Controversial Settlement Divides New York Nurses

New York State Nurses rallied for safe nurse-to-patient staffing ratios. Photo: NYSNA.

After a strike threat and a contentious ratification vote, 13,000 members of the New York State Nurses Association settled a contract that achieved gains but fell short of the union’s goal of winning safe nurse-to-patient staffing ratios.

The four-year agreement includes annual pay increases of 3 percent, increased tuition reimbursement, retiree health benefits for nurses who retire early, and a new process to enforce staffing levels.

For months the union had been bargaining with the New York City Hospital Alliance, composed of Montefiore, Mount Sinai, and New York Presbyterian.

These three hospital systems rank among the city’s largest private employers. The union bargaining units include seven main hospital campuses plus many clinics and ambulatory services, a homecare facility, and a freestanding emergency department.

Members had high expectations after the union threatened to strike if the Alliance didn’t take their demand for safe patient limits seriously.

At Presbyterian, nurses voted 91 percent to ratify the agreement. But there was much deeper opposition at Mount Sinai, where 42 percent voted no, and at Montefiore, where nurses narrowly voted the contract down, 51 to 49 percent.

Members who opposed the deal argued that the union could have won more if it hadn’t backed away from a strike.

“I think we could have galvanized the entire city of New York around patient staffing and finally forced these huge corporate hospitals to take our demands seriously,” said Tre Kwon, an intensive care nurse at Mount Sinai.

Mount Sinai nurse Robin Krinsky disagrees. “I don’t think a strike would have given us more money,” said Krinsky, a member of the union’s statewide Board of Directors, and a locally elected leader. “The Alliance would have commercials and advertisements and a whole campaign to say these selfish nurses were offered tens of millions of dollars to increase staffing levels and went out on strike.”


A bargaining survey last summer got thousands of responses back. The results were clear, according to bargaining team member Michelle Gonzalez, an intensive care nurse at Montefiore Moses: “The number one priority was safe staffing ratios.”

Ratios are mandatory limits on the number of patients a nurse can be assigned. Enforcing them means forcing hospitals to hire more nurses.

Hospitals commonly cut costs by forcing nurses to take on more and more patients. This understaffing is dangerous for patients who need more medical attention than an overstretched nurse has time to provide, and dangerous for nurses who speed up, miss breaks—often working straight through a 12-hour shift—and risk workplace injuries and burnout.

Contract action teams were organized in each hospital. Members engaged their colleagues on each shift and recruited hundreds to attend bargaining sessions, where many were invited to speak about the issues.

In February, thousands of union members and community supporters picketed at a dozen sites. The following month, nurses voted 97 percent to authorize a strike.

The strike date was set for April 2, and the union organized rallies on March 18 to deliver the notice. (Federal law requires health care workers to give management at least 10 days’ notice before a strike.) The action was livestreamed on Facebook.

Within days, the Alliance offered movement on staffing in exchange for the union walking back the strike notice. The bargaining team agreed, and union leaders postponed the strike indefinitely.

On April 9 the union announced in a press release that it had achieved a four-year tentative agreement including “historic staffing ratio language.”

But when nurses learned what the contract language on staffing actually said, a vote-no campaign bubbled up from below at two of the three hospital chains.


This is the second time the union has bargained with the three chains jointly. Prior to 2014, each bargaining unit negotiated its own deal.

In 2014-2015, the union fought for ratios but ended up with professional practice committees instead. These are joint nurse-management committees that can discuss issues like staffing, but have no enforcement power.

The union heralded that deal too as “historic” for having “achieved enhanced staffing ratio/grids” and the committees as creating an enforcement mechanism with “new teeth.”

From the union’s perspective, “the purpose of professional practice committees was to organize nurses to be more vocal about their issues and solve their problems by bringing solutions to management in an organized manner,” said Diana Torres, a nurse at Mount Sinai West.

But, she said, “the majority of the time what happens is that you have a wonderful committee and a great meeting and bring everything to management and nothing happens. You waste your time and energy.”


This time, the union won a commitment from the Alliance to fill hundreds of vacancies and then to establish that as a baseline staffing level.

Additionally, the Alliance agreed to spend $25 million each year for four years to improve the staffing levels from there.

That breaks down to $8.3 million dollars per hospital system, per year, or 56 new nursing positions per year that each system will hire.

Labor-management “allocation committees” will decide how to distribute those positions across the hospitals, departments, and shifts within each chain.

Union spokesperson Carl Ginsburg said complying with the new contract will require the hospital systems to put “a permanent ‘Now Hiring’ sign on the window.”

A sticking point for some nurses was that staffing grids will be calculated at the department level—how many nurses for how many patients—rather than setting a maximum number of patients per individual nurse.

“Imagine that you have to cut up and disperse pieces of a pie to five people,” said Xenia Greene, a pediatric nurse and bargaining team member in the Montefiore system. “Ratios set limits on how much pie any one person can be given, while grids just say how many people the pie has to split between, so one person can end up with a lot and others with less.”



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For instance, if one nurse gets fewer patients because of their acute needs, a grid allows the hospital to assign extra patients to another nurse. With a ratio, to reduce a nurse’s patient load the hospital would need to call in an additional nurse.

The union’s proposed state legislation on staffing, based on California’s nurse staffing law, would set per-nurse limits. The union made a bargaining proposal based in part on the ratios in the bill, but the Alliance rejected it.

Still, bargaining team member Anthony Ciampa, a cardiac nurse in the Presbyterian system who is on release from the hospital to work full-time for the union, hopes that the allocation committee can achieve per-nurse limits.

“We will build our staffing on ratios of each nurse getting a certain number of patients,” said Ciampa. And if nurses are routinely assigned too many patients, he said, “then you can bet your bottom dollar we will push for more nurses.”

“Ratios are the gold standard for nurse unions because they really work,” said Rebecca Givan, a labor studies professor at Rutgers University. “They improve patient care and the lives of nurses. Grids have not been shown to have the same kind of empirical effect that ratios have.”

What a Difference Ratios Make

by John Pearson

John Pearson is an emergency department nurse at Highland Hospital in Oakland, California, and the Alameda Health System chapter president of SEIU Local 1021. But before that, he was an E.D. nurse at Kings County Hospital in New York City. Here he explains the difference he has seen firsthand now that he works under California’s ratio law, which limits the number of patients any nurse can be assigned:

My current Emergency Department is less than one-third the size of the King’s County ED. State- and contract-mandated ratios, and nurses organizing to enforce them, are the reason for the difference.

Here’s how it works: you’re allowed max four ED patients at a time. If one of them meets Intensive Care Unit criteria (based on the nurse’s judgment), it’s max two. If it’s a trauma patient, it’s max one. If a nurse is off the unit, on break, in a meeting, etc., that nurse doesn’t count in the ratios. Management must provide another nurse to take your assignment. Charge nurses must be relieved of all administrative duties to be counted in the numbers.

The results are dramatic. Kings County E.D. had about 150 beds and 12 nurses on a shift. The E.D. I work in now has about 50 beds and 26 nurses.

Even with ratios, we have to be organized to enforce them. In 2014, management at Highland staffed us at the state-mandated ratios out of fear of fines. But they fudged the numbers of breaks, transports, meetings, etc. This is dangerous. Every time we transport a patient or go on break and another busy nurse “watches” our patients, we’re putting the patient’s health and our licenses on the line.

So we started a campaign to enforce the ratios. We spread the word about the rules and how management was breaking them.

After many months of organizing and pushing back, we got “break nurses” to cover us for lunches. They do all the work we would do if we stayed. Not doubling up assignments—it’s against the law and the contract.

Then we spread our campaign to the rest of the hospital system. We also won 24/7 transport nurse staffing and thousands of dollars in back pay for management’s failures to follow the contract, plus a letter of apology. They had to budget for new positions and hire more nurses.

The new agreement creates an expedited process to address an employer’s failure to post or fill new vacancies or to maintain a minimum number of nurses on each shift.

The new process terminates speedily in a hearing before a panel composed of one union representative, one employer representative, and one third party from a private arbitration and mediation firm. The panel’s decision is binding.

Within the Mount Sinai system, Mount Sinai West and St. Luke’s have a joint contract and already had grids.

The main campus didn’t. Going into bargaining, it had “the worst contract of all the hospitals,” said Krinsky, who served on the bargaining team. “We’ve never had grids, so this is historic for us.”


Still, she said, members were angry that the union didn’t win ratios and that the number of added nurses was so small. But she sees the new contract as giving the union forward momentum towards its staffing goals.

“The hospitals refused to negotiate ratios, so the closest we got to it was grids,” Krinsky said. “But each contract is a stepping stone that paves the way for something more.”

Torres, who was also on the bargaining team, believes the union settled far too short.

“We [would have] needed over 200 nurses to establish something that looks like safe staffing ratios in our contract at Mount Sinai West,” she said “We also needed over 300 nurses at St. Luke’s, over 600 at Mt. Sinai’s main campus, and over 1,000 at Montefiore.”

Out of the $8.3 million allocated to the Mount Sinai system, the main campus will take two-thirds, while St. Luke’s and West will split what’s left. For West that shakes out to adding nine nurses.

“You can’t make a grid or chart that looks any different than what it does now with nine nurses,” said Torres. “This is like putting a Band-Aid on a gunshot wound.”


Meanwhile Montefiore, unlike the other systems, already had ratios in its contract for some departments—but nurses there had hoped to improve them and to win ratios in the overflowing emergency rooms, where there are none. The current ratios are seen as wholly inadequate, Gonzalez said, and staffing remains the top issue.

The problem is especially acute in low-income areas like the Bronx, where she works, where patients are less likely to have access to care until a health problem reaches a crisis point.

“We are getting complex health cases involving life-saving medications,” Gonzalez said, “and these patients should be in the ICU where a nurse can check on them every 15 minutes. Instead, nurses are responsible for critically ill patients alongside five other patients.”

After the no vote at Montefiore, the union shifted money originally slated for retiree health so that the system will add 65 nurses per year instead of 54. On the re-vote, the contract passed.

Disclosure: During this campaign, the author was invited to provide organizing advice to NYSNA on a voluntary basis.

A version of this article appeared in Labor Notes # 483. Don't miss an issue, subscribe today.
Chris Brooks is a staff writer and organizer with Labor