There once was a union maid

she never was afraid

of goons and ginks and

company finks

and the deputy sheriffs who made the raid

she went to the union hall

when a meeting it was called

and when the company boys came around

she always stood her ground.

–Woody Guthrie and Pete Seeger

On the Sunday before Labor Day, Dorcas Butler puts on a long, lilac-colored dress and drives from her home in Wake Forest to Chapel Hill to address the Unitarian Universalist congregation at The Community Church. She’s nervous as she makes the trip and as she waits her turn at the podium near the altar. Her job as a nurse on the cancer unit at Duke University Hospital doesn’t involve much public speaking. But Butler has an important message she wants to preach this morning at the “Labor in the Pulpit” worship service: The nurses at Duke need a union.

Clutching a white Bible in one hand, she reminds the congregation that Jesus was an advocate for working people. Then she draws a quick breath and begins to describe the pressures that have been piling up on nurses at the top-ranked medical center in recent years.

On the oncology floor, Butler’s patients affectionately call her the “angel of death,” and it’s not hard to tell how she came by the nickname. Her warmth is right there on the surface, evident even from the podium in her direct gaze and easy laugh. She likes to pray with her patients–or for them if they’re not strong enough–and she’s inspired by her work with the terminally ill. But lately, Butler often leaves the hospital feeling as if she’s let her patients down.

“My job is to help them and their families cope, and to explain the process of dying, which is different for every person,” she says. “I believe the patients have a right to that and I believe God wants me to be there when someone dies. But many nights, I just don’t have the time to spend with them.”

Eight years ago when Butler first came to Duke Medical Center, things were different. There was more support staff, nurses had fewer patients to care for and patients weren’t as sick as the ones now being admitted to the hospital. With insurance companies insisting on quicker stays and more outpatient care, patients who do wind up in the hospital are often very ill and in need of extra attention.

But instead of supporting the nurses at Duke, Butler says, hospital management has increased workloads, cut benefits and corners on supplies, and relied on mandatory overtime to fill holes in staffing–a policy that has been eliminated since the union drive started last fall. Union supporters say even experienced nurses are leaving in droves because of the stress. And with staffing levels down by 10 percent at Duke, the remaining bedside nurses are stretched thinner every day. “We do the best that we can because we love what we do,” Butler tells church members. “But we often feel like we can’t do the job the way it should be done.”

The frustrations came to a head on Butler’s floor last fall, in an unusually frank conversation between a nurse and a patient. The patient also happened to be a former president of Local 465 of the International Union of Operating Engineers (IUOE), which represents maintenance workers at Duke University. When a nurse confided in him about low morale and high turnover at the hospital, he urged her to contact his union for help in launching an organizing drive.

The patient died before the drive got underway, but nurses took his suggestions to heart. In April, a group of bedside nurses–Butler among them–filed a petition with the National Labor Relations Board for an election to join the IUOE. That vote, originally scheduled for June, was delayed after union leaders filed unfair labor practice charges, claiming the hospital had used illegal tactics to discourage nurses from supporting the drive. Hospital management settled the charges in July by agreeing to follow labor-board rules and the board is expected to schedule another election early next month, barring any last-minute changes in strategy by the union. Ballots will be cast by 1,400 hourly nurses and 1,050 salaried nurses who work at Duke’s main hospital campus.

The stakes are high. If nurses vote for a union at Duke, it would be a first for a private hospital in the state. Duke officials aren’t eager to gain that distinction. They’ve hired consultants from Ogletree, Deakins, Nash, Smoak & Stewart–a leading union-busting law firm based in South Carolina–who’ve been churning out leaflets and advising hospital managers on how best to stamp out pro-union sentiment.

Duke used the same tactics to defeat two previous attempts to organize workers at the medical center. Those campaigns were led by clerical and technical workers at the hospital and didn’t include nurses. The first drive began in the mid-1970s, after changes in federal law made it easier for hospital workers to organize. That effort took two years and lost by a slim 59 votes. The second campaign began in 1977 under the leadership of the American Federation of State County and Municipal Employees union. In a 1979 election, the union lost by more than 200 votes.

Whereas the earlier drives were inspired by the broad goals of the Civil Rights and workers’ rights movements of the 1960s and 1970s, the current union campaign has bubbled up in reaction to specific cost-cutting strategies of the managed-care era. Duke nurses say they’re tired of being asked to do more with less, especially when it comes to their patients. The name of their organizing committee tells the story: Nurses United for Patient Advocacy.

With a union, nurses say, they could bargain over such concerns as excessive overtime and work schedules that don’t allow enough room for individual attention to their patients. They’d also have backing when disputes arise over how many patients can be safely cared for on their floors. “Now, you go to your nurse manager about your patient load and they tell you, ‘if you don’t like it, you can leave,’” Butler says.

Are patients in danger? Duke nurses are careful to say that they are still providing quality care. And the hospital is loathe to release the number of incident reports filed by its staff or the number of complaints made to its patient-information department. But speaking generally, advocates for the nursing profession aren’t so restrained.

“I hate to be alarmist, but when people have a family member in acute care, they need to be attentive,” says Susan Pierce, associate professor of nursing at UNC-Chapel Hill and a 31-year veteran of the field.

The North Carolina Board of Nursing and the N.C. Nurses Association have been fielding a growing number of calls from nurses across the state who feel their workloads have reached the breaking point. So has the hospital industry’s own self-regulating agency, the Joint Commission on Accreditation of Healthcare Organizations. (The commission leaves it up to hospitals to determine adequate staffing levels, although the agency is now exploring the need for industry-wide standards.)

While hospital patients are more likely to be inconvenienced than endangered by the strains on bedside nurses, professional leaders say, when caregivers in the trenches feel pushed to the wall, something deeper is wrong. “Nurses are trying to maintain this health-care system as a quality system,” says Gwen Waddell-Shultz, president of the N.C. Nurses Association and a associate chief for nursing education at the Veterans Administration Hospital in Durham, across the street from Duke. “The big picture is that our health-care system is sick.”

As they head toward a union election, nurses at Duke are trying to bring that larger picture into focus. Before she steps down from the church podium, Butler reminds the Chapel Hill congregation that they also have a stake in the outcome of the drive.

“I believe a union may help in giving us some kind of say in how we take care of our patients,” she says. “Duke is a great hospital, but they’ve lost sight of the fact that patients come first. So let them know how you feel if you have a family member over there.”

Duke is not alone in experiencing labor pains. Across the country, thousands of hospital nurses are joining unions–including traditional blue-collar organizations such as the United Auto Workers. Even doctors are rethinking their ideas about organized labor. The American Medical Association recently founded a fledgling collective-bargaining group called Physicians for Responsible Negotiation. The difference between the new organization and a traditional union is that the former will not authorize strikes. Instead, it will rely on the AMA’s political and public-relations muscle as leverage in disputes.

Labor historians and health policy experts say the new wave of health-care organizing is an aftershock from a decade of upheaval in the industry. Hospitals are facing serious financial pressures as their traditional sources and methods of payment have shifted under managed care. And hospital workers are feeling the pinch. Fault lines have opened up in two directions, says Jonathan Oberlander, an assistant professor of social medicine at UNC-Chapel Hill. With managed care companies pushing for shorter stays and fewer procedures, hospitals are seeing fewer patients. And with the federal government scaling back Medicare payments for care provided to the elderly and disabled, hospitals are being paid less for the patients they do see. “They’re being squeezed from both sides,” Oberlander says.

Add to that the rising number of people without health insurance who end up in hospital emergency rooms and you have a prescription for fiscal pain. The N.C. Hospital Association reports that profit margins for Tar Heel hospitals declined from 6 percent in 1997 to a razor-thin 0.5 percent by the end of 1998, and many fell into the negative numbers between 1999 and the current fiscal year.

Duke University Health System officials declined to be interviewed for this story. But hospital leaders have said publicly that Medicare cutbacks alone will cost Duke $160 million over the next five years. The medical center’s employee newspaper states that operating expenses will exceed projections this year by nearly $30 million, making it difficult for Duke to reach its goal of a 2 percent profit margin. As a teaching hospital, Duke has also been hurt by cuts in federal subsidies for physician-training programs.

Hospital leaders haven’t told employees what specific cost-cutting moves they’ll make this year. But historically, nursing staffs have been the first to fall to the budget ax. Many longtime Duke nurses still remember the massive job cuts the hospital made in 1994 and 1995 as part of a reorganization that was designed to slash $70 million from the medical center’s operating budget.

“That’s really when things started going downhill,” says Connie Donahue, a Triangle native who’s spent 15 years at Duke as an intensive-care nurse. “Duke brought in a big consulting firm and they had experts following people around trying to figure out where to cut. I think back then the hospital thought we were going to be more outpatient-based. But it hasn’t turned out like that. Our patients now are coming in a lot sicker. And the pinch from the nursing staff cuts has just been tremendous.”

To complicate matters, a statewide nursing shortage has made it harder to fill gaps that have opened up again on hospital floors. The number of students graduating from nursing schools in North Carolina has been falling every year since 1995. The N.C. Center for Nursing reports that the average age of nurses in operating rooms and critical care units is now 54.

Duke and other Triangle hospitals have to compete with insurance companies and drug firms that are offering trained nurses higher salaries. But while market forces play a role in how many people go into nursing, the current scarcity is also a result of specific decisions by hospital managers, says Pierce of UNC. “Nursing responds to supply and demand,” she notes. “When nurses get laid off, fewer nurses are interested in coming into the profession.” A decade ago, Pierce did a study that showed hospitals could reduce nursing shortages by giving nurses more decision-making power and respect, since most of the caregivers leaving the field cited those issues as the source of their dissatisfaction.

Union supporters say that hasn’t happened at Duke, where extra shifts, “floating” nurses to units outside of their specialties and hiring agency nurses–many of whom make higher salaries than staff nurses–have been the strategies of choice. Duke nurses have also watched as benefits such as support for continuing education, college tuition for children and vacation and sick time have been trimmed back.

Since nurses filed for a union election, some things have improved. Managers at Duke have begun to close beds to new admissions when staffing is low for the first time in memory. The administration has also dumped mandatory on-call and overtime hours in many departments and has announced a 2 percent raise for nurses.

Hospital leaders have told nurses they’d like to do more, but their hands are tied while the union drive is underway. In a March letter to hospital staff, CEO Michael Israel went so far as to blame the organizing campaign for exacerbating staffing shortages by scaring away new recruits and tarnishing Duke’s image as a premiere medical center. Statements that “undermine our reputation can reduce the willingness of public officials or private donors to provide essential financial support,” Israel wrote. “In turn, diminished financial support would impair our ability to recruit and retain staff.”

But pro-union nurses say they have no choice but to speak up. “We’ve had open forums and meetings with management for years, but things just keep getting worse,” says Donahue, as a worry line makes a sudden appearance between her brows. “We’ve just felt that a deaf ear has been turned and it’s time for us to take some independent action.”

This union maid was wise

to the tricks of company spies

she couldn’t be fooled by the company stool

she’d always organize the guys

she’d always get her way

when she struck for higher pay

she’d show her card to the National Guard

and this is what she’d say

Oh you can’t scare me I’m sticking to the union.

Violet Blumenthal has just finished a string of 7 a.m. to 7 p.m. shifts on the labor and delivery floor at Duke, and her exhaustion carves a sharp edge in her voice. During half of those shifts, she went without lunch or even a bathroom break. Blumenthal has been at Duke for 10 years and in nursing for a dozen. But no matter how competent and organized she is on the floor, most days, there’s more work than she can handle.

“On Saturday, I didn’t get out of there until 9:30 p.m.,” says Blumenthal, who joined the union organizing committee in March. “And if a co-worker hadn’t helped me, it would have been even later.”

On this particular weekend, the birthing center was even more crowded than usual. In addition to new arrivals that had to be admitted, there were two babies who were having trouble breast-feeding and needed extra care. Blumenthal says she has a good manager who tries to make sure things run smoothly. But many times, managers are just as overwhelmed as the staff.

“It’s not my boss’s fault. She’s out there on the floor in scrubs with us,” Blumenthal says. “But our census is up and our activity is up. When you’re trying to work with a first-time mom and do everything they need to have done, and still get them out in 48 hours to keep the HMO happy, it’s just very difficult.”

Marge Dooley is another veteran nurse who wants a union at Duke. She works on a surgical floor caring for urology, plastic surgery and ear-nose-and-throat patients. Dooley says her job has always been a juggling act between routine chores and spontaneous acts of compassion or crisis-management. But these days, she often has too many balls in the air.

The reason? Five years ago, there were 11 nurses on the day shift on Dooley’s 31-bed unit. Now, she says, there are only seven. “What that means is you have to prioritize,” Dooley says, punching out words in the jackhammer rhythms of her native Staten Island. “You might not be able to take a walk down the hall with a patient because you’re too busy giving out meds. You might not have time to show his family what they need to do to take care of him when he goes home in a few days. Teaching is really the biggest piece of nursing, and that’s the piece that gets pushed aside.”

It’s also the piece that gives nurses the most job satisfaction and attracts new recruits to the field–a counterweight to the low pay and erratic hours that prevail in this female-dominated profession.

Sharon Kornegay-Shaw is one of those new recruits. She got her nursing degree two years ago and now works the night shift on Duke’s cancer unit. She’s seen her share of overtime and shifts without breaks. But she says the hardest thing about her job is knowing that she might not be able to respond to all the needs.

“You want to be able to sit on the bed for 20 minutes if you have to and hold that patient’s hand,” Kornegay-Shaw says. “When they call and you can’t get in there right away, you feel bad.”

It’s not just the number of patients but the severity of their illnesses that’s making things tough on nurses, Kornegay-Shaw says. “Some of the older nurses say they might have had 10 or 11 patients in the past, but six or seven of them were ‘walkie talkies’ who could get up by themselves. Our patients now are really quite sick. They need a lot of help.”

At 35, Kornegay-Shaw is one of the younger nurses in her unit. She says if she’s the future of the profession, something has to change.

“It’s frustrating when you’re doing 120 percent and you still feel you’re not doing your best. You leave work and you feel like you were the worst nurse in the world. You want to do it all–take care of the mind, body and soul. Some days I feel like I didn’t really take care of my patients. I just did what I had to do.”

Tom Cantaffa has had similar feelings as a nurse in the cardiac intensive care unit at Duke. He’s also watched holes open up in staffing, seen benefits reduced and heard managers ignore complaints from front-line staff. But the burly, bearded New Jersey native is voting against the union. After attending organizing committee meetings, researching union bylaws and talking with Duke administrators, he’s convinced that collective bargaining is not the answer to the problems nurses face.

“Unions can be a good thing for certain situations,” Cantaffa says. “But most of the issues they’ve [union supporters] raised have to do with staffing and the amount of staffing. And the union can’t impose staffing regulations on the hospital or instantly produce more nurses.”

Before the drive began, Cantaffa was working on a proposal for “shared governance” at Duke–a system other hospitals use to involve nursing staff in decisions about patient care and procedures–and he’d gotten some encouraging signals from top managers. By contrast, he’s been turned off by what he views as the self-serving approach of IUOE organizers and pro-union nurses.

“This is really nurses united for nursing advocacy and that’s fine. Let’s just say it and not cloud things up with talk about patient advocacy,” Cantaffa says. “Yes, there are problems and valid issues out there. I just think we should go through all the internal channels before we look to outside representation.”

April Perry is another vocal critic of the union drive. She’s an advanced practice nurse–one of the salaried nurses who were not originally part of the proposed bargaining unit, but were added later at Duke’s insistence. The union agreed to include those nurses in the unit, then tried unsuccessfully over the summer to reopen talks with the labor board about restricting the bargaining group to hourly nurses.

Technical wrangling aside, Perry–who coordinates clinical research at Duke’s Pediatric Cardiovascular Program–says the organizing drive has failed to tap the concerns of nurses who don’t do bedside duty. After 18 years climbing the ladder of her profession, she’s deeply uncomfortable with the trappings of organized labor–strikes, informational pickets and bargaining for benefits. “If given the choice, I’d rather represent myself,” she says.

Like Cantaffa, Perry is also skeptical that collective bargaining will bring concrete benefits to Duke nurses, given the belt-tightening many hospitals are being forced to do. “There were times in the 1980s when we were getting bigger raises,” she says. “But there weren’t HMOs then and there was no Balanced Budget Act [a 1997 federal law that reduced Medicare payments to hospitals]. One of the things I hope management does is educate nurses more about the financial pressures facing the hospital.”

Perched forward in her seat in the cheerful, Technicolor lobby of the medical center’s new children’s wing, Perry says she’s eager for the union to be voted down so that nurses and managers at Duke can start hammering out solutions together. “We can’t fix the staffing until the vote is over with. And closing beds would be a problem with or without the union,” she says. “I do feel the administration’s ears are open and they will be open to making changes if this union is voted out. The threat of the union is stronger than the union itself.”

Bonnie Castillo has heard that argument before. Until 1993, her organization–the California Nurses Association (CNA)–was dominated by nurse managers, researchers and educators whose approach to workplace problems was “let’s go with the flow,” Castillo says. But then a group of bedside nurses ran a slate of candidates and took over the leadership, refocusing attention on the issues of spiraling workloads and stretched-out staffing on hospital floors. The newly revitalized association has become a model for health-care organizing, signing up 9,000 nurses in the last five years and winning passage of a landmark bill that sets minimum nurse-to-patient ratios at all acute-care hospitals in the state.

Patient care issues remain at the heart of the 30,000-member association’s lobbying and organizing work. “When we get called by nurses, overwhelmingly the issues are related to patient care and staffing,” says Castillo, a nurse who is now an organizer with CNA. “It’s not about money, it’s about having a voice. Nurses want to be able to speak up on behalf of their patients without being singled out as a whiner or complainer.”

Duke nurses say one reason they decided to organize with a traditional labor union is that professional organizations couldn’t offer them the same level of protection or clout when it comes to addressing workplace issues. The N.C. Nurses Association doesn’t emphasize collective bargaining and until recently, wasn’t paying much attention to the problems of bedside nurses.

Executive Director Sindy Barker says that’s because the association’s membership is mostly nurse managers and advanced practice nurses who haven’t had the same complaints. Also, in a “right to work” state like North Carolina, where employees aren’t required to join unions that bargain for their benefits, workplace organizing is expensive. “We went to a board meeting recently and we were told you can count on spending $1,000 per member to organize a unit,” Barker says. “We just don’t have that kind of money.”

Even some nurses who support a union at Duke have questioned the choice of a group that represents blue-collar workers to back their drive. Organizing-committee members point out that the IUOE already has experience bargaining with Duke, and has negotiated contracts for nurses in New Jersey, Nevada and California that include language about “floating,” overtime, “cross-training” and other key job concerns.

At an organizing committee meeting last month, Lisa Francioce, a pediatric nurse from New Jersey who now works for the IUOE’s health-care arm, told Duke nurses she frequently fields questions about why nurses should join unions as opposed to existing professional associations.

“We often hear, ‘how professional can operating engineers be?’” Francioce said. “To me, professionalism is having some say over your working environment. Right now, you guys have no rights at all and that’s not professional. By having a union contract, you set guidelines and have some recourse. When you hear ‘unprofessional,’ go ask your hospital CEO if they have a contract or not.”

You women who want to be free

just take a little tip from me

break out of that mold we’ve all been sold

you’ve got a fighting history

the fight for women’s rights

with workers must unite

like Mother Jones, bestir them bones

to the front of every fight.

On an overcast weekday afternoon, a dozen or so nurses, union organizers and supporters gather in the multi-tiered parking deck across from Duke Medical Center. They distribute signs, leaflets, balloons and water bottles and amble across the street to take up positions on the sidewalk.

A few cars slow down to read the signs: “Where Have All the Nurses Gone?” “The Best Hospital Should Be the Best Place To Work!” A few drivers honk. A few people stop to ask questions or directions. But mostly, the picketers are on their own.

Many of the nurses on the sidewalk are here on their day off. Others have come early to their shifts or are staying on after they’ve ended. While union supporters march outside the hospital, some of their co-workers inside the building are busy posting angry messages about the protest to a Web site run by a group of anti-union nurses.

Pro-union nurses at Duke know they have an uphill fight. In North Carolina, where only 3 percent of workers are union members–the lowest proportion of any state–few people are informed about or open to collective bargaining. The unfair labor practice dispute has slowed momentum and allowed Duke’s anti-union consultants more time to sow doubts and highlight divisions among the staff. And so far, the organizing campaign at the hospital has been more of a family fight, with little outside support.

If nurses vote in favor of the union, they then face the challenge of recruiting members and keeping them active enough to present a strong front in bargaining negotiations with Duke. They’ll also have to deal with the larger questions confronting the medical center: how to compete and survive in a changing health-care climate.

But union supporters are confident that if they stick to their core issues, they’ll be successful. Besides, many nurses say, they have no other choice.

“If I make a mistake on my job or leave something undone, I’m going to be sitting before the board of nursing and Michael Israel won’t be sitting there with me,” says Kornegay-Shaw. “This is about patient care and patient safety–that’s what it boils down to, whether people want to admit it or not. I understand that the hospital has a budget and a bottom line. But my bottom line is that my patient needs care.” EndBlock