Nurse Power: The History & Future of Nursing Unions

Evaluating the Efficacy of Nursing Levers of Power

When discussing nursing power, it is crucial to critically examine how nurses have historically organized themselves and sought to effect change. In their research paper, “An Intersectional Critique of Nursing’s Efforts at Organizing,” authors Wesp, Bowman, and Adams compare the three most common means of nurse organizing: shared governance, professional organizations, and unions. 

Nursing Unions

Today, roughly 18 percent of US nurses are unionized. Unions are one of the oldest forms of worker power building and, to date, by far the most effective. Unlike any other form of organizing pushed by the Nursing PMC, nursing unions are the only ones that meaningfully empower nurses to improve their own work conditions, fight for better wages, resist toxic work environments and retaliation, and, in doing so, improve patient outcomes. 

Researcher, nursing historian, and reproductive health nurse practitioner Mary Bowman, DNP, WHNP-BC, expands on the history of nursing unions presented in their article: 

They continue, 

Another nurse researcher with a particular interest in the story of the California Nurses Association is John Silver, RN, MBA, PhD.  Dr. Silver has dedicated his career to the study of nursing power. It’s what led him to pursue a PhD in comparative studies and to write his first book, Just a Union of Nurses: The Rise to Political Power of the California Nurses Association.

In his book, Dr. Silver detailed the journey the California Nurses Association took to break away from the Nursing PMC paradigm and ultimately become the most progressive and powerful nursing union in the country. 

But Dr. Silver never intended that: “This was never meant to be a book about unions. What interested me was the political empowerment of nurses across the board. So I looked for nursing groups that had actually accomplished something politically, and this was the only nursing group I could find who had.”

Instead, Dr. Silver says the book was meant to serve as a model that nurses could follow to build political power and tackle the issues they faced across the nation. His peers’ reception in academia and nursing management, however, showed just how threatening his work was to the status quo. 

“When I published this book back in 2013, and I sent out copies to various peers in the profession, I must have gotten 50 emails back from nurses calling me a communist, a traitor to my profession, and saying ‘This is going to tank your academic career’ and ‘What the hell were you thinking?’ I was shocked. That was the roller coaster,” Dr. Silver says. 

Today, unions like National Nurses United (NNU) are serving as bastions of bravery and integrity, fighting for bedside nurses through policies such as mandated staffing ratios and evidence-based workplace violence reduction measures. To date, NNU is the only nursing organization of any stripe pushing for the abolition of Immigration and Customs Enforcement (ICE) and the removal of Palantir from American healthcare—two of the most pressing issues facing Americans today.

Shared Governance Models

In the 1970s, as nursing unions were gaining power and posing an increasing threat to the corporate interests that ran American Hospitals, nursing academics were working overtime to come up with palatable alternatives they could push to divert the revolutionary energy building on the bedside. They landed on the Shared Governance Model. 

According to Wesp et al, “Shared governance was transplanted into the nursing sphere by Virgiana S. Cleland…Her original vision of the organizational structure was part of a new ‘employee-management-relations’ strategy crafted in response to widespread collective bargaining efforts by staff nurses, whose goals of epistemic authority were becoming increasingly incompatible with the economic goals of their employers.” 

Shared governance models in nursing vary from hospital to hospital, but all generally include a structure of councils or committees. They are made up of nurses (appointed, not elected) who serve in various groups meant to tackle particular problems and “to give nurses a voice.” 

While this organizational structure was clearly chosen to undercut nursing labor power, it does have some benefits for improving patient outcomes. 

One nurse who fully believes in the power of this model is Meenaz Bachoo, RN, MSN, a nurse of 17 years who has worked within shared governance models her entire career and has used the infrastructure to improve the lives of her patients. She says that Shared Governance Councils provide a space and time for nurses to have a voice in practice decisions: “At the core, they’re about nursing empowerment.”

Bachoo says she has seen impressive results from ideas brought forth at SGM meetings, leading to impactful improvements in nurse-led patient safety metrics, such as reducing falls, blood culture contamination, and discharge times.

Another nurse with a long history of involvement in SGM leadership is Sarah Matuszak, RN, DNP, a former critical care nurse and current research fellow at Froedtert Health: “One thing I’m particularly proud of are the skills fairs our SGMs have been able to facilitate training opportunities for bedside nurses. This gives them dedicated time to learn and ask questions in a low-stress environment. The feedback we have received from our nurses has been positive,” Dr. Matuszak says. 

But not everyone is convinced of the power of Shared Governance. Dr. Silver points skeptically to the obvious conflict of interest and corporate capture baked into SGMs: “Anything that the administration of a facility, especially in the corporate system, approves or sets up, it’s because it remains under their control. Unions, on the other hand, are not under their control,” he says. 

The literature seems to agree with that sentiment. Wesp, et al. conclude, “More recent literature on shared governance heavily implies the dominant purpose of nursing shared governance is to achieve high-quality patient outcomes, including nurse-sensitive indicators and patient satisfaction scores, not to empower nurses.” 

The authors hit on this sentiment directly, musing, “Furthermore, if shared governance really delivered on its promises to provide shared decision-making with bedside nurses, why would administration have to solicit us for our participation?” 

Professional Nursing Organizations

Professional nursing organizations are the last lever of power to explore and perhaps the most important. There are over a hundred, but the preeminent, most well-funded, and crucial one for this conversation is the American Nurses Association (ANA). Founded in 1896, the ANA has served as the capital of the Nursing PMC world.

That’s because the ANA has been the leading force to “professionalize” nursing, and in doing so, created the class divide that has kneecapped the profession’s political power and resulted in the formation of the Nursing PMC. 

To look at the history of the ANA is to view a deeply conservative organization operating within a conservative nation. Their neoliberal progressivism, which they tout in the modern era, is actually quite new and doesn’t hold up under scrutiny. In actuality, the ANA has spent the better part of the last one hundred years on the wrong side of multiple social justice movements, including barring Black nurses from the organization from 1916 to 1964 and opposing nurse labor strikes from 1950 to 1968 and waiting until 1988 to address the AIDS crisis. 

They also refused to acknowledge lesbian nurses in the 1980s and have long been criticized for their lackluster, cowardly refusal to meaningfully support feminist causes, despite being an overwhelmingly female-dominated profession. 

Instead, the ANA has long worked lockstep with the nursing academics to close off the profession to groups they view as undesirables: chiefly the poor, the working class, and until very recently, People of Color. 

The original inflection point was in 1965, when they released a report that advocated that a bachelor’s degree should be the minimum entry point into the profession. This deeply elitist and racist gatekeeping policy was a transparent attempt to maintain their segregationist policies for the many red states in their federation. It was also a slap in the face to the majority of nurses in the profession who had become nurses through diploma programs, LPN/LVN programs, or associate degree programs. 

To the Nursing PMC, this move was absolutely essential to achieving their singular goal: gaining the same level of prestige, wealth, and power as their physician colleagues. The backlash to the position statement was fierce and immediate, but they didn’t care. They then spent the 61 years advocating fiercely that a BSN should be the minimum point of entry to this profession. This policy never changed, despite the well-documented harm this has caused to the profession and BIPOC nurses and patients. 

In addition to their class war in nursing education, the nursing elite have spent an equal amount of time, effort, and dollars fiercely lobbying against legislation that bedside nurses–and even nurse researchers–have for decades demanded to protect both nurse and patient safety. 

Take mandated staffing ratios, for example. For years, the ANA claimed they were never against nursing staffing ratios. Instead, they support nurses’ autonomy in controlling their own ratios. In 2022, faced with overwhelming opposition from grassroots nursing sentiment, led by nursing unions, they amended their position to say they totally support mandated nurse staffing ratios…as one tool in the toolkit. 

The truth is this: everyone in nursing knows the ANA has worked tirelessly against nurses by opposing ratios for decades. They, and their cherished bedfellows, the American Organization of Nurse Leaders (AONL), which, notably, is a subsidiary of the American Hospital Association, have colluded to lobby against this crucial rallying policy that both bedside nurses and the overwhelming evidence from the literature support.

The most recent example was in Massachusetts in 2018. Here, the ANA, led by its Massachusetts chapter, worked hand in hand with hospital lobbyists and hospital systems to pour $26 million into a campaign to fight Question 1. Corporate interest won, and Massachusetts nurses and patients lost.

This type of obvious double-dealing and transparent opposition to the needs of bedside nurses is why nurses overall have completely abandoned the ANA. According to Dr. Silver, the American Nurses Association has a membership rate of less than 4 percent nationally, with the state chapters not faring much better. 

The 130-year legacy of the American Nurses Association can be described as one long betrayal: of BIPOC nurses, of the working class, and the patients we serve. And it is this long con that has led to the battle lines we see drawn today between the working-class nurses on the front lines at the bedside and in the community, and the contemptuous nursing elite who both loathe their non-graduate nursing counterparts and desperately need them to achieve the political power they seek. 

Dr. Silver summarizes it plainly, “The ANA has been one of the biggest barriers to nursing power.”

Imagining A New World

The state of the crisis in nursing cannot be overstated, but the solutions are equally transparent. US nursing began its downfall when we yielded our power, expertise, and compassion to the unending and equally unearned confidence of the hordes of upper-class white women who told us we needed to be saved from ourselves. 

Reversing that mistake is how we take our power back. What nurses today need are leaders from our own ranks to step forward and lead us in the fight for our profession, our nation, and for the chance at having a future. 

This means new professional organizations, built by nurses, and for nurses, held accountable to us. It also means new ways of learning, and new ways of practice. 

I believe a new world is possible, and that nurses can build it. If only we step into and embody our power that so many have long-exploited for their own gain.