lllllllllllllllllllillllllllllllll lllllilllliilllllllll . 1 ”MARY 1293 10552 7737 Michigan State ‘ University \.'77 # wvw-wv This is to certify that the thesis entitled "Collective Bargaining in the Michigan Nursing Profession" presented by Lawrence Kirk Handren has been accepted towards fulfillment of the requirements for _MasieLs__ degree in EMIUdUStY‘i 6] Relations &J#/i/W Major professor Date March 5: 1984 0-7639 MS U is an Affirmative Action/Equal Opportunity Institution MSU LIBRARIES .—:—. RETURNING MATERIALS: Place in book drop to remove this checkout from your record. FINES will be charged if book is returned after the date stamped below. gall-3‘85 '7 - Li ' COLLECTIVE BARGAINING IN THE MICHIGAN NURSING PROFESSION By Lawrence Kirk Handren A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF LABOR AND INDUSTRIAL RELATIONS School of Labor and Industrial Relations 1983 ABSTRACT COLLECTIVE BARGAINING IN THE MICHIGAN NURSING PROFESSION By L. Kirk Handren The nursing profession has begun to accept unionism as a legiti- mate mechanisim in advancing its constituents' professional and eco- nomic interests in negotiating with hospital employers. To evaluate the impact of unionism in the profession, information on nursing wage levels, educational backgrounds and collective bargaining practices was solicited from Michigan hospitals. The intent of the research was to identify some of the reasons for the profession's increasing accep- tance of collective bargaining in the hospital sector, and examine the effects collective bargaining has had on the hospital-nurse employment relationship. Data collected in the survey indicated that while has grown in in acceptance at all levels of the hospital nursing hierarchy, it has been most successful in the lower skill levels. Its success at these levels has been such that it may be in danger of extinguishing itself by increasing the cost of unionized labor to a point where it is no longer feasible for hospitals to employ significant numbers of unionized nonprofessional or lower skill nursing personnel. TABLE OF CONTENTS Chapter I. II. III. IV. VI. INTRODUCTION Definitions LITERATURE REVIEW METHODOLOGY MSU Survey Design . . Methodological Implications MSU SURVEY FINDINGS Nursing Personnel Belonging to Religious Orders Education Salaries . The Union Impact on Salaries Shift Differentials Educational Incentives Fringe Benefits Conclusions NURSING UNION ACTIVITY IN MICHIGAN HOSPITALS Introduction . Organizational Patterns Unsuccessful Organizing Attempts Work Stoppages . . . . . . Agreement Durations Years of Union Representation . Professional Associations and Unions Conclusions COLLECTIVE BARGAINING STRUCTURES Multiemployer Bargaining Pattern Bargaining Conclusions . ii .102 .107 .112 .118 12 15 37 37 46 60 60 62 67 85 .124 .124 .124 .136 .139 .143 .144 .146 .164 .167 .167 .170 .173 VII. LEGAL ASPECTS OF HOSPITAL-NURSE COLLECTIVE BARGAINING . . . . . . . . . . . . . . . . . . . . 174 Hospital Labor Relations Legislation . . . . . . . 174 Legislative Impacts on Michigan Hospitals . . . . 190 Appropriate Bargaining Units . . . . . . . 19o Supervisory Personnel in Bargaining Units . . . . 201 VIII. BARRIERS TO COLLECTIVE BARGAINING . . . . . . . . 210 1K. CONCLUSIONS . . . . . . . . . . . . . . . . . . . 219 APPENDIX A. Nursing Data Sheet - School of Labor and In- dustrial Relations, M. S. U. . . 211 B. Edited Senate Dtbate Regarding the 1947 Labor Management Relations Act, Section 2(2) Ex~ clusion of the Nonprofit Hospitals . . . . . . 232 C. Hourly Salary Comparison of Unionized and Nonunion Full-Time RNs, LPNs, and Aides Em- ployed in MSU Survey Respondents, 1979 . . . . 234 H. Hourly Salary Comparison of Unionized and Nonunion Full-Time RNs Employed in MSU Survey Respondents by Hospital Bed Size, 1979 . 235 E. Hourly Salary Comparison of Unionized and Nonunion Full-Time LPNs Employed in MSU Survey Respondents by Hospital Bed Size, 1979 . 237 F. Hourly Salary Comparison of Unionized and Nonunion Full-Time Aides Employed in MSU Survey Respondents by Hospital Bed Size, 1979 . 239 C. Hourly Earnings of Full-Time Nursing Personnel in MSU Survey Respondents by Type of Bargaining Representative and Nursing Position . . . . . 241 H. Number of Respondents Providing Shift Dif- ferential Information, by Category and Type of Information Provided (supplements Table 21). 242 1. RN Shift differentials Reported in Cents Per Hour, by Union Status and Hospital Bed Size . . 243 J. Educational Incentives and Reimbursement Programs Reported by MSU Survey Respondentd . . 244 K. FTE Nursing Positions by City Size; FTE « Nursing Positions by Hospital Bed Size; FTE Nursing Positions by Type of Hospital Control . 245 L. Unsuccessful/Incomplete Formal Organizing Ef- forts Reported by Hospitals Responding to the MSU Nursing Survey (since 1970) . . . . . . . . 246 M. Work Stoppage Summary . . . . . . 248 N. Labor I.aw Status of Michigan Hospitals . . . . 249 BIBLIOGRAPHY . . . . . . . . . . . . . . . . . . . 351 iii OO\! 10. 11. 12. 14. 15. 16. 17. 18. 19. 20. 21. LIST OF TABLES Questionnaire Composition According to City Size, Bed Size and Type of Hospital Control . Response Rate According to City Size, Bed Size and. Type of Hospital (‘ontrol. . Characteristics of Hospitals Reporting Members .of Religious Orders on their Nursing Staffs . Distribution of Active RNs in Michigan (1977) Ac- cording to Initial Nursing Education and Year of graduation. Percent Distribution of Active RNs by Educationai Preparation, According to Age, Michigan, 1977 Regionzil Mean Hourly Nursing Salaries, United States, 1980.. . . . Mean Average Hourly Wages, Michigan Hospitals, 1979 Mean Hourly Nursing Wage Levels, Michigan Hospitals, Fall, 1979. . Percent Distribution of Active RNs in Michigan by Age in Selected Employment Settings, 1977 Hourly Salary Levels of Full-Time Nursing Personnel in Michigan Hospitals by Hospital Bed Size, 1979. Mean Hourly Sal:1ry Level Differentials by Hospital Size and Nursing Position . . . . . . National Mean Hourly Nursing Sala1ic by Hospital Control, 1979- 1980. . . . . . . Mean Hourly Michigan ”N Salaries b) Type of Hos— pital Control and Bed Size, 1979. National Union/Nonunion Full- Time l'ourly Nursing Salaries, 1979. . . Hourly Salary Levels of Unionized and Nonunion lull- Time RNs, LPNs and Aides Employed in Michig.1u Hospitals, 1979 . Union/Nonunion Hourly RN Salaries in Michigan Hos- pitals, By Hospital Bed Size, 1979. . Union/Nonunion Hourly LPN Salaries in Michigan Hos - pitals, by Hospital Bed Size, 1979. . Union/:{onunion Hourly Aide Salaries in Michigan Hos- pitals, by Hospital Bed Size, 1979. . MSU Survey Mean Full- Time Nursing Salaries by Bar- gaining Agent Type and Nursing Position, 1979 RN and LPN Professional/Non-professional Bargaining Representative Status, by Hospital Size, 1979 RN Shift Differentials According toUnion St11tus and Hospital Size, 1979 . . . . . . iv .41 .44 .60 .64 .66 .69 .70 .79 .80 .81 .83 .85 .911 .95 .96 .97 101 102 103 22. 23. 24. 25. 27. 28. 29. 30. 31. 32. 33. 34. 3S. Hospitals Offering Starting Salary Incentives to RNs with Baccalaureate Degrees over Hospital Diplomas. . Hospitals Offering Starting Salary Incentives to RNs with Associate Degrees Rather Than Hospital Diplomas. Hospitals Offering Financial Incentives to Their RNs to Increase their Education, by Hospital Size and Union Status. Part- Time Nursing Personnel Fringe Benefit Packages by Hospital Bed Size, 1979. Full and Part- Time Hospital Nursing Personnel Fringe Benefit Package Selection Policies by Union Status, 1979. . Union Representation in MSU Survey Respondents by Nursing Category. . Union Representation of FTE Positions by Nursing Category, 1979. . Union Status of MSU Survey Resppndents' RNs, LPNs, and Aides by location (City Size) . . . . . . . Union Status of MSU Survey Respondents' RNs, LPNs, and Aides by Hospital Bed Size. . . . . . . . . Union Status of MSU Survey Respondents' RNs, LPNs, and Aides according to Hospital Control Type. Unsuccessful Union Organizing Drives by Year and Hospital Type . . Yearly Nursing Work Stoppages Reported by MSU Survey Respondents . Nursing Work Stoppages (in Days) According to Hos-. pital Control, 1979 . . . . . Collective Bargaining Agent Tenures by. Hospital Con- trol Type, 1979 . IISU Survey Respondent RN/LPN Wage Levels by 'l‘ype 01: Bargaining Representative, 1979 . . . Years of Union Representation According to Nu1sing Position and Hospital Control Type,1979 Nursing Bargaining Unit Case Determinations . Hospitals with Supervisor Organizations, by City Size, Bed Size and Control Type . . . . . 108 198 110 114 115 125 126 130 102 193 206 208 AMCBWNA AFGE AFSCME AFT AFL-CIO ANA BLS CNA CWA DHEW FMCS FNHP FTE GDAHC HMO HELP HREBIU IAM IUOE LIUNA LMA MCHIS MERC MLPNA MNA NFLPN NLRA NLRB NWLB OPBIU PA PERA RIFT SEIU TEAMSTERS UPIU USWA LIST OF ABBREVIATIONS Amalgamated Meat Cutters and Butchers of North America American Federation of Government Employees American Federation of State, County and Municipal Employees American Federation of Teachers American Federation of Labor-Congress of Industrial Organizations American Nurses' Association Bureau of Labor Statistics California Nurses' Association Communication Workers of America Department of Health, Education and Welfare Federal Mediation and Conciliation Service Federation of Nurses and Health Professionals (AFT) Full-time equivalent positions Greater Detroit Area Hospital Council Health maintenance organization Health Employee Labor Program (SEIU-TEAMSTERS) Hotel, Restaurant Employees and Bartenders Union International Association of Machinists and Aerospace Workers International Union of Operating Engineers Laborers' International Union of North America Labor Mediation Act (Michigan) Michigan Cooperative Health Information Service Michigan Employment Relations Commission Michigan Licensed Practical Nurses' Association Michigan Nurses' Association National Federation of Licensed Practical Nurses National Labor Relations Act National Labor Relations Board National War Labor Board Office and Professional Employees International Union Public Act(s) Public Employment Relations Act Rhode Island State Federation of Teachers Service Employees International Union International Brotherhood of Teamsters, Chauffers, Warehousemen and Helpers of America United Paperworkers International Union United Steelworkers of America vi INTRODUCTION Hospital wages and other employee benefits are rap- idly rising to industrial levels, bargaining rights are being extended, and unionism is spreading. Many of these developments are long overdue. But there is no accom- panying rise in labor productivity to help pay for the rising labor costs. Nor has an effective alternative to the strike, as a method of settling contract disputes, been achieved. A crises -— not only of money but of lives -— is in the making. 1 Anne Sommers Anne Sommers' synopsis of the labor scene in hospital settings is eleven years old. In an area of labor relations that has undergone tremendous transitions in the last quarter century, detailed descriptions or accurate summations of prevailing conditions in the labor-management forum have frequently bordered upon obsolescence within months of their release or publication. Sommers' brief but to-the-point analysis is an exception to this rule. The message it conveyed has withstood the test of time, and is as true today as it was over a decade ago.2 Organizaed labor is expanding its scope and reaching out to industries tradition- ally specialized in their functions and activities, such as the hospital industry. At no other time in American history has the hospital more fully felt the impact of the union 1Anne Sommers, Hospital Regulation: The Dilemma of Public Polic (Princeton, N.J.: Industrial ReIations Section of r1nceton University, 1969), p. 228. 21bid. 2 movement than in the past several years.3 A November, 1974 article in Supervisor Nurse stated that "Unionization -- or the threat of it -- is gradually forcing hospital management to change either its philosophy of the purchasing and handling of labor, or its attitude toward collective bargaining and organized labor."4 Unlike the long history of labor-management relations in industrial settings, collective bargaining is a relatively contemporary development in American hospitals. The number of hospital workers represented by labor organiza- tions in the late 19605 was approximately 9 percent. By mid 1977, the proportion of hospital employees under union con- tracts generally exceeded 20 percent.5 Since 1929, the health care industry has consumed an in— creasing share of the gross national product, accounting for over $162 billion in expenditures in 1977 (8.8 percent of the gross national product for that year), and is predicted to reach a spending level of $280 billion by 1982.6 Per capita spending in the industry has more than quintupled since 1960, from approximately $142 to over $737.7 These figures demon- strate the important social, political and economic impact 3Susan Levine, "Unionization in Hospitals," Supervisor Nurse 5 (November 1974): 61. 41bid. SRichard U. Miller, "Hospitals," in Collective Bargaining: Contemporary American Experience, ed. Gerald G. Sommers (Madison, WI: Industrial Relations Research Association, 1980), p. 373. 61bid. 71bid., p. 374. 3 of the industry, and underscore the importance of understanding the complexities of the labor-management issues which have emerged as collective bargaining has become more established in the industry. Clearly, collective bargaining has an important role in the health care industry and nursing profession for a number of reasons. First, since labor costs constitute upwards of sixty percent of the total cost in the health care industry, negotiated settlements often have, or are portrayed to have unsettling effects on cost containment efforts.8 Secondly, the need for the continuous delivery of health care services in hospitals places a premium on the maintenance of the labor- management relationship and the ability of the relevant vehicles for conflict resolution to function successfully. Third, considering the industry's status as a service industry blending mixtures of public and private ownership of resources, no single existing industrial relations model is totally adequate for either describing health care collective bar- gaining or for formulating and evaluating policies to deal with its problems. Finally, when it comes down to confronting employers with legitimate demands in the one way that simply cannot be ignored -- by striking -- many nurses have had to face the cognitively dissonant dilemma of sacrificing their desires for improved employment conditions in the name of "professional dignity." In this respect, the relatively recent advent of unionism in the nursing profession is an 8Ibid., p. 375. 4 appropriate indication of the choice nurses have traditionally adopted (i.e. "professional dignity" has increasingly been out- weighed by desires for better employment conditions). However, other factors besides the "professional dignity" or "status" arguments exist to help explain the slow development of unionism in the health care field. Organized labor has been preoccupied with more lucrative fields (eg. automotive, transportation, steel, mining, etc.), and top labor officials have shown disinterest in the hospital industry. Unions have historically been discouraged from concentrating on hospitals because of their size and location.9 The lack of legislation facilitation unionization in hospitals in most states has been another obstacle to the spread of hospital unionization. The Taft-Hartley Act of 1947 excluded nonprofit hospitals from its provisions which protected or encouraged collective bargaining. However,.this exception was removed in August of 1974. The nature of the hospital work force itself is quite important. Hospital nursing staffs have been characterized by high turnover rates, at least partially attributable to the fact that (historically) the vast majority of nurses are female, and working temporarily or in careers 9Many small hospitals are located in small, non-union communities, and two-thirds of all short term hospitals average 200 or fewer beds. Levine, "Unionization in Hospitals," p. 66. At the time of the MSU Nursing Survey, 63 percent of the hos- pital facilities were under 200 beds, and 43.6 percent of the facilities were located in cities of less than 10,000 in population. "Michigan State University School of Labor and Industrial Relainns Nursing Survey," East Lansing, MI.: 1980. (Report prepared fOr hospital administrators containing a sum- mary of the data obtained through the survey), Table 2. 5 characterized by relatively short terms of continuous duration.10 The reluctance of unions to organize industries with large numbers of minority group workers has also impeded widespread unionization.11 The nurses' professional associations have also been involved in stifling the growth of unionism among nurses. As early as 1937, the American Nurses' Association (ANA) was recommending against nurses becoming members of unions, main- taining that "in their professional associations, nurses have the instruments best fitted and equipped to improve every phase of their working and professional lives."12 Finally, one of 10According to a 1979 National League for Nursing study on nurses from baccalaureate nursing programs, only 46.7 percent of the graduates were working as full-time nurses five years after their graduation, and 36. 6 percent of the graduates re- ported working as full- time nurses ten years after their grad- uation. "Nurse Career- Patterns Study," Hospital Topics 57 (May/ June 1979); pp. 5-9. 11David R. Matlack, "Goals and Trends in the Unionization of Health Professionals," Hos ital Pro ress 53 (February 1972), p. 40; and Leo B. Osterhaus, I:THe Effect of Unions on Hospital Management: Part II: Factors Stimulating and Inhibiting Unions," Hospital Progress 48 (July 1967), pp. 78-79. 12It should be noted that while the cited example of the ANA as being officially on record at one time as discouraging union membership, the example occurred in 1937, with the organization "apparently fearful of inroads by the burgeoning unions. The ANA was not blind to the deterioration of nursing conditions, nor were they advocating total subordination to employers inso- far as the terms and conditions of employment were concerned. Shortly afterward (in 1938), the ANA urged the State nurses' associations to "assume the responsibility in their communities for standards of care and emgiloyment conditions. " Although the state associations enjoyed " ittle success” in following through on these policies, the seeds were planted for the ANA economic security program, whose objectives were "to secure for nurses . . . protection and improvement of their economic security; reasonable and satisfactory conditions of employment and . . . to assure . . . nursing service of high quality.‘ Thus, while the ANA was discouraging unionization, it was also becoming in- volved in attempts to negotiate terms and conditions of employ- ment with nursing employers. Daniel H. Kruger, "Bargaining and the Nursing Profession," Monthly Labor Review 84 (July 1961), 699- 701. the major obstacles in the path of nurSing and/or hospital unionism has been the resistance of hospital administrators and directors, and the other "professionals" working with nurses. From 1947 to 1974, nonprofit hospitals operated outside the coverage of the National Labor Relations Act (NLRA). Their exemption from the Act fostered a "no holds barred" approach to collective bargaining that encouraged conflict between hospitals and their employees. In the absence of a legal framework governing the bargaining environment, several negative conditions influencing the employer-employee relation- ship flourished; employer paternalism at best, blatently un- fair labor practices in the opposite extreme. Up to this point, the evolution of unionism in hospitals and in the nursing profession has been treated on a more or less interchangeable basis. In actuality, they are separate events, but by no means are they mutually exclusive. The pri- mary reason for examining the two subjects in the same vein is simple; they are both integral constituents of the health care industry, and they maintain a type of symbiotic employer- employee relationship in which hospitals would be hard-pressed to function without nurses, and nurses would be equally hard- pressed to obtain employment without hospitals. In August, 1976, the Michigan Cooperative Health Infor- mation System (MCHIS) reported that 70.4 percent of the active 13 registered nurses (RNs) and 71.5 percent of the active 13Licensed Health Occupations, Michigan, Nurses, 1975, (Lansing, MI:_MicHiganC60perative Health Information System, Michigan Department of Public Health, 1976), p. 17. licensed practical nurses in the state were employed in hospitals.14 In December, 1978, the MCHIS reported that 70.0 percent of the active RNs in Michigan were employed in hos- pitals.15 The U.S. Department of Health, Education and Wel- fare (DHEW) has estimated that as of June 1, 1974, 74.6 percent of the RNS in the United States were employed in hospitals and nursing homes, while roughly half of the LPNs were hospital-employed.16 A 1979 National League for Nursing Re- port on the career patterns of nurses graduating from baccalaureate nursing programs found sixty-six percent of the 17 Each of these graduates entering hospital employment. reports indicated that nursing homes were the second largest or most common primary employment setting for nursing personnel. One common trend surfaces in all of these reports -- hospitals are the largest employers of nursing personnel in the health care field, frequently employing as many as nine times the numbers of nurses accounted for in the second most common employment categories. This is particularly true among the more skilled positions in the nurSing hierarchy. Public health agencies, nursing homes, homes for the aged and convalescent centers frequently have staffing mixtures that rely heavily 14Ibid., p. 33. 15Licensed Health Occupations, Michigan, Registered Nurses, 1977, (Lansing, MI: Michigan cooperative Heaifh Information System, Michigan Department of Public Health, 1978), p. 13. 16U.S. Department of Health, Education and Welfare, Health Resource Statistics, 1976-1977. 17 "Nurse Career-Patterns Study," p. 6. 8 upon LPNs, aides and orderlies employed under the direction of RNs employed in supervisory roles. Other fields of employment include schools, occupational and industrial health settings, doctor's offices and private duty settings. Primarily due to the relative case of obtaining data on a large number of subjects through the use of a questionnaire mailed to nursing employers throughout the state, hospital- employed nurses are the primary focus of this study. Reinforc- ing the decision to concentrate on hospital-employed nurses .is the fact that they are the largest individual primary em- leoyment setting classification. The Michigan State University School of Labor and Indus- trrial Relations Nursing Survey (MSU Survey) was conducted tlirough the use of a one-page questionnaire which is included ir1 the Appendix. The length of the questionnaire was delib- Exrately limited to a two-sided one-page form, since it was ftalt that a long and complex questionnaire would substantially ianair the return rate. The questionnaire was designed to so- ];icit information on prevailing conditions in the Michigan hos- Ilital-nurse employment setting, and was mailed to administra- ‘tors and directors in every Michigan hospital.18 K 18The original mailing list used in the MSU Survey was taken from the 1978 American Hoppital Association Guide to the Egglth Care Field(Chicago: AHA, 1978), pp. A110-A118. The MSU Survey questionnaire is largely patterned around the One-page questionnaire used by Karen Sue Hawley in her 1967 Economics of Collective Bargainipg_py Nurses. Hawley's ques- tionnaire and accompanying material was primarily concerned With nursing salary and educational levels, and hospital char- aCteristics. Absent from Hawley's questionnaire was any ma- terial soliciting information on benefit levels, collective bar- gaining and work stoppages. The MSU Survey questionnaire re- presents a synthesis of Hawley's solicitation format and addi- tional inquiries intended to provide data on areas not examined by Hawley. The intent of the MSU Survey and the accompanying research contained in this study is to identify and examine some of the reasons for the increased interest by nursing profession in organized labor (and vice versa), and arriVe at some answers to the questions of whether union representation has proved to be quantitatively advantageous for hospital-employed nursing personnel. This study empirically examines the labor- management relationship in the Michigan nursing profession, and.is not intended to provide a statistically definitive con- :firmmtion or contradiction to the several relevant hypotheses tliat are examined throughout the text. While the key issue cxf this study revolves around whether union representation has prroved to be quantitatively advantageous for hospital-employed tnarsing personnel, several ancillary issues and/or questions are open to examination. Although published reports and data obtained through re- \Fiewing the pertinent literature provide a valuable supplement t<> the MSU Survey, much of the ensuing analysis is based on illformation recorded in the returned MSU Survey questionnaires. 1118 primary issue addressed in the questionnaire is that of “fliether nurses represented by unions in collective bargaining agreements for their (hospital) employers are in a quantita- tively superior position relative to their nonunion counter- parts in terms of salary, shift differentials and benefit packages. Information obtained through the questionnaires also indicates the areas in which union organizing efforts have 10 been most (and least successful). This applies to the location of the hospitals, their size and types of control. In the same token, the questionnaires indicate which divisions of nursing personnel (head nurses, RNs, LPNs or aides) have been most receptive to unionization. In terms of the wage and benefit packages being offered to nursing personnel by hospitals, the hourly salaries, educational assistance programs, hiring bonuses, shift «iifferentials and full- versus part-time fringe benefit cxfferings are examined. Nursing staff aggregate educational backgrounds are sur- vxeyed, leading to possible generalizations regarding the tumionization preferences of nurses from differing educational backgrounds . Finally, information obtained through the returned ques- txionnaires revels which labor organizations have been most atztive in organizing and representing nursing personnel in Btichigan hospitals, and information on the nature of the var- iJDUS hospital and nursing staff collective bargaining agree- Inents, including the duration of the agreements, the expiration dates, etc. It should be noted that much (if not all) of the data Contained in this document has been addressed by independent research efforts of labor organizations, hospital associations and their constituents, and professional associations repre- senting employees' interests in the industry. The American Hespital Association publishes a yearly guide containing 11 information on hospital characteristics, inpatient and personnel data. The Michigan Hospital Association collects salary data from its members and maintains a comprehensive annual summary of state industry wage levels. Other hospital groups cooperate in the exchange of information regarding union organizing efforts and trends. Professional nursing associations collect data on nursing wage and educational levels. Labor unions may also collect and analyze extensive economic data. However, substantial problems arise in .accessing and collecting data from these sources, and pre- snenting it in a meaningful format. There has not been a ssignificant willingness on the part of many of these organi- zzitions to disseminate the data they collect (beyond their cnvn membership or constituency), leaving a void in the current Cc>llection of labor relations data. Facilities and organizations in the health care industry llave demonstrated a great deal of concern regarding the con- fiidentiality of constituent bodies. The possibility that in- fk)rmation collected by members of the industry may fall into LHIintended hands and be used in ways viewed as detrimental to industry participants frequently limits the access to existing data. For these reasons, the collection of wage and benefit data and information regarding past, present or anticipated unionization efforts aimed at hOSpitals can be a sensitive and arduous task. However, the void in the existing and accessible body of literature regarding the collective bargaining relationship between hospitals and nurses would 12 seem to justify the effort to draw together data from the various participants in the hospital-employee relationship, and present it in such a manner that it becomes a positive addition to the existing body of relevant literature. Definitions The terms that are used and abbreviated extensively throughout this study are defined in the following alphabeti- cal list. lAides: See "Nurse Aides and Assistants.” Ccyllective Bargaining: Negotiations between a labor union or organization and an employer for a written labor contract covering the terms and conditions of employment. Frederally Controlled Hospitals: Hospitals administered, staffed and directed by a department or agency of the Federal government. In Michigan, the hospitals falling into this category that are included in the analysis are administered by the Veterans Administration and the Department of Justice. l:‘ringe Benefits: The term applied to benefits in addition to the direct wages paid to employees. It includes such items as sick pay, insurance benefits, pension benefits, shift differentials, educational assistance, and other similar benefits. c3¢3neral Duty Registered Nurses (RNS): Nurses who have gradu- ated from a formal program of nursing education (hospital- affiliated diploma schools, associate, or baccalaureate programs) and have been licensed by the appropriate State authority. RNs are the most highly educated nurses with the widest scope of responsibilities, potentially including all aspects of nursing care. In Michigan, RNs must meet the educational requirements, pass a nationally standard- ized written examination, and be licensed by the State Board of Nursing. The Board may grant a license to a nurse duly licensed as a RN in another state, territory or country, if the applicant's qualifications are deemed equivalent to those required in Michigan. 13 Head Nurses: Nurses (generally RNs) who are responsible for the nursing service and patient care on one organized nursing unit. While "head nurses" may be active at several levels in the hospital organization chart, for the purposes of this study, the term refers only to those nurses with immediate supervisory responsibilities over general duty nurses. They may or may not perform general duty tasks in addition to their first-line supervisory roles. Hospitals: Institutions whose primary function is to provide inpatient services, diagnostic and therapeutic, for a variety of medical conditions, both surgical and non- surgical. They may be classified by length of stay (short-term or long-term), as teaching or nonteaching, by major type of service (psychiatric, rehabilitation, general, etc.), and by control (government, federal, state or local, non-profit, propritary). No distinction is made in the study between allopathic and osteopathic hospitals. Hospitals under the direct control of the U.S. Air Force, or other military services were not included in the analysis. Ldibor Unions and/or Organizations: Organizations representing employees for the purposes of dealing with the employers concerning labor disputes, wages, hours of employment, grievances or other conditions of employment. Ilicensed Practical Nurses (LPNs): Nurses who have practical experience in the provision of nursing care, but are not graduates of a formal program of nursing education. Their work is performed under the supervision of either a RN or a physician. To practice in Michigan, LPNs must be li- censed by the State Board of Nursing. For a license to be granted, the Board requires a high school diploma or its equivalent, the completion of a practical education program (usually 12 months in duration), and the passage of a written exam. ILocally Controlled Hospitals: Hospitals administered and directed by a county, city, or dully controlled by a city and county, or.a hospital district or authority. LPN: see "Licensed Practical Nurses." Non-profit Hospitals: Hospitals administered by any corporation or association in which no part of the net earnings inures to the benefit of any private shareholder or individual. 14 Nurse Aides and Assistants (aides): Auxiliary nursing workers who function as assistants to RNS and LPNs in providing less skilled nursing services and patient care assign- ments. Traditionally, "nurse aides" have bign women, and "orderlies" and "attendants" have been men. For the purposes of this study, "aides" is a generic term that refers to nurse aides, orderlies, and attendants. Nursing Personnel: The blanket phrase refering to RNs, LPNs, and aides, unless otherwise noted. Proprietary (profit-making) Hospitals: Hospitals administered by a corporation or association in which any portion of the net earnings of the institution inures to the benefit of any private shareholder or individual. Religious Hospitals: Hospitals administered and directed under the authority of religious orders or denominations. In Michigan, all of these institutions are administered or controlled on a religious/non-profit basis. Rst see "General Duty Registered Nurses." State Hospitals: Hospitals administered and directed by the Michigan Department of Mental Health. Supervisors: see "Head Nurses" unless otherwise noted. 19U.S. Department of Health, Education and Welfare, Health Resource Statistics, p. 167. CHAPTER II. LITERATURE REVIEW Perhaps the most obvious difficulty or void in the exist- ing body of literature dealing with labor relations in the health care industry is the lack of material comprehensive enough in design that the multifaceted nature of collective bargaining in the industry is fully addressed. While the literature addressing distinct aspects of collective bargain- ing in the hospital sector is voluminous, few efforts at synthesizing the material have been made. This examination of current labor relations in the hospital sector attempts to address the area in a more comprehensive nature than hereto- fore has generally been the case. An effort is made to pro- vide conclusions that may be combined to overcome the generally fractionalized nature of the existing literature. Correlations between salaries and hospital bed sizes, types of control and union status have been addressed by other researchers, but attempts to synthesize this material have been limited. Changing trends in nursing educational backgrounds have been addressed previously, but accessible summaries of these (as well as other trends) have been limited. Besides the material on educational and salary histories, the impact of unionism on nursing wage levels is addressed in a more direct way than has previously existed. Several other wage related issues are addressed, including, the failure of hospital wages to exhibit major (real) increases since the 19605, the differing success labor organizations have had in organizing various skill levels in the nursing hierarchy, and 15 16 the wage levels in hospitals operated under differing control types. The primary thrust of the research contained in this document is aimed at answering the question of whether the advent and growth of unionism in the hospital sector has proved to be quantitatively advantageous for members of the nursing profession. Similar to many questions in the disciplines of economics and collective bargaining, the answers to queries involving alterations in nurses' economic status due to collective bar- gaining activity are neither absolute nor definitive in that they can only be interpreted from a singular point of view. Specific information concerning the economic status of nurses engaged in hospital-based employment is examined at length in the literature as well as the MSU Survey in order to lend support to some theoretical assumptions concerning nursing and collective bargaining, while disproving or casting other assumptions in a more suspicious light. Several collective bargaining trends in the profession are reviewed based on the existing literature and MSU Survey data. Changes in the lengths of collective bargaining agree- ments between hospitals and nursing personnel are examined, with the results tending to confirm the general trend toward longer agreements. The immediate and direct impacts of Public Law 93-360 upon union organizing in Michigan hospitals, as well as work stoppage activity and the relative performance of unions and professional associations are examined. 17 Perhaps the most significant contribution of the MSU Survey to the body of literature addressing collective bargaining and labor relations is that it provides an easily accessible and comprehensive body of data depicting actual field conditions, presented against a background of relevant contemporary litera— ture. When viewed in concert with the supporting material, the MSU Survey results confirm some commonly adhered to assumptions regarding labor relations activity in the nursing profession, and provide new conclusions with far-reaching implications regarding the future of unionism in the (hospital) industry. Because of the carefully documented results of the MSU Survey, and the ease of accessing the results for future researchers (as opposed to restricting access to the data), the greatest value of the material may lie in its potential use as a cornerstone against which future collective bargaining conditions in the profession may be measured or evaluated. In developing the MSU Survey's methodological critique, four major sources were drawn upon. Three of the four sources concentrate on the appropriate formulation of evaluation designs and their application in contemporary programs and economic settings. The other source, by Stephen Issac and William Michael, is a leading technical handbook on statistical techniques, data analysis and measurement, and research methods.20 20Stephen Issac and William B. Michael, Handbook in Research Evaluation, (San Diego: Edits Publishers, 1971). 18 Carol Weiss' publications on evaluation methodology address themselves to utilizing the results of evaluations, and the purposes for undertaking evaluative studies.21 The thrust of Weiss' material is directed at applying various evaluation techniques to social programs. Edward Suchman provides a set of guidelines and reference points to consider in developing an evaluation or survey program.22 Perhaps the closest study to the MSU Survey in terms of style and methodological approach is Karen S. Hawley's Economics of Collective Bapgaining by Nurses.23 Hawley used a questionnaire soliciting information on hospital character- istics, nursing salary and educational levels, for all hos- pitals in Iowa. While Hawley addressed collective bargaining by nurses in her text, the focus of her research on the hospital-nurse relationship was aimed at supply and demand questions in the nursing labor market, rather than the broader examination of the relationship from a collective bargaining viewpoint used in the MSU Survey. However, Hawley's basic premise of compiling data for use in an examination of the hospital-nurse employment relationship through a comprehensive state-wide hospital survey was a relatively direct methodo- logical or theoretical forerunner of the MSU Survey. Several 21Carol H. Weiss, Evaluating Action Programs, (Boston: Allyn and Bacon, Inc., 1972); Evaluation Researéh, (Englewood Cliffs, N.J.: Prentice-Hall, Inc., 1972). 22Edward Suchman, Evaluation Research: Principles and Practice in Public ServiCe and SOcial Action Programs, (New York: Russel Sage Foundation, 1967). 23Karen Sue Hawley, Economics of Collective Bargainipg by Nurses, (Ames, Iowa: Industrial Relations Center, Iowa State University, 1967). 19- other recent texts and journal articles provided general over- views of the development and structure of collective bargain- ing among hospital-employed nurses. Norman Metzger and Dennis Pointer authored one of the major texts addressing employee relations in the health care 24 Particularly notable in this publication are the industry. chapters on the development of collective employee activity in the industry, and the legal environment hospitals Operate in. Metzger and Pointer document the contemporary history of collective bargaining in the industry from shortly after 1900, tracing the involvement of the key professional and labor organizations in the growth of unionization in the hospital sector. Their review of hospital coverage under federal labor law (prior to P.L. 93-360) is relatively com- prehensive, while their discussion of state labor laws impacting the hospital-nurse employment relationship also provides a useful tool from which the wide range of pre-P.L. 93-360 legal environments may be examined. The research of Richard U. Miller is widely borrowed 25 Miller's work contained in Gerald upon in this thesis. Sommers' compilation of material on collective bargaining comprehensively addresses collective bargaining in hospitals, 24Norman Metzger and Dennis D. Pointer, Labor-Management Relations in the Health Services Industpy, (Washington, DC: The Science and’Healih PhbliCations, Inc., 1972). 25 Miller, "Hospitals,". 20 providing historical data, information on the organizations active in representing hospital employees, wage and benefit levels, and labor-management conflict in hospitals. Miller found labor market structures in the hospital industry fluid, unionization uneven and bargaining outcomes frequently un- certain, possibly due to collective bargaining's relatively recent arrival in the industry. Miller's research also in- dicated that while hospital unionization has significantly increased in the past two decades, the momentum of the initial growth has not maintained in the 19705, and the growth that has occured has been quite limited geographically. Other im- pacts of hospital bargaining found by Miller included increas- ing levels of conflict arising from the insertion of patient care demands into the bargaining dialogue, an increasing willingness to strike and continual potential for conflict due to hospital administrator's strong anti-union stances. Ronald L. Miller has examined the development and struc— ture of collective bargaining among RNs by reviewing the involvement of the ANA in collective bargaining between hospitals and RNs.26 Miller theorized that the militant activism of some of the ANA affiliates produced improvements in the employment conditions for RNs in general. Even though there have been widely-scattered improvements 26Ronald L. Miller, "Development and Structure of Col- lective Bargaining Among Registered Nurses," Personnel Journal 50 (February-March 1971), 134-140, 158, 218-225. 21 in employment conditions either directly or indirectly attrib- utable to collective bargaining among RNs, Miller concluded that (as of 1971) RNs -- particularly th05e in administrative, supervisory or educational positions -- still showed no strong tendencies to accept and support collective representation. Although his articles preceded Richard Miller's "Hospitals" by approximately nine years, both authors found that attempts to bring questions regarding professional practices into collective bargaining have been relatively unsuccessful. The evolving trends in hospital unionization and their future implications have been addressed in several recent journal articles. Susan Levine indicated that unionization is either directly or indirectly forcing hospital management reevaluate its philosophy of purchasing and handling labor, and its attitude toward collective bargaining.27 Levine cited research supporting the conclusion that unionization in the hospital sector (either real or threatened) has had several relatively specific impacts. Written personnel policies have been established or improved. Administrators have become more sophisticated in utilizing their personnel more effectively with a greater willingness to secure sound legal advice in the employee relations area, and less paternalistic in their dealings with employees. With the Levine, "Unionization in Hospitals," pp. 61-75. 22 possibility of unionism present, hospital management may find it more advantageous in the long run to manage their employees in such a way that union representation offers little appeal. Changing trends in union activity in the hospital sector have been addressed by Gail Bentivengna.28 Bentivengna found that while union activity among hospital employees has been concentrated in a few industrial states (particularly in the west coast, industrial northeast and Great Lakes region), in- creasing activity has also been noted in smaller hospitals in small towns lacking significant industrial bases. This trend has become increasingly evident in southeastern, western and southern states. Bentivengna cited the increasing impor- tance of "quality of life" issues among the largely profess- ional hospital work force. The integration of work with other activities was also addressed in view of the high percentage of women employees in the industry and their desire for flexible working hours and extended leaves of absence for education and a variety of other personal reasons. Jerome Koncel addressed the increasing demands of pro- fessional employees in hospitals -- improved economic standards and corresponding improvements in professional and patient care standards -- and the employees' increasing assertiveness in pursuing those demands as evidenced by the 28Gail Bentivengna, "Labor Relations: Union.Activit¥ Increases Among Profess1onals," Hospitals 53 (April 1, 19 9), pp. 131-139. 23 increasingly common willingness to resort to strike action. Koncel's research indicated that nurses are seeking union representation to make their voices heard and seriously considered by hospital management (in addition to improve- ments in wage levels and working conditions). Daniel Kruger has examined the development of bargaining in the nursing profession using the ANA's historical invovle- ment as a focal point.29 Although published approximately twenty years prior to the MSU Survey, Kruger's material is applicable for several reasons. Discussing the subject matter included in many of the contemporary collective bar- gaining agreements, Kruger found that the extension of coverage to the various positions in the nursing hierarchy frequently varied between agreements. Some only included staff nurses, others covered all professional nurses perform- ing nursing services, including supervisors but excluding directors and assistant directors of nursing. Current litera- ture indicates that the variance in the inclusion of super- visory nurses (i.e. nurses not directly involved in patient care, such as educational coordinators and instructors, etc.) is still common. Kruger's research examining the ANA also indicated that agreements were usually of one- or two-year durations, and that none of the two-year agreements contained reopening clauses. MSU Survey findings indicate that since 9Kruger, "Bargaining and the Nursing Profession," pp. 699-705. 24 1960, the trend has been toward longer agreement durations, occasionally with wage reopener clauses. Kruger also cited several problems and prospects regarding collective bargaining in the nursing profession that have proved to be increasingly important over time. Included in his discussion was the nurses' view of unionism and aspects of collective bargaining as being unprofessional and incom- patible with professional ethics and prestige, exceptional employer resistance to the use of collective bargaining, and inadequate legal protection covering collective bargaining in the health care field. Paul Frenzen's research supported the conclusion that the 1974 amendment to the National Labor Relations Act encouraged 30 Organizing the growth of unionism in the hospital sector. activity following the amendments was particularly heavy in nonprofit facilities, whose labor relations status was re- classified by the 1974 amendments. The 1974 amendments (P.L. 93-360) to the NLRA were definitively analyzed by Yvonne Bryant, whose findings con- curred with those arrived at by Frenzen, i.e. that union organizing attempts in health care facilities have signifi- cantly increased since the passage of the 1974 amendments placing all non-government health care institutions under the _30Paul D. Frenzen, "Survey Updates Unionization Actlvities," Hospitals 52 (August 1, 1978), pp. 93-104. 25 31 Brynat's findings indicated that provisions of the NLRA. the initial success unions had in organizing drives following the 1974 amendments was relatively short-lived. In the first ten months following the amendments, unions won approximately sixty percent of the elections conducted, fifty-eight percent in the next twelve months, and only forty-seven percent during the next seven months. Thus, Bryant's statistics indicated that the trend toward union representation victories taking place around 1975 gradually began to reverse itself. Although published prior to the passage of the 1974 amend- ments, Dennis Pointer's critique of public policy dealing with labor relations in the health care sector provided an extensive review of the frequently conflicting federal and state labor law environments, and concluded that a revision in the legal framework was necessary.32 Examining another legal issue in the health care industry, William Emanuel and Robert Legros have addressed the issue of whether members of a religious congregation employed in a hospital are eligible for inclusion in a collective bargaining 33 unit. Although their research found that the NLRB and the 31Yvonne N. Bryant, "Labor Relations in Health Care Insti- tutions: An Analysis of Public Law 93-360," Journal of Nursing Administration 8 (March 1978), pp. 28-29. 32Dennis D. Pointer, "Hospital Labor Relations Legislation: An Examination and Critique of Public Policy," Hospital Progress 54 (January 1973), pp. 71-76. 33William J. Emanuel and Robert Legros, "Sisters as Union .Members: What Do the NLRB and Courts Say?" Hospital Progress 59 (January 1978), pp. 46-54. 26 appellate courts are more in conflict than in harmony on the issue of including members of religious congregations in hospital collective bargaining units, the NLRB has generally found that the members of a religious congregation employed in a hospital affiliated with that congregation are unlikely to be included in a bargaining unit there. However, this question did not appear to be one of great magnitude in the MSU Survey, in which less than ten percent of the reporting facilities indicated that they had any nursing staff members who belonged to religious orders. Several journal articles addressed the issue of appropriate bargaining units in health care facilities. Daniel Kruger has reviewed the principal factors considered by the NLRB in nursing bargaining unit determinations.34 In examining several unit determination cases, Kruger found that the Michigan Employment Relations Commission (called the Labor Mediation Board at the publication date of Kruger's article) has generally followed the guidelines and precedents estab- lished by the NLRB. Kruger reviewed the factors relevant in nmking a unit determination decision, and concluded that in unit determination decisions in professional nursing, occupational titles do not have the same significance of meaningthey possess in business and industry. Rather, the functions of professional nurses are of key importance in 34Daniel H. Kruger, "The Appropriate Bargaining Unit for Professional Nurses," Labor Law Journal 19 (January 1968), pp. 3-11. 27 bargaining unit determination issues, as well as other factors normally considered by the NLRB. Stephen Pepe and Robert L. Murphy have reviewed NLRB guidelines covering appropriate bargaining units in the health care industry, citing the four NLRB cases whose outcomes com- prised the NLRB positions(s) on appropriate health care bargain- ing units.35 Pepe has also written on the legislative history and rationale of the NLRB in addressing these questions.36 In his examination of the sc0pe and composition of health care bargaining units, Wayne Emerson concentrated on the ANA position on nursing unit determinations, and the question of whether RNS be included with other professional employees.37 Writing on unit determinations in the public sector, Michael Moore and James Chiodini reviewed the basic criteria in bargaining unit determinations and the.key factors affect- ing the choice of a bargaining unit structure.38 State laws covering bargaining units and their implementation were ad- dressed in their work on the public sector. 35Stephen P. Pepe and Robert L. Murphy, "The NLRB Decisions on Appropriate Bargaining Units," Hospital Progress 58 (August 1975), pp. 36-43, 69. 36Stephen P. Pepe, "ApprOpriate Health Care Bargaining Units: An Unsettled Question," Hospital Progress 58 (January 1977), pp. 48-54. 7 ,, . . . . Wayne L. Emerson, Appropr1ate Barga1n1ng Units for Health Care Professional Employees," Journal of Nursing Admini- stration 8 (September 1978), pp. 10-15. 8 . ' . . . . . _ M1chael L. Moore and James Chiodlna, "Unit Determ1nat10n Cr1teria in Public Sector Employment Relations," Journal of Collective Negotiations 8 (March 1979), pp. 235-252. 28 Discussing the inclusion of supervisory personnel in bargaining units, Virginia Cleland traced the history of regulations affecting supervisors' bargaining unit status, including several cases in which differing outcomes were arrived at in determining supervisory personnel's place in collective bargaining.39 The debate concerning the question of whether nurses can function as professionals and (at the same time) union members without violating the tenets of either role has been addressed by Betty Hopping.4O Hopping identified the irritants that encourage employees to seek union representation, the ideals unionism is based on, and the idealogical foundation of pro- fessionalism in nursing. Hopping concluded that the funda- mental difference between unionism and professionalism is the method by which each exerts control over its members, and that unionism ignores or supresses merit, experimentation and camaraderie between professional and employer. Also writing on the issue of professionalism in nursing, Anthony Lee has indicated that physicians overwhelmingly disapprove of union- ism among nurses.41 Physicians surveyed by Lee indicated that unionization among nurses leads to deteriorating patient care and (deteriorating) nursing attitudes toward their employer. 39Virginia 8. Cleland, "The Supervisor in Collective Bar- gaining," Journal of Nursing Administration 4 (September-October 1974), pp. 33T35. 40Betty Hopping, "Professionalism and Unionism: Conflict- ing Ideologies," Nursing Forum 15 (Fall 1976), pp. 372-383. 41Anthony A. Lee, "How Nurses Rate with MDs," RN 42 (July 1979), pp.-26-29. 29 Examining the issue of professionalism in nursing from a different perspective, Norma Grand concluded that the major barrier to collective action in the field has been the "pro- fessional" self-concept nurses have had, and their correspond— ing reliance on employers' paternalism.42 Grand felt that collective action designed to improve nursing working condi- tions has succeeded, although the "professional" justification for strike action -- that improved benefits and working conditions are directly correlated with better patient care -- has an inherent disadvantage; namely, that when working con- ditions are poor, the quality of nursing care also deterior- ates. Grand also traced the involvement of the ANA in collective bargaining, and the decline of employer paternalism. John Lawrence addressed barriers to collective bargaining, and called apathy among nurses the profession's most widespread threat.43 Lawrence identified the second-class role of women in American society, the voluntary subjection to, and dom- inance by physicians and administrators, and political inaction as the primary obstacles faced by the nursing profession. Joseph Alutto and James Belasco surveyed RNs in three general hospitals (religious, county and community) in western New York, exploring militant attitudes among 42Norma K. Grand, "Nursing Ideologies and Collective Bargaining,” Journal of Nursing Administration 3 (March- April 1973), pp. 29-32. John C. Lawrence, "Confronting Nurses' Political Apathy," Nursing Forum 15 (Fall 1976), pp. 363-371. 30 white-collar workers.44 Through the use of a questionnaire soliciting information on the subjects' opinions of strikes, collective bargaining and unionism by professionals, the authors found that while nurses had a relatively unfavorable view of collective bargaining and professional associations, their attitudes toward strikes and union representation by professionals was somewhat favorable. Younger nurses tended to evaluate strikes and unions more favorably than their older professional counterparts, and age was the single best predictor of attitudinal militancy, although marital status, type of employer, seniority and personal characteristics were also examined as predictors of attidunal militancy. Lynn Donovan's survey of nursing attitudes on striking concluded that the strongest justification for resorting to strike action is better patient care, but salaries and working conditions were also prominent reasons cited for striking.45 In their examination of work stoppages in the health care industry, Pointer and Metzger found a significant correlation between the extent of collective employee activity (i.e. rec- ognition requests and current negotiations), and the incidence of work stoppages.46 Spontaneous work stoppage activity in 44Joseph Alutto and James A. Belasco, "Determinants of Attitudinal Militancy Among Nurses and Teachers," Industrial and Labor Relations Review 27 (January 1974), pp. 216-227. 45Lynn Donovan, "15 Nursing Ripe for a Union Explosion," RN 41 (May 1978), pp. 63-68. 46Dennis D. Pointer and Norman Metzger, "Work Stoppages. in the Hospital Industry: A Preliminary Profile and Ana1y51s," Hospital Administration (Speing 1972), pp. 9-24. 31 the absence of union or professional association presence was minimal. While federal hospitals were reported as having almost no work stoppage activity, a relatively high degree of conflict was reported by state and local hospitals, some- what surprising considering that a majority of states granting public employees organizational and collective bar- gaining rights also (like the federal government) prohibit strikes. Pointer and Metzger felt the explanation for this was the ANA and the American Federation of State, County and Municipal Employees (AFSCME) use of mass resignations and sick calls in state and local facilities, circumventing "no strike" laws while pressing recognitial and employment demands in these facilities. Higher incidents of work stoppages were also correlated with recognition requests (versus hospitals with negotiated agreements), increasing hospital bed sizes, and geographic location -- hospitals in the Pacific, east northcentral and west northcentral accounted for a particularly high percentage of stoppages, while southern hospitals re- ported relatively low numbers of stoppages. Examining the difficulties faced by mid-level nursing service personnel in work stoppages, Ada Jacox solicited information from participants in a 1965 Ohio hospital work stoppage that centered around wages, compulsory membership in the state nurses' association, and the inclusion of head 47 nurses in the bargaining unit. Jacox concluded that more 47Ada Jacox, "Conflicting Loyalties in Collective Bar- gaining: An Empirical Illustration," Journal of Nursing Administration 1 (September-October 1971): 19-24. 32 than any other group, head nurses were caught between con- flicting loyalties and expectations of the hospital admin— istration and staff nurses. Whatever the reasons and influences affecting their decisions, nurses caught in the conflicting tensions expressed feelings of guilt for either having failed to support colleagues, administration and nursing superiors opposing the work stoppage, or having left patients. At the conclusion of the conflict, many head nurses were left with feelings of frustration and disappoint- ment, largely residual effects of their conflicting loyalties. Michael Miller traced the historical development of nurses' right to strike, and arrived at several conclusions.48 Miller's material indicated that the working relationship between professional nurses and their employers is in a state of deterioration, and that most nursing employers believe that relatively high turnover rates will resolve tensions between themselves and their employees. Miller pointed to compulsory arbitration as the most acceptable alternative to strike action. Myron Fottler examined wage levels in metrOpolitan hos- pitals between 1966 and 1972, attempting to discern the impact of unionism on nursing wages.4g Fottler found that the union impact had been significant, particularly in private 48Michael H. Miller, "Nurses' Right to Strike," Journal of Nursing Administration 5 (February 1975), pp. 35-39. 49Myron D. Fottler, "The Union Impact on Hospital Wages,” Industrial and Labor Relations Review 30 (April 1977), pp. 342-255. 33 hospitals, raising overall wages between four and eight per- cent. Consistent with other studies and generally held assumptions, his findings indicated that unions tend to organize the largest and most easily accessible organizations, and that their greatest impact occurs in the early stages of organizing (economic theorists tend to minimize the union impact in the long run, emphasizing market forces as the primary wage determinant). Also brought out in his study was the difficulty in measuring spillover effects (i.e. employer wage decisions resulting from the threat of unionism), but to the extent that these employer reactions to the threat of unionism exist and employer raise wages to forestall unionism, union-nonunion wage comparisions understate the union impact. While Fottler indicated that unionism has impacted hospital wage levels, its impact on overall hospital costs for the period studied appeared to be in the range of between one and two percent, thus not a significant contribution to recent inflationary trends in the hospital industry. The difficulty in measuring spillover effects resulting from actual or perceived threats of unionism to nonunion facilities has been addressed by Daniel Mitchell, who theorized that unions might potentially have no pay-raising SO impact. It is Mitchell's contention that employers might offer a wage figure in negotiations so artificially low that 50Daniel J. Mitchell, Unions, Wages and Inflation, Washington, DC: The Brookings Institution, 1980). 34 the finally agreed upon figure would be equivalent to what they would have unilaterally determined without the union. In measuring the union impact on wages, Mitchell observed that while union earnings for broad groups of workers are usually higher than nonunion earnings in the American labor market, other forces leading to above-average salaries make blanket observations questionable, particularly when applied to specific industries. Some of these forces, and the determinants of wage rates were discussed in his publication. Jack Stieber and Adolf Sturmthal have addressed the his- tories and activities of the ANA in varying extents.51 Stieber's work was the more extensive of the two in the nursing area, examining not only the ANA history, policies and current activities, but the state affiliates' collective bargaining background, particularly that of the Michigan Nurses' Association (MNA). Doris McLaughlin studies the history and extent of union activity in the Michigan nursing profession, concentrating on the role the state legislature and courts have played in collective bargaining in the state.52 The impact of the 1974 health care amendments to the NLRA, and their impact on employment relationships in the health 51Jack Stieber, Public Employee Unionism: Structure, Growth, and Policy, (Washington, DC: The Brohkings Institution, 1973; Adolf Sturmthal, White-collar Trade Unions, (Urbana, IL: University of Illinois Press, 1966). 52Doris B. McLaughlin, Michigpn Labor: A Brief History from 1818 to the Present, (Ann Arbor, MI: Institute of Labor and Industrial Relations, University of Michigan-Wayne State University, 1970). u. .u. care industry have been assessed by AndriaKnapp.53 Her work included extensive reviews of the legal framework governing the health care industry, the history of the NLRB decisions effecting the industry and their impacts, the Congressional intent behind the 1974 amendments, and the role of the Federal Mediation and Conciliation Service (FMCS) in the industry. In a work somewhat similar to that of Knapp, Jerold Jacobsen has examined the role of the FMCS, the NLRB, and the major case decisions affecting the employee-employer relation- ship in the health care industry in light of the 1974 amend- ments.54 John Fossum has summarized many of the basic areas in industrial relations particular to the health care field.55 His material has been expanded upon by William Werther and Carol Lockhart, whose publication details the responsibilities and obligations of employers and employees in health care facilities with regard to collective bargaining under the 56 A clear picture of the roles of the relevant parties NLRA. and the ways these roles affect the collective bargaining relationship, and a summary of the "emerging forces in 53Andria S. Knapp, Labor Relations Law Problems in Hospitals and the Health Care Industpy, (Chicago: American Bar A550ciaii0n Section onilabor Relations Law, 1977). S4Jerold D. Jacobsen, Labor Relations in the Health Care Industry, (New York: Practising Law Institute, 1977). 55John A. Possum, Labor Relations: Development, Structure, Process, (Dalias, TX: Business Publications, Inc., 1979). 56William B. Werther and Carol Ann Lockhart, Labor Relations in the Health Professions, (Boston: Little, Brown and Co., 1976). 36 labor relations" is included in Werther and Lockhart's work.57 Gail Hallas used questionnaires and interviews with Florida nurses to examine the current state of nurses' attitudes toward their employers and their profession.58 Hallas found that hospital-related issues -- inadequate staffing levels, poor employer-employee communication, poor administration, morale, wages and patient care -- were of significant importance in causing nurses to leave hospital employment, and frequently, the entire profession. Attitudes of nurses toward their professional association were also examined, and found to be frequently critical of their association's activities and the benefits generated from their membership, essentially constituting another reason to leave the profession. 57Ibid. 58Gail G. Hallas, "Why Nurses Are Giving It Up," RN 43 (July 1980), pp. 17-25. 1"- CHAPTER III. METHODOLOGY MSU Survey Design With the basic reasons for studying collective bargaining in the nursing profession enumerated in the introduction, some attention should be paid to the methodological framework em— ployed in the MSU Survey. The goal of this study was to empirically examine the labor-management relationship in the Michigan nursing industry, concentrating on the hospital- employed nurses. To gather information on this subject, a questionnaire was developed and mailed to administrators and directors in every Michigan hospital. The questionnaire and an accompanying cover letter was mailed on August 13, 1979, to 247 hospitals in Michigan. This 247 hospital population represented all of the facilities in the state that were listed in the 1978 American Hospital Association Guide to the Health Care Field (AHA Guide). A stamped, self-addressed return envelope was included with each questionnaire to encourage prompt responses. Return envelopes used in the first mailing included the respondent's name, to reduce any possible confusion and duplication of effort in arriving at an appropriate follow-up mailing list. The initial mailing requested that the questionnaire by completed and returned by August 31, 1979, giving hospital officials eighteen days to reply. Eighty-five administrators returned the questionnaire by the August 31, 1979, target date. However, several incomplete 37 ..v" u ...o .5“ 9 I. t\'\ us‘ .yod Iao . nu‘. I E 38 forms were returned, and other respondents informed us that they would not respond to the MSU Survey without the endorse- ment of the Greater Detroit Area Hospital Council (GDAHC). Because of the time involved in the GDAHC endorsement pro- cedure, one follow-up mailing was made on August 31, 1979, to all non-GDAHC hospitals that had not responded to the initial mailing. This follow-up included another questionnaire and cover letter further explaining the MSU Survey, and requested a return of the completed questionnaire by September 14, 1979; two weeks after the date of the follow-up mailing. This mail- ing also included a stamped, self-addressed return envelope, although the hospital names were not printed on them as they had been in the initial mailing. It was felt that the lack of the respondent's name on the envelope might aid the return rates by further encouraging respondent anonymity. Post cards weresent to GDAHC members informing them of the decision to delay their follow-up mailing pending the endorsement ruling of the GDAHC Questionnaire Review Subcom- mittee. The GDAHC approved a recommendation to endorse the questionnaire on September 27, 1979, on two conditions. The first condition stipulated that the confidentiality of the responding institutions be protected by eliminating any cells used in tables contained in data summary prepared for the hospitals containing less than four units (hospitals). In the second condition, it was agreed that the difficulties of comparing data on cities of roughly equivalent populations in ‘ 5"A'11“ 1:..L;b$ u .... ‘na‘: ‘iu' b vu k-\‘ I 055 ' 1 r I ‘ I. . 3‘ Ex“ lutobo 5| ’3; a ; w " “a. ....,,".. . . , . .A, . . a: ‘ but“. ‘ W' 0 '1: :4. ..§ «I»; ‘ 1 H k. r hvl ‘1 'IA . \I“ >1":.L r, e.- [I \ " . \fl . 1" ‘. fl 39 metropolitan (or urban) and rural areas would be addressed in any data summary prepared for the responding hospitals. Another copy of the questionnaire and an accompanying cover letter including these conditions was sent to GDAHC- member hospitals on October 3, 1979, requesting that the enclosed questionnaires be returned by October 15, 1979. Once again, stamped, self-addressed return envelopes were included in that mailing. This follow-up also omitted any identification of the respondent on the return envelope. Additionally, letters and questionnaires were sent to two hospitals currently in operation, but not included in the AHA Guide from which the original population had been chosen.59 The addition of these two facilities brought the total number of hospitals solicited to 249. From the figure of 249, an effective population of 243 hospital facilities was arrived at. The two military hospitals in Michigan were excluded from the analysis, and four other facilities returned questionnaires or letters informing us 60 that they had closed, or ceased hospital operations. This attrition eliminated a total of six hospitals from the 59Heritage Hospital (Taylor), and Olin Health Center (East Lansing) were omitted from the list included in the AHA Guide. 60Columbia Medical Hospital and Nursing Home (Detroit), the Salvation Army William Booth Memorial Hospital (Detroit), the Salvation Army William Booth Memorial Hospital (Grand Rapids), and Devine Infant Hospital (Wakefield) replied that they had closed or discontinued hospital operations. 40 original population solicited (249 hospitals), leaving the effective p0pulation of 243 facilities. The two follow-up mailings (one to GDAHC members and one to nonmembers) yielded 53 usable responses, for a total of 132 usable responses, or a return rate of 54.3 percent. While several of the questionnaires were returned as late as mid- January, 1980, they were excluded from the analysis. Thus, the findings of the MSU Survey are based on 132 responses from 243 facilities, or a 54.3 percent return rate. Table 1 compares the composition of the MSU Survey pop- ulation and the 132 usable responses according to the h05pital location (by city size), bed size, and type of control. The largest number of hospital facilities (43.6 percent) were located in cities of less than 10,000 in population. A break- down of the returned questionnaires shows a striking similarity in that 42.4 percent of the usable returns were from hospitals located in these smaller cities. Solicitations and returns from this city size category were within 1.2 percent of comprising equal proportions of their totals. The second largest number of hospitals were located in the largest cities in Michigan (100,000-plus in population). This was also reflected in the responses. The remaining third (32.1 percent) of the hospitals solicited were relatively evenly distributed in cities ranging from 10,000 up to 100,000 in population. Returned questionnaires reflected a similar pattern, with a slightly higher re5ponse rate from the cities of 10,000 to 25,000 in population. ~I..~-Q o ‘1‘... fi ‘lu 41 TABLE 1 QUESTIONNAIRE COMPOSITION ACCORDING TO CITY SIZE, BED SIZE, AND TYPE OF CONTROL Questionnaires Questtionnagres Category mailed returned Number Percent Number Percent City Sizea: less than 10,000 106 43.6 56 42.4 10,000 to 24,999 27 11.1 22 16.7 25,000 to 49,999 27 11.1 12 9.1 50,000 to 99,999 24 9.9 17 12.9 100,000-plus _§2 24.3 _35_ ._l§;2 Totals 243 100.0 132 100.0 Number PercentC Number Percent Bed Size: 1-100 99 40.7 61 46.2 101-200 54 22.2 23 17.4 201—300 35 14.4 18 13.6 301-400 17 7.0 8 6.1 401-p1us -_§§ 15.6 __RR 16.7 Totals 243 99.9 132 100.0 Number Percent 7 Number PercentC Control: Proprietary 5 2.0 1 0.8 Non-profit 145 59.7 77 58.3 Religious — — - _ Federal gov't. 6 2.5 3.0 State gov't. 14 5.8 10 7.6 Local gov't. 53 21.8 25 18.9 Non-profit/Religious 20 8.2 7 5.3 Other - - 4 3.0 Info. not given ._;1 - __Z_ .__l;§ Totals 243 100.0 243 99.9 aCity sizes are categorized by population. bRefers only to fully or partially usable questionnaires. cDoes not add to 100 due to rounding. 42 A comparison of the mailed and returned questionnaire composition according to hospital bed sizes is consistent with the comparison drawn in the city size category. The largest number of mailings and returns were to and from hospitals of fewer than 100 beds. H05pitals of 101-200 beds were the next largest suprpulation, and had the second largest number of returned questionnaires. The smallest category was the 301- 400 bed size hospital. Only 7 percent of the questionnaires were mailed to these facilities, and they accounted for 6.1 percent of the returned questionnaires. In the 243 hospital survey population, 165, or 67.9 percent of the facilities were controlled on a non-profit or non-profit/ 61 religious basis. The breakdown of the returned questionnaires provided in Table 1 indicates that 86, or 66.1 percent were 62 from these non-profit hospitals. In the effective population surveyed, 30.1 percent of the facilities were controlled by federal, state, or local government authorities. Governmentally controlled hospitals accounted for 29.9 percent of the total returns, a difference of less than one percent. In both cases, 61All of the hospitals in Michigan administered by religious groups operate on a non-profit basis. 62Data included in the AHA Guide classifies religiously administered in Michigan as being non-profit/religious. Hence, no questionnaires were sent to "religious" facilities. However, two institutions indicated their control as singularly "religious" on the questionnaire. These respondents were classified as "non-profit/religious." 43 local government authorities controlled over 60 percent of all of the governmentally administered facilities. Viewed in total, Table l exhibits substantial similarities between the compositions of the solicited population and the return population. In no category do deviations exist between the composition of the h05pitals solicited and the hospitals responding to the MSU Survey that are large enough to cast doubt upon the representativeness of the MSU Survey and its results. Table 2 exhibits the response rates categorized on the basis of city sizes (in population), bed sizes, and types of hospital control. As was the case in Table 1, no substantial deviations exist in the response rate that would seriously impinge upon the representativeness or accuracy of the infor- mation obtained through the MSU Survey. Hospitals in cities of 10,000 to 25,000 and 50,000 to 100,000 in population show higher return rates than the total population. Hospitals of 101-200 beds were the only category with a return rate of more or less than ten percentage points from the overall 54.3 percent return rate. In terms of hospital control types, the major category -— non-profit and non/profit/religious hospitals -— had a 52.1 percent return rate, only 2.2 percent less than the total return rate. Proprietary hospitals had the lowest return rate (20.0 percent), buth they only comprised 2 percent of the total number of facilities solicited. State .-.q“‘l" 1:. .u.‘/‘ I' — 0‘ ' v6. n1. . \ 9“ "l | O I. . 3\\ T ‘7'. .‘l‘ \ "I .I'vai ..,._; 1 . ‘7‘“ . "a "_ IN .:.-.1.. ., 4.“ #5,}. .,.:‘: n; r“) 44 TABLE 2 RESPONSE RATE ACCORDING TO CITY SIZE, BED SIZE, AND TYPE OF HOSPITAL CONTROL Facilities Usable Return Category solicited . responses rate City sizea: less than 10,000 106 56 52.8 10,000 up to 25,000 27 22 81.5 25,000 up to 50,000 27 12 -44.4 50,000 up to 100,000 24 17 70.8 100,000-plus ' _§R ‘Ré 42.4 Totals . 243 132 54.3 Bed size: 1-100 99 61 61.6 101-200 54 23 42.6 201-300 35 18 51.4 301-400 17 8 47.0 401-p1us _§R _32_ 57.9 Totals 243 132 54.3 Control: Proprietary 5 1 20.0 Non-profit 145 77 53.1 Religious - 2 - Federal gov't. 6 4 66.7 State gov't. 14 10 71.4 Local gov't. 53 25 47.2 Non-profit/Religious 20 7 35.0 Other - 4 - Info. not given __; ___ - Totals 243 132 54.3 aCity sizes are categorized by population. and federal hospitals are somewhat overrepresented, with respective return rates of 71.4 and 66.7 percent. In summary, the MSU Survey solicited information from every nonmilitary hospital in Michigan over a several week period, and received usable data from 54.3 percent of the ‘ .qu ‘ "~- 1 ... a? .. An 9. it C" m,‘ «1'. '_‘. 45 hospitals. Roughly 44 percent of the hospitals solicited were located in relatively small cities. Slightly less than 25 percent of the hospitals were located in cities of over 100,000 on population.63 The remaining third (32.1 percent) were evenly distributed between cities of 10,000 to 100,000 in population. The composition of the returned questionnaires reflected a corresponding trend. The similarities in the compositions of the mailed and returned questionnaires applied to the hospital bed size and control-type categories as well. At no point did the reSpective compositions appear skewed enough to indicate cause for concern over the representative- ness of the data gathered by the solicitation efforts. Response rates shown in Table 2 were similarly encouraging. Some underrepresentation was evident from hospitals located in the largest city sizes, and state-administered hospitals. How- ever, no Obvious evidence exists in the response rates that would indict the ability of the MSU Survey to portray an accu-ate informational portrait of the actual hospital popu- lati’h in Michigan. 63The city size category of 100,000-plus in population was the largest in the questionnaire. The seven cities falling into this category include Detroit (1,513,601), Grand Rapids (197,649), Flint (193,317), Warren (179,260), Lansing (131,403), Livonia (110,109), and Dearborn (104,199). Newspaper Enterprise Association, Inc., The World Almanac and Book of Facts 1979 (New York: Newspaper Enterprise ASsociation, Inc., 1978), p. 230. 46 Methodological Ipplications The need for evaluation or examination rarely occurs in an atmosphere of complacency. In the same vein, problematic areas in employee relations are the settings wholly appropri- ate for examination and evaluation. The basic rationale for evaluation is that it provides information for action, and contributes to the rationalization of decision-making. Although it may serve other functions, such as knowledge- building or theory-testing, its primary justification is its addition to improved decision-making, adding weight to the thrust for positive change or future directions in programs, policies, professional relationships, occupational groups, etc.64 However, in "real world" settings, indefective exam- ination and/or evaluation is not always practical or possible.65 In discussing the pitfalls in the evaluation of social action programs in contemporary settings, Peter H. Rossi has stated that "while it is true that in a Panglossian best of all possible worlds, the best of all possible research designs can be employed, in'a comprised real world, full of evils as it is, it is necessary to make due with what is possible within the limits of time and resources."66 64Carol H. Weiss, ed., Evaluating Action Programs: Readipgs in Social Action andiEvhiuation (Boston: Allyn and Bacon, Inc., 1972), pp. 318-320- 65Peter H. Rossi, Evaluating Action PrOgrams, ed., by Carol H. Weiss (Boston: Allyn and Bacon, Inc., 1972): p. 232. 6 61bid. F..«.-.—.‘_..fir is. . 47 While classic experimental designs have "prestige, power, and symmetry," evaluations employing quasi-experimental or non-experimental designs often have the overriding virtue of feasibi1ity,67 The evaluator who attempts classic experimental design in evaluating programs of conditions and "encounters Obstacles and fouls up is less productive than the one who adapts his designs . . . to the possibilities."68 Examination employing nonexperimental schemes "can produce good results that are sufficiently convincing for many practical purposes (and) . . . be full of detail and imagery, provacative and rich in insight," Offering more information than would have been available without any study at all.69 The ”case and field study" research methodology employed in this study offers the additional advantages of being par- ticularly useful as background information for planning major investigations in the hospital-nurse employment setting. Because it is intensive, it brings to light "important variables, processes, and interactions that deserve more extensive attention," and pioneers new ground, often acting as the source of "fruitful hypotheses for further study."70 67Carol H. Weiss, Evaluation Research (Englewood Cliffs, NJ: Prentice-Hall, Inc., 1972), p. 73. 6 81bid. 69Ibid., pp. 73-73. 7OStephen Isaac and William B. Michael, Handbook in Research Evaluation (San Diego: Edits Publishers, 197i), p. 20. 48 Finally, the case study data provided in this study provides useful anecdotes or examples to illustrate more generalized statistical findings.71 Substantial efforts have been made to limit the possible threats to the validity and reliability of the MSU Survey. However, several possible threats are inherent in a survey of this type, and these methodological questions merit some attention. A measure's reliability refers to the degree to which the measure may be depended upon to secure consistent results upon repeated applications. Therefore, the reliability of the MSU Survey indicates the probability Of Obtaining analogus results upon repeated uses of the questionnaire. For example, if the questionnaire was distributed at several chronological inter- vals in a time series evaluation or design, and yielded sub- stantially dissimilar results (beyond variations that could be explained by changing wage settlements, increasing union organizing activity, hospital expansion, etc.), its reliability would be Open to question. In analyzing the MSU Survey's re- liability, three primary sources of unreliability should be considered.72 Subject reliability refers to the subject's mood, moto- vation, etc., and how these factors may affect his or her attitudes and behavior regarding a survey. 711bid. 72Edward Suchman, Evaluation Research: Principles and Practice in Public Service and Socigl AEtion Programs, (New York: Russel Sage Fouhdation, 1967), pp. 115-131. 49 Situational reliability refers to the conditions under which the survey measurements are made. Some circumstances or conditions may tend to produce results that are not re- flective of the actual conditions in the population being studied. Instrument reliability includes both subject and situ- ational reliability factors combining to produce an evaluative instrument (the questionnaire) of low reliability. For example, a poorly worded interview or questionnaire (especially ambiguous or leading inquiries) may lead to a random variation in the responses. Reliability criteria have traditionally represented the dependability or stability aspect of an evaluation, referring to the evaluative instrument's freedom from random and un- systematic error. The results Of systematic error could be consistent, and therefore reliable. This type of chance variation "is present in all evaluation and constitutes an important aspect of any measuring instrument or procedure."73 Reliability is a necessary condition for validity. An evaluative technique unable to replicate its results upon continued applications because of large random errors Obvious- ly cannot be used to measure anything, and therefore cannot 73Ibid., p. 116. A slightly expanded discussion Of the relevant reliability and validity aspects is included in L. Kirk Handren, "Methodological Aspects and Comments on the Evaluative Design of the MSU Nursing Survey," East Lansing, MI, 1980. (MimeOgraphed paper supplementing the actual thesis.) 50 be used to measure anything, and therefore cannot have any validity. Validity refers to the degree to which a measuring instrument succeeds in doing what it purports to do. Validity problems are inherent in all measurement. Edward Suchman has arrived at a three point check for attempting to 74 First, factors tending to pro- increase survey validity. duce unbiased measurement should be emphasized. Additionally, checks against which one may determine the degree of validity present should be included (if possible), and attempts should be made to correct known sources of invalidity. The MSU Survey questionnaire was limited in length and scope for several reasons. Because it was felt that a long and complex questionnaire would significantly reduce the rate of return, the length was deliberately limited to a two-sided one-page form. The first four questions solicited information on the hospital characteristics (location, size, control and personnel counts). Questions six through nine and eleven through thirteen solicited information on wage and benefit levels for full- and part-time nursing personnel. Questions fourteen through twenty-one requested information on the hospital-nursing staff collective bargaining history and activity. Question five requested data on the number of nurses belonging to religious orders, and number ten requested an aggregate breakdown on the nurses' educational backgrounds. The questions were arranged in related groups to lend some Suchman, Evaluation Research, p. 126. 51 continuity to the questionnaire format, and simplify the process of retriving and recording the information to the greatest extent possible. Attempts were made to phrase the questions in the most neutral language possible, avoiding subjectivity in the questions and answers whenever possible. In most cases, questions were either multiple choice, or answerable with figures or brief factual data (e.g. organization names, con- tract expiration dates, etc.). While every effort was made to state the questions as clearly as possible, any mail survey involves the possibility of misinterpretation between the solicitor and the survey respondent. Question number two requests the type Of hospital control. The multiple choice question offered six control types, and asked that all the applicable types of control be indicated. The question was intended to divulge the primary source of control (i.e. was it a "state hospital," "city hospital," etc.). Some methodological or classification problems arose from this, and were allieviated in several ways. Some ques- tionnaires indicated the sole source of control as religious, while others indicated dual religious/non-profit control. Because of this, and the data from the AHA Guide, which in- dicated that all of the hospitals in the survey population under religious control were in fact religious/non-profit facilities, the seven forms in question were classified as "non-profit/religious" facilities. 52 Other returned questionnaires indicated control by a combination of the federal, state and/or local governments. To a certain extent, this is a perfectly valid answer. Hospital facilities may be accredited, licensed, or reimbursed by all of these governmental levels (or their agencies), but in each case, there is a primary type of control. Two re- turned questionnaires contained no response to the question on control, and four returns submitted control types that did not fit into any of the listed categories. Question number three requested personnel counts in the hospitals (excluding medical interns, residents and trainees).75 Information gained through compiling the answers to this question allowed other data in the study to be tabulated according to the hospital sizes in terms of personnel (versus hospital bed sizes). The personnel countsobtained form a type of aggregate average. Actual counts fluctuate daily, but when viewed in aggregate form, the reported figures provide clues as to the personnel levels maintained by the hospitals. Question six requested data on monthly salary levels. However, large numbers of questionnaires were returned with hourly rather than monthly data. Because of this, the analysis of wage levels contained in this study was performed in hourly, rather than monthly terms. To convert the reported 75The NLRB has held that hospital interns and resident physicians have no collective bargaining rights under Taft- Hartley, because they are not "employees" within the meaning of the law, but students pursuing a graduate medical educatlon. Cedars-Sinai-Medical Center (223 NLRB 251, 1976). 53 monthly salary figures to hourly earnings, the monthly numbers were divided by 160, or the equivalent of four 40-hour weeks (one month). Other requests on the questionnaire soliciting wage information were originally stated in hourly terms. Several answers to question number sixteen brought another methodological question to light. Number sixteen requested the record of formal organizational attempts by unions directed at nursing personnel since 1970. Some answers indicated that no formal records Of every attempt exist or were kept, and that the answer relied upon the respondent's memory. Another possible problem exists in this question in the lan- guage used. The question requests data on the "formal efforts by a labor organization to organize . . . nursing personnel." Defining the term "formal efforts by a labor organization" was left to the discretion of the respondents. For the pur- poses of this study, informal discussions with, or inquiries by labor organizations regarding the organizational status and/or desires of the nurses do not qualify as organizing efforts. These instances are difficult or impossible to document, and the seriousness of these efforts is largely a matter of Opinion. "Formal efforts" by labor organizations referred to efforts in which employees (of the hospital) were involved in organized solicitation efforts with the knowledge and consent of the union, or union representatives or agents (with the knowledge of the hospital administration) actively 54 solicited the support of nurses for the purposes of electing a collective bargaining representative. In a mail survey of this type, there is little that can be done by the researcher to assure the subject reliability, aside from Offering the respondents the greatest degree of cooperation possible. In this regard, the respondents of the MSU Survey were promised a report of the data collected through the use of the questionnaire, and that the data would be discussed in aggregate form. All information obtained through the survey was treated confidentially, assuring the greatest degree of anonymity possible. Administrators re- sponding to the MSU Survey were promised a copy of the aggregate findings upon their request. No serious subject reliability threats seem present. One of the goals in developing the questionnaire was to inject as much objectivity into the measuring instrument as was possible. The questionnaire allows little room for ed- itorializing, and provides a factual base of information to work with. None of the conditions under which the MSU Survey was conducted seem indicative of a possible bias, or reflective of innaccurate field conditions that could prove harmful to the situational reliability. However, in applying the MSU Survey in a reliable and valid manner, it is important to remember that the results are based upon hospital-employed nursing personnel in a specific geographic region, and are 55 not necessarily reflective of nursing employment conditions in nonhoSpital employment settings. The failure to consider this condition could easily invalidate potential applications of the findings.76 Several factors support the conclusions that the research in the MSU Survey is valid. It provides an objective data base for the examination of the several assumptions regarding the hospital-nurse employment relationship that are included in this study. However, it is important to keep in mind that fact that the MSU Survey is not intended to provide a statis- tically significant confirmation or contradiction of the relevant topics discussed in this study. At each step in the interpretation and application of the MSU Survey and accompany- ing research, it must be remembered that the object of the studies was to empirically examine the labor-management relationship in the Michigan nursing profession. There can be little argument as to the veracity Of the MSU Survey's sampling validity. The solicitation of data from from all of the nonmilitary hospital facilities was a 76There is no reason to doubt that the methodology employed in the MSU Nursing Survey could be broadened to include all employers of nurses in a larger geographic area. However, to accomplisy such a survey, considerable additional resources would be necessary. 56 luxury that eliminated any serious challenge to the selection Of the sample population.77 The MSU Survey analysts cannot lay claim to being totally without bias or preconveived attitudes on the subject of collective bargaining or employee relations in the nursing profession. Obviously, without interests and perceptions of the subject under study, the MSU Survey and ensuing research would not have taken place. However, the Objective data collection technique, stressing factual, documented information lends itself quite well to an unbiased analysis. Naturally, the respondent's attitudes toward the MSU Survey could not be controlled, and the nature of the information requested from the respondents is admittedly controversial and highly sensi- tive, but no evidence has been encountered to indicate that members of the sample population deliberately concealed infor- mation, or provided inaccurate information. Nor is there any reason to believe the administrative conditions (i.e. the auspices of the MSU Survey, etc.) led to invalid findings. Theoretically, a threat to the MSU Survey's validity does exist in the technique used to classify the responding 77The MSU Survey originally solicited information from all of the hospital facilities in Michigan, including the military installations. However, because these facilities are staffed by military personnel, and are subject to different regulations governing the employer-employee relationship (and have policies restricting the type of information they can release), they were excluded from the analysis. For the purposes of the MSU Survey, "military" facilities refer to the hospitals administered and staffed by military personnel from the U.S. Army, Navy, or Air Force. Veterans Administration hospitals are included in the research under the classification of "federally controlled" hospitals. 57 hospitals according to location or city size. This classifi- cation method is actually demographic rather than geographic, as it is done according to a city's population. The first question in the questionnaire addressed the hospitals'location, offering five city sizes (from 100,000-plus, to less than 10,000), and requested the respondent to indicate the correct category. This type of classification could theoretically lead to difficulties arising from the comparison of data on cities of similar population in metropolitan versus rural areas. For example, a hospital located in a city with a small population, but which is actually part of, or surrounded by a large metropolitan or urban area could appear to be located in a rural or nonurban area. However, cases of this actually happening in Michigan are exceptions to the rule. An examination of the geographic distribution of hospitals in the state shows that the hospitals located in suburban areas tend to be located in suburban municipalities with populations large enough to keep the findings relatively distortion free. In choosing city sizes as the method of demographically classifying facilities, the theoretical issue of noncomparable data on cities equivalent in population, but located in rural or urban regions should be considered. However, it was felt that the advantages accruing from this method of classification, including its convenience for administrators to deal with in answering the questionnaire, its basically representative nature, the ease of presentation and the overall v‘“ Ab.‘ Av- . r '9 5- .ns 58 representativeness of the actual demographic environment outweighed the problem of rural-urban inconsistencies. In summary, the MSU Survey is not immune to the threats to valid and reliable inference. Some of the wording con- tained in the questionnaire (particularly in regard to the recent history or records of union organizing activity), the conversion of the salary data to hourly figures, and the delay in the follow-up mailing to GDAHC hospitals should all be considered in evaluating the reliability and validity of the data. However, none of these conditions seem significant enough to impair the ability of the research to present an accurate empirical examination of the labor-management con- ditions between Michigan hospitals and their nursing personnel. In further regard to the reliability and validity of the study's findings, the degree of their accuracy is linked to their application. The case study or single project evaluation is the prisoner of its setting. The evaluation is confined to observing effects at one time and place, under the conditions of the moment. It is difficult to determine the lengths to which the observed results may be generalized and applied to other situations. Broad sweeping generalizations based upon information contained in this study that are applied to superficially related (but actually differing) environments are of questionable validity until appropriate follow-up or augmentive research is accomplished. 59 While some case studies are particularly vulnerable to subjective biases, the wide sample used in the MSU Survey counteracts potentially serious questions of subjectivity. A characteristic of evaluative research is that it takes place in action settings.78 The MSU Survey is no exception to this rule. Information was solicited from action oriented environments, in which the research was a matter of secondary priority. To succeed in this environment, the evaluation had to adapt itself to the "real world" environment, and disrupt the respondents' routine operations as little as possible. When viewed in the context of investigating and evaluating a contemporary real world action oriented setting, and synthe- sizing the resultant data into an objective studx finding the right mix of detail and condensation, the research does indeed emerge as a valid, reliable addition to the existing body of information on labor-management relations. 78Weiss, Evaluation Research, p. 92. CHAPTER IV. MSU SURVEY FINDINGS Nursing Personnel Belonging to ReligiOus Orders Twelve of the 132 responding hospitals (9.1 percent) replied that they had nursing staff members who belonged to religious orders. Six of these hospitals were located in cities of 100,000-plus in population, and eight were 401-bed or larger facilities. Of the twelve facilities reporting members of religious orders on their nursing staffs, only four reported the hospital control type as being religious. Table 3 illustrates these figures. TABLE 3 CHARACTERISTICS OF HOSPITALS REPORTING MEMBERS OF RELIGIOUS ORDERS ON THEIR NURSING STAFFS . . 'RNs in hos- C1ty Size piggis Control piggis Beds piggis relig. pitals - orders under 10,000 2 Religious 4 1-100 1 under 1% 5 10,000-25,000 3 Non-Prof. 6 101-200 2 l to 2.5% 3 50,000-100,000 2 Federal 1 300-400 1 2.5 to 3% 2 100,000-plus 5 Local 1 401+ _R other 2 Total T7 Total i2 Total 12 Total 12 SOURCE: MSU Survey Data. The largest percentage of RNS reported by any hospital as belonging to religious orders was 4 (percent), but this was a facility with only sixty-two full-time equivalent (FTE) RN (7 0 —_.__.- 61 positions.79 Thus, only two or three RNs in this hospital were actually members of a religious order. Three hOSpitals replied that the information regarding their nurses' memberships in religious orders was unknown. One facility did not answer the question (number five on the questionnaire), and one facility answered "N/A." The one hospital under local control in Table 3 reported that none of their RNS were members of religious orders, but ”some aides" were members. A total of 115 hospitals (87.1 percent of the respondents) replied that none of their nursing personnel were members of religious orders. The information obtained on nurses' memberships in relig- ious orders indicates that very few hospitals employ, or rely on members of religious orders to staff their nursing depart- ments. In a minor way, this would seem to be indicative of the evolution of the profession in the United States from 79Full-time equivalent (FTE) positions refer to forty hour per week positions or budget slots. In the questionnaire, they were arrived at by adding the reported numbers of full- time nurses actually employed, and the numbers of budgeted full-time vacancies. Also, two part-time employees or Openings are equal to one FTE position. 62 its early stages, when members of religious orders were quite active in providing hospital nursing services.80' The presence of members of religious orders does not seem to effect the union or collective bargaining status of their hospital-employers. Six of the 12 hospitals reporting members of religious orders among their nursing employees also reported their nursing personnel as unionized. In five of those cases, the RNs were unionized. Apparently, the presence of members of religious orders on hospital nursing staffs is relatively isolated, and has a negligible impact on the collective bargaining process. EdUCation While 81 percent of the responses provided answers to the MSU Survey questionnaire concerning educational backgrounds of their nursing personnel, several difficulties arose in com- piling the data in a valid format. The questionnaire requested the percentages of respondents' RNS with baccalaureate degrees 80Historically, it was not uncommon for hospitals operated by, or in cooperation with, the Catholic Church to utilize substantial numbers of nuns in the provision of nursing services. The Seventh Day Adventist Church has also been directly involved in the administration of several hospitals located worldwide. However, this church has been actively in- volved in divesting itself of its hosPital operations - none of which are, or have been located in Michigan. Because nuns and/or members of the Seventh Day Adventist Church may eschew union membership on religious grounds, the MSU Survey solicited information on the religious composition of hospital nursing staffs to arrive at a conclusion regarding the effect (if any) a significant number of nurses belonging to a religious order would have on the hospital-nursing staff collective bargaining status. 63 ”plus at least one year of post-graduate training; baccalaure- ate degrees; associate degrees and hospital diplomas. The intent of the questionnaire was to solicit percentage figures that accurately portrayed the aggregate educational backgrounds of the responding facilities. Several questionnaires contained circled figures, indicating that they were estimates.81 Roughly 20 percent of the responding facilities failed to include any answer to the query, and answers that were pro- vided were frequently in absolute, rather than percentage terms. Because of the extensive interpreting necessary to reduce the data to a common and meaningful form, and the associated reliability and validity threats that are inherent in such interpretations, alternate data prepared by the MCHIS describing the educational backgrounds of active RNs in Michigan is relied upon in this report. In 1978, the MCHIS reported that the numbers of graduates of associate degree programs had shown noticeable increases since 1960. Table 4 provides information on the educational backgrounds of the active RNs in Michigan, according to their years of graduation. While the percentages reported in Table 4 vary widely according to the graduation years, less than 3 percent of the RNs graduating prior to 1960 received 81The sixth question in the questionnaire requested data on wage and salary schedules, and asked respondents to "circle each figure which is an estimate." Several completed question- naires were returned with answers to questions aside from number six circled, indicating estimates rather than documented factual data. Nursing educational levels were circled in several cases. -\ m..~w~<_~. 64 .44 .a .flwsmn .gpzso: Qantas to pecansmson smmmgomz .HE .wcmmcmgv unmm .momssz commumwwom cmmfl;OMz .Eoumxm :0mmeLowcH guano: o>wumpomoou cmwwsufiz ”mumaow .mpoppo wcmuuoaop ucomosaon xHDmQOEQ ommH op0m -on :OWHmscmpm mo “mos ecu wcw>wm mom:OQmos Om .ommH soumm woupmum AHHmsocow menstLQ oohwow oomMOOmmfiuom so: HmN m mam a can m was.s mow m mat m cam m was N tow H Nwa mmN as -52: eossampmm a nnmfi whoa. mcmm coma mmmfi «mmfi memfi «cam mmmfi mmmH muse» :0wumosva -msmm -onma -mcaH -ocm~ -mmmm -omm~ -mvmw -ome -mmm~ osomom -< wcwmuzz Owumspmpu mo poo» Hmwpwch ZCHHSHSQ no man; Qz< ZCEEQEA 625$? 449$th OF OZHPEOUB‘ :33 ZEU< no 20Hb.~mHm._.ch v mqm<9 ." I" ... vb» Ila u.- 015 it ‘1 65 associate degrees (less than 1 percent prior to 1955). In each successive graduation group since 1960, the proportions coming from associate degree programs have increased. Using the intervals from Table 4, the proportion of active RNs in Michigan from associate degree programs has more than doubled every four years, from the 1950-1954 period, to 1970-1974. By 1977, 45.2 percent of the active RNs in Michigan were from 82 The chief significance of this associate degree programs. statistic lies in the fact that, for the first time, hospital diploma graduates were displaced as the largest group of active RNs. A 1976 MCHIS report further substantiated this changing trend in the educational preparation of the active Michigan RNs. Although the report was compiled from data collected two years earlier than the 1978 MCHIS document, the trend toward increasing numbers of associate degree holders was becoming increasingly evident, particularly among younger nurses whose entrance into the labor market has been relatively recent. Data from the 1976 MCHIS report is reproduced in Table 5. In- formation from Table 5 illustrates the increasing tendency of younger nurses to have graduated from associate degree programs. How have educational preparations affected income levels? According to a February, 1980, report in RN magazine, they 82The 45.2 percent figure refers to the initial type of nursing education. The 1977 MCHIS report cited in the text documented the fact that a small percentage of the active RNs held higher nursing degrees in addition to their initial ed- ucational qualifications. 66 TABLE 6 DISTRIBUTION OF ACTIVE MICHIGAN RNSzPY EDUCATIONAL PREPARATION AND AGE, 1977 - Educational PreparatiOn 6:56 Agfiive (percent distribution) up Hosp. Associate Baccal. 4 Not Diploma Degree plus Given Total All Ages 35,996 66.2” 14.9 17.0 1.8 100.0 v.4). Under 25 years 3,973 50.5 31.4 17.7 0.9 100.0 25 to 29 years 7,136 52.1 22.1 25.0 0.9 100.0 30 to 34 years 5,090 62.7 15.8 20.5 0.9 100.0 35 to 39 years 4,055 65.5 16.1 16.8 1.6 100.0 40 to 44 years 3,910 70.1 12.4 15.5 2.1 100.0 45 to 49 years 3,804 77.3 8.0 12.5 2.2 100.0 50 to 54 years 3,654 80.9 5.3 11.1 2.7 100.0 55 to 59 years 2,332 82.5 4.3 10.0 3.2 100.0 60 to 64 years 1,517 83.0 2.6 10.5 4.0 100.0 65-plus years 522 82.5 1.0 9.4 7.1 100.0 Not given 3 - - -- - - 3 Percent distributions are based on State-wide MCHIS surveys. SOURCE: Michigan Cooperative Health Information System, Michigan Nurses, 1975 (Lansing, MI.: Michigan Department of Public Health, 1976), p. 18. 67 really have not made much difference. While baccalaureate graduates have reported higher mean incomes than associate degree graduates, experienced hospital diploma nurses are still "slightly ahead in the economic sweepstakes."83 Salaries The MSU Survey addressed itself to several areas in terms of wages and benefits. In these areas, information was solicited on gross earnings (which were converted to gross hourly earnings in the analysis), shift differentials, starting salary and continuing education incentives, full- versus part-time benefit packages, and the designs of the benefit packages. The issue of salary and benefit levels and the data obtained on them raises questions about the value society 84 Despite significant assigns to the nursing profession. wage increases over the last ten years, hospital wage levels continue to be relatively low. In 1968, BLS statistics ranked 85 In spite the industry next to last of ten major industries. of the rapid expansion in the industry since that time, hos- pital wage levels have failed to show corresponding increases. 83Lynn Donovan, "What Increases Income Most?" RN 42 (February 1980): p. 28. 84Andrea L. Lucas, "What's Nursing Worth?" RN 43 (January 1980): p. 32. 85Miller, "H05pitals," p. 380. 68 Fringe benefits have also suffered in comparison with other industries. In December, 1978, the United States Chamber of Commerce reported that an average of 36.7 percent of all private industry's payroll costs were accounted for by fringe 86 Hospital fringe benefit costs benefit expenditures in 1977. were 25.7 percent on the average, the lowest for the twenty- one industries surveyed.8 On a more personal level, salary levels provide a bench- mark against which individuals evaluate their career situa- tions. Recent studies have indicated that income is the fourth most common reason among RNs for changing jobs, and the first 88 While such most common reason for contemplating a change. intangible job factors as a "sense of achievement, knowing you help others, intellectual stimulation and fellowship with colleagues" have all been mentioned above salaries on nursing hierarchies of needs, income levels manage to surface above these others as tangible, de jure obtainable issues in the collective bargaining forum. A national survey of nursing personnel salary levels by Andrea Lucas published in January, 1980, estimated nurses' mean income at $6.78 per hour.90 However, the regional mean 86Ibid. 87BNA, Daily Labor Report, December 18, 1978, pp. Bl-B20. 88Donovan, "What Nurses Want," RN 43 (April 1980): p. 26. 891bid., a. 24. & 90Lucas, "What's Nursing Worth?" p. 32. 69 for the Great Lakes region (Wisconsin, Illinois, Indiana, Ohio and Michigan) was $7.04 per hour. Table 6 illustrates the survey findings on a geographical basis. TABLE 6 REGIONAL MEAN HOURLY NURSING SALARIES, UNITED STATES, 1980 . Hourl mean . Hourl mean Reg1on incgmea Reglon in)c,omea Far West $7.92 (+16.8%) Plains States $6.57 (-3.1% Great Lakes $7.04 (+3.8%) Mideast $6.48 (-4.4% New England $6.88 (-1.5%) Southeast $6.43 (-5.2% Midsouth $6.64 (-2.l%) South Atlantic $6.43 (-5.2% Rocky Mountains $6.63 (-2.2%) Total $6.78 aParenthetical figures indicate the percentage difference from the national mean in each region. SOURCE: Andrea L. Lucas, "What's Nursing Worth?” RN 43 (January 1980): p. 35. The survey population for Table 6 was a maxture of RNS (92 percent) and LPNs and LVNs (8 percent).91 Almost 22 percent of Lucas' survey population reported their primary places of employment as "non-hOSpital" settings, while 78.3 percent reported hospitals as their place of employment. The signifi- cance of this data is two-fold. First, the mean hourly salaries are bound to be slightly lower than corresponding means in strictly RN surveys, due to the 8 percent mixture of LPNs and LVNs. Second, because almost 80 percent of the respondents in the survey were employed in hospitals, the 91Licensed Vocational Nurses (LVNs) have the same educa- tional and professional standing as LPNs. In California and Texas, LPNs are referred to as LVNs. 70 figures are highly reflective of hospital (rather than public or occupational health, private duty, etc.) pay scales. Table 7 illustrates the mean average hourly wages for selected nursing personnel in Michigan hospitals. As would be expected, head nurses were at the top of the four-step salary scale, with average hourly earnings of $7.44. Staff RNs were next on the scale, at $6.50, followed by LPNs ($4.95) and aides (3.99). TABLE 7 MEAN AVERAGE HOURLY WAGES, MICHIGAN HOSPITALS, 1979 . . Mean average Number of hos- Pos1tion hourly rate pitals reporting Head Nurse (RN) $7.44 110 RN (Staff) $6.50 128 LPN $4.95 130 Aide $3.99 ‘ 49 SOURCE: Michigan Hourly Compensation Survey, January 1979. Data obtained in the MSU Survey provided further evidence of the relatively high nursing salary levels in the Great Lakes Region. General duty RNs were reportedly receiving hourly salaries ranging from $2.78 to $13.97. Table 8' contains a summary of the data concerning mean hourly nursing wages. 71 TABLE 8 MEAN HOURLY NURSING WAGE LEVELS, MICHIGAN HOSPITALS, FALL 1979 Position Average Average Average Minimum Maximum Mean Head Nurse $7.52 $9.05 $8.26 RN (Staff) $6.45 $7.87 $7.27 LPN $4.95 $6.08 $5.48 Aide $3.95 $4.79 $4.44 Note: See Appendix, Table 6,1, for supplementary data on these wage levels. SOURCE: MSU Survey Data. The figures reported for each nursing position exhibit increases of roughly 11 percent over corresponding figures in Table 7. While the Table 7 figures were contained in a 1979 publication, the data was actually collected almost a year prior to the MSU Survey, at least partially accounting for the across the board increase in the salary figures. Average mean levels for LPNs were 23.4 percent above the hourly figures for the aides. There was a 32.6 percent increase in the average mean levels for RNs over LPNs, and a 13.6 percent increase in the head nurses! hourly mean above that of RNS. The figures in Table Be are based upon sample populations roughly equivalent to those in Table 7. In each nursing position listed in Table T8, the average hourly maximum rates are between 20 and 23 percent above the minimum levels. Thus, given the current salary figures from Table 18, newly employed nursing personnel in Michigan hospitals can anticipate their future earning potential to t .5. ' \ “in - n -‘— I (I) (p .. ‘F/ IA. If! ‘I '8 ’v’ 72 peak at roughly 20 percent above their starting rate. Unfor- tunately, the MSU Survey was not able to measure the number of years necessary for the nursing personnel to reach their respective income ceilings. What is the likelihood that hospital-employed nurses will remain employed at a facility long enough to reach the maximum salary levels? Probably not very great. Table 79, from the 1978 MCHIS report on RNS, compares the age compositions of RNS in five employment settings. The data contained in the table supports the generally accepted hypothesis that nurses (RNS in this case) frequently enter the labor market in hospital settings, but repeatedly leave their initial positions for other hospitals or areas of employment. In three of the four employment categories listed in Table '9 (other than hospitals), the percentages of active RNS actually increased with increasing age levels (prior to the 60-plus years category). However, hospital employment became less common with advancing age. 73 TABLE 9 PERCENT DISTRIBUTION OF ACTIVE RNS IN MICHIGAN BY AGE IN SEL- ECTED EMPLOYMENT SETTINGS, 1977. ‘ Employment All A e Setting Ages 20-29 ~3o-39 40-49 50-59 60+ Hospital 1 100 36.8 28.8 17.7 13.4 3.2 Pvt. Duty 100 13.1 19.7 23.5 23.9 19.8 Schools 2 100 6.4 19.3 29.8 31.8 12.7 Occpt. Hlth 100 5.6 20.2 26.8 35.4 11.9 Other3 100 15.6 39.7 23.8 15.6 5.4 1Abbreviation for Private Duty Nursing. 2Abbreviation for Occupational Health Nursing. 3Excludes employment in nursing homes, nursing schools, offices, community health centers, or self-employment. SOURCE: Michigan Comprehensive Health Information System, Re istered Nurses, 1977, (Lansing, MI: Michigan Department of PUEIIC HeaIth, 19785, p. 50. An April, 1980 national survey of professional nursing goals by Lynn Donovan revealed that 40 percent of the nursing labor force drops out of the job market at some point in their careers.92 Nine percent leave the profession entirely, 4.4 percent drop out because of job frustrations, 1.5 percent because of long hours, and 2.4 percent because of the demands of the job.93 In addition to this alarmingly high attrition factor, contemporary nurses exhibit strong tendencies to switch jobs within their specific employment categories. Today's nurse holds her first hospital staff job an average 92Donovan, "What Nurses Want," 0. 29. l. 93lbid. 74 of 2.3 years; her second, 2.33; her third, 2.76; her fourth, 3.37.94 Hospital staff nurses responding to Donovan's pro- fessional goals survey had been in their present jobs an average of 3.89 years. These rapid turnover rates do not represent promotions or transfers. There was a 75 to 85 per- cent chance that the nurse was also changing employers in his 95 or her job switch. Donovan found that "job 'expectancy' or duration for the profession as a whole stood at three years 96 While and ten months between (job) changes (in 1980)." nurses 45-plus years of age have averaged seven full years at each job they've held, nurses in the 25-to-34 and 35-to-44 year old age groups have held their jobs for only 2.6 and 3.9 97 Viewed in total, this information leads years, respectively. to several conclusions. The hospital-employed nursing attrition rate is far higher than the prevailing rate in other nursing employment settings. The profession as a whole is characterized by an exceptionally high drop out rate (40 percent), either permanently, or for spans that frequently range from one to ten years.98 94lbid., p. 27. 9516id., p. 29. 96lbid. 97lbid. 98Inherent in the assumption that "the percentage of hos- pital staff RNS receiving maximum hourly salaries due to their extensive tenure is relatively small" is the further assumption that hourly maximum salary levels are at least partially based on continuous or cumulative institutional lengths of service (as well as performance evaluations, etc.). 75 Contemporary nurses, particularly those in hospitals and under age forty-five are virtually in constant movement in the labor market. Hospital staff nurses frequently hold their first four jobs an average of less than three years apiece, and switch employers with each change about 80 percent of the time. The high turnover rates seem to be related to several factors; labor market conditions that find employers in substantial competition for the limited supply of nursing personnel (encour- aging high rates of mobility throughout the market), the high stress levels and demands upon nurses in hospitals relative to other avenues of nursing employment, and the relative youth of hospital-employed nurses that allows them to pursue numerous alternative career options. These factors all support the conclusion that the percentage of hospital staff nurses receiving the maximum hourly salary due to their continuous length of 1.99 In spite of the rapid nursing service is relatively smal turnover rates in hospitals, it is theoretically possible that nurses could reach maximum salary levels more frequently than the evidence presented on this topic leads one to believe. A salary schedule offering maximum wage levels within two or three years of employment would make maximum levels relatively 99Hospital staff nurses responding to, and serving as the survey population of the 1980 RN Survey edited by Andrea L. Lucas exhibited the following characteristics: 92 percent were RNs, 8 percent were LPNs or LVNs; 78.3 percent were employed in hospitals, 21.7 percent in nonhospital settings; 20.7 percent were covered under union contracts, 79.3 percent were nonunion. Lucas, "What's Nursing Worth?", p. 39. 76 easy to Obtain as far as lengths of service are concerned. In the presence of such a schedule, maximum salaries would be attainable even for the new job hopping enterants into the nursing labor market. Some evidence also exists to support the conclusion that experience has a relatively negligible impact on nursing income levels. A February, 1980, income survey by Donovan indicated that its "most shocking finding" was that "chances are better than even you'll (hospital staff nurses) never make "100 Donovan's 1980 income survey much more than a beginner. suggested that "despite some slow, steady gains, about two- thirds of the 1,595 nurse respondents earned between $10,000 and $15,000 a year - regardless of the length of time in the * field."101 More specifically, this survey found that 72.9 percent of the new graduates entering hospital service are receiving between $5.00 and $7.50 per hour, yet more than half of the respondents with fifteen-plus years of experience make "the same $5.00 to $7.50 that most graduates are command- ing in less than a year."102 Donovan's 1980 income survey concluded that "if you're (hospital staff nurses) not interested in a promotion or career advancement, and prefer to simply 'do' nursing, chances are better than ever that y0u'll never wind up making much 100Donovan' "What Increases Income Most?" p. 28. 101lbid. 102lbid., p. 30. 77 more than a beginner."103 Although Michigan is located in the second highest paying region in the country for nurses, this generalization probably holds true in the state. MSU Survey figures indicated that the average mean hourly wage for head nurses (from Table i8) was only 9.8 percent above the average minimum. The mean for RNs was 12.7 percent above their average minimum. The mean for LPNs was 10.7 percent above their average minimum, and the aide mean 12.4 percent above the average minimum levels. This information further reinforces the picture that the nursing salary growth potential in Michigan hospitals in quite limited. While average maximum hourly rates are roughly 20 percent above the minimum (or starting) levels, the average wage rates are roughly 11 per- cent above the minimum levels. Whether or not working in a large hospital is more chal- lenging, stimulating, and generally satisfying may be open to debate. But there is little doubt about the financially quanti- fiable rewards employment in larger facilities brings, whether compared with small-hospital salaries, or with national and regional mean wage levels. Donovan's 1980 income survey reported that the mean hourly nursing salaries in hospitals from 50-199 beds were 6.2 per- cent lower than the national mean, while hourly means for 200- 399 bed and 440-plus bed hospitals were 2.2 and 6.2 percent above the national mean, respectively. Table 10 examines the 103lbid. 78 mean salary levels of full-time nursing personnel employed in hospitals responding to the MSU Survey. It supports the hypothesis that nursing salaries tend to increase in larger hospitals (relative to smaller facilities). Almost without exception, the hourly wage levels reported in each nursing category increased with each corresponding increase in the hospital bed size. Average mean salaries for head nurses were 26.5 percent higher in the largest (401-plus beds) hospitals than in the l-100 bed facilities. Hourly RN means increased 18.3 percent, LPNs 23.4 percent, and aides 35.9 percent over the same increase in bed sizes. The LPN category was the only one in which there were not straight line wage increases with each increase in hospital bed sizes. However, in the case of the LPNs, wage levels did show overall increases from the 1-100 to the 401-p1us bed size hospitals. The trend toward larger salaries in larger hospitals that was demonstrated on a national level in Donovan's 1980 income survey was confirmed and expanded upon by the MSU Survey. 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H oo>HH ooo .oHoH H.HH HH H.HH HH H.HN H H.HH H H.NH NH N.NH HH ou H H H H H H H H H H H H ozHH H.HHH NHH H.HHH NN H.HHH H H.HH HH H.HHH HN H.HH HH HHoooH zH H.H N I I I I H.H H I I H.H H oo>HH ooo .oHoH H.NH HH H.NN NH H.HN H H.HH H H.HH oH o.NN NH ou H H H H H H H H H H H H Hzm Hose Hooooou HHoooH +HHH HHH-HHH ooH-HoN ooN-HoH HHH-H oNHH oom HooHoHoz mNHH omH HH=H DH: Ho HDHm am so pommn mzmp com we opsmHm .mcucoa mm mm poupoaomu 142 mNmH NNmH «com mH o.om H.mHH HH HHHOHocoz HNHH ONmH cN HHHzm H o.N HH.H m Hmoog\oumum umoumq umoHHHmm Hmomcoq amouhocm :uwcoH numcoH mucopHucH HHHHHomm --muwo>-- --ow:mm-- :meoz owmho>< mo honssz mo ooze H HNHH .Homazoo Hmoom9m ham manmb mucmEOHmasmv QmDH>Omm ZOHHOmm mHZMQZOAmmm mo mmmZDz : xNocoea< Appendix I RN SHIFT DIFFERENTIALS REPORTED IN CENTS PER HOUR, BY UNION STATUS AND HOSPITAL BED SIZE Ln.’ : ém_'_ 7.. 243 Appendix I RN SHIFT DIFFERENTIALS REPORTED IN CENTS PER.HOUR, BY UNION STATUS AND'HOSPITAL BED SIZE .AFTERNOON . Uhion Nonunion Total Bed Size n ¢ _ n. ¢ n. ¢ 1-100 15 35 36 25 51 28 101-200 10 43 8 40 18 42 201-300 6 61 8 35 14 46 301-400 1 45 4 64 5 60 401-p1us 4 49 4 40 8 44 Total 36 43 60 32 96 36 ‘NIGHT . Union Nonunion TOtal Bed Slze n ¢ n ¢ n ¢ 1-100 15 39 36 34 51 35 101-200 10 46 9 41 19 44 201-300 6 70 8 35 14 50 301+400 1 60 4 70 5 68 401-p1us 4 52 4 40 8 46 Total 36 48 61 38 97 41 Appendix J EDUCATIONAL INCENTIVES AND REIMBURSEMENT PROGRAMS REPORTED BY MSU SURVEY RESPONDENTS 244 Appendix J EDUCATIONAL INCENTIVES AND REIMBURSEMENT PROGRAMS REPORTED BY MSU SURVEY RESPONDENTS Per semister/ term, or credit hour reimbursement schedules: $200 maximum $200 or 75% (whichever is less) 50% 50% plus additional tuition smplements $350 maximun two-thirds of tuition 75% for fullvtime employees; 50% for part-time over 24 hours per week 100% for full-time; prorated for part time 100% for first $250, and 75% of the difference up to $600 per year for full-time; 50% for the first $250 and 37.5% of the differ- ence up to $600 per year for part-time 75% up to 8 cr. hrs. per semister for 32-plus hour per week em- ployees 75% up to $250 per term 50% up to 6 cr. hrs. for full—time; 50% up to 3 cr. hrs. for part- time employees. 75% up to $300 per semister for 1mionized employees; 50% of this for part-time and nonunion employees $45 per credit hour (maximun) $50 per credit hour (maximum) 100% for 9 credit hours per year 100% for up to $50 per credit hour Per year reimbursement programs: $100 (maximum) 50% up to $500 $125 (maximum) $300 $150 $400 $200 $500 Achievement related aid programs: #1) A=80% #2) percentage for A or B B=70% C=60% #3) A, B or C reimbursed at 100$ of cost below C=0% Othe reimbursement programs: 75% of total costs 100% of total costs 100% of tuition . 75% for night shift nurses; 50% for afternoon shift nurses Appendix K FTE NURSING POSITIONS BY CITY SIZE FTE NURSING POSITIONS BY HOSPITAL BED SIZE FTE NURSING POSITIONS BY TYPE OF HOSPITAL CONTROL Z45 .Mnendhcx FTE NURSING POSITIONS BY CITY SIZE City Size HN RN LPN Aide Totals 'Reportingl 1TH),000+' 390 3,508 1,845 2,592 8,335 24/ 59 50,000-100,000 261 2,979 1,327 1,812 6,379 17/ 24 25,(HHJ-50,000 117 1,050 561 581 2,309 11/ 27 10,000-25,000 172 770 565 1,439 2,946 18/ 27 under 10,000 306 1,041 911 1,756 4,014 49/106 'Totals 1,246 9,348 5,209 8,180 23,983 119/243 FTE NURSING POSITIONS BY HOSPITAL BED SIZE Bed Size HN RN LPN Aide Totals Reporting 1-100 304 900 710 1,109 3,023 54/ 99 101-200 215 ' 1,050 592 1,023 2,880 22/ 54 201-300 152 1,546 789 1,044 3,531 15/ 35 301-400 152 1,302 787 691 2,932 8/ 17 401+ 423 4,550 2,331 4,313 11,617 20/ 38 Totals 1,246 9,348 5,209 8,180 23,983 119/243 FTE NURSING POSITIONS BY TYPE OF HOSPITAL CONTROL Hospital Control HN RN LPN Aide Totals Reporting Proprietary 3 2 2 21 28 1/ 5 Non-profit 718 5,070 2,829 3,605 12,222 69/145 Non-profit/Rel. 154 1,552 769 687 3,162 10/ 20 Federal gov't 53 454 179 505 1,191 3/ 6 State gov't 52 258 332 2,146 2,788 7/ 14 Local gov't 225 924 681 1,090 2,920 23/ 53 Other 25 1,061 385 89 1,560 4/ 4 No Info. 16 27 32 37 112 2/ 2 Totals 1,246 9,348 5,209 8,180 23,983 119/243 1 'Nuzfirst figure indicates the number of hospitals that provided infonmnion on FTE nursing positions by the categories listed. Theifigure in the right hand column indicates the total number oflumpitals in each category in the 243-facility effective population. 2 Abbreviation for Non-profit/religious. 3 Nocxmtrol type was indicated by these two respondents. Source: Questions one, two, four and six in the MSU Nursing Data Sheet. Appendix L UNSUCCESSFUL/INCOMPLETE FORMAL ORGANIZING EFFORTS REPORTED BY HOSPITALS RESPONDING TO THE MSU NURS- ING SURVEY (since 1970) NmoaN may an voweOmONQON mowmmv mww uwwopm-:o: ooo.ooN ~2 pm z Nm NNMONQ-:o: ooo.oN News: mnmN fi.nomv\:Nmm >o>93m mo oENu um mmOOONQ eN Nm uNwoem-:oe ooo.oN News: mnmN\mNoxnozNooum :ezov wouo>z om .u.>ow oco.ON Noon: oumN\mNoumEnoH NmooN ooo.ow News: mueoEEou SONNm com NONpeou AONNm xuNuV Nmo>\eoNumNNGNMNo gonna NmuNamo: NmuNmmo: :ofiumuoq No maze NnuNnmo: JIIIIIIIIIIJIIIII 247 Appaufix:L-conthned .uoozm mama xo>psm mcwmuoz am: can mo cooueo>om use :ooume .eoouesom .Naom .ozu.o:o meoNumosc :« wouhomou :oNumENow2H "eousom .mONcheoNumoso ooeuouou o:u.:N woueoeoooo moeo ecu one: oNnmu mNzu eN UONNOQON mahowwo meNNwemwNo xNeo one .>NN>Nqu one mo .umox who: mopooop NmENow 0: use .»HN>Nuom eofles oEom soon on: opocu peep oONNQON mNmuNmmo: Nocuo .oN noses: eoNonoao oo ..ooo .:aene: .zmoouoeocz wewuozmcm meENm mopmmeeofiumosc mcwepouou mNmuNOmo: 6:» mo Nmeo>om thoz .mpoxpoz oomamONo< use mumflcfizomz mo :oNumwuomm< HmeofiumehoucH man Now cONNmN>opnnNNw wchmemMNo on» mo mafia on» u< .eoNea NmeoNumeuoueN meoNo N mxo>psm ago No oeNo oeo ea eoooee eea oNNoea-eoe eee.eeN aNaN\m2uma< -coo mewon whommo meNNwemMNo ooo.om NcoNeoeoo NNoeoN cow .o.>om eee.eN N\mzuma< -Nso ope m2dq w mzzv .co>Nw mumpm News: No: mpNomON :oNuuoNo-moeNn .coNuooNo :oNumueomONQON 2m mNcu so: mam NNMONQ-:0: +ooo.00N mnmN\u:oeenooveN .uEmE ”whommo mNsu ou NONNQ voncoNcs ONO: mome w mZQN flooNozeo: Ohm xNu:ON emm NNWONQ-:oe +ooo.ooN wnmN\=Nmm -Noo NoseOmpom mcwmuse NNmV mnmN\:oN:D :meofles empoomon mooonmEo: rIIIIIIIuIIIIIrIInIzaulllllnulirllllxnlltltxl .NueH whoeeouumm w new 4835 22:3QO 48.0; NNQN\=me I/l/l/ENEN: Appendix M WORK STOPPAGE SUMMARY 248 Appendix M KIRK STOPPAGE SIMIARY STARTING GROUP DATE LENGTH BEDS HOSPITAL TYPE Aide 3/ 77 26 Days 21 State RN 7/ 78 28 Days 56 Nonprofit LPN 7/ 78 28 Days 56 Nonprofit LPN 11/77 64 Days 93 Nonprofit Aide; 11/77 64 Days 93 Nonprofit Orderly 11/ 77 64 Days 93 Nonprofit LPN 7/79 122 Days 127 Religious Aide 5/68 35 Days 143 Nonprofit LPN 7/ 76 19 Days 145 Nonprofit Aide 7/ 76 19 Days 145 Nonprofit HN (1971) 14 Days 158 Nonprofit RN (197]) 14 Days 158 Nonprofit RN 3/78 45 Days 199 Nonprofit LPN 3/78 45 Days 199 Nonprofit LPN 3/73 30 Days 214 Nonprofit Aide 3/7-3 30 Days 214 Nonprofit Aide 4/ 75 15 Days 224 Nonprofit Aide 5/72 1,004 Days 239 Nonprofit RN 8/77 25 Days 243 Nonprofit RN 12/ 77 76 Days 256 Nonprofit RN 12/78 1 shift 409 Local Gov't. Aide 2/79 4.5 Days 409 Local Gov't. LPN 2/79 4.5 Days 409 Local Gov't. LPN 5/77 13 Days 473 Religious Aide 5/ 77 13 Days 473 Religious RN" 3/70 2 Days 524 Local Gov't. Aide 3/70 2 Days 524 Local Gov't. LPN 3/70 2 Days 524', Local Gov't. SOURCE: 1611 Survey Data . Appendix N LABOR LAW STATUS OF MICHIGAN HOSPITALS 249 053a 0008 “50500038 50300 ou “Ewan 05 03:08 0N0 000.838 053% 855500.30 N00 3.50m .0 0898:. :55 0.8 000838 0005 MO 0500 .8835 .800 on 95.380 035 050008 :55 056055005 0008 05 0558.3 83:58:00 33 05 0030000 8558a 0088m 550 0000.0 00550008 5 0008350 .880 No: 008 088350 05350 .505 N05: 505000.300 5030p 0:0 508:0 .505 we 085005808 .805 52” 3 0008350 05505 85853. . 38$ 000850 on . €35 eNN.mNe-NeN.mNe 05380 .083er 93 82950 53602 .oo< 95323 0.85.605 833 .m .085 -0588: 53:59, 5 0.555 0 mo 088 05 5 0:500:30: 000.580 0380 on 50:00 0005 00559.0. 0.8000 05 0:0 0003508858030 .05on 000.538 ea 508.50 0850.53 .884 0.8000 05 00000.5 .N . 4530.5th0 00:08th 3505885 x8500 ”00:80 N550 @585 005m 005N000 $8305 0550:0005: ou 005.55 53053 08305882 .N 932 m0» m0» 2 00% .2 3.3 $32 0.80m .00: 8004 A: 00% m0» 3 m0» OH 33 $5 $52 m0» m0» m0» mmmfi @332 5.83:0: 052 no» no» no» $2 $32 0.80m .002 .884 . H: 00» m0» MWm0» mmma N.NN—4N 030005.508 mummz NVm0» 00% o: 33 magma N005 \0008 .8004 .8 .000 .800 - . oNN Ema N30: .o.m 88800 N03052: N8» no» on $2 002: .o.m N288 83055880 50500038 05:0w8 05.30 005m .3 00.880 090 5:: now 500.82 ow New? Runway. w550w8n N05906: 55.8550 .5200 on New: 25.300: zauNENz .8 03.2.8 :5 e093 z 538% 250 .0025 000 50 85005005 58000505 "0500055055 .8050 905005000 . 500500 -0505 .8000 5 0500 cc 0508> .0500 03 505005580 050500000 00 .8505 00055000 505000555005 0050>0< 8000080 <52 55 0050555005 0000 0505000 05.805505 .50 800290 SN .80 520.80-00.00 028000 .32 .8 505. .02 .030 00 .020 .0 .580 08 .8000 :2 50555500 5 0050005 000 00 50500005000 .50 0505000508000 050 .00055000 0.83 0 05000005 ummz 000 0053 05080550 -00 005005 005.080 50 055500 55500505 .000055000 2.83 00505550 50055000 050805 00 5850005 50500005 .020 255 om . 52 .N 555 8008808 58.008: 82.000 .> .00 00 .2025 685250 000505: -52 050 505500 .0000m 50 5050000005 50050053. 305 .02 50000 5 050055 050 00082000 50550850350080 . 5.20 :5 .05 Z... .8550 .008 23.2 .000 0.8 02 00 .0 m: 68805 .520 000 552 3 .0838: 080.55 0 5000505050 5000500 .8500500505 00500050 0500550 .8 00500 050 00000 000 050 50555005 05.000585 0 50 000.880 000 0550.05 000000500 003 0000 050 5550 .050055000 055005505 00880 00¢ 005002 000 05503 .305 5 00500500 0.83 08505805 .8580 050055.55 05.0 50500005000 05. 050505000 50500005000 05 000550 00 05005508 .8580 050055.55 0053 .00055050 50055000 50 0000 000 5 50500005000 05050 00055000 <20 000 .035 00 535 805 .52 .00 550 5 .oz .22 .<.0 05. .52 .0 2:3 5 .oz .22 :50 .3 088:0 00 . 802 .0 253 0: .oz .22 .420 505005 .55 8000562 083 500505: .5020 00 552 02 4000080 08.80 085002 03% .000000080 0858: 80:0 .32.. 05.85 50580500 005500 000 0500053 00000000 505005005055 00000 080 505 0000 50505.0 00050500550 0053 00000 000 555550 00 005.80 003 08505553 055080 505550 00000 000.035 00005 00 0580 0050555005 50000505005 .88 505005005055. 008000 0502 000. .5005 55055 0050555000 00000 88 8500500505 0055000 0202 000 050 .0050555005 50000505005 .50 0000080 000 50 050550 003 8055 .m 5550 .03 .0000 .05 9D 8.5 005002 085 005. .0580 50000002 083 505002 95 500250 #8505550 000 50 50555050505000 000 000 050505000 5050508 00500050 .0505505550 50 0580 05000000 850558 000 0053 8.5500 050 0005 00 00050 000 080 000505550 .2 .55 .3 BIBLIOGRAPHY BIBLIOGRAPHY Abodeely, John B. 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