In the seven and half years Ali Marcanti has been working as a nurse, she has been yelled at, pushed against a wall, and put in “all sorts of shitty situations,” she says. But she never actually cried on the job until the winter of 2021, she recalls, when a Covid patient in his 70s who had been sitting alone in a room for hours turned to her, in tears, and said, “You were supposed to take care of me.”
It was the height of the pandemic and Marcanti, now 32, had been busy tending to another Covid patient who was on a high-flow oxygen machine, along with two additional patients who required significant attention but were “not in terrible shape,” she says. “The acuity level trickled down to units that weren’t as used to working with patients who were so sick,” Marcanti recalls, which meant that at the medical-surgical unit at United Hospital in St. Paul, Minnesota, she had to prioritize those with higher needs. The man in his 70s, by contrast, was relatively stable, though with some mobility challenges, and was simply waiting to be transferred out of the hospital.
It was because she was so busy, she says, that she wasn’t able to step into his room until she had been on her shift for several hours.
Marcanti, whose hospital is part of the Allina Health system, went into nursing not only to mend people’s bodies, but “to talk to people, to talk them through being at the hospital,” she says. “It’s scary. Not having someone available to walk them through that is kind of devastating and super lonely for the patient.” Confronted with how discarded this patient felt, she recalls crying into the reusable mask that had already worn down the skin on her nose.
Marcanti cited this experience, which she blames on inadequate staffing, as one reason why she joined 15,000 Minnesota nurses on a three-day strike starting September 12, in the largest private-sector nurses’ strike in U. S. history. Nurses’ contracts at 15 hospitals in the Duluth and Twin Cities metro areas expired this summer, and when all of the nurses walked out together, in a show of cross-hospital coordination, the call for safer staffing served as a rallying cry.
The massive work action at hospitals that represent seven health systems and 13 labor contracts (some contracts are bundled together) attracted national headlines and boisterous picket lines. But more than a month later, nurses like Marcanti — worn by the harrowing experiences of the pandemic — have not yet secured a contract, which means they are still being denied the staffing improvements they’re calling for, alongside paid family leave, wage improvements and other demands. With bargaining stalled, nurses are looking for new ways to apply pressure to decision makers at the hospitals — and some are saying that another strike has not been ruled out.
Chris Rubesch, 36, is the vice president of the Minnesota Nurses Association (MNA), the union that represents the nurses, and serves as one of the negotiating team members of his bargaining unit, alongside his day job as a cardiac nurse at St. Mary’s in Duluth, part of the Essentia Health system. (Disclosure: MNA gave $500 to Workday Magazine’s 2022 fundraising drive.) He says that, following the strike, there’s been no progress at the bargaining table on the most important issues — particularly staffing. “Hospitals are very, very hesitant to engage in that topic, and we have been told by some facilities off the record that they won’t engage, and that legislation is the only way they would do that,” he says. “They want to be able to make changes based on whatever they see as a business need.”
Last spring, MNA, which is an affiliate of National Nurses United, threw its weight behind the Keeping Nurses at the Bedside Act. The statewide bill would have created committees in which nurses and management jointly establish staffing levels, and limit the number of patients nurses are responsible for caring for at a given time. But the legislation was blocked in the Minnesota Senate in May. The Minnesota Hospital Association, which represents hospitals that employ MNA members who went on strike, lobbied against the proposed bill.
Some are now looking to their contracts to secure similar protections. Across the facilities, nurses are proposing to set up staffing committees that would be composed of nurses and members of management who would be responsible for creating staffing grids, which determine the ratios of nurses to patients. Any changes to those staffing grids would have to be approved by 51% of nurses working on that unit.
The goal, says Marcanti, is to give nurses more of a voice, so they can ensure that staffing levels are adequate. The scenario where a Covid patient was left waiting in a room for hours with no nurse checking in, she says, was avoidable with simple fixes, like scheduling a free charge nurse, who is responsible for overseeing a particular unit, or a resource nurse, who helps nurses with jobs on the floor. “Ideally a charge nurse could have gone and helped him, or we could have had a grid that called for a resource nurse to do similar to what the charge nurse did,” she says.
But hospitals have rejected nurses’ staffing proposals, with Allina Health, which currently has four hospitals in negotiations, recently calling nurses’ staffing provisions “unreasonable.” According to Becker’s Hospital Review, an industry trade magazine, Allina Health “posted an operating income of $128.8 million for the year ended Dec. 31, up from the $36.3 million loss in 2020, according to its financial results. The 10-hospital system saw its net income jump 400.8 percent in 2021 to $381.1 million, compared to $76.1 million the year prior.”
Essentia Health, which has two hospitals that are negotiating a bundled contract, publicly released its own proposal from October 10, which calls for mediation when there is disagreement between the union and management. If mediation is happening and the union and management have met twice within 30 days, management can unilaterally implement whatever policy they want, according to the proposal. “The Employer and the Association agree that it is important to ensure appropriate staffing levels on hospital nursing units to provide optimal patient care,” states the proposal.
But Rubesch says this is a far cry from what nurses are calling for, because management would still have the ultimate say in staffing decisions. “If I had to boil down the six months of back and forth in negotiations,” he says, “it’s that they want all of the control and none of the responsibility.”
Rubesch’s bargaining unit is also proposing language to ensure that nurses be allowed to use their clinical judgment to refuse to perform a staffing assignment they believe is unsafe, without facing discipline or losing their jobs. (Management has, so far, rejected the proposal.) Minnesota’s Nurse Practice Act says a nurse has a responsibility to provide safe care, and MNA interprets that to mean that if a nurse feels they can’t provide safe care, they have a responsibility to refuse that assignment.
Research shows that higher nurse-to-patient ratios lead to better health outcomes for patients, and even save lives. One study published in the August 2021 issue of the International Journal of Nursing Studies looked at data from a Swiss university hospital from 2015 to 2017. It found that “shifts with high levels of registered nurses” had 8.7% lower odds of mortality. “Conversely,” the study states, “low staffing was associated with higher odds of mortality by 10%.” Other studies in the United States have led to similar findings.
Staffing is not the only area where nurses and management are far apart. Nurses across the facilities are asking for wage increases of between 24% and 29% over three years, and most hospitals are countering with proposals of wage increases between 12% and 12.5% over the same time period, according to a union spokesperson. Nurses at most hospitals are also asking for paid family leave, to take time off to care for an ailing parent, or a newborn baby.
A spokesperson for Essentia Health sent a statement asserting that, under management’s current proposal, new nurses who work full-time would see their salary increase, from their starting pay, 30% over three years. “We have repeatedly asked the MNA for details regarding implementation of its proposals,” reads the statement, “but the union has not provided those details in order to evaluate its proposals accurately.”
But, according to Rubesch, “What he didn’t tell you is that, per their September 20 proposal, they want to alter the wage grid so that a nurse with 15 years of service would get a 1.6% raise and a nurse with 20 years of experience would get a 0% raise. Our nurses are not interested in selling each other out, and they are not interested in something that isn’t equitable.”
“Everything for Essentia in this negotiation is about new nurses,” he added. “But they also need to retain the workers they already have.”
Given the lack of progress at the bargaining table, the union is finding new ways to apply pressure. On November 2, hundreds of nurses and community members held their first public protest since the September strike, targeting the corporate offices of U.S. Bank in Minneapolis, to oppose, as MNA put it, “the corporate greed that has eroded our healthcare system.” Board members of three major medical systems — Allina Health, Fairview Health Services and Children’s Minnesota — serve in high-level positions at U.S. Bank.
“Board members are responsible for the CEO, so when the CEOs aren’t negotiating with us, we have to take it to the board members,” says Shiori Konda-Muhammad, a nurse in the cardiac intensive care unit at North Memorial Health Hospital.
The corporate associations are of concern, the union said in a flier distributed at the event, because “banking executives don’t share the same priorities as Minnesota’s patients and healthcare workers.”
These aren’t the only notable ties. A board member of Allina Health, Tim Welsh, previously worked for 26 years at the global management consulting firm McKinsey & Company. Lawrence Cho, senior vice president and chief strategy and growth officer for Allina Health, also previously worked at the firm. There are other areas, meanwhile, of direct collaboration. In 2021, Christine Webster Moore, executive vice president and chief human resources and administrative officer at Allina Health, posted on LinkedIn that Allina “participated in the 7th edition of the #WomenInTheWorkplace report, a joint effort with McKinsey & Company and LeanIn.org.” And in March, Neil Rao, a partner at McKinsey & Company, delivered the opening remarks for a conference put on by the Minnesota Hospital Association.
McKinsey & Company has come under fire for overseeing corporate “downsizing” and mass layoffs, sanitizing the images of rights-abusing governments, and helping fuel the opioid crisis. The firm, which is famously secretive, did not respond to a query about its collaboration with Minnesota hospitals.
In response to the rally, Allina Health released a statement accusing nurses of not being “serious” about negotiations. “We believe bringing negotiations to a common table with other health care systems can move us toward a contract agreement,” the statement reads. “We renewed this request as recently as October 31 and have not heard anything from the union.”
Yet Rubesch says that nurses “would be interested in” jointly negotiating among all the hospitals, but are concerned that Essentia Health has opted out. “Why would we leave nurses behind?” he asks. “There is a major concern that by attempting to peel us off, they will try to avoid the common issues. We’re disappointed that this is something Essentia would divide us on.”
Paul Omodt, a spokesperson for Twin Cities Hospitals Group (comprised of Methodist, Children’s, Fairview, and North Memorial hospitals), says, “We will continue to negotiate in good faith to reach a fair and equitable agreement and we once again call on the MNA to agree to mediation to help find agreement on wages and other issues. We believe an independent, trained third-party mediator can be helpful for everyone involved. MNA continues to refuse mediation.”
Rubesch says, “MNA is not outright refusing mediation. We haven’t agreed to use mediation at this time. We know a mediator is going to pressure us to move off of issues the hospital doesn’t want to talk about. We are fearful a mediator will pressure us to drop staffing, because the hospital doesn’t want to talk about it. The deal has to include staffing.”
“If the hospital association was willing to engage and work on staffing with the help of a mediator,” he added, “that is something we would certainly consider.”
With negotiations stalled, union members are having conversations about what to do next.
“Another strike is certainly on the table, we would never take that off the table,” says Rubesch. “As we approach that decision and begin talking to members about that, we are also looking at other ways we can put pressure on facilities.”
In the meantime, nurses’ staffing concerns persist, as they are working under their old contracts until they agree to new ones (though sometimes, when there’s a settlement on a contract, pay provisions can be applied retroactively).
While the Covid crisis is not as acute today as it was in the winter of 2021, Marcanti says staffing concerns are just as relevant. “The hospital machine, in general, has been trying to decrease the number of staff to take care of patients for years…decades,” she says. “This isn’t a new agenda. Healthcare is expensive, cutting labor costs is a really easy way for them to save money. Covid accelerated that.”
According to the Minnesota Hospital Association’s own report, released in October, health facilities in Minnesota are seeing higher turnover among healthcare workers, with vacancy rates up 21% in 2022, compared to 6% in 2021. While the Minnesota Hospital Association calls this a “workforce shortage,” National Nurses United noted in a December 2021 report that, “As of Nov. 6, 2021, the National Council of State Boards of Nursing reported that there are more than 4.4 million RNs with active licenses, yet according to the U.S. Bureau of Labor Statistics, there are only 3.2 million people who are employed as RNs, with 1.8 million employed in hospitals.”
“There is no shortage of RNs,” wrote the union. “Rather, there is a shortage of good, permanent nursing jobs where RNs are fully valued for their work at the bedside through safe patient staffing levels, strong union protections, and safe and healthy workplaces.”
Konda-Muhammad, who is one of four MNA co-chairs at her hospital and serves on the negotiating team, points to staffing issues as a key factor pushing nurses out of the field. “In the cardiac ICU, if there aren’t enough nurses, patients have to wait downstairs, then that delays their treatment,” she says.
“It’s a never-ending cycle,” she adds. “There’s bad staffing, people get stressed out, then they leave. I feel like that’s been going on for so long. We get them up to speed, then they get fully burnt out, and then leave, and we have to do it again.”
When asked to comment on this scenario, North Memorial sent a statement which reads, “Staffing challenges are the result of unplanned sick time, personal and medical leaves and most importantly, unfilled positions. Recruiting and retaining nursing talent is a top priority and one we are continually addressing with urgency.”
But, Shiori says, “Retention and recruitment are important to us, too. That’s why we’ve put forward proposals regarding staffing issues. They could fill holes in the schedule ahead of time, and instead they wait until the last minute. Simple stuff like that could make a lot of difference, but they’re not doing that.”
“There’s so much they could do with a lot of the contract proposals that are meant to help with nurse retention,” she adds. “It seems that they are not listening to what we think is important.”
According to Marcanti, “There are a lot of frustrated nurses frustrated with what the employer is not offering still. We are still fighting. We’re not satisfied.”
Joshua Mei contributed research to this article.