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“To Keep Not Only Patients but Ourselves Safe, We Have to Unionize”

Nurses at Mission Health hospital in Asheville, North Carolina, are about to vote on a union. We talked to five of them about why they’re organizing, how health care–worker unions can improve patient care and safety, and what a victory would mean for establishing a beachhead for unions in the South.

Sarah Kuhl joins the fight to unionize nurses at Mission hospital in Ashville, North Carolina. (Photo by Christine Rucker)

Interview by
Jonathan Michels

Right now, nurses in North Carolina are mailing in their ballots in what could be one of the most consequential elections of their lives — and it isn’t the 2020 presidential election. After a five-month delay under the National Labor Relations Board (NLRB), more than 1,700 nurses at Mission Health hospital in Asheville will finally decide if they want to form a union with National Nurses United. The election results will be announced by the NLRB on September 16.

HCA Healthcare is one of the wealthiest hospital corporations in the world with 180 hospitals in the United States and the United Kingdom. The for-profit, multinational conglomerate purchased the nonprofit Mission hospital in February 2019. Within months of the sale, nurses and patients in the mountains of Western North Carolina witnessed a sharp decline in their quality of care amidst widespread complaints over staff cuts, long wait times, supply shortages, and burnout.

That was before the coronavirus hit.

Rather than refocusing its significant resources on the burgeoning pandemic that infectious disease experts predicted could kill at least two-hundred thousand Americans, HCA leaned into an anti-union campaign to intimidate and divide the frontline health care workers.

In May, Matthew Cunningham-Cook and Jonathan Michels wrote a piece for the Intercept that examined how HCA capitalized on the pandemic by petitioning the NLRB to delay the election even as it raked in more than $1 billion in federal relief funds. Then in the interim, while nurses struggled to care for COVID-19 patients without PPE and safe staffing levels, HCA paid professional union busters $400 an hour to conduct in-person meetings inside the hospital to turn nurses against the union.

The outcome of this labor struggle will have far reaching implications. For HCA, it will mean that they can’t expand in supposedly one of the most corporate-friendly environments in the nation. For the nurses, not only will unionizing give an opportunity to improve their working conditions and the safety of their patients, but it’s also a sign that big business can no longer count the South a union-free corporate safe zone.

A successful union vote could help usher in a new era of labor organizing not only in North Carolina, the second-least unionized state in the country. Mission nurses are continually contacted by health care workers throughout the South who are closely watching the union drive in Asheville. They, too, want to know how they can unionize their hospitals.

Journalist Jonathan Michels spoke with several Mission nurses — Kelley Tyler, Susan Fischer, Jill Rabideau, Trisha Stevenson, Lori Hedrick, and Marie Oakes — about the difficulties of forming a union in the Appalachian Mountains of North Carolina, the union-busting campaign they say they’re up against, and the implications that the union drive has for the South and the nation.

The interviews have been edited for brevity and clarity.


JM

What was it like to work at Mission Health hospital before it was acquired by HCA?

JR

I am from Haywood County, and was proud to drive to Mission for so many years because it was the good hospital to work at. Didn’t mind at all to drive. It was worth it to me because — and it sounds corny as crap — but Mission’s catchphrase used to be “pursuing excellence.” And we really were. We did things based on science and best practice, and that made it straight to the bedside having direct positive effects on our patients. It has been heartbreaking to see things dismantled in less than a year that it took us years and years and years to build.

LH

I am not one of those people that felt like Mission was the greatest place to work beforehand. There were definitely problems and cuts were starting to be made when I first started working in the hospital when Ron Paulus, the CEO took over. It was because in Western North Carolina, we take care of a large population of uninsured people. The finances were not great.

But at the same time, the cuts being made seem to be more at the bedside than anywhere else. Once HCA took over, this just exponentiated beyond anything that we could have imagined.

JM

How was the takeover by HCA explained to workers and how did conditions actually change at the bedside?

JR

We were lied to when the courting process for the buyout was going on. I can very vividly remember Paulus saying that we were going to be like a flagship for HCA, that we were the largest purchase they would make, but our scores were good, our patient outcomes were good. And they were going to use what we had going to make their other hospitals better. That’s the sales pitch we were given, and that there wouldn’t be any changes at the bedside for a year. Boy, that was a big fib.

TS

We had to meet certain metrics that were unrealistic and they weren’t congruent with the care that we were providing prior to HCA. With HCA, we really saw a change, and this implementation of very aggressive metrics — whether it was collecting urine, moving a patient from point A to point D, discharging patients, or increased nurse-to-patient ratios. The unsustainability became extremely evident.

Senior nurses just started leaving by the droves. The few that remain are [staying at Mission] primarily out of convenience, flexibility. And even now, those people are questioning why they’re still here, like myself.

JR

There are days that I go and sit in a parking deck and I think, wow, I really worked hard today, and I did a horrible job. I have stayed after my shift to bathe people. Clocked out, turned my phone off, and then given people showers. It’s very frustrating that the people making the choices aren’t actually in our environment to see how dangerous it is for our patients.

JM

Many of the nurses who are native to North Carolina told me they grew up believing lies about unions, particularly that they are illegal in the South. Kelley, you are one of the few North Carolinians I have spoken with who was raised in a pro-union family. How did that perspective shape how you approached the union drive at Mission?

KT

I remember when I started working at Mission Hospital [in 1985] that my dad said we needed a union. One of the first days I was at work, I told people where I was from and they knew it was a paper mill town with a very strong union. They said, “No mention of unions at the hospital because you’ll be fired.”

Over the years, I really felt like we had a great administration and that we didn’t need a union until this last year [when HCA purchased Mission]. I am seeing the patient care go down, I’m seeing the quality of the products we’re using go down. It’s just not in the best interest of the community. Since we’re the majority of the critical care in this area and in all of Western North Carolina, the community needs to know what has happened.

I wasn’t sure what a union would look like in a hospital but very much wanted to make sure that our voices were heard and that we were taken seriously.

JM

The union drive started in May 2019 when four nurses met with an organizer with the National Nurses Organizing Committee. Tell me about the early days of the campaign and how you got involved.

JR

I wish this had been my idea. I wish I had actually had time to sit and think about it and formulate how to get some sort of infrastructure to push back. But it wasn’t me. I just happened to be at the table. Sadly, about three or four months into it, conditions deteriorated so badly that [the nurse who started the union drive] felt in order to protect her license, she needed to leave the system, and she did.

SF

On May 18, 2019, Jill Rabideau called me. I can’t remember if she remembers that I was actually in a union. I was in the United Food and Commercial Workers [International] Union in Chicago, and that’s what helped put me through [nursing] school without having any student loans. I worked there for twelve years. I can’t remember if we ever had that conversation or not, but maybe she thought I was a Midwesterner, so I would be open to the idea of the union. [Laughs]

But anyway, she called me that afternoon. She said, “Sue, what would you think about trying to form a union at Mission Hospital?”

I was like, “What?” I said, “Who’s on the phone? Jill Rabideau?”

This is, you know, the Southern conservative girl. It just kind of floored me that she was calling me. She said to me, “Sue, I know you feel the same way that I cannot continue to work at Mission without trying to do something to make it better for the families in our community. The care and the safety of our patients is deteriorating. And I was hoping that you would help me with forming a union.”

And I said, “Sure.”

I had my reservations. This is North Carolina. Only 2.3 percent of our businesses, I don’t even think hospitals except for the VA, are unionized. So I knew that it would be a tough thing to do.

JM

During that early period, you had to meet in secret to avoid losing your jobs. You all organized the union meetings under the guise of the “book club,” is that correct?

SF

We didn’t even have a book! [Laughs] We didn’t want people to come out and say, “Hey, would you like to join our meetings to unionize?” We would say, “Would you like to come to our book club?” If anybody came around to listen to us talking, we didn’t want to be using the word “union.”

Even when it was Mission prior to HCA, the word union, I believe they had it in their handbook that they didn’t want any talk of unionizing. It probably could have caused me to be fired.

JR

It’s scary, because Mission is the largest employer in the area. Historically, if you get fired from Mission, you’d have a hard time getting a job somewhere else. But people are to the point that they’re so angry and disillusioned that losing their job is not too bad of a thought, as opposed to losing your license.

JM

Since you had to organize in secret, how were you able to amass enough support to petition the NLRB for a vote?

JR

It was just word of mouth. Nurses talking to nurses and doing our research and asking questions, and verbalizing our concerns on the units. What’s going on? What bothers you? We pretty much all had the same concerns, particularly around patient care and staff safety.

It was empowering when you’re talking to somebody that is in a different unit than you and you have the same concerns. And there’s hope that there might be a potential to be able to do something about that concern that will directly affect your patients, which is why we all did this in the first place. It gives you some hope.

SF

Mission is a very large hospital. We have 1,600 nurses voting. So many of us had no idea who worked in each of these departments until we started organizing and we started meeting one another, understanding our trials and tribulations in our departments. We have a better understanding of each other. We have become a family, which has given us much greater strength to push forward and to win this.

JM

Marie, you became involved in the union drive several months later while you were still recuperating from stage 3 uterine cancer. Why did you feel it was so important to put your energy towards winning the union?

MO

I wasn’t even back at work yet and I went to the first [union] meeting. I still had dressings on.

I was out of work for seven weeks. Apparently [the union drive] had been around since May of last year, but my nursing friends did not want to get me sidetracked because they know I have a mouth. They did not want to sidetrack me when I had my surgery. They wanted me to get better, stand on my feet. And then they told me the news. I went nuts.

When we have the union, HCA has to pay attention. We will be listened to. This has been coming for so long. I’m glad I’m here because there’s a reason why even through my sickness, I didn’t quit. Because in my lifetime, I want to see justice for these poor patients that cannot say anything. If we get our hands tied, how can we serve them? We can’t.

JM

Why do you think HCA is so threatened by the nurses’ union?

SF

Money. Profits. The control of being able to tell us what to do. They don’t want to have to spend the money on supplies to protect us or the patients.

Health care should never be profitable. When [Mission] was not-for-profit, yes, they still had to make a profit, but it was geared towards patient care. For-profit hospitals are geared towards making money for their shareholders.

JM

The idea that health care shouldn’t be about making money has been a constant concern raised among the nurses that I have interviewed. Has it been a primary focus of the Mission campaign?

SF

No. The foundation of the campaign has been to be able to take care of our patients safely and to provide a safe hospital for our community. But of course, that whole HCA idea of profits comes into play. It’s kind of hard to take care of patients when their idea of keeping a hospital system is paying their shareholders.

[HCA CEO Sam] Hazen makes $27 million a year. Who needs $27 million a year? What do you do with that kind of money?

JM

What do you hope to achieve by having a union at Mission?

KT

Our ICU is a one to three [nurse-to-patient ratio]. I would like to see that go back to a one to one, or a one to two. Step-down patients need a one to three; and bedside, surgical, and med surg needs to be like a one to four. If you don’t have a nursing assistant, then your ratios need to be different.

Basic care. Getting people out of bed and to the bathroom. Brushing their teeth. Combing their hair. Having someone to speak with. All of that makes a huge difference in what a patient’s outcome is. We don’t have the time or energy for that anymore. We’re failing the patients.

TS

I think having control over how you practice bedside nursing, having safety measures built into a contract. Larger than that, this is an enormous thing for North Carolina and the South. Certainly these corporations have the money. They have the legal teams to throw all the money at union-busting. But [unionizing] would set an enormous precedent.

JR

Sometimes I wish I could just walk away, but I don’t know why I can’t. There’s a lot of us that just can’t, because we have a love for it. We have a love for the community, and we want to get back to pursuing excellence. I don’t see another way to do that.

I’m under no illusion, [the union] is not going to be a magic bullet. We’re going to have to work from now on. If you were to talk to any organized hospital and talk to their core of nurses that are in the professional practice committee, in the bargaining committee, they’ll tell you, it’s a lot of work. But the reward for the work they’re doing makes it worth it, and it’s not money.

JM

How are you feeling this close to the election?

SF

I feel pretty good. HCA is still up to its anti-union busting tactics. I think they have stopped the thirty-minute meetings with the nurses that they felt were on the fence still. I think that has stopped, but their screen savers have been at times a bit annoying. There was one in particular that was sexist. They have tape across a woman’s mouth. I think it said NNU [National Nurses United]. Sending out these flyers, putting them on vehicles just saying awful things about some of the nurses that are unionizing. That’s been backfiring on them because a lot of people have been very angry about it.

JM

Have you mailed in your ballot?

MO

My friend Cecilia has done [nursing] forty-nine years. I’ve only done it forty-seven. So, today at four o’clock, I have three nurses who’ve done forty-nine, forty-seven, and forty-five years together. That’s 141 years of nursing. We’re gonna take our picture in front of our mailboxes and we’re telling the world that we are voting “yes.”

(Photo by Christine Rucker)
JM

Despite widespread support from the Asheville community and a strong core of nurse leaders, the election is not guaranteed. What will you do if the nurses lose the election?

MO

If we lose this election, I have made it plenty clear that I will put my resignation in because I will feel doomed. I don’t want to feel that way. I am seventy-three. I’m going to be seventy-four next month. I’ve been through hell.

But let me tell you, I’m not going to suffer what HCA is going to impose upon us. I’m not. That’s not a coward’s way out. That’s just saying I’m going to take care of me because I can’t do anything with my hands tied.

TS

[The union] is the only reason I am currently in my job. I am 100 percent burnt out. I’ve seen nurses leave who have only been working for six months, and I’m eight years with this. So I would say that it is probably the most important thing I could ever vote for, to affect change in our working climate and to provide safety.

LH

If [the union] doesn’t go through, I’m really scared to see what’s going to happen. The nurse ratios, right now, because of the short staffing on a regular medical floor, it’s six patients to one nurse. And we’ve already heard that in other HCA hospitals, the ratio is seven to one. I mean, this is gonna lead to patient deaths. If we don’t do this, if we don’t win this, that’s the bottom line.

JM

How significant will it be to win a union in health care in the South during a global pandemic?

SF

Oh, my gosh. Yeah. That’s gonna be a game changer. I mean, this is really big. I’m so proud of us for coming together and doing this. You can tell I get a little emotional thinking about it.

JM

Have you heard from nurses working at other hospitals?

SF

I haven’t, but we’ve been told there are other nurses and other hospitals that are watching very closely at what happens with us. I hope that I can be a part of helping NNU organize other hospital systems across North Carolina and the Southeast. I still want to be involved, not only here at Mission, but of course, in other hospitals, so that I can encourage other nurses and let them know that they can do it, too.

It’s very important in health care, especially today. HCA has 180 plus hospital systems, clinics, and outpatient surgery centers. They’re just buying up the Southeast, and these hospitals are going to need unions to make sure that their patients and communities are safe when they walk through the doors of that hospital. Until we can get Medicare for All, this is what we have to do.

Nurses have always been at the forefront of fighting for safe patient care but it’s hard to do when you have a for-profit hospital system. You’re disposable to them. In order to keep not only patients but ourselves safe, too, we have to unionize.

End Mark

About the Author

Kelley Tyler is a nurse at Mission Health hospital in Asheville, North Carolina.

Susan Fischer is a nurse at Mission Health hospital in Asheville, North Carolina.

Jill Rabideau is a nurse at Mission Health hospital in Asheville, North Carolina.

Trisha Stevenson is a nurse at Mission Health hospital in Asheville, North Carolina.

Lori Hedrick is a nurse at Mission Health hospital in Asheville, North Carolina.

Marie Oakes is a nurse at Mission Health hospital in Asheville, North Carolina.

About the Interviewer

Jonathan Michels is a freelance journalist and health care worker based in Durham, North Carolina.

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