Ruth Stricklen Pullins
A Healthcare Conversation: The Union Environment
The Healthcare industry today is a significant player when one considers its tremendous growth over the
last five years. We have seen a rise in Hospitals playing the lead role in negotiating with private
practices and moving toward healthcare conglomerates – HCA, Humana and even Kaiser Permanente
are examples. This can partially be attributed to the advanced strides that have been made in the
technological area. The government has attached significant resources to reimbursement for quality
measures and the installation of the electronic medical record; the goal of one patient; one record.
There does not appear to be any plateau to this upward trend in the near horizon. According to the
Medical Group Management Association (MGMA), “The Federal Trade Commission continued to block
four deals in 2012 arguing that healthcare consolidation was too much for one area . . . Among the
recent healthcare targets were proMedica and St. Luke’s Hospital in Ohio.” (Cheung-Larivee, Karen,
MGMA, 2012). Historically, hospitals have enjoyed a mostly union free environment. Contrary to this
phenomenon, other industries have, until now, been very familiar with the strategic and political
environment of union negotiations. Unions are no longer thriving and, in fact, are now on the decline
nationally. Over the last several years Unions have begun looking to other industries (some might say
specifically targeting healthcare) to build membership and so, a conversation will begin, if it has not
already, between the Healthcare industry and Union representatives.
“The healthcare industry seems to be bucking a national trend of declining unionization. Some workers
apparently find union membership more attractive when they are concerned about job security or
working conditions, two issues that emerged in the recent economic downturn when hospitals had to
deal with tightened budgets. The number of healthcare workers who are members of unions or covered
by a collective bargaining agreement has increased to nearly 1 million in 2009, or approximately 12.9
percent of non-physician healthcare workers, according to the Bureau of Labor Statistics.
In the past six months alone, delayed contract negotiations have occurred and strikes planned at major
institutions such as University of Chicago Hospital, Tufts Medical Center in Boston and Kaiser
Permanente's Kaiser Los Angeles Medical Center, indicating a disruptive trend not restricted to one
region. The nation's largest healthcare unions, such as California Nurses Association and Service
Employees International Union, have been working to secure neutrality deals with large hospital chains,
such as Nashville, Tenn.-based Hospital Corporation of America. HCA signed a neutrality agreement with
the unions, allowing the organization of workers at 20 of the system's hospitals, in April 2010.” (Gamble,
Molly, 2011 Becker’s Hospital Review).
It is timely then, to review the pendulum swing—to have the conversation and prepare for ongoing
discussions and negotiations.
For an HR director, entering a unionized environment in any industry can be challenging based upon
unknown territory, protocols, and politics. This paper establishes that although there are some
anomalies within the healthcare industry, overall, it is not dissimilar to other industries. Negotiations,
whether informal or formal, are based on a process. This process is grounded in precedence from prior
rulings and fairness. This paper looks at the fundamentals of negotiation; offering a blueprint for the
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new HR director in how to become successful in negotiations, (the definition of success being a win-win
for employees and employer). We then have a conversation with three seasoned executives in
healthcare to gain their perspective.
Fundamentals of Negotiation:
Dean Gooderham Aceson, who served as US Secretary of State in the Harry S Truman Administration,
and played a central role in the creation of the North Atlantic Treaty Organization, was noted as saying:
“Negotiation in the classic diplomatic sense assumes parties more anxious to agree than to disagree.”
This is a fundamental position that an Employer—and hence the HR director needs to determine where
it stands early on prior to beginning any negotiations. Is the goal to have a win- lose strategy or should
the goal be for both sides to walk away feeling they have gained something in the process?
As a precursor to a negotiation, it is important to reference the fact that there has to be some type of
conflict prior to determining a need for negotiation to take place. This could be in the form of
dissatisfaction amongst employees with management, specific issues that have not been addressed, or a
triggering event. Once the conflict is recognized, it may or may not be addressed but it moves into the
pre-negotiation stage.
During the pre-negotiation stage, needs and goals are determined. This is followed by formal
negotiation planning, preparation, organization, and, finally, fact-finding and analysis. It is here that
introductions are made and ground rules established. Depending on the players on both sides,
emotions may be high, there may be posturing and positioning, but importantly, the establishment of
the negotiation range is established.
During the negotiation stage, one would expect communication to begin with an education of needs,
settlement, trade-offs and tentative settlement. Both parties are aware of external pressures,
deadlines, progress and consequences, and this is where there could be an impasse or closure, but
hopefully there would be agreement.
The language is then formalized, ratified, with final approval. It is then implemented and the parties
determine compliance, self-enforcement and a dispute resolution mechanism.
To summarize, below is an outline for negotiation sessions:
First Session: This is where the parties would create the bargaining environment; determine the
principles for good relations; determine schedules and exchange proposals.
Second Session: Assess the specific demands; ascertain the other party’s demands; get a feel for the
importance of those demands.
Third session: Prepare for counterproposals
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Subsequent sessions: Will include looking for areas of agreement; remove negotiation points that are
impossible to find a resolution; finalize agreement from other party on contract clauses and agreements.
1) Formation of the Contract. An offer to commit to a contract remains open and can be accepted
until it is withdrawn.
2) Obligation to Execute a Written Agreement Neither party is required to enter into a contract
simply based on agreeing in principle.
Effective negotiation:
The French philosopher, Joseph Joubert said, “Never cut what you can untie.”
There are many strategies that one can employ in being effective during negotiations. More often than
not, effective negotiations move forward when the other party sees you as meeting them half-way or
more than half-way. This can be in simple situations such as meeting rooms, availability, making
concessions early on, or when the other party finds your outward demeanor to be calm, positive,
flexible, and respectful.
Be Prepared: As with any presentation, meeting, or work product, it is vitally important to come to the
negotiation table prepared. Review the other party’s position prior to coming to the table. Know its
history in conducting negotiations—for example, what concessions have they made in the past, what is
its style, who are the players?
Be Honest: If you are prepared you will have most of the information at your fingertips, but if you do
not know— admit you do not know rather than be found later as misquoting a key factual piece of
information.
Be Informed: Just as it is important to have reviewed the opposing party’s position, history, etc.; It is
equally important, if not more so, to know your own position. Know your veto power, know the
management, front line supervisor and employees’ experiences and what their shared objectives could
become as you agree to specifics or make concessions. Know your bargaining authority.
Don’t make false promises: You may have every intention of fulfilling a proposal, but unless you are
100% certain, do not commit, as it leads to false expectations followed by loss of trust. Be to the point
and know when to close. If your point has been made and accepted—do not belabor it. Always,
maintain a calm demeanor.
Order of negotiations: Think about what might work more effectively in attaining company goals. It is
helpful to get some agreement on non-economic issues discussed at the beginning to assist with
momentum. Sometimes the economic factors are so tied to others outside the table, giving you bits and
pieces, it is hard to determine what the actual bottom line is. You want to keep talks going and not get
stalled on economic issues while the other non-economic issues can have discussion and partial
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agreement. There are many parts to an agreement. Some are major financial issues, or there might be
a big issue on schedules that you know going in will be very contentious. You may have to table certain
issues to allow some breathing time on both sides, perhaps to cost out a proposal, get political buy-in,
approval from higher level executives, so if you can put certain items on hold while others do research,
on either side, and proceed with other less volatile issues it helps in keeping negotiations moving
forward. Sometimes an issue on any given day or session will be simple posturing and maybe even just
public relations for either side with little substance expected or wanted and the parties can debate
those immovable forces forever at that session without any movement. If you limit the time take a
break, or table the topic the effect is like refreshing the screen and it gives you a chance to move on.
All of the above are strategies that can be helpful in being an effective negotiator.
At one time or another, each of us will face a ‘first time’ of conducting negotiations. It can be
intimidating for an HR leader to remain calm when entering this new territory. Having insight as to who
is at the table is helpful not only in putting your team together, but is key in understanding the Union
team members. Experience in going through the process will improve that ability to be able to discern
thought processes; however, talking to people who have that experience is helpful. I thought it would
be useful to interview HR leaders in the health care field to gain their perspective. I also found the
research provided through the Academy to be insightful .
Interviews:
Three Hospital Executives from across the country shared their perspective on how best to create an
effective framework and deliver successful negotiations while maintaining positive relationships in a
somewhat divergent employee base, (from a highly skilled nurse to an entry level clerk) which naturally
translates to different employee needs and expectations. Below is an overview of that discussion.
Depending on the question, an executive may have refrained from answering either because they found
it non-applicable to their situation or because they simply did not have an answer.
Hospital A:
1200+ employees; 500+ nursing and nursing support staff
Hospital B:
750+ employees; 300+ nursing and nursing support staff
Hospital C:
3,000+ employees; 300+ nursing and nursing support staff
All three executives are seasoned with more than 40 years combined experience.
1. Given that hospitals are charged with treating patients and coverage is 24/7, would you agree that
healthcare might be at a disadvantage when compared with other industries in effectively
negotiating around benefits and schedules for nurses? If you agree, have you moved toward
working more with contracted labor (non-union) rather than in-house unionized employees or
have you found other effective techniques that enable you to navigate through the negotiation
process?
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HOSPITAL A:
It may affect future recruitment because many nurses may not want to work in a union
environment and pay dues for something that is not tangible. If you have a situation
where there is a rich nurse to patient ratio and good benefits it is difficult to be able to
quantify what a union would provide.
HOSPITAL B:
No doubt about it. We have laws that dictate nurses to patient ratio. Given the nursing
shortage in this part of the country, unions have us in a captive seat.
HOSPITAL C:
I don’t see why there would be a disadvantage. My previous experience was outside the
healthcare industry with a large employer who had a very high percentage of the
workforce in around the clock operations, so I really don’t see much of a difference,
other than the obvious work being performed. However, there are no techniques
around it. This is a closed shop and we have to defend why we bring in any additional
support.
2. According to the Fair Labor Standards Act, a Registered Nurse can be classified as Exempt. Would
this have any bearing to you when preparing for negotiations?
HOSPITAL C:
Anyone who is a union member is considered non-exempt.
3. A key issue often raised in negotiation for nurses unions is safe nurse-to-patient staffing ratios.
Can you comment on this issue?
HOSPITAL A:
There are major concerns in operations that have been paid little to no attention in the
past…therefore, providing a shock effect to the staff. It makes sense to practice a safe
nurse-to-patient staffing ratio because we want to provide good safe patient care.
Problem for us is and this gets into the weeds, unions are strong in this part of the
country. We are paying very well in hourly rates and benefits whereas others pay less
and meet the ratios. We cannot afford to have many Certified Nurse Assistants (CNA’s)
anymore. Ratios were great in that they improved patient care but limits how many
nurses we can hire. RN’s are doing work that CNA’s should do
HOSPITAL B:
Yes, it seems to be one of the top 2-3 issues from what I read. We have a very positive
ratio which benefits our Hospital. It’s clear that while hospitals try to tighten belts, they
look at staffing and nurse to patient ratios as a topic.
HOSPITAL C:
Not an issue.
4. Do you believe that physicians are able to partner effectively with their support staff while at the
same time understanding their unionized status and some of the conditions that apply? Do you
see a need to educate physicians and upper management in these complexities?
HOSPITAL A:
Most physicians have no idea and it doesn’t impact them in any way.
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HOSPITAL B:
The physicians at our hospital don’t have skin in the game—the number of nurses
doesn’t affect them even though they don’t get things done as fast.
HOSPITAL C:
We have educated the physicians that there would not be any intrusion
on patient care.
5. The Healthcare industry is on the rise. Do you believe that despite the fact that private-sector
union membership nationally is on the decline, that we may see a more unionized workforce in
the Healthcare industry and why?
HOSPITAL A:
It depends on how healthcare reform impacts people. It can depend on the mission and
objectives of the communities for supporting the unions especially for nurses union. For
example, when the nurses go on strike they could jeopardize patient care. Given that
they make $60-$70/hr plus benefits, the community does not always have sympathy.
On the flip side: there will be a huge demand in healthcare as boomers need medical
attention and retire there maybe opportunity to ramp up union activity because of that.
HOSPITAL B:
Because the unionized environment is on the decline nationally, healthcare maybe an
area worth tapping into that thus far has only been minimal .
HOSPITAL C:
It depends how people are affected by healthcare reform—we are going to see more
patients to take care of with less dollars; that is true whether or not unions grow or
shrink in terms of healthcare
6. What are your thoughts of micro-bargaining units—the idea that unions can pick small subsets of
employees to organize? Of note, in the case of Specialty Healthcare and Rehabilitation Center of
Mobile, 357 NLRB NO. 83 (2011) the board ruled that nursing assistants may form a bargaining
unit.
HOSPITAL A:
It’s obviously not the ideal way for an employer, but from what I am hearing, it is
happening more often. It certainly gives the union an edge once they are in. I think
employers need to be aware so its efforts to maintain a non-union environment do not
only include traditional large work groups. It has not happened yet at my healthcare
organization.
HOSPITAL C:
No we don’t see micro bargaining units where unions can pick sections to organize—our
unions would never allow for that scenario to occur.
7. One issue often raised in negotiation for nurses unions is the safe nurse to patient staffing ratios can you speak to that issue?
HOSPITAL A:
HOSPITAL B:
It’s clear that while hospitals try to tighten belts, they look at staffing and nurse to
patient ratios. These are major concerns in operations that have paid little to no
attention in the past…therefore, providing a shock effect to the staff.
From my personal experience we ensure that there is a safe nurse to patient staffing
ratio and so this has not been an issue at the bargaining table.
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HOSPITAL C:
We have a very positive ratio which benefits the Hospital.
8. If you had one piece of advice to offer to a new HR director to help them identify negotiating
‘pitfalls’ and how to avoid them, what would it be?
HOSPITAL A:
To stay as closely aligned with your employees as possible. Partner with employees so
they self identify as employees of the Health System not so they identify as members of
the Union.
HOSPITAL B:
Maintain a healthy productive environment.
HOSPITAL C:
The key is to think strategically. Remember to maintain your cool and stick to the
facts. My guiding principle has been: Is it fair? What are the resources? What is
currently working? What is not? How does it affect the entire workforce?
The Art of Persuasion—Thinking Styles
In Academy III, The Negotiation Process, we studied The Styles of Persuasion. Ranelle Rae wrote a
presentation which she based on the 1977 book, The Art of Thinking, (re-released in 1982 as The Styles
of Thinking) by Bramson and Harrison.
She theorizes that knowing the styles of persuasion will increase the negotiator’s
effectiveness, improve understanding of the team dynamics, and reduce frustration when dealing with
people who have different negotiation styles.
Below is an overview of the different thinking styles. I examined these styles alongside the interviewer
(myself) and interviewees to see if I was able to see any distinct style. In each case, I took the most
prominent style. I applied this to the executives I interviewed and also to myself. Of course, I also
applied this theory in ongoing negotiations to determine the style of the other party and how best to
influence them.
The Idealist
According to the description by Rae, I (similar to 37% of the population), am an Idealist. I think this was
reaffirmed in my interactions in negotiations with others. I realized that I do not like conflict. I have
high standards—always aiming for perfection. I do not like pushy people. Most importantly, I believe
that building the relationship is key to successful outcomes and I will always want to engage all sides.
Others can find this frustrating because they see more of a need to be combative to win the negotiation
but, as evidenced in the chart at the end of the paper, non-traditional bargaining seeks for a
compromise and a win- win situation. The article by Rae indicates that the Idealist is usually passiveaggressive and this is where I must disagree. I may seek a harmonious relationship but I am always
extremely direct in my position.
As I examined the responses and nuances to the interviews with the executives, it was interesting to
note my perception of their persuasion styles:
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The Realist – Executive A
According to Rae, 24% of the population are realists. She writes that the realist does not like to waste
time and is very incisive. I believe Executive A has the thinking style of a realist. He was very factual in
his responses, “No doubt about it we have laws that dictate nurses to patient ratio. Given the nursing
shortage in this part of the country, unions have us in a captive seat.” And, “It depends on how
healthcare reform impacts people. It can depend on the mission and objectives of the communities for
supporting the unions especially for nurses union. For example, when the nurses go on strike they could
jeopardize patient care. “ I appreciated the realist. He was the most thorough in his responses. Rae
notes that the realist is confident about the world and believes in the decision-making process. She
theorizes that if a realist sees hesitation , their inclination is to take over and take charge. Rae suggests
that one should not surprise the realist as it causes defensiveness—the realist likes to feel in control.
Rae goes on to recommend that a negotiation strategy for anyone facing the realist might be to plant
the idea with the realist and then let them assume credit for it.
The Synthesist - Executive B
Only 11% of the population has the Synthesist thinking style. I believe the second Executive I
interviewed was a Synthesist. It was not so much what he said but rather his style. He seemed more
objective, almost apart from the interview. All executives had the option to respond to all questions. His
responses were such that he did not directly answer all of them. Rae states that the Synthesist likes to
play ‘devil’s advocate’ and that this can be an asset in negotiating because it provides for other options
that may not readily come to mind. The synthesist’s proposals can be theoretical or abstract in its
thinking. Rae believes that the Synthesist is the most difficult of all types to influence. My shortest
interview was with Executive B, probably because it was difficult to pin him down or glean details. Rae
writes, “If you ask a synthesist a question, you may get a question in return.”
The Analyst - Executive C
Executive C: “The key is to think strategically - Remember to maintain your cool and stick to the
facts. My guiding principle has been: Is it fair? What are the resources? What is currently working?
What is not? How does it affect the entire workforce?” I believe executive C has the Analyst thinking
style. Rae writes that the Analyst is able to provide structure and stability to the process. The Analyst
may be perceived by others as being inflexible. Executive C was very prepared for the interview, not a
lot of emotion—hard to read. I was very attentive in the interview. In retrospect, it was not only
because as an interviewer, I should be, but because I picked up on what Rae believes which is, to be
successful in communications with the Analyst, one needs to listen intently to details and not interrupt.
Rae further states—do your homework, and check all details (which I did!). Of course, I was not in a
negotiation position in my interview in the bargaining sense, but it is interesting to realize that this
persuasion style carries through in communication even in a non-confrontational setting.
The Pragmatist
From what we learned when discussing the different thinkers and how that translates to their
persuasion style, the pragmatists see the world as being very unpredictable and chaotic. They are high
energy and enthusiastic. Eighteen per cent of the population are Pragmatists. The asset of the
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Pragmatist is that they are flexible which can be very helpful in negotiating. However, the Pragmatist
can be passive aggressive. Rae states that the pragmatist can be the easiest of all thinkers to influence.
She write that an important point to remember when dealing with a Pragmatist is to give a sales pitch
and to have fun with the interaction.
SUMMARY
The underlying theme that resonated throughout the interviews is that each Hospital Executive wants
to be fair to their employees and that a resolution that could be obtained whereby both parties believe
it to be a win-win is more desirable than the alternative. The Bureau of National Affairs, Inc., outlines
the differences between the traditional win-lose negotiation and the non-traditional win-win
conclusion. It gives direction to and endorses the trend I found in my interviews.
In my experience, I find more success with negotiating from a non-traditional foundation than the
traditional philosophy. With the non-traditional philosophy, there seems to be more opportunity for
long-term relationships, which translates to more success stories.
Nontraditional Bargaining vs. Traditional Bargaining
Nontraditional and traditional bargaining differs in language, attitude, and technique. The two types of
bargaining are compared in the following chart.
Non-Traditional Bargaining
Traditional Bargaining
Participants see themselves as problem-solvers
working toward a common purpose
Participants see themselves as adversaries
The goal is mutual gain.
The goal is victory.
The relationship between the two parties is
cooperative and based on equality and respect.
The relationship is adversarial and based on
position and power.
Problem-solving is used as the operating method.
Arguments, counterarguments, offers and
counteroffers are used as the operating method.
Participants reach decisions through consensus.
Participants reach decisions through compromises.
The focus is on mutual interests.
The focus is on separate interests.
The parties fully exchange and share information.
Each party limits the information it shares with the
other party.
Participants include only serious interests in their
considerations.
Participants include frivolous demands to use as
bargaining chips later on.
The parties explore interests and alternatives.
The parties make offers or threats.
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In closing, in beginning negotiations, maintain realistic expectations and be willing to compromise.
Know that you are not always going to get everything you want and it is good to share this philosophy
with your team. Be prepared. Always respect the other party. It’s about the relationship—and you
want to maintain it.
References:
Academy III: the Negotiation Process, April 2012, Orlando Florida
Cheung-Larivee, Karen, MGMA, December 2012.
Expert Negotiators: Rafanowicz, David, Chief Negotiator, City of Orlando; Hachigian, George, Police
Labor Council, Chief Counsel
Gamble, Molly, May 2011 Becker’s Hospital Review.
Interviews (3) Hospital Executives
Lareau, N. Peter, et al., Drafting the Union Contract. A handbook for the Management Negotiator.
Bender and Company, 1992
The Bureau of National Affairs, Inc., Collective Bargaining. Negotiations and contracts, 1993
Ruth Stricklen Pullins
Chief HR Officer
The University of Kansas Physicians
3901 Rainbow Blvd
Kansas city, KS 66160
(913)945-5010
rpullins@kumc.edu
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