Union membership has declined steeply in recent decades. Increasingly, organized labor is targeting the healthcare industry as a growth opportunity. This is creating a leadership challenge for OR directors and managers.
In 2012, approximately 21% of hospitals in the US had a union nursing staff. That percentage could soon increase as an unintended consequence of healthcare reform.
Labor relations expert Jim Trivisonno was recently quoted in Modern Healthcare: “The Affordable Care Act means people will have to look at costs, and that sometimes leads to change and less job security. And that leads to more organizing activity.”
Unions can play a positive role in healthcare, but they often create obstacles to effective OR management. Surgical services leaders need to understand the labor dynamics that could soon have a larger effect on OR staffing decisions.
Complex challenge
Healthcare unions are concentrating their efforts on several issues. Top priorities include clinical quality and safety.
Shortly after the nation’s first Ebola patient died last fall in Dallas, nurses across the country staged protest actions. Union leaders argued that hospitals were not providing nurses with adequate training and protective equipment to care for infected patients. The protests succeeded in focusing public awareness on Ebola readiness and safety.
Nurse unions have also prioritized staffing issues. In 2013, union supporters in Congress introduced the Registered Nurse Safe Staffing Act. This bill would require hospitals that participate in Medicare to appoint a committee to create a unit-by-unit staffing plan. These committees would be composed of “at least 55% direct care nurses or their representatives.”
Nurse staffing is a complex issue, and supporters of the bill argue that higher RN ratios will cut costs by reducing complications. Including more RNs in the staffing mix can also reduce overtime and agency costs. However, this legislation could also work against efforts to introduce appropriate efficiencies in OR staff structures.
For hospital surgery departments, costs are not the only issue. Unions can hamper efforts to improve OR performance by persistently blocking change. This can be especially problematic for an underperforming OR that requires significant improvements in processes and organization.
Although unions do present many leadership challenges, effective OR directors can learn to mitigate conflict and work constructively with union representation.
Alecia Torrance, MBA, BS, RN, CNOR, senior vice president of clinical operations at Surgical Directions, a consulting firm in Chicago, has experience with leading both union and non-union ORs. Torrance recently shared several strategies for working effectively with union staff.
Create a discussion forum.
Difficult relations between OR management and union staff can be exacerbated by poor communication. The solution is to establish a forum for discussing union concerns.
Torrance recommends monthly meetings between OR leadership and labor representatives.
“A regular nursing council meeting provides the opportunity to go over any issues the union wants to bring forward, typically clinical practice issues, policies and procedures, and pay issues,” Torrance says. “The agenda should be established collaboratively by the union and management, and it’s critical that it be a defined agenda that is set ahead of time.”
Monthly meetings are not a cure-all, but they do provide an organized setting for hearing union concerns and explaining management decisions. Union nursing councils can be a natural fit in Magnet hospitals, which emphasize nurse participation in shared decision making.
A council system also provides an added benefit for OR managers. “As a director, when a staff member comes to me with a complaint, I can say, ‘Go to your representative on the council and have them put it on the next agenda,’” Torrance notes. Groundless complaints often go no further.
Be ready to make your case.
It is always important to make sure staff understand the rationale for new policies or procedures. But when staff are unionized, poorly explained changes can result in big headaches.
Torrance worked recently at a high-volume urban surgery department with a union staff. One of her goals was to improve efficiency by converting sequential work steps into parallel processes. The union pushed back. “They believed that parallel processing would increase infections because it sped up the traffic in and out of the OR,” she says.
OR leadership responded by doing research and bringing in experts to provide independent assurance.
“We provided the data, explained what was happening, and even got the hospital’s infection control director to come to a council meeting to talk about why parallel processes do not increase risk,” Torrance says. Keeping good minutes at council meetings proved to be important because challenges continued to arise even after an agreement had been reached on process reform.
Compromise effectively.
When working with unions, clear victories can be rare. The key to success is to make effective compromises.
“Say you are trying to improve start time accuracy,” Torrance says. “Part of that is streamlining workflows during the 30 minutes before the first case of the day.” But nurses who are accustomed to inefficient processes will often feel rushed by streamlining efforts. If the nurses are represented by a union, resistance to change could be strong.
“One possible compromise is to move nurses’ arrival time from 7 am to 6:45 am, giving them an extra 15 minutes on prep,” Torrance says. Because nurses will also leave earlier at the end of their shift, the department will be “losing” 15 minutes per staff member per day. However, given the importance of first case on-time starts to overall department efficiency, the trade-off is worth it.
Work hours can become a major issue. At the urban hospital noted above, Torrance worked with OR leaders to develop nursing specialty teams. The goal was to provide surgeons with a higher level of clinical support. The problem was that specialty teams would require changes to the shift structure.
“A lot of the nurses worked 12-hour shifts,” Torrance says. “If some of the nurses switched to 8- or 10-hour shifts, we could implement specialty teams with the same headcount. Otherwise, we would need to hire additional staff.”
The union opposed this change and brought in a professional mediator. “It was a time-intensive process, but we did end up with a resolution,” Torrance says. Several volunteer staff members were assigned to more than one specialty team. This provided the flexibility to staff the teams without increasing full-time positions.
“It wasn’t an ideal solution, but it was functional,” Torrance says. “It achieved agreement between the hospital, the union, and surgeons, and it allowed us to move forward with an important service enhancement.”
Do not give up on corrective action.
Union presence can make it harder to take corrective action with underperforming staff. Don’t throw in the towel, though. Verbal and written warnings are often critical to making staff take OR policies seriously.
“Any time you are delivering any kind of verbal warning, a union representative has to be in the room,” Torrance says. “In my experience, union reps can become very combative, to the point where they take over the conversation for the employee.” If an OR director is unprepared to manage these encounters, staff may conclude they cannot be held accountable for problems like chronic tardiness.
Two strategies are important. First, make sure you carefully document the employee behavior that is leading to the disciplinary action. Second, involve hospital human resources personnel in corrective action meetings.
“Good HR people are trained to handle these encounters, and they can be extremely helpful in making the discussion more balanced,” Torrance says. If a case does go to the grievance process, having clear documentation and HR backup is critical.
Know when to draw the line.
Although compromise is essential, OR leaders should be aware of the point where union demands become unreasonable.
At the high-volume surgery department referred to earlier, the union demanded 1 hour of paid time off per pay period—so nurses could go to the bank and deposit their paychecks. This “employee benefit” is not known in any industry or profession. The request was rejected outright.
“The lesson is that you shouldn’t be afraid to say no to requests that don’t have a lot of merit,” Torrance says.
Proactive effort
Workers are less likely to unionize when they feel they are valued and their needs are addressed. OR directors should cultivate a staff-focused leadership style.
“One of the keys is being approachable,” Torrance says. “OR directors should make themselves available by rounding regularly and interacting with staff.” Transparency is also important. “Effective leaders are upfront about their goals for the OR, and they are committed to sharing data about department performance.”
Nurses should be involved in decision making. “OR directors and managers should also advocate for their staff and help their nurses develop professionally,” Torrance says.
Making sure compensation is in line with community standards is critical. But for many OR nurses, predictability is just as important as pay. Creating an efficient, high-utilization schedule that enables a predictable shift structure will help staff balance work with other responsibilities.
New Year’s resolution
Staff-focused leadership is important in any OR, unionized or not. “As the organized labor trend unfolds this year, surgical services leaders should place renewed emphasis on building an OR where all nurses can thrive,” Torrance says.
“In ORs where leaders create a positive, productive, and rewarding work environment, nurses are able to meet their needs without turning to a union organization.”
This column is written by the perioperative services experts at Surgical Directions (www. surgicaldirections.com) to offer advice on how to grow revenue, control costs, and increase department profitability.
References
American Nurses Association. Safe Staffing: The Registered Nurse Safe Staffing Act, H.R. 876/S. 58.
Carlson J. Reform, new labor issues likely to keep unions busy in 2014. Modern Healthcare. January 15, 2014. http://www.modernhealthcare.com/article/20140115/ NEWS/301159931.
Olin J. Nursing Unions: A Still Undecided Controversy. “Notes from the Nurses’ Station” blog at RN Central (rncentral.com).
Reese D. Nurses go on strike for proper gear, training to protect them against Ebola. Washington Post. November 10, 2014. http://www.washingtonpost.com/blogs/shethe-people/wp/2014/11/10/nurses-go-on-strike-for-proper-gear-training-to-protectthem-against-ebola/.
