After three days on the picket line in New York City, over 7,000 nurses represented by New York Nurses Association (NYSNA), an affiliate of National Nurses United (NNU), ended their strike on Jan. 12, 2023. 

Nurses from Mount Sinai and Montefiore hospitals walked off the job on Jan. 9 in an effort to enshrine safer and more enforceable staffing ratios at their workplace. Their central demand was, first and foremost, to ensure better patient care at the hospitals, which are both privately owned nonprofits. The nurses’ collective strike action was ultimately effective—they claimed a historic victory as their employers conceded to contract language that would ensure safer staffing. Both units voted in January to ratify their contracts with 98% approval.

“This is not a money issue,” said Sharon Miller, a registered nurse who has worked in the medical-surgical unit of Montefiore hospital in the Bronx for five years. On the first day of the picket at Montefiore, Miller told The Real News, “When you give a nurse nine patients, how can she honestly care for your mother, your father, your sister, your brother, or even for herself? She cannot give a hundred percent of her care.”

“We need to provide safe quality care for all our patients regardless of their ZIP code, regardless of their immigration status, regardless of their color during the pandemic,” said Nancy Hagans, president of NYSNA, on the picket line. “We lost a lot of black and brown people because of lack of care. When you come to the hospital, we don’t have enough staff. We’re unable to provide care. That’s what it’s all about: It’s about patient care.”

The NYSNA strike came on the heels of dozens of other labor actions in the healthcare sector over the past two years, and it will likely help inspire another year of labor militancy as collective bargaining agreements for tens of thousands expire, including 75,000 Kaiser Permanente workers in the Northwest. Eight hundred NYSNA nurses at Northwell South Shore hospital in Long Island, New York, have already delivered a strike notice for Feb. 27, demanding safe staffing and fair wages nearly a year after their contract expired. 

According to Johnnie Kallas, project director of Cornell University’s Labor Action Tracker, there were 39 strikes by healthcare workers in 2022—up from 33 in 2021. The Bureau of Labor Statistics, which only tracks strikes by 1,000 or more workers, found that a combined 32,000 nurses comprised a quarter of all major strikes in 2022. “It’s fair to say, anecdotally, that many of the strikes we’ve seen have been offensive strikes, meaning they’re fighting for something, rather than against concessions,” said Kallas, who is working on a more systematic analysis of recent healthcare strikes’ outcomes.

Indeed, nurses have gone on the offensive for lower patient-to-staff ratios around the country, as the COVID-19 pandemic—and, more recently, the “tripledemic” of RSV, the flu, and coronavirus —collapsed healthcare systems that were already strained by hospitals’ compulsion toward profit rather than patient care. 

Physical, mental and moral injury

According to nurses at Montefiore, emergency room nurses were working with severe staff shortages and were forced to treat 15 to 20 patients at a time. The shortages continued, even with 700 vacant positions at the hospital. Mount Sinai nurses confronted similar struggles, with over 500 positions still open.

In addition to long-term staff shortages, nurses have been fighting to reopen units that would alleviate severe patient overcrowding—an issue that predates the pandemic. In 2020, when the COVID-19 pandemic struck New York City and forced Montefiore Medical Center in the Bronx to cease placing highly contagious inpatients in its hallways, Michelle Gonzalez, an ICU nurse who’s worked at the hospital for nearly 12 years, believed a years-long struggle was over. 

Hospital staff, backed by politicians, had been fighting with Montefiore management for years over the issue. Patients, sometimes contagious or in critical condition, would no longer have to heal without the privacy of a room, and with blinding fluorescent lights gleaming overhead 24 hours a day. And nurses, though still overburdened by understaffing, could better manage their care. There would be less triaging; less shuffling of patients between hallways and rooms based on fast calculations of their health. 

But in 2021, Gonzalez and her colleagues were dismayed to find the practice slowly creeping back into place. By the start of 2023, TVs had been installed to entertain the 30 to 40 “hallway patients,” Gonzalez claims, that the hospital treats on any given day. To her, that symbolized the hospital management’s decision that poor patient care would be permanent.

“Timely intervention is not like a war unit,” Gonzalez said. “It’s animalistic to put someone in the hallway, with no option for oxygen or suction, which are required for lifesaving emergencies.”

Part of the problem is that the hospital had closed a 34-bed medical-surgical unit and was refusing to reopen it. To do so would mean hiring more nurses and other staff. “It’s lying dormant. It’s actually scary because it’s a dead unit,” Gonzalez told The Real News. “The institution has the space to give rooms to hallway patients. They’re choosing not to because it’s cheaper for them to keep us all in one spot.”

In January, picketing eight miles south of Montefiore at Mount Sinai on the Upper East Side, Cora Cajulis stood in the midst of a crowd of thousands of nurses wearing red NYSNA beanies, gloves, and scarves. Cajulis, a nurse practitioner of 33 years, echoed Sharon Miller’s sentiment. “Number one, we are fighting for the patient’s care,” she said. “Number two, is for us to be respected as nurses.”

“Just imagine: nurses don’t take breaks. You forego your lunch breaks and you hold your pee. That’s the reality in nursing,” said Juliet Escalon, a nurse practitioner with just under 10 years of tenure at Mount Sinai.

Over the past three years, nurses and other healthcare workers across the country have suffered physical, mental, and moral injury, as well as mass death and disease, as they struggled to take care of the avalanche of COVID patients. “No amount of wages will pay for the therapy we need for the trauma we’ve experienced,” said Gonzalez. “When you close your eyes at night, you see the emergency room, the ICU; you see the people who you couldn’t help and it kills you on a soul level.”

Now, in 2023, the profession is hemorrhaging nurses with no signs of stopping. Understaffing compounds understaffing as the burden mounts and fewer nurses are willing to take on the pileup of work left behind by those who leave. As cited in an NNU report, of the 4.4 million licensed registered nurses in 2021, only 3.2 million were actually working nurses. Health Affairs found that over 100,000 nurses quit in 2021. Meanwhile, survey after survey shows nurses will continue to leave the profession in droves, leaving a deficit of between 200,000 and 450,000 nurses by 2025, according to one McKinsey & Co. report. 

Studies have found that lower nurse-to-patient ratios lead to substantially fewer patient deaths and readmissions. Given those statistics, it’s little wonder patients stood by their healthcare providers on the picket line. Sara Lobman, who was treated for lymphoma at Mount Sinai in 2019 and has since come back for blood work and other testing, said she could tell that the hospital needed more nursing staff badly. “The big line the hospital uses is that ‘The strike is hurting the patients,’ but that’s crazy,” she told The Real News. “This could be fixed in five minutes. All the hospital has to agree to is decent staffing that would help the patients much more.”

It was the harm caused, on patients and nurses alike, by hospitals’ unwillingness to properly staff up that pushed approximately 16,000 NYSNA nurses at several privately owned hospitals across New York City to give 10-day strike notices on Dec. 31, 2022, after their contracts expired and employers failed to settle on new agreements. Some units, comprising roughly 9,000 nurses, reached tentative agreements or ratified contracts by the strike deadline of Jan. 9, but 7,000 nurses at Montefiore and Mount Sinai were forced out on strike.

Picket signs blasted the hospitals’ exorbitant executive compensation in lieu of proper staffing, a trend in both nonprofit and for-profit hospitals across the US. The Lever reported that Mount Sinai paid its CEO Kenneth Davis $5.6 million in 2019, and Montefiore compensated CEO Philip Ozuah $7.4 million in 2020. Meanwhile, both hospitals have spent millions on either risky investments, like hedge funds or private equity, and on setting up potential tax shelters in the Caribbean and Central America. During the strike, the hospitals were reportedly offering some replacement nurses nearly $10,000 per week, an enormous sum that still couldn’t attract enough staff to stem the chaos left by the NYSNA nurses withholding their labor.

Mount Sinai hospital administrators did not respond to requests for comment. In an email response, a Montefiore spokesperson wrote, “We’re pleased that NYSNA nurses at Montefiore Medical Center have ratified their contract. We came to these negotiations with great respect for our nurses and a commitment to address the issues we knew were most important to them.”

In the end, nurses won a number of concessions from their employers, including 19% raises over three years, the reopening of the closed unit at Montefiore to relieve overcrowding, investment in community health programs, and, of course, the central demand: better staffing ratios and enforcement, particularly in the ER and neonatal intensive care units. 

The national fight for safe staffing

While NYSNA claimed a historic victory, it was not without precedent. In addition to their own organizing, NYC nurses were inspired and supported by other nurses around the United States who had won their own labor fights over the past three years. “We were in chats with nurses throughout the country,” said Gonzalez. “They sent us language throughout the past year for the contract… They’re excited to see our movement. Part of not having fear was talking to other workers about being on strike.”

It was only last September when 15,000 nurses with the Minnesota Nurses Association (MNA) launched the largest private-sector nurses strike in history—and won. The three-day strike came after nurses at 15 hospitals in the Duluth and Twin Cities metro areas were denied fair contracts by their employers, with the central sticking point being, unsurprisingly, staffing.

Tricia Ryshkus, a night nurse who has worked at the Children’s Minnesota Hospital in Minneapolis for 11 years, was among the strikers. While she works in the medical-surgical unit, she explained that the worst understaffing was in the emergency department, where one triage nurse may be assessing the sickness of 50 to 60 children. “Children can get sick and go south quickly,” she said. “They’re OK and then they’re not. You may have triaged a patient an hour ago, but their condition could have changed for the worse and you wouldn’t know because you keep having to keep up with who’s coming in the door next.”

After the strike, it would take three more months of negotiations and another strike authorization before the hospitals conceded to many of the nurses’ demands in mid-December. Hospitals were under pressure to settle after MNA nurses threatened to strike again in the midst of the holidays and a surging tripledemic. Management would have struggled even harder to find replacement nurses. “Because we were able to give a bigger punch, we got movement and they finally agreed to staffing language,” said Ryshkus. 

In addition to the highest pay raises MNA nurses have seen in over 20 years, they won contract language that gave nurses a number of checks over staffing levels, including a say in how those levels are set and when they can be reduced, as well as protections from management discipline for nurses who raise alarms about unsafe assignments. 

Following the victory, like many nurses unions across the country, MNA is fighting to enshrine safe-staffing ratios in state legislation. In 2021, New York passed a staffing law that brought hospital management and nurses together into committees, where the two would establish patient-to-staff ratios for specific units. But as New York Focus and City & State reported, its implementation was marred by hospitals unilaterally imposing ratios without nurses’ input and the NY Department of Health unable to enforce the law—ironically, due to understaffing.

California is the only state that legally requires minimum patient-to-nurse ratios in every hospital in the state, yet hospitals there have not been spared from the staffing crisis. Healthcare workers have responded in kind, though not all have found themselves on the offensive.

1,800 nurses represented by California Nurses Association at Alta Bates Summit Medical Center, which is part of the nonprofit Sutter Health network, have been in negotiations for a new contract since June 2021. The nurses have struck three times in the past nine months, but their employers won’t budge. 

The Alta Bates nurses first struck in a one-day walkout in April involving over 6,000 other nurses at Sutter facilities. In October, Alta Bates struck alone for five days, after the 16 other bargaining units had already settled contracts. They hit the picket line once again beginning Christmas Eve last year for nine days into the new year, toughing it through the atmospheric river storms that battered California.

Longtime nurses at the hospital say they have a dire nurse retention problem, which is exacerbating the chronically high nurse-to-patient ratios. “The other night, we needed 21 nurses in labor and delivery, but they had 10,” said Thorild Urdal, a nurse in the high-risk labor and delivery unit who has worked at Alta Bates for 37 years. “This kind of stuff happens over and over.”

The sticking point for nurses at Alta Bates is competitive wage increases. “It’s not about extortion,” explained Eric Koch, a nurse in the telemetry unit who has worked at Alta Bates since 1991, and is a member of the bargaining committee. According to the nurses, Alta Bates has struggled to keep pace with the wages and conditions of other hospitals, including Kaiser Permanente, whose nurses won 22.5% raises and staffing concessions in December. “It’s the idea that for nurses, for young people, it’s just foolish to expect them to not want 20% more money and better working conditions somewhere else.” 

“We need a package that’s competitive so that we don’t ever lose nurses,” Urdal added. 

But according to the rank and file, some nurses have been feuding with their own union, CNA, not only to fight for better wage increases, but to fight against concessions. “Sutter and our union are willing to sell out younger nurses, doing away with the traditional pension plan,” Urdal explained. According to Urdal and Koch, CNA encouraged nurses to accept Sutter’s most recent contract proposal that included a two-tier pension system, under which new nurses could only receive cash balance plans, losing the option of financially superior defined-benefit plans that present nurses have. 

Alta Bates nurses firmly voted down the contract offer by 86% on Dec. 21. As of this publication, since their most recent strike, the nurses have had only a single bargaining session with management on Feb. 1, where they presented a counterproposal to Sutter’s “last, best and final” offer. Sutter was expected to share their response in the latest bargaining session on Feb. 15, though details of said response have not yet been made public.

In an email response, CNA/National Nurses Organizing Committee field director Khadija Kabba wrote, “CNA will continue bargaining with Sutter until we reach a contract nurses ratify by a democratic vote of the membership.”

Urdal and Koch believe Sutter ultimately would like to close the Alta Bates facilities, which disproportionately serve people of color and poorer communities in the Bay area. Such a move would fall in line with decades of hospitals’ corporate consolidations, which have contributed to cyclical nursing staff shortages since the 1970s, and their gutting and closing of less profitable facilities, like the unit closure at Montefiore that exacerbated the hospital’s crisis of hallway patients. Indeed, NYSNA has linked Montefiore nurses’ struggles in the Bronx to the hospital’s disproportionate investment in its hospitals in the largely white and wealthy Westchester county.

“They’re not gonna stop fighting”

According to Kallas of Cornell’s Labor Action Tracker, as labor actions by nurses continue in 2023, whether a strike will yield gains for workers “has to do with an analysis of the employer you’re dealing with.” 

Large hospital systems, even nonprofit networks like Sutter, have more resources to withstand strikes, he explained. Kallas pointed to the difference between the protracted, 10-month strike by Massachusetts nurses in 2021 at St. Vincent Hospital, owned by the for-profit giant Tenet Healthcare, and the one-month strike that same year by nurses at the much more cash-strapped Mercy Hospital in Buffalo. “You have to have an understanding of the employer’s power,” he said.

For the nurses who have already won better contracts, enforcement will be the next step. “We’re now doing the rollout of education and making that language real and active,” said Ryshkus. 

At Montefiore, Gonzalez is aware that the hospital’s problems won’t be solved overnight. Indeed, NYSNA nurses at New York-Presbyterian hospital, which reached an agreement with their employer before the Jan. 9 deadline, have already staged protests against the hospital’s doubling of retirees’ healthcare costs, an alleged violation of their new contract.

“I have always known this contract wasn’t going to be the end of the fight. If anything, it might be the beginning,” Gonzalez said. “I think our administration should be on the lookout. Nurses have just got a taste of what true power looks like. They’re not gonna stop fighting.”

“I think a huge lesson for all of us was not only did we all win really good contracts that we can be proud of and build on for our next contracts,” Ryshkus continued, “but we learned a valuable lesson in solidarity, and what that means. That we can take risks and still be ok, and win.”