[Originally published in Synapse, Feb 5, 1998]
In the twilight of a day that had started out with rain, candles flickered at the busy intersection of Geary and Lyon last Thursday, Jan. 29. Here, a hundred or so Kaiser nurses and their supporters held a vigil in front of Kaiser San Francisco on the second day of the strike. A few patrons trickled out of the hospital, past security guards. Drivers honked in support.
This scene was occurring throughout Northern California, marking the end of the nurses' fourth strike since April against Kaiser Permanente, the largest managed care organization in the state. It has been a year since the nurses' contract with Kaiser expired and the battle at the negotiating table began.
The California Nurses Association (CNA), which represents 7,600 Kaiser nurses in northern California, blames the deteriorating working conditions and patient care on Kaiser policies. Kaiser has emphasized to the media that the nurses walked out on patients during the worst flu season in ages.
They contend that the nurses have disrupted patient care and have not made an effort to bargain in good faith. A meeting, called by a federal mediation team, was taking place Wednesday, Feb. 4, as we went to press.
The contract dispute revolves around wage increases, benefits, and patient care language that will allow nurses more control over the care they give. Kaiser's proposal includes a six-year contract, a two-tiered wage scale, and reduction of benefits and sick leave. ICU in Crisis Conditions are so bad, the nurses say, that people are leaving the field voluntarily.
The changes in staffing have had a snowball effect. In the past three years, CNA says, Kaiser has laid off 1,600 nurses and filled many of these positions with "care partners," unlicensed personnel without a degree who arc given tasks such as feeding patients, changing dressings, and drawing blood.
Kaiser spokesperson Runda Ghnaim told Synapse that the staffing changes were implemented as a response to the reduced numbers of patients needing hospital care. As care was being shifted lo the outpatient setting in recent years, fewer nurses were needed on the wards.
Staffing reductions began in 1994. Now, because of the nursing shortage, Kaiser is actively hiring nurses. Nurses claim that Kaiser's shortsighted plan harmed patients and contributed to the current nursing crisis.
Some nurses described how a care partner had given a patient the wrong dose of heparin; others had stories of surgeries being canceled because a patient was given a meal at the wrong lime.
These mistakes add up to mandatory overtime for the RNs who are charged with the responsibility of supervising care partners. While care partners are not used in the intensive care unit, staffing reductions in the past year have stretched nurses to their limits.
Patients are coming into the ICU much sicker, but because staffing is low, nurses take on a bigger chunk of the responsibility and are often doubling their shifts to get the work done.
“Basic care has been denied because we're stretched so thin,” said Eva Guthrie, an ICU nurse for over 20 years. “We have been so short-staffed for the past six months we can't even get someone to help us turn a heavy patient.”
As a result, the nurses jeopardize their own health. Some say they fear that a mistake made while stressed out could cost them their license.
ICU nurse Gil Roux said that Kaiser San Francisco has had to redirect patients from a full ICU to other wards—a condition called “divert” — two to four days a week since September, more frequently than he remembers in his 24 years' experience.
“We're essentially doing a triage to move out patients to accommodate new ones,” said Roux.
Often, critically ill patients are being moved off before they are ready, which causes even more problems. Guthrie described how patients who get carotid surgery are discharged after a day — hardly enough time to recover. Some of these patients end up right back in the ICU.
With the current situation in health care, when the push is for patients to leave the hospital as soon as possible, it's no surprise that patients coming in are sicker than ever.
The nurses are demanding language in the contract, to ensure that they have a say in the staffing of a ward. Kaiser has proposed the creation of a Nursing Quality Committee, which would include staff RNs.
CNA was not satisfied with Kaiser's two-page proposal, which “didn't have any teeth in it,” according to Terri Ross, CNA's San Francisco labor representative. CNA responded with a detailed eight-page counterproposal but is still awaiting Kaiser's response.
Contract Conflict While Kaiser is trying to hire new RNs, there aren't many RNs to be hired. The terms of the new contract are not making it any more attractive to work there, either. Kaiser had originally proposed wage decreases, which were eliminated in subsequent negotiations.
CNA is still not happy with their current proposal, which calls for a wage freeze in Sacramento Valley and Santa Rosa for six years (the duration of the contract), and a wage freeze for one year and a two percent cost-of-living raise for each year after in the greater Bay Area.
In the past, contracts have been no longer than three years. All the other hospitals in the area, with the exception of St. Luke's in San Francisco, have a wage increase written into new contracts, according to Ross.
The average annual salary of an RN in the Bay Area in 1996 was about $50,000.
Right now, a new nurse at Kaiser is paid an hourly wage of $24.21 and a nurse who has worked with Kaiser for 16 years is paid $29.87.
Kaiser is proposing that hospital nurses in the Bay Area and nurses who perform hospital-like duties in the clinic setting, such as administer chemotherapy, will be paid on one wage scale, while clinic nurses in the Bay Area and all nurses in Sacramento and Santa Rosa will be paid on another wage scale —a two-tiered system.
Kaiser's rationale for creating different pay structures is that the cost of living differs from area to area and that clinic nurses and hospital nurses have different duties.
Ross charges that the creation of a multi-tiered system is a way for Kaiser, as the employer, to bring the top tier down in the future. In addition, Kaiser does not charge different member rates for different regions.
Lastly, new nurses in any region will start at four percent below “market rate,” which means that new nursing graduates will be paid $15-$19 an hour.
“We take great exception to how they determine 'market rate... This is going to create a lower class of nurses for all time, and we think that is like eating our young,” said Ross.
Another Kaiser proposal the nurses reject would cost them holiday and vacation time. According to Ross, if a nurse calls in sick, the first seven days of the sick leave will be taken away from time scheduled for holidays and vacations.
No one wants vacation leave deducted, but no one wants to work when they are sick and risk spreading the illness to colleagues and patients, said Ross.
Even though Kaiser has withdrawn a proposal, which would have reduced health care benefits for nurses and their families, they are still asking that nurses accept a $10 co-pay on each prescription and each doctor's office visit (including emergency and preventive care visits).
For patients who require life-long medications, such as children who need a monthly prescription for asthma medication, this proposal is still a stung in the pocket, said Kit Costello, president of CNA.
Kaiser wants retiring nurses to accept their “Senior Advantage” package, which critics contend is inferior to what Kaiser provided under the old contract — and even inferior to Medicare.
Because of the inhospitable conditions at Kaiser and elsewhere under managed care, some nurses are going into other careers, going back to graduate school, or pursuing the management side of health care. Support and Opposition CNA representatives say that they will continue to strike every month for the next few months if the current talks fail.
An estimated 99% of the 7,500 Kaiser nurses participated in the strike, according to Costello. Of the approximately 600 nurses at Kaiser San Francisco, 17 crossed the picket line to return to work.
Some nurses who were striking were called back in to care for a critical situation, and managers came out during the strike to ask for volunteers to take care of a patient in the neonatal intensive care unit.
Nursing students here at UCSF are sympathetic to the plight of the Kaiser nurses, but many feel that CNA's tactics are not accomplishing anything other than antagonism and dissidence.
“Future strikes should be longer,” said Natalie Olsen, a nurse who is applying for an advanced degree here. “But then again, I wouldn't want to be out of the hospital for a month.”
Because Kaiser is able to divert patients and collect a skeleton crew to maintain services during the strikes, the tactic has not been effective to date. Nurses are becoming increasingly frustrated with the lack of progress, not to mention the effect it has on patients, some nursing students say.
“Nurses are losing wages, losing hopes... they don't have the resources to be strong anymore,” said Karen Kerr, a master's degree candidate in the School of Nursing.
One PhD candidate who asked not to be named, said, “It's just stupid... they're not accomplishing anything by striking for just one day. Besides, they've gotten what they wanted —their pay raise.”
The strike has received much support from other nurses in the field, said Costello. The sentiment among ward nurses at Moffitt-Long Hospital, is that of sympathy with their Kaiser colleagues.
“We were in the same situation here at UCSF, working without a contract for three years,” said Estela Yamat, a nurse on 9 Long. “Only the Kaiser nurses are more overworked — I feel sorry for them.”
Approximately 400 of the 1,800 nurses working at UCSF hospitals and clinics are CNA members, according to Cecilia Wavrick, the UCSF rep for CNA.
While solidarity among Kaiser RNs is strong, solidarity within the profession is not, some Kaiser nurses say. Most notable is the split between the management nurses and those who work at the bedside, which has become more acute in the setting of managed care.
Managers — many of whom had not participated in direct patient care for years — took over bedside duties during the strike.
Some nurses in the Bay Area, including advanced degree candidates here at UCSF, do not agree with the CNA philosophy.
In 1993, CNA disaffiliated from its umbrella organization, the American Nurse Association. The ANA was more concerned with supporting the hospital business and creating favorable situations for nurses in management positions than they were about the conditions of the bedside nurse, according to Wavrick.
The split came between nurses who thought CNA should be a purely professional organization and those who thought it should also function as a union to represent workers.
“Unfortunately, that decision has been made by managed care organizations who treat us very much like workers and commodities,” said Ross.
Community Response The prognosis for the current talks is not hopeful, sources say, citing Kaiser's recent ad campaign in the Chronicle, which blames the breakdown in negotiations on CNA. Yet strike participants feel that they are beginning to reach the public.
A few patients joined the nurses on the picket line, including one elderly man using a cane. Among those who came out to support the nurses were members of the United Educators’ Association, a union, which represents schoolteachers. For teacher Steve Shapiro, the nurses' struggle is poignant because of the similar plight of schoolteachers.
“Public school teachers and nurses are in similar professions —both are undervalued, underappreciated, underpaid,” said Shapiro.
Many teachers are members of Kaiser and teach the children of Kaiser nurses. Those that stick with the strike say that it's not about the wages.
“If this was about money, we wouldn't be in this profession,” said Viola Scurto, a long-time Kaiser nurse who used to run a restaurant and a clothing boutique before going into nursing.
“You're not as worried about selling the wrong dress as you are about giving the wrong medication.”
