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Last spring, three healthcare locals of the Health Professionals and Allied Employees put their employers on notice as they prepared to negotiate their expiring contracts: Give us nurse-to-patient ratios or we will strike. Prior to bargaining, HPAE had surveyed nurses in New Jersey and found that the No. 1 reason nurses were leaving hospital jobs was due to unsafe staffing.
HPAE Local 5118 at Cooper University Medical Center, Local 5004 at Englewood Medical Center and Local 5030 at Palisades Medical Center created a credible strike threat that succeeded in winning ratios at the bargaining table. This highlights how collective bargaining has become a critical tool in the fight for safe staffing in hospitals and a crucial step toward improving patient care.
In 2023, nurses represented by the United Steelworkers at Robert Wood Johnson University Hospital in New Brunswick went on strike for five months until the hospital agreed to include language to mandate nurse-to-patient ratios in its contract. HPAE helped walk the picket lines with these sister-union nurses and did whatever they could to support them. When the striking nurses spoke publicly, HPAE members spoke with them on the picket line. HPAE members advocated alongside them at a Senate Health, Education, Labor and Pensions Committee field hearing headed by Sen. Bernie Sanders (I-Vt.). When they finally settled their contract with nurse-to-patient ratios, HPAE members cheered for them.
“We came to understand that nurses and other healthcare workers had reached their limit and were unwilling to tolerate the status quo any longer,” says HPAE President Debbie White, RN. “They were so outspoken that it became our primary goal to bargain safe staffing into every contract thereafter.” The locals established contract action teams that were active and engaged in every hospital. They mobilized members to participate in actions from leafleting to speaking out at town halls focusing only on unsafe staffing. “At this point,” White says, “the employers knew that no one would be ratifying a contract without ratios.”
In a 2024 position paper, HPAE reveals that the multitude of research shows that hospital understaffing negatively affects patients, staff, families and the community. Nurse-to-patient ratios have been consistently shown to decrease the likelihood of patient mortality, and decrease adverse outcomes like infections, bed sores and patient falls. Understaffing and chronic moral injury also lead to high turnover, burnout, decreased patient satisfaction ratings, and higher hospital administration costs.
This was demonstrated in Local 5118 at Cooper University Medical Center, the first local to win safe staffing language. Doris Bell, the local president says that winning safer staffing was about more than numbers. “Nurses were leaving because they couldn’t handle the stress and the responsibility,” she explains. “With better ratios, patient care has improved. Nurses can spend more time with their patients, and outcomes—like lower infection rates and fewer readmissions—are improving.” Bell emphasizes that these changes benefit patients and help nurses cope with the overwhelming demands of the job.
“The hospital, a Level 1 trauma center, negotiated 1:4 nurse-to-patient ratios, and they use that to attract nurses,” says White. “The nurses who work in hospitals with better staffing are more likely to remain in their jobs. Retention is an enormous issue in our hospitals right now because nurses will simply not remain in jobs that put their licenses and patients’ lives in jeopardy”.
The second hospital to win safe staffing language was Local 5004 at Englewood Medical Center. Members of the local built upon the momentum of both the strike and the Cooper settlement. Also, these nurses were particularly outraged that wages in their hospital were below market value in their region, so they were also able to win dramatic wage increases. The employer, realizing that the contract would not be ratified without both staffing language and fair wages, conceded.
Finally, after months of bargaining with Hackensack Meridian Health, Palisades Medical Center agreed with HPAE Local 5030 to establish nurse-to-patient ratios for the first time in the hospital’s history as well as benefits for support staff. Tara Rojo, the nurses union president at Hackensack Meridian, sees the new staffing ratios as a game-changer for nurses and patients alike. “Short staffing hit new nurses the hardest,” Rojo says. “Mentoring becomes impossible when you’re managing eight patients at once. With enforceable ratios, we can finally focus on patient safety and better outcomes. It’s a huge accomplishment.”
Three months later, nurse members of HPAE Local 5089 at University Hospital in Newark— New Jersey’s sole public hospital and the only Level 1 trauma center in the northern part of the state—became the fourth local to secure a contract that includes enforceable nurse-to-patient ratios.
Banita Herndon, president of the University Hospital local, was adamant about the necessity of a 1:5 nurse-to-patient ratio on medical-surgical units. “Understaffing affects patient care,” she explains. “But I’m equally concerned about preventing burnout in nurses. When we have better ratios, we can spend more time with patients, help them with long-term care planning, and ensure they don’t have to return to the hospital.” Herndon says that patients in public hospitals often rely on emergency rooms for primary care, and improved staffing has allowed nurses to connect them with long-term health resources, helping to reduce overcrowding.
Enforcing the new ratios is now the priority in each of the locals. As Doris Bell notes, “We have to stay on top of the hospital to make sure they follow the contract.” The stakes are high, and Bell believes that passing state legislation mandating these ratios would be the best way to ensure consistent, statewide compliance. “Making it law would force every hospital, public or private, to abide by it.”
Union members are empowered by the success of their bargaining efforts, but they recognize that management’s reluctance often comes down to financial priorities. “Hospitals want flexibility to allocate profits where they see fit, which is really code for not wanting to spend money on staffing,” says White. “But patients come to hospitals for nursing care, not lavish lobbies and well-manicured grounds. Without safe ratios, nurses are stretched too thin to offer the support and care patients need.”
The victories experienced by HPAE have set a precedent. “It’s no coincidence that once the first contracts were settled, others followed” says White. “One settled, and then the next,” she explains. “Momentum built, and suddenly we had the biggest employer, Hackensack Meridian, agreeing to the same language. These wins demonstrate the undeniable power of collective action. We built, among our members, a credible strike threat, and the employers knew it.”
Although the progress of the union is undeniable, the fight is far from over. These victories through collective bargaining have provided a foundation to continue advocating for safe staffing and better care for all patients. White says a second objective, which is equally important, is passing the Patient Protection and Safe Staffing Act in New Jersey. The bill models a new Oregon law, and HPAE was able to kick off the year with a State Senate Health Committee hearing on this newly introduced bill.
“Our Code Red campaign to win staffing ratios in labor contracts must be reinforced by a statewide law,” White says. This legislation would ensure all hospitals adhere to safe staffing standards, holding them all accountable for the same important level of care. “We’re using the momentum from these contracts,” she says, “and we won’t stop until safe staffing is guaranteed for every nurse in New Jersey, not just the hospitals with union contracts.”
[Adrienne Coles]