I recently had a conversation with a self-described early-career, mid-level hospital administrator/manager. This person -- who agreed to the interview on the condition of anonymity -- reported that in a prior life she was a registered nurse, but moved into management for a variety of reasons, including less work stress, a better schedule, and a potentially better financial future.
When I brought up the topic of physician and nursing unionization efforts, her answer was not at all what I expected.
After confirming that I would never share her name or demographics, she stated that she is secretly very pro-union within healthcare.
After expressing my shock -- that management would be at all pro-union -- I asked her why.
She pointed out that she is profoundly aware of the increasing difficulties facing doctors, nurses, and other healthcare workers in our progressively disruptive workplaces (one main reason she left clinical nursing), and noted that healthcare has now been rated as the in the U.S. She said she feels that corporate management (at her mega-hospital corporate structure) seems increasingly detached from the realities of the healthcare workplace. Instead, they seem primarily interested in profit (or at least combatting financial losses) and staying afloat in an ever more challenging healthcare financial battlefield. She confided that she is left unsure where worker conditions and patient outcome concerns fit into her facility's management plans.
She also shared two themes increasingly voiced by her team member peers and management supervisors when there is talk (not frequently) about workplace conditions and patient safely issues. Theme #1: Doctors and nurses are "adrenaline junkies" and chose to go into this chaotic lifestyle -- why feel sorry for them? Theme #2: Doctors and nurses, by their training, certification, licensing, and state and federal rules are the ones obligated to make healthcare safe for patients. It's their job to figure out how to make it work, while it's management's job to figure out how to make a profit (a division of labor)!
She reports that she feels intense pressure from above and even peer pressure from within her management team to continually find ways to cut costs, increase patient volumes, and squeeze more performance out of doctors, mid-levels, and nurses -- thus increasing profits.
Therefore, she says that if she goes to her management supervisors and advocates for her workers, requesting changes within the workplace (that will invariable be seen as increasing costs), she will be viewed as "weak" and not able to "control [her] troops." She goes on to say that if she pushes for workplace changes, one of two things (or both) will happen. First, her hopes of rapid advancement within management will be delayed or squelched. Second, senior management would probably replace her with someone they thought to be tougher and better able to control their workers.
However, she posits, if her facility was unionized and the union were to confront management and insist on the same workplace changes, she feels an entirely different scenario would play out. She notes that she would probably not even be brought into that process.
Corporate management (located in a distant state) would probably send in a negotiating team to deal with the union. She suspects that, faced with a strike-related shutdown of the hospital or various services, the management negotiating team would work for the best solution for management, but as a bargaining solution, there would end up being negotiated improvements for the workers and the workplace.
Thus, the result would be the improved workplace outcome she might have sought -- but without the risk of her losing her job!
She goes on to say that with the combative conditions she currently sees dividing management and hands-on healthcare workers (suits versus scrubs) she does not see any pathway other than unionization that can force management to bargain and thus improve healthcare workplaces.
When I asked if she feels that other administrator/managers might feel this way, she replied that she suspects that many who have migrated out of the clinical workforce (as she did) into management may have similar feelings. But she also counters that she is seeing increasing numbers of administrator/managers who are now entering healthcare management with little to no clinical background.
Coupling this conversation with others I've recently had with those on both sides of the healthcare workplace equation, it appears that opposition is, in fact, widening.
On one side, management at many facilities seem increasingly isolated from their frontline worker colleagues and often hold the perspective that their own workers are an obstruction to profitability. Meanwhile, many doctors, nurses, and other frontline workers perceive management as oppositional, and senior management in particular as increasingly (no clinical representation) and predominately focused on profit, at the expense of workplace conditions and patient outcomes. Meanwhile, our healthcare workplaces face harsh criticism from outsiders, and remain the in the U.S. -- and getting worse.
Unless this expanding chasm between management and frontline workers can be bridged, then maybe the manager I interviewed is correct -- will unionization be the only way to improve many of our healthcare workplaces?
is an adjunct assistant professor in the department of medicine at Duke University School of Medicine in Durham, North Carolina. He frequently advises and mentors healthcare workers and managers at all levels on issues involving the healthcare workplace.