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Going to a nurses union meeting is a little bit like going to an evangelical church service.

Contract talks begin next week on new four-year contract.

“We all have to stand up, and it’s a struggle,” says Veronica Cambra, a nurse reporting a grievance at Kaiser Hospital in Fremont, Calif., as though she’s giving testimony. “And we will overcome this, OK?”

The rest of the nurses respond with the passion of a devout congregation, humming “Mmm hmmm,” and “That’s right,” through the series of speeches.

Members of the California Nurses Association rallied in Sacramento in May to raise awareness around what they say are patient care concerns in California hospitals. (April Dembosky/KQED)

But this is no church service, and nurses are not here to worship. The California Nurses Association is rousing its troops for battle. California’s powerful nurses’ union will begin bargaining next week with Kaiser Permanente on a new four-year contract for nurses at its Northern California hospitals. (Kaiser Health News is not affiliated with Kaiser Permanente.) Kaiser operates the largest hospital system in the state, by number of hospitals and number of hospital beds, and is the eighth largest health system in the country.

The union is anticipating Kaiser will propose cuts at the negotiation, and leaders want to make sure nurses are ready to fight back, and, if necessary, go on strike.

“We are going to use the power of 18,000 of us to make sure the reason we got in this profession is fulfilled,” Grabelle says.

Big Difference From Last Negotiation 

Four years ago, nurses ratified the first contract proposal Kaiser offered without objection. The hospital didn’t make any cuts to wages, pensions or other benefits, and nurses didn’t push for any increases. Both sides had reason to keep tensions at a minimum, according to Joanne Spetz, an economics professor at the University of California San Francisco School of Nursing.

Last time the nursing shortage was still a recent memory, she says, and Kaiser wanted to hold on to its experienced nurses. It was also the end of a recession, and nurses didn’t want to appear greedy.

But a lot has changed in the last four years. The economy in northern California has improved. And the Affordable Care Act has fundamentally changed hospital economics. For starters, Spetz says, the health law is generating a lot of new customers for Kaiser.

And if there is growth, Spetz says, the nursing group is following a union’s classic role, “which is to say, ‘Well, if there’s going to be increased net revenue, we should get a cut of that.’ ”

But the union isn’t talking money yet. The leaders are framing all their demands around patient care. Nurse practitioner Rachel Phillips says she is under unrelenting pressure at work to see more patients in less time.

“When I first started at Kaiser, I wasn’t rushed with my patients,” Phillips says. “I could have 30 minutes with a new patient. That time has been whittled away. We’re currently asked to see patients every 15 minutes, regardless of the complexity of their medical issues.”

Telephone advice nurses say there aren’t enough nurses staffing the call centers.

Frequently, people will abandon their call because they become discouraged, or don’t have time to keep waiting,” says Janna Burt, a nurse at Kaiser’s Sacramento call center.

Kaiser says a lot of the union’s claims are misleading or untrue.

“For 70 years, we’ve had the same mission: to provide high quality care and to improve the health of communities where our members live,” says Barbara Crawford, Kaiser’s vice president for quality.

She says Kaiser, and all hospitals, are grappling with broader economic issues affecting health care, like the overall demand for hospital care going down.

“We actually need [fewer] nurses in the hospital,” she says, adding that improvements in technology and reductions in hospital infections means there are fewer patients staying in the hospital — on average 250 fewer per day now compared to a few years ago. She gives the example from earlier this year when her husband had foot surgery.

“He was in and out the same day, and he did not have general anesthetic, he didn’t need general anesthetic, and he did beautifully,” she says. “I would say, four years ago, he probably would have been in the hospital four or five days.”

She says Kaiser values its nurses and that they are now needed more in the outpatient setting or for home health services, as a matter of these economic shifts and patient preferences: “Most people really don’t want to be in the hospital. They want a choice about where they receive their care.”

The Affordable Care Act also puts pressure on hospitals to cut costs, she says. Medicare reimbursements are going down, which cuts into hospital revenues. And health reform has made the insurance market a lot more competitive, so Kaiser has to be aggressive on price.

“As consumers have opted to join us, our expectation and promise to them is that we keep their costs down,” she says.

Strike Threat is Sketchy PR Territory for Union 

But the nurses have power in numbers, says Spetz. The California Nurses Association founded a national arm — National Nurses United — that has been gaining members across the country, most recently in right-to-work states like Florida and Texas. Spetz says this local fight likely has national aspirations.

“Given that Kaiser exists in multiple states, there may be a broader strategy of trying to demonstrate their strength, demonstrate their willingness to fight, demonstrate their political power on a national stage, which could be beneficial in trying to get representation in other Kaiser regions, as well as other states,” Spetz says.

California nurses have already been pushing Congress to pass legislation that would establish national nurse ratios similar to California’s. These require hospitals to have at least one nurse on staff for every five patients.

“Those efforts are going to be helped anytime they get some positive national view –- or fear –- quite frankly, of their power,” she says.

“Given that Kaiser exists in multiple states, there may be a broader strategy of trying to demonstrate their strength, demonstrate their willingness to fight, demonstrate their political power on a national stage,” Spetz says, “which could be beneficial in trying to get representation in other Kaiser regions, as well as other states.”

She says if California nurses win on wages, benefits, and patient care, they’ll inspire nurses in their national network to push for similar fights in their own states.

The ultimate question is what impact all this has on patients. Studies are mixed on whether union advocacy actually results in better patient outcomes. A new report from the University of Massachusetts finds patients at recently unionized hospitals in California suffered fewer heart attacks, strokes and infections. While UCSF’s research indicates that nurse ratios in California have increased nurse morale and wages, but have had no effect on patients’ health.

April Dembosky covers health for and The California Report. Reach her at adembosky@kqed.org.