LR23 / Nurse unions and patient outcomes

Type of Patient Safety Practice
Clinical Risk Management Practice (CRMP)
Related practices from PaSQ database
“Best fit” category of the reported practice


Patient safety theme the SCP/clinical risk management practice is aimed at
The relationship between nurse unions and patient outcomes
Objective of the CRM practice
Examination of the relationship between the presence of a bargaining unit for registered nurses and the acute myocardial infarction mortality rate for acute care hospitals. The authors also discuss how registered nurse wage, hospital bed size, volume of patients, and other organizational factors may influence and confound this relationship [p.143, 1].
Short description of the CRM practice, including any references for further information
In one study, that tried to determine if there is a relationship between acute myocardial infarction (AMI) mortality rate, adjusted for patient age, gender, type of AMI, and chronic illnesses, for acute care hospitals, and the presence or absence of a bargaining unit for registered nurses, because hospital mortality can be a function of many factors other than whether hospital nurses are unionized, were estimated 4 regression models to control for these other characteristics. All the models include the RN union variable as a predictor because it is the variable of interest [p. 146-147, 1].
Innovator of the SCP, country of origin
California. USA [p.144, 1]
Involved health care staff
Nurse unions [p.144,1]
Tested in which countries/health care systems, health care context(s) and/or clinical specialty/specialties, including references
All acute care hospitals in California [p.145, 1]
Summary of evidence for effectiveness, including references
The significant finding in a study is that hospitals with RN unions have 5.7% lower mortality rates for AMI after accounting for patient age, gender, type of MI, chronic diseases, and several organizational characteristics. [p.149, 1] Although didn’t identify a causal relationship, the approach in this study demonstrates that there is a positive relationship between patient outcomes and RN unions. Further exploration of the relationship between unions and patient outcomes must be done [p.150, 1]. Other studies emphasize that unions may affect the quality of care, although the mechanism may be difficult to ascertain. Unions may improve the quality of care by negotiating increased staffing levels that, according to Kovner and Gergen, [2] improve patient outcomes. Alternatively, unions may affect the organization of nursing staff or the way nursing care is delivered in a fashion that facilitates RN-MD communication. This is the “voice” function of unions described by Freeman and Medoff. [3] Yet another possible mechanism by which unions can improve care is by raising wages, thereby decreasing turnover [4, 5], which may improve patient care. There is the argument that union activity spurred by employee discontent will affect patient outcomes [8, 9, 10, 11]
Summary of evidence for transferability (transferability across health care systems or health care contexts or clinical specialties), including references
Findings from a study do not rule out the potential nonrandom selection bias regarding the presence of unions; therefore, it cannot determine causation. The direction of bias might go in either direction. [p. 149, 1]
Summary of available information on feasibility, including references
In one studiy issue of causation was a limitation [p.147, 1]. There are several confounding factors to consider when try to determine if RN union status is a predictor of patient outcomes. Some argue that wage is the important factor in attracting and retaining high quality nurses and that a union’s only function is to win higher wages. Thus, the wage, not the union, is the causative factor and the union is only the instrumental factor[5, 6, 7]
Existing implementation tools, including references
Regression models [p.146,1]
Potential for/description of patient involvement in the CRM practice, including references
Not specified
Bibliography (for each reference: author(s), year, title, journal/internet link, page(s))
[1.] Seago, J A, Ash M (2002), Registered Nurse Unions and Patient Outcomes, JONA, Volume 32, Number 3, pp 143-151 [2]. Kovner C, Gergen PJ. Nurse staffing levels and adverse events following surgery in U.S. hospitals. Image J Nurs Sch.1998;30:315-321.[3.] Freeman R, Medoff J. What Do Unions Do? New York, NY: BasicBooks; 1984. [4.] Aiken LH. The hospital nursing shortage. A paradox of increasing supply and increasing vacancy rates. West J Med.1989;151:87-92. [5.] Spetz J. Nursing wage premiums in large hospitals: what explains the size-wage effect?. AHSR FHSR Annu Meet AbstrBook. 1996;13:100-101. [6.] Hirsch BT, Schumacher EJ. Monopsony power and relative wages in the labor market for nurses. J Health Econ.1995;14:443-476. [7.] Hirsch BT, Schumacher EJ. Union wages, rents, and skills in health care labor markets. J Labor Res. 1998;19:125-147. [8.] American Organization of Nurse Executives (AONE). When work redesign prompts unionization activity. Nurs Mgn.1994;24:36,38 [9.] Sherer JL. Union uprising. California nurses react aggressively to work redesign. Hosp Health Netw.1994;68(24):36,38. [10.] Aiken LH, Smith HL, Lake ET. Lower Medicare mortality among a set of hospitals known for good nursing care. MedCare. 1994;32:771-87. [11.] Wilson CN, Hamilton CL, Murphy E. Union dynamics in nursing. JONA. 1990;20:35-39.
Dr Lavinia Panait, National School of Public Health and Management, Romania
National School of Public Health and Management, Romania
Any additional information on the CRM (e.g. implementation barriers and drivers)