Livia Gershon | Longreads | June 2018 | 9 minutes (2,201 words)

Kate Phillips, a nurse who works in the intensive care unit at The Johns Hopkins Hospital, in Baltimore, is part of a group trying to form a union. “Every nurse here has talked about times where he or she felt unsafe because there was not enough staffing, not enough equipment, or medicines came late because there were not enough pharmacy techs,” she told The Sun. The administration, she went on, “can basically make all the decisions and they don’t look at things from the perspective of patient care like we do.” This past January in Virginia, Patty Nelson, a psychiatric nurse who is the chapter chair of her local union, called on the state’s general assembly to expand Medicaid as soon as possible, citing clients with mental illness and addiction who can’t get the treatment they need. And the California Nurses Association (CNA), the largest union of nurses in that state, has emerged as a champion of a single-payer health care system, fighting their way to their capitol. “We understand that these legislators are not going to do this on their own,” Bonnie Castillo, a registered nurse and executive director of the union, told California Healthline, a health care news site. “It’s going to take a movement of their constituents, nurses and other health care professionals. Legislators are going to need an intense amount of pressure, and that’s what we’re doing: We’re knocking on every door, we’re meeting and organizing.”

Nursing work, like most other health care jobs, is growing fast: the Bureau of Labor Statistics projects that the United States will add 438,100 jobs in registered nursing by 2026. Their strength in numbers has also brought organizing power: while most of the labor movement has declined in the face of pressure from unfavorable laws and moneyed opposition, in the past decade, nurses’ unionization rates have been gaining momentum, with tens of thousands more members.

When people talk about supporting unions as a policy goal for the left, their objectives are often curbing inequality and boosting wages. That’s a crucial part of what the labor movement has always done. But at a moment when the Democratic Party looks like it might start standing behind unions in a way that it hasn’t for generations, the example of unionized nurses suggests another reason to support organized labor: When workers have more power, they tend use it to shift their jobs away from generating maximal profits for their bosses and toward helping their patients, customers, students, or whoever they serve—which is to say, all of us. To allow our political and economic system to meet more people’s needs, we need to harness the knowledge and ideas of the people whose work brings them into contact with those needs every day.


Since 1954, membership in unions has dropped from a peak of 35 percent of wage and salary workers in the U.S. to 11 percent today, even though attitudes toward unions have remained consistently positive. The decline is due in large part to increasingly sophisticated techniques in what’s known as union avoidance. According to the Economic Policy Institute, a liberal think tank, three quarters of American private employers confronting a unionization campaign hire a union avoidance firm, which adds up to as much as $1 billion a year in anti-union spending. Most companies also force workers to attend one-on-one meetings with supervisors in which they’re questioned about supporting the union, and about a third of these companies fire one or more union activists—which is illegal but subject to sanctions too minor to make much difference.

As the attacks have accumulated, unions have been loyal in supporting Democratic politicians. Yet Democrats have failed to enact labor reforms that could help, even during periods when the party held control of the White House and Congress. In 1965, southern Democrats joined a filibuster that blocked legislation banning state “right to work” laws, which dramatically weaken unions’ negotiating power. In 1978, a bill that would have made it harder for employers to flout federal labor laws and prevent workers from forming unions was similarly defeated. And in 1993, President Bill Clinton kicked a union-backed labor reform bill over to a commission, where it stayed until Republicans, led by Newt Gingrich, the House Speaker, took over, and squashed it. As a presidential candidate, Barack Obama declared his support for a law that would have made it far easier for employees to organize, but once in office, he let the bill die.

When workers have more power, they tend use it to shift their jobs away from generating maximal profits for their bosses and toward helping their patients, customers, students, or whoever they serve.

During the labor movement’s years of decline, many came to see unions as a vestigial social organ, characterized by a stubbornly narrow focus on raising its members’ wages. A typical primer on unions lists the “pros” of higher wages and better benefits counter to “cons” such as “loss of autonomy” and a “less collaborative work environment.” In fact, the movement has never been simply about narrow self-interest; in 1893, Samuel Gompers, a longtime president of the American Federation of Labor, declared that what the movement wants is “more schoolhouses and less jails; more books and less arsenals; more learning and less vice; more leisure and less greed; more justice and less revenge; in fact, more of the opportunities to cultivate our better natures.”

Today, an increasing percentage of union members are in public-sector jobs, which means that union members tend to be more aligned than ever with social goals like granting universal health care, ensuring access to education, and curbing the expanding power of corporations and private interests. The same is true of the people who are most likely to become new union members, as shifts in the job market move away from manufacturing and toward fields like medicine and technology—where organizational goals are, at least in theory, tied to a common good.

As caretakers, nurses have emblematized a public-minded approach among union activists. In 1974, in the Bay Area, 4,400 members of the CNA staged a groundbreaking strike against 44 hospitals and other health care facilities. Their top demand was not higher wages but the right of bedside nurses to be involved in decisions about staffing levels and assignments. Pablo Gaston, a sociologist now at Rutgers University, recounts in a forthcoming book how the head of the hospitals’ negotiating team took umbrage at the idea of giving nurses “a major voice in the decision-making process as to how staffing takes place and how nursing care is delivered.” The nurses, convinced that their input was exactly what the hospital needed, walked out, bearing signs reading “Patients are our business,” “Better Staffing—one night nurse for patients is unsafe,” and “Nurses need a voice in patient care.” Twenty days later, they won a contract that met their demands for a seat at the management table—and, perhaps just as important, they set a precedent for others to do the same. When registered nurses at a hospital in Santa Rosa went on strike the following year, they wrote in their newsletter that the alternative would have been “swallowing their personal and professional integrity and capitulating to an uncaring administration in an industry of care.”

In the Nineties, amid Clinton-era changes to health policy, a wave of mergers and corporate takeovers swept the hospital industry. Nurses again rose as a powerful force. In California, the CNA seceded from the American Nurses Association—an organization led mostly by nurses working in management rather than bedside care providers, and which was often hesitant to confront hospital executives. In 1999, California became the first state to pass a law requiring minimum nurse-to-patient staffing ratios in acute care hospitals; since then, the CNA and other nurses’ unions have won contracts setting similar mandates in hospitals across the country. The CNA also helped write a state law on staffing levels that took effect in 2004; the result was more jobs as well as an assurance that sufficient time and attention could be given to every patient.


Describing unions in terms of patient care makes for better PR than discussing raises and employment opportunities. But I know from experience that it’s a genuine argument. Between 1998 and 2003 I worked on and off for the Service Employees International Union (SEIU), where I met a lot of nurses involved in the cause. As a union staffer, I talked with many long-time nurses who were horrified at the way their jobs were increasingly controlled by far-away managers. Where they’d once been able to stop and sit by the bed of a patient who was crying in pain, now they had to keep moving from room to room, inserting IVs and updating charts, without much human connection. Hearing their stories, it was apparent that the interests of nurses and patients were almost seamlessly intertwined. Of course the nurses wanted raises—who doesn’t? But they also believed that increasing pay at their hospitals would attract more, better-qualified colleagues who could help them do the best possible job. They wanted to reduce nurse-patient ratios because running around all day made them miserable; it’s also true that solving their problem would, by default, improve the quality of care.

It may come as no surprise that there’s good evidence showing patients do better in union hospitals: A team of economists who studied California hospitals in the late 1990s and early 2000s found that unionization seems to lead to more successful patient outcomes. Other research has concluded that lower nurse-patient ratios are associated with fewer patient falls and lower death rates from in-hospital cardiac arrest.

By talking to workers not merely as victims of an unfair economy but as experts in their fields, with much to contribute in creating policy, politicians could encourage greater participation among the large swaths of people who are disaffected—and perhaps win new supporters, too.

It’s not just highly educated care workers who see their fates as employees tied to the interests of those they serve, it’s also the armies of low-paid workers responsible for children, nursing home residents, and people with disabilities. Take Patricia Walker, a home care worker in Florida and SEIU member, who has been part of Fight for 15 protests and campaigns against federal cuts to Medicaid. She told the union’s website that she and the woman for whom she provides care see each other as partners in this activism. “We worry about each other,” Walker said. “I worry she won’t have anyone to help her take care of herself, and she worries that I will be out of a job.” In recent labor demonstrations, teachers, news reporters, graduate students, and others have made cases for their unions on the grounds that their work has high stakes for everyone in their communities.


Political scientists say that most of us vote based not on a careful examination of the matters at stake but on cues that encourage us to register aspects of our identity. It’s increasingly clear that Donald Trump’s victory in 2016, for instance, was driven largely by white racism. It’s easy for those who didn’t vote for him to despair—and a focus on work and unions won’t solve that profound problem—yet the labor movement might provide ways of encouraging white people to view their political selves differently.

A rural white guy who resents the power of urban elites and gets enraged at the thought of undocumented immigrants entering the country may also be a paramedic who takes pride in caring for people of all races and wants better funding for health care. A well-established body of research shows that people’s satisfaction with their lives is closely tied to how much meaning they find in the work they do; by tapping into that sense of being—by talking to them as workers who are not merely victims of an unfair economy but also experts in their fields, with much to contribute in creating policy—politicians could encourage greater participation among the large swaths of people who are disaffected, and perhaps win new supporters, too.

Lately, it seems as though the Democratic Party might be getting the message. Democratic leaders recently introduced what they’re calling the Workers’ Freedom to Negotiate Act. The bill would give existing federal labor laws real teeth, extend legal protections to people currently classified as contractors rather than employees, and get rid of “right-to-work” laws. Another pro-union bill, the Workplace Democracy Act, supported by high-profile Democrats such as Senators Cory Booker, Kirsten Gillibrand, Elizabeth Warren, Bernie Sanders, and Kamala Harris, would revive the early Obama-era effort to make organizing easier. If successful, this legislation would allow workers to form a union just by getting a majority signed up on union cards, rather than requiring them to go through an extended election process that employers can often swing their way.

These efforts face serious obstacles: Donald Trump has appointed members to the National Labor Relations Board who have already moved rules governing union activity in an anti-labor direction. He has also put a set of policies in place limiting the power of unions representing federal workers. Perhaps most devastating is the Supreme Court’s ruling this week in the Janus vs. AFSCME case, which effectively imposes “right-to-work” restrictions on public-sector unions across the country.

If Democrats could fully, and responsibly, embrace the unions they’ve held at arm’s length for decades, making pro-labor policies a central part of their campaigns this November and beyond, it would help build a new, optimistic vision for the party. Nurses have been doing this work for decades, and if others follow, there is a chance to do best in the service of others while we gain more for ourselves.


Livia Gershon is a freelance journalist based in New Hampshire. She has written for the Guardian, the Boston GlobeHuffPostAeon and other places.

Editor: Betsy Morais
Fact-checker: Ethan Chiel