economy was on the upside and more employment opportunities existed for nurses, shortages would occur (Gelinas & Bohlen, 2002). Hospitals would attempt to fill RN positions with lower-wage workers, such as LPNs or nurse aides, and only as a last resort would raise RN wages (Phillips, 2003). During these times, CB was particularly useful for nurses because it provided a tool to demand a voice in decisions affecting them and their job security. Such demands continue to be relevant in today’s health care environment (Forman & Davis, 2002).

Traditional and Non-Traditional Collective Bargaining Strategies to Effect Change

This next section contrasts traditional CB and non-traditional CB strategies. It describes how both types of strategies can empower nurses to gain control over their practice.

Traditional Collective Bargaining

Traditionally, the principle of equal power frames negotiations for both the union and employers. Negotiating techniques labeled "rights-based" or "traditional" CB have been developed to allow each side to maintain the appearance of power in the face of confrontation. Based on experience of what constitutes success, each side will have given much thought to the composition of its bargaining committee, to the list of demands it will make, and to strategies for winning.

The constitution and bylaws of each group may regulate the size and selection process of the bargaining committees, but generally a size of five to seven members is recommended.

The preliminary phase of the traditional CB process culminates in a proposal or list of demands that is brought to the negotiating table.
This size is small enough for unity to be maintained and yet large enough for the distribution of tasks. To maintain the appearance of unity, usually one person is designated the group’s major spokesperson; another person will be designated secretary or recorder. A major preliminary task for committee members is to poll each group’s constituency to determine the negotiating issues and priorities. Additionally, throughout a contract period, problems with the current contract are documented in preparation for the next bargaining sessions. "Effective bargaining is a continuous process" (Rainsberger, n.d., Effective Negotiations, p. 2). The preliminary phase of the traditional CB process culminates in a proposal or list of demands that is brought to the negotiating table.

Traditionally, the CB process occurs in phases. In early sessions, formal exchange of proposals and considerable posturing occurs as "both sides attempt to emphasize the legitimacy and righteousness of their ...position" Rainsberger, n.d., Effective Negotiations, p. 4). Serious discussion begins during the middle CB sessions, with most attention given to secondary issues. The third phase is the crisis phase when, as the deadline approaches, the primary issues are addressed. "The intensity and tension of bargaining will increase and the process will become considerably more chaotic" (p. 4).

Throughout the three phases, each side will give constant attention to developing and presenting "solid arguments….to explain and justify its position on every issue introduced in negotiations" (Rainsberger, n.d., Effective Negotiations, p. 3). Techniques of argumentation, logic, and persuasion are used strategically for maintaining a position of power and for winning acquiescence to demands.

Non-Traditional Collective Bargaining

Using the "we vs. they" approach of traditional CB may accomplish a desired contract that results in improved working conditions for nurses. Another result, however, may be long-lasting adversarial relations between nurses and their employers (Dennison, Drummond, & Hobgood, 1997). "It’s hard to recover from the table pounding, the bluffs and the gamesmanship" (Bilchik, 2000, p. 39). As a result, a newer, more collaborative method, labeled interest-based bargaining (IBB) or "win-win" bargaining, has been found to be useful for some nurse CBUs (Bilchik; Steltzer, 2001). This newer, more collaborative method is likely to be useful when the goal is to establish shared governance structures that contribute to achieving organizational autonomy or control over practice.

This newer, more collaborative method is likely to be useful when the goal is to establish shared governance structures that contribute to achieving organizational autonomy or control over practice.

Shared governance describes a system in which nurses have organizational autonomy, i.e., control over their practice, and in which nurses have input into "the broader unit and decision-making processes pertaining to patient care" (Hinshaw, 2002, p. 92). This organizational autonomy is distinct from clinical or individual autonomy (Kramer & Schmalenberg, 2002). Setting up an organizational structure that contributes to nurses’ control over practice requires "open communication processes among nurses, physicians, and administrators…on hospital policy and procedure committees, fostering "strong, productive nurse-physician relationships," and providing for "the interdisciplinary richness needed for effective patient care policies and procedures" (Hinshaw, 2002, p. 95). Using IBB as a bargaining strategy can set the foundation for such collaborative relationships.

The intent of IBB is to jointly problem solve ways to meet each side’s interests or what each side wants, rather than taking "bottom line" positions, which implicitly conveys the concept of entitlement and/or rights (Carlton, 2000, p. 1). Brainstorming and information sharing develop ideas and options. "Options are then evaluated both in terms of their effectiveness in resolving the problem and their acceptability to the parties. The objective of the entire process is to reach agreement by consensus" (Interest-Based Bargaining, 1997, Background, 2nd paragraph). This problem-solving technique requires a training period of the negotiating teams to learn how to identify each side’s interests, how to create options for meeting those interests, and how to find ways to satisfy mutual interests (Spangler, 2003). Communication, information sharing, and consensus building techniques also are practiced in the training sessions (Interest-Based Bargaining Training, n.d.).

Choice of Strategy

In many situations, using IBB results in a process and end product that are more satisfying than with the use of traditional CB (Hiraoka, 1994; Kirkner & Sharfstein, 2003; Peterson & Lavant, 2000). Success with IBB is difficult, however, in organizations where management assumes an authoritarian stance, does not involve employees in developing policy, has been subject to many grievances, and is not trusted by employees.

...the choice of strategy may depend on the specific bargaining goal and whether the possibility exists of building collaborative relationships.
Therefore, the choice of strategy may depend on the specific bargaining goal and whether the possibility exists of building collaborative relationships. Also, use of IBB does not preclude returning to traditional CB should collaborative efforts fail (Kirkner & Sharfstein, 2003).

A study by Paquet, Gaétan, and Bergeron (2000) is instructive when considering the form of CB that might be of most use in the current health care environment. Matching 19 cases that used traditional CB with 19 cases that used IBB, they compared CBAs to determine whether the method used would differentiate numbers and types of negotiated changes. Because IBB is built on cultivating understanding between the two parties and open discussion of interests, IBB was expected to yield more changes to the CBA, more mutual gains, and more innovative changes than traditional CB; but each method was expected to yield similar numbers of union gains. Changes were categorized as monetary, fringe benefits, union recognition, grievance settlement, seniority, working hours, work organization, and labor relations, such as joint committees and partnerships. They found that IBB resulted in more changes, mutual gains, and innovative changes per CBA, but it also resulted in more union concessions and far fewer union gains than with traditional CB.

The findings of Paquet et al. (2000) seem to imply that nurse CBUs should study the outcomes desired in terms of whether there are mutual gains to be realized or whether the changes sought are solely union gains. For instance, a shared governance structure is associated with organizational autonomy (Hinshaw, 2002), but also has been shown to lead to improved patient outcomes (O’May & Buchan, 1999), which is desired by both the CBU and management. Thus, perhaps IBB would be most useful for realizing these mutual gains when negotiating the introduction of a shared governance model. If the desired change would primarily benefit the union, e.g., hours of work, wages, fringe benefits, and grievance settlement, likely traditional CB would be the better choice. Skill is needed to know which strategy to use in a given situation.

Use of Both Traditional and Non-Traditional Collective Bargaining Strategies: An Example

In this section, a nurse union leader’s narrative account of hospital labor-management relations is presented. This case study exemplifies the complexities involved in choosing the appropriate CB strategy.

An Account of Ongoing Efforts to Change the Environment with Collective Bargaining

...whenever an issue was addressed, both sides quickly digressed into traditional CB battle mode, and at times they had to resort to mediation and arbitration to reach a contract agreement.

The CBU at this hospital was organized originally by ONA over issues of nursing wages and benefits. Since its inception many years ago, however, the CBU also sought opportunity for input into issues that affect the patient care environment and nursing practice because of the belief that nurses, and not management, were the experts in that area. The employer consistently met such overtures for input with a paternal approach to resolving problems or affecting change: "Do it because I say so, and because it is good for all of us." As a result, whenever an issue was addressed, both sides quickly digressed into traditional CB battle mode, and at times they had to resort to mediation and arbitration to reach a contract agreement.

Nevertheless, depending on managerial leadership, various attempts were made to resolve conflict in a less hostile manner. For instance, in the early 90s, the groups engaged in a week long "Relations by Objective" seminar off-site. Over 50 participants from various levels of management and staff took part in the event, which was funded by both parties and conducted by the Federal Mediation and Conciliation Services. The purpose was to improve communication between the two sides by developing the IBB "win-win" approach to problem solving and conflict resolution. As a result, some trust was developed across the organization, and productive, consensual dialogue about issues resulted. Over time, however, individual managers attending the event were replaced for various reasons, and trust dissipated to the previous low level.

Collective Bargaining During System Redesign

As top management personnel continued to change, the underlying philosophy of the organization regarding employee relations in general, and nursing relations specifically, became more and more unclear. This confusion fueled more distrust. For each perceived negative act or communication perpetrated by management, an equal or fiercer response was fired from the CBU. In the mid 1990s, these negative feelings flourished when the hospital announced that one of the four campuses would be closed and nursing layoffs would be inevitable. The CBU was astonished. There were national rumblings of an impending and unprecedented nursing shortage. Increased numbers of patients were being admitted to the hospital, and they were more critically ill than ever before. Yet management was closing beds and reducing an already stretched nursing staff.

The existing ONA CB contract between the nurses and the facility contained layoff language that guarded a nurse's seniority but did not consider specialized nursing expertise. The difficulty imposed on the employer by the language was intentional.

...the collective bargaining unit agreed that it would be best for the patients if skill/expertise stipulations were incorporated into the layoff language.
The feeling was that if the language was too difficult to implement, there would be less chance of a layoff. Although this strategy had been effective over the years, this time, the employer made it clear that a layoff was inevitable. It was a hard sell to the CBU members, particularly those who faced layoff, but the collective bargaining unit agreed that it would be best for the patients if skill/expertise stipulations were incorporated into the layoff language. Therefore, the CBU worked with management to develop a system of layoffs that would protect seniority, take into account level of experience and specific skills, and allow the registered nurses choice with regard to bumping options. Eventually the employer closed one campus, laid off the nurses, and moved the remaining services and nurses to other campuses. The employer later found that in order to staff the newly aligned structure every nurse had to be called back. Further, additional RNs had to be hired to replace those who had sought other employment in frustration over the confusion and stress of the downsizing.

In the late 1990s, more stresses were introduced by the employer, which added anxieties to the already strained relationship with the CBU. The employer announced new redesign efforts including potential mergers with other health care facilities and another change in top leadership.

The CBU contended that management's insistence on the use of mandatory overtime to achieve adequate staffing was resulting in unsafe practice and poor patient outcomes.
The frustrated RN staff continued to dwindle as the burden of working under short staffing conditions increased. The crisis point was reached as management regularly began to use mandatory overtime in an attempt to "Band-Aid" the staffing problem on a shift-by-shift basis.

In the spring of 2001, the CBU members had had enough as they prepared a contract proposal for the pending negotiations. That proposal was simply that there would be no more mandatory overtime. The CBU contended that management’s insistence on the use of mandatory overtime to achieve adequate staffing was resulting in unsafe practice and poor patient outcomes. In turn, hospital management was adamant that it would not relinquish the ability to mandate RNs to work overtime. Seeing no acceptable recourse, nurses employed a traditional CB strategy and went out on strike.

Collective Bargaining Strategies During the Strike

During the 81-day strike, CB took on an additional focus. On various occasions during the previous decade, the employer had suggested the concept of participative management/shared governance to the CBU. Knowing that this concept was being described in the literature as a management innovation, however, the union leadership had been wary about establishing such relationships. Long ago, the CBU had established in contract language several labor-management committees in an effort to influence managerial decision making. Despite practice-related recommendations being made to management by these groups, however, management never had demonstrated it felt any obligation to accept nursing recommendations. Therefore, the CBU suspected shared governance was proposed as a model to merely give the appearance that the employer wanted staff input. Initially the CBU believed that in reality it was a mechanism to manipulate the union members into submission and limit the CBU's ability to grieve bad outcomes. The CBU’s rationale was that if one collaborated with management, one would be hard pressed to formally initiate grievance procedures should the need arise. was obvious that the non-nursing executives at the negotiating table did not understand the concept of shared governance or how to relate to nurses on this issue.

Increasingly, however, research was showing that the shared governance structures found in Magnet hospitals were leading to positive health outcomes for patients (e.g., Aiken, 2002). Magnet status, a designation of the ANA American Nurses Credentialing Center, was based on stringent criteria. These criteria were based on the ANA Scope and Standards for Nurse Administrators (American Nurses Association, 1996) and on 14 "Forces of Magnetism." McClure and colleagues (McClure et al., 2002), gleaned the Forces of Magnetism originally from a 1983 study of 165 hospitals. These 165 hospitals had created a nursing practice environment that attracted and retained registered nurses by including shared governance structures conducive to autonomy and control over practice.

The CBU in this hospital did covet such an environment. Therefore, a year prior to the strike, it had put aside its fears and had expressed to management an interest in working together to achieve Magnet status for the facility. The new Chief Nurse Executive (CNE) had gone so far as to bring in Magnet reviewers and to form a planning committee.

Despite this yearlong effort, at the beginning of the strike, the two sides found themselves as far as possible both from Magnet status and a contract settlement. Rather than despair, the CBU looked to the literature for possible reasons and solutions to the standoff.

Eighty-one days into the strike, new relationships had been formed and a plan had been developed for building both organizational and clinical autonomy into a shared governance model.
Noting that Hess (1995) found staff and manager nurses held differing views of shared governance, resolution of the CBU’s mandatory overtime issue seemed to be tied to resolving the two sides’ differing perspectives of the meaning of the Magnet shared governance criterion.

For the CBU, the criterion meant a model that included shared decision making regarding hospital policies that would lead ultimately to control over resources affecting practice, including personnel and mandating overtime. Such control over practice, labeled organizational or professional autonomy, had been contrasted in the literature to clinical autonomy, defined as "individual decision making for a patient" (Kramer & Schmalenberg, 2002, p. 42). Both types of autonomy were included in the Magnet governance structure criterion (Urden & Monarc, 2002). Kramer and Schmalenberg (2003) found, however, that almost 60% of their sample of 280 Magnet hospital staff nurses reported having little or no control over nursing practice. Perhaps management in these hospitals was unwilling to relinquish the power of control over resources, as had been suggested by Bruder (1999) of management in general. Therefore, hospital management would interpret shared governance as meaning only clinical autonomy. Such an interpretation seemed to be the view of the CBU’s management.

The CBU knew it could not trust management to design an effective system of organizational and clinical autonomy without its input. Believing strongly, however, that the future of the hospital and its ability to achieve quality health outcomes for patients was dependent on such a system, the CBU had a stake in making it happen. And so, the CBU decided to return to the table and engage in conversations about shared governance. Even though management was interested in a discussion of this kind, it was obvious that the non-nursing executives at the negotiating table did not understand the concept of shared governance or how to relate to nurses on this issue. As a result, all non-nursing administrators were asked to leave and only nurse managers negotiated with the CBU on how such a process might work. Because the CBU trusted the CNE and believed her intentions were noble, it was willing to work with her and accept joint accountability for that work. Eighty-one days into the strike, new relationships had been formed and a plan had been developed for building both organizational and clinical autonomy into a shared governance model. Hospital management conceded that with a shared governance model and an 18-month transition period, the facility would do away with using mandatory overtime to staff the hospital.

The strike was over and so were the old ways of doing business. The old labor-management committees gave way to a newly formed, Magnet-like structure. Included were a Quality Council, a Professional Development Council, a Nurse Practice Council, and a Management Council. All of these were to report to the Nursing Commission, which would provide leadership and serve as a clearinghouse and decision-making body for the other four councils.

The power of unions and CB is being used to gain control over nursing practice and to create professional practice environments.
Nursing administrative leadership was changed shortly after the strike ended, however, and management delayed implementation of the shared governance plan. It was necessary for the union to "push" for action on the contracted plan for two years before the committees began to meet. The point to be made is that because of the contract language, the CBU was empowered to insist on implementation of the plan.

This case study demonstrates the complexities of bringing about change in the patient care environment. Nevertheless, without the presence of a CBU and its use of CB strategies, it is doubtful that management would have relinquished its total control over the patient care environment. By using the traditional CB negotiating strategies including the weapon of a strike, and by using IBB to collaborate in an atmosphere of trust, two significant changes were made: elimination of mandatory overtime and development of a shared governance plan. Rebuilding a commitment to collaboration on the part of both sides, and renewing a trusting relationship, will be required to build a satisfactory shared governance structure. Should this rebuilding not occur, traditional CB strategies to gain control over practice such as determining staffing patterns, continuing elimination of mandatory overtime, and protection from reassignment may be used.


As nurses continue to leave hospitals and/or the profession due to their lack of professional autonomy, and as the nursing shortage becomes more acute, those who remain increasingly are organizing for collective action. The power of unions and CB is being used to gain control over nursing practice and to create professional practice environments.

...non-traditional CB, labeled interest based bargaining, has emerged as a strategy that leads to more satisfying collaborative relationships than those resulting from traditional CB.
The protection of labor law empowers organized nurses through CB to compel management to follow established contracts and change practices such as mandatory overtime and maintaining high patient-to-nurse ratios that are resulting in an unsafe patient care environment. The ANA and its constituent states have used traditional CB, particularly during nursing shortages, for the past 60 years to improve the economic and general welfare of nurses. Now, in the last 15 years, non-traditional CB, labeled interest based bargaining, has emerged as a strategy that leads to more satisfying collaborative relationships than those resulting from traditional CB. Based on the recognition of common goals and mutual interests, IBB can foster relationships such as those found in successful shared governance settings. These settings are associated with organizational autonomy or control over practice, a factor to be cultivated in the face of the current nurse shortage. In many settings, however, a combination of traditional and non-traditional strategies may be most effective, depending on the bargaining goal and labor-management relationship. Regardless of strategy, CB empowers nurses to find a collective voice to change unsafe patient care environments, and thereby, achieve quality health outcomes for patients.


Karen W. Budd, PhD, RN, CNS

Karen W. Budd is Professor Emeritus of Nursing at Kent State University where she continues to teach nursing theory. She has been Chair of the Kent State Faculty Senate and a member of the American Association of University Professors (AAUP) - Kent Council. Through these experiences she has learned the value of organizing for collective action. While representing faculty on various upper level university committees, she witnessed firsthand what it meant to the welfare of faculty and students to have shared governance assured through the collective bargaining agreement. She is currently the Ohio Nurses Association (ONA) President, and is a past member of the ONA and Greater Cleveland Nurses Association Boards of Directors. Dr. Budd received her PhD, MSN, and BSN degrees from Case Western Reserve University, where she taught nursing theory and maternity nursing. She also has been a clinical nurse specialist in high-risk pregnancy, and a staff nurse in pediatrics.

Linda S. Warino, BSN, RN, CPAN

Linda S. Warino is a certified post anesthesia staff nurse at Western Reserve Care Services in Youngstown, OH, and is Executive Director of ONA District Three. She has earned state and national recognition for her leadership skills. She has held many elected and appointed offices, including membership in the United American Nurses Executive Council and on the Advisory Board of The American Nurse; President, First Vice President, and Director of ONA; numerous positions with ONA District Three; and Chair of the Youngstown General Duty Nurses Association, a local collective bargaining unit. Ms. Warino has received ADN and BSN degrees from Youngstown State University.

Mary Ellen Patton, RN

Mary Ellen Patton has been a staff nurse leader during her entire nursing career. In 1965, she led the effort to organize the nursing staff at her facility in Youngstown, OH, which became the first collective bargaining unit of ONA. In 1972, she became the first staff nurse to be elected to the ANA Board of Directors. She has remained a sought-after mentor of nurse leaders. In 1995, the ANA Board of Directors established the Mary Ellen Patton Staff Nurse Leadership Award. She also has been active at the state level, working continuously in various positions, including that of ONA Treasurer. In 2003, Mary Ellen retired from the position of Executive Director of ONA District Three, a position that she held for over 20 years.


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© 2004 Online Journal of Issues in Nursing
Article published January 31, 2004

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