Why are hospitals keeping nurses away from patients in need?

On June 27, nurses in Austin, TX at Ascension Seton Medical Center and in Wichita, KS at Ascension Via Christi St. Francis and Ascension Via Christi St. Joseph went on strike for one day. The historic strike was the biggest strike by nurses in both Texas and Kansas! When the strikers attempted to come back to work the following day, they were met by security and non-local administrative staff who informed them that they had been locked out for three days. Facing retaliation and vowing to renew their efforts if working conditions do not improve, the nurses returned to work during the first week of July. Tempest member Snehal Shingavi spoke to nurses at all three locations to understand what went into organizing the strike and how nurses responded to the lockout.

Interviewees:

Monica Gonzalez, RN at Ascension Seton Medical Center Austin for 19 years (National Nurses United member)

Taylor Critendon, Critical Care RN at Ascension Seton Medical Center Austin for 5 years

Shelly Rader, RN, at Ascension Via Christi St. Francis, Wichita, KS for 15 years

Marvin Ruckle, BSN/RN in the Neonatal, ICU, at Ascension Via Christi St. Joseph, Wichita, KS for 34 years

Snehal Shingavi: Describe a day at work in your position.

Monica Gonzalez: I work on a medical-surgical unit – a neurological unit that cares for stroke patients. We’re also a Urology/ENT [Ear, Nose, and Throat] unit, so if you have issues in your throat or bladder, we care for that, too.

My shift starts at 6:45 a.m., but I get there early so that I can be better prepared. We do bedside reporting with the outgoing shift, which can take between five minutes to upwards of thirty minutes, depending on patient participation. The first four hours are the busiest, because we have to do assessments and administer medications.

We usually have a six-patient assignment. I work nights, so the 6:1 patient-to-nurse ratio is standard for us. The day shift has a 5:1 ratio. We should be dealing with only four patients, especially if they are neurological patients who need assessments every four hours. We’re not given the appropriate patient-to-nurse ratios. I have brought up at our unit meetings that we are dealing with an unsustainable patient-to-nurse ratio, but the managers say that this is expected of us. It makes it difficult to provide the best care for our patients because we are lacking support staff. So, nurses have to pick up the slack. We are turning and positioning our patients every two hours. If we get a new admission, we do a two-person skin check to see if there are wounds or cuts. Our patients who are more fragile get skin assessments every shift. We do everything the day shift does only with more patients and less staff.

If we haven’t completed our documentation during the shift, nurses will often stay late to finish.

Taylor Critendon: It’s pretty hectic. You come in and get a report from the night nurse. You’re figuring out medications, lab work, what vitals need extra attention, special equipment – and quickly patients start calling. People need to go to the bathroom first thing in the morning or they need their medicine in the morning. Unfortunately, you have to prioritize patients’ needs at a time when everyone is calling for attention. Someone needs pain medication; someone has soiled their bed. We have a lot of critically ill cardiac patients and respiratory patients. And you’re dealing with their critical issues at the same time as you are dealing with a whole range of other issues.

There is only one care technician (same as a nursing assistant) on our floor. It has been hard to retain those folks who are essential for nurses. We will have medical-surgical overflow patients, patients who are more mobile and can walk, but we can’t help them because there are more critical patients who need immediate care. The folks who need to work on mobilization get pushed back—and they are normally ones that a care tech could deal with. Sometimes we have patients who need two people to help turn them and that person will have to wait. Care techs can help with hygiene, getting patients to the restroom, basic things, but our care techs can sometimes have up to 15 patients while they are dealing with getting vitals and blood sugars, and even they have to prioritize.

This is what causes moral injury – that digs into every nurse and care tech. Like a patient had to soil their bed because I couldn’t get them to the bathroom. It affects the care our patients get and their dignity. It takes a toll on you and the patient when this happens every day. It’s what causes nurses to leave the profession or leave Ascension.

Shelly Rader: Back in 2003, when I was hired at St. Francis, the sisters ran the hospital – it was a nonprofit, Catholic hospital. The nuns would come down, and talk to patients and nurses. They would pray with nurses if they wanted that. If there was a critical patient, the sisters would come down and talk to you—and they appreciated everything that you do. Patients were very well taken of. In the ER if you had three patients to every nurse, that was unusual. As the time progressed, and it was sold to Ascension, Ascension cut everything out. We lost part of our retirement, we lost discounts in the cafeteria, and we are no longer able to keep nurses at the bedside. There are only a few of us now that have been there longer than 15 years. The people who had been there as long as I have are leaving in droves, either quitting the profession or leaving hospital work. I cannot leave my patients. There is a silver lining somewhere and I am going to find it. And that is how the union came about and nurses said that they had had enough. And we are building this union stronger and stronger and the nurses will come. We need to build it better for the nurses who will follow us, so they don’t have to go through what we go through.

We have been in moral distress way before the pandemic. And then with the pandemic, things got worse. For instance, yesterday, there were 56 patients in the ER—26 of them were admit holds (waiting to be admitted to a room), and twenty in the ER waiting area. There were no rooms for the admit holds. And because we are the ER we do not get to close our doors. We have people who walk in, ambulances that continue to come, emergency services that we must provide. So, when you have one ER nurse that might have six patients and three of them are intensive care patients (meaning that one nurse takes care of them because they are so sick), and three might be medical-surgical patients, and a few might be heart attack or stroke patients (because we are a Level I center). And when you have so little staff, each patient begins to have decreased care.

Ascension knows this. They know that we are short-staffed. We all leave worried that things have fallen through the cracks.

Marvin Ruckle: In the neonatal, ICU work can vary. Some days can be very good; you might have one critically ill baby or three babies that are grower/feeders that need to gain weight and eat before they can go home. Other days are really hectic, where you have more than that. In my unit, the nurses work very well together and there is a strong camaraderie.

At St. Joseph, we got the union in March, and we’ve had a bargaining session with other Ascension nurses in Wichita and Austin, and we’re all asking for the same thing. We’ve asked them to let us bargain at the same time, but Ascension has refused. We could see the writing on the wall with what was happening with the other hospitals. They like to pretend the union doesn’t exist here. We knew that the best thing for us to do was to have all three hospitals strike at the same time. Ascension management was telling staff that it would take a year to bargain the contract. And rumblings through management and talking to staff, they are now saying that it might take two years to get a contract. We want the same things that the other nurses want and we had power together.

Nurses here are all very close. Sometimes it is good in one department and terrible in another department. The patient-to-nurse ratio is uneven all over the hospital. The critical babies in the neonatal ICU can get very sick very fast, so things can happen very fast and nurses have to be ready at that very second. I occasionally will work the adult floors, and on the medical/surgical floor, a nurse can have as many as eight or nine patients. You have patients that need turning, and who are at risk of falling. These were all reasons that we needed a union to begin with.

SS: What got you involved in the strike?

MG: What drove me to strike was that management doesn’t consider what we are saying; they don’t listen to our suggestions about how we could improve. We want to keep our patients safe and provide the best care. And when we can’t, you see nurses getting frustrated and leaving the job for something better.

I’m on the bargaining team and have been involved in actions – we did a candlelight vigil, and we visited senior management. We did a lot of things to get attention on our issues, but they’ve refused to listen. And that’s created a great deal of frustration amongst the staff.

TC: I was involved with the unionization of the hospital since the beginning. I’ve been critical of my hospital for a while. We used to be a little local hospital. We had nuns. When I started, Ascension, a corporation that goes around the country buying up nonprofit Catholic hospitals, they had just shown up. They made a lot of policy changes and made their presence felt. We felt their presence during the pandemic. We saw them take away resources. When the pandemic first came to Austin and we had a lot of critically ill COVID-19 patients, they had multiple resource nurses to turn patients, we had med runners in the hallways to grab medicine quickly. We had staff who would help with taking PPE on and off.

We had all hands on deck because we were a community that rallied together to deal with the crisis. But a few months later, during the second COVID-19 surge, they got rid of the nurses in the halls who would help with medications and PPE, they got rid of the turn team that would help with the patients who were weak from COVID-19. They were essentially saying do more with less. And over time, people were just done, emotionally and physically. You felt defeated every day and you weren’t even provided with the resources to provide adequate care. It was demoralizing for a lot of nurses and folks were choosing to leave the bedside. I just remember sitting between two patients and looking out the window, and watching patients teeter on the brink of death and waiting for a ventilator to become available so that your patient could get intubated and vented. It was awful and heartbreaking to know that this was happening in your hospital.

That was a big eye-opener. Nurses were there every day providing care. But administrators weren’t there—we never saw them walking the hallways or helping with patients. There is no hospital without nurses. But we also learned that we didn’t actually need administrative staff. They didn’t do anything. There was nothing to validate their existence. Between the surges, the staff asked for a meeting with the administrative staff. We said, we are hemorrhaging. We are losing nurses. And we can’t afford to lose any more staff. We said you must do more to retain nurses. We talked about the lack of equipment and staff, how we were doing more for not enough pay. They were able to give us an extra nurse for the Critical Care floor, but they didn’t do the same for all the other floors that were also struggling in the same way that we were. And that was when folks started reaching out to National Nurses United (NNU) to ask for help in organizing. We were underground for a good while. But we started going to other floors and talking to other nurses. That was taboo at the time—nurses talking to nurses. We won our union in September of 2022 and started negotiations in November. And all we see at the bargaining table are the lawyers that Ascension has hired. We never see the administrators.

They have seen all forty-five of our proposals. We have agreed on seven. The main five that would improve conditions for nurses and patients are the ones that there are no agreements on. We have signaled repeatedly that we are prepared to escalate. We had a vigil where we mourned the loss of patient and nurse voices. We had a picket in April. We have had several unit-specific fights with management. Ascension has always had the resources to provide adequate care and resources for our patients. They can pay for all of the things that nurses are asking for. They choose not to. They have no shame. And that was why we escalated to a strike.

SR: I’ve been involved in the union for more than a year. My husband is in the IAM [International Association of Machinists and Aerospace Workers] in Wichita, KS. Speaking with other nurses was amazing. We had started bargaining in February. And there was no one local from Ascension across the table from us. We were looking to get a good contract, but we were talking to people who had no understanding of what our community was like and how our nurses worked. We organized against workplace violence and  staffing shortages. Ascension had the ability to avert this strike. Our nurses were upset by Ascension’s tactics. Our nurses were organized and coordinated and got the whole community involved.

MR: It goes back to me getting involved in the union. There was a distinct change as soon as Ascension got involved in the hospital. In 2013, Ascension laid off a lot of RNs. And it gets me really annoyed when they blame the pandemic for everything because things were bad well before that. We have been short-staffed since way before the pandemic. Then they started taking away benefits, cutting pay and health care. I was frustrated. And there was nothing I could do against a huge corporation by myself. But once we talked about unionizing, I had to get involved. I’ve worked all over the hospital and I know people all over the campus. I know the workflow all over the hospital. It was clear that the problem wasn’t limited to my area, but was all over. That’s when I was all in. I wanted to be on the bargaining team because I felt like I had been there so long and could speak to issues affecting nurses all over the building.

SS: What was the strike like?

MG: The strike was empowering and invigorating. To see so many people out there supporting us – not just fellow nurses, but staff from our hospital and other local hospitals. There were other unions out there to support us: folks from Austin/Central Texas unions – RWU (Railroad Workers United), Starbucks, DSA, and there was even a pilot out there to support us.

Doctors, nursing students, and a lot of community members. The honking when people drive by was like an explosion of energy on the line. You know that saying, “Every time a bell rings an angel gets its wings.” Well, it was like that. Every time a car honked, the picket line got more energized.

TC: I was a little nervous the week or so before it. But on the day of, all of our work paid off. It was the most empowering day of my life. A lot of nurses echoed that sentiment. Just standing there and seeing the number of nurses who came out. Up until then, we had nurses show up, but not a lot. But these were people that I had spoken to and explained their rights to. I felt so proud of those nurses. I felt so supported. I watched as these nurses came out of their shuttles and began chanting and picketing. So not only was it empowering because our community was behind us. But I also felt like a proud mom because nurses who were cautious or reluctant stepped out into their own power. There was a moment when we all turned toward the front of the hospital where there were security guards and administrators, but the volume of the chanting echoed from the walls and continued to build. I got goosebumps. There were so many people who came out to picket with us. If I were an administrator, I would have been afraid.

SR: The community support was fantastic. The Machinists and Pipefitters came out. UPS workers and firefighters. People brought water. Cars honked. Community members were incredibly supportive.

All of the nurses from all over the hospital coming out, holding their heads up, and walking the line. Ascension has divided us all up—nurses don’t get chances to talk to each other. But once we got the union in, nurses were constantly talking. I’d never spoken to so many nurses from all over the hospital. We were on the phone talking to each other, solving problems. That was something we never had before and that we had now.

MR: The strike was awesome. It was very well supported. There were a lot of nurses out there, including some that I wasn’t sure would not cross the picket line. There were people there from other unions picketing with us, including the teachers union, the folks from Spirit Airlines who were out on strike, UPS workers, and several other unions. It felt like we had the community on our side. And we had workers from other industries. Corporations are making money off their work, too.

SS: Did you learn anything from being on the strike?

MG: I knew we had community support, and we had a lot of union support before. But for the folks that had not participated before, they could really see how much community support there was, and to see that they were not alone.

TC: Throughout the whole process there was a lot of hope. I have been living off that hope. I have been speaking to people and explaining the issues, and you’re never hundred percent sure what anyone is thinking. But the strike really validated that hope and the camaraderie. And we learned that we have so much more in common than we will have with managers or administrators. It was a validation of who had the real power. And once people get a hold of that and understand that idea, there is no way to take that away from people. And that’s what the strike demonstrated: We have a strong majority of nurses who know their rights, know who has their back, and are confident in demanding their rights.

SR: That we are very powerful and we will not back down. We will keep pushing for our patients and our community. Our patients should get the care that they deserve.

MR: NNU had really well-prepared us for the strike and what to expect. The biggest thing for me was experiencing all of the support that we had, and that surprised me a little bit. It was all of us fighting for the same thing and against the same kind of greedy corporations.

SS: What was the lockout like?

MG: There was a group of us that returned to work the following day. They had tables set up to check people in – and this was unusual. We can usually go in through a lot of different entrances. During the lockout, we all had to come in through one entrance and get checked in. People who struck or didn’t go to work on the day of the strike were not allowed to go in, but they didn’t know the difference between nurses who had struck and nurses who weren’t working that day. They actually used the tables as barricades against the door to prevent us from entering. It was infuriating.

I’ve been there for almost twenty years. There was a nurse that had been there for forty years. It was extremely frustrating to see that they would rather lock us out than bargain in good faith.

We gave the hospital more than a ten-day notice (we are only required to give them ten days) before we struck. They could have come to the bargaining table and negotiated. But they decided to cancel elective surgeries and transfer patients.

TC: We continued to flex our power during the lockout. We had our return-to-work delegation on the 28th. We wanted to make it clear that Ascension was putting their resources into short-term temporary staff instead of letting people who knew the facility and the patients back into the hospital. That really brought out our righteous anger. But we were able to show Ascension’s true colors. And it was initially daunting to hear about the lockout, but they were essentially asking people to come in during the strike even if it was their day off. And these folks were locked out even though it was their day off. That really backfired on Ascension because it made people much more receptive to the union’s message.

SR: It was incredibly hurtful to be locked out, because Ascension knew that it was a one-day strike. And they talked about how they needed to bring in all of these nurses and had to pay them for so many hours. They locked out all of these nurses and told us that we had all been temporarily replaced.

They had hired temporary security guards for several weeks. Those were the guards that met us at the door and told us we could not come in. You could ask anyone at Ascension who the regular security guards were and we knew them and they knew us. But these guards were different.

MR: The lockout was frustrating. They had a lot of security there and that was unusual because you usually can’t find a security guard. Several of us went to the front door and they directed us to a side door. They contracted with a company to check out whether we could work that day. There were seven security guards at that door. One of the biggest things that I’ve noticed over the years is that there has been a cutting back on security guards. We’re not in the greatest neighborhood at St. Joseph. We have had shootings in the parking lot, we have a psych floor, we have patients that get very upset especially parents who want to see their children, but DCFS had to get involved, and we have to deal with that, face-to-face. It can be very dangerous.

SS: What’s the mood like now that you are back to work?

MG: From the people who I’ve spoken to who walked the line or struck, they are very supportive. They are upset and pissed because Ascension put out an email at that time saying that the traveler nurses were great and some of them wanted to come back. And why wouldn’t they? The working conditions had never been as good as the traveler nurses had it. They only had three medical/surgical patients to deal with. And as soon as we came back to work, it was back to the status quo. Ascension has the resources to staff us better, to pay the nurses appropriately to recruit and retain the nurses that we need to better care for our patients.

TC: People are still frustrated. People came back to work on July 1, and the place was a mess. During the strike and lockout, the hospital had never been staffed as well. On my unit, the patient-to-nurse ratio is 3:1 or 2:1 if their condition warranted it. But during the strike/lockout, the ratio was 2:1 or even 1:1. I have never seen that happen.

So, when nurses came back to work, after this incredible staffing, people had to go back to the earlier, harder patient-to-nurse ratios. Ascension was able to find the resources when it wanted to for the travelers but it couldn’t for us.

SR: We are all trying to figure out what comes next because they are not listening. Some of the nurses that had a day off on the day of the strike were told they were locked out. That made nurses very angry. Nurses are ready to fight. We will return to bargaining and we will see if Ascension will actually play ball.

MR: I think that mostly people feel incredibly good about the strike. A lot of nurses were nervous leading up to the strike, but after the strike, the nurses were energized. And the confusion that management created by changing hourly who could come back and when only made nurses angrier. There is a lot of frustration, especially since the replacement nurses had only one patient each, but we go back to the overworked conditions.

SS: What happens next?

MG: We hope that management comes to the table and bargains with us to reach a contract. We want them to agree to a strong contract that guarantees good care for our patients. Now that they have seen what we are capable of, and the number of nurses who are willing to strike for our patients, we believe this puts us in a strong position to get them to negotiate.

TC: We have two bargaining sessions coming up in July. We have spoken to a lot of our nurses and told them to prepare for another strike. I think this is the first Ascension hospital that has unionized. They are out of touch. They continue to hold off and try to get away with inadequate staffing, trying to silence nurses. Another strike feels likely.

SR: I would like for Ascension to talk to us about staffing, workplace violence, recruitment, and retention of nurses. At the table, the nurses had pay at the bottom of their list. It was about safe staffing and giving us the resources to keep nurses. We hope that Ascension will actually address our issues, and if that doesn’t happen, who knows what will happen.

MR: We will be bargaining on Friday, and I am eager to see what happens at bargaining. Ascension has not given us any counter-offers on any of the critical issues yet. We had met with them a few days before the strike, and they didn’t have anything to offer us at all. I’m hoping that after the strike they might be willing to work with us, but we will have to see.

SS: What would you say to a coworker who is sitting on the fence or reluctant?

MG: It’s not about you—it’s about making the changes in the hospital to make things better for our patients, for us, and for the rest of Texas and even the country. We can’t stand idly by and let Ascension do what it wants without any consequences. We are here to advocate for our patients, and by not pressuring Ascension we are failing them. It’s not just five or six nurses—it’s hundreds of nurses and no one is alone here.

TC: When you are at work, you work alongside other nurses. And these nurses are making sacrifices so that every other nurse can benefit. Solidarity is a bit of a culture change in Texas, the idea that you show up for me and I show up for you is not about one nurse. This is about making a cultural change across Texas. Across the southern states. The corporatization of health care, businesses profiting off the suffering of patients, and the unsupported hard work of nurses, it’s going on everywhere. This is about more than the nurses here. And we have to stop the profiteering off of people’s lives that dominates health care today.

SR: Is there something that you have questions about or that I can give you advice about? Is there something that you still need information about? I answer their questions. But I tell them, it was Ascension that locked you out; it was Ascension that didn’t bargain. Ascension sends out these emails to tell people what happened at the bargaining table, but none of them were actually there. Ascension says all of these things to try to scare nurses (about scheduling and about management relations), and none of it is true. The union is not trying to change these things, especially when they are working. The falsehoods that Ascension is putting out are just scare tactics.

MR: I think that a lot of the people who are on the fence saw how we all came together on the picket line, and the people who came were very energized. People who are still on the fence, if they understand what we are doing and what we can do for them, will see that the changes we are making will make a huge difference down the road. You have to have patience and endurance to get to that point, and then it is totally worth it.

SS: Any final thoughts?

MG: I just want to be clear: everything we do impacts our patients. Our ability to recruit and retain leads to better care. Having more staff leads to better care. Every unit that is adequately staffed leads to better care. We could be doing more to help our patients, but Ascension is standing in our way.

TC: We have worked really hard and I am proud of where we are. But I am not satisfied with Ascension. A lot of nurses are not satisfied. But a lot of us are prepared to do what it takes to provide adequate care for our patients.

SR: Nurses want to take care of our patients the best way that we can. And in order to provide that care, Ascension has to provide more staff. They need nurses, they need support staff, pharmacy techs, and security. But when they are lining their pockets with all of that money, they don’t want to give even a little back.

MR: I’m not surprised, but it is disheartening that Ascension is being so difficult. They are a huge corporation that is a nonprofit but is acting like a for-profit corporation in their daily operations. And that’s fine as long as there is safe staffing, the patients are safe, and nurses are recruited. There are twenty thousand nurses in Kansas who are not working at a bedside, so there is no shortage of nurses. They just won’t work in unsafe conditions. I’m at the end of my career, and I could have said that I have done enough. But I decided that it was bigger than me, and I’m doing this for the nursing profession and the young nurses coming in. I want them to have long, prosperous careers. New nurses coming in feel defeated, morally degraded, and that’s not what this should all be about. And if I can help make it better, it would be the biggest thing I could do in my career.

Featured image credit: Wikimedia Commons; modified by Tempest.