When Nurses Go on Strike

In SuperFreakonomics, we wrote about the very mixed evidence concerning health outcomes when doctors go on strike or leave town for conventions. Surprisingly, when doctors disappear for awhile, patients don’t seem to suffer, and maybe the opposite in the short run.

But what about nurses?

A recent study by my friend Jonathan Gruber, an economist at MIT, and co-author Samuel Kleiner, finds that things go haywire when nurses go on strike. From the abstract of their recent NBER working paper:

We utilize a unique data set collected on nurses’ strikes over the 1984 to 2004 period in New York State, and match these strikes to a restricted-use hospital discharge database which provides information on treatment intensity, patient mortality and hospital readmission. Controlling for hospital-specific heterogeneity, patient demographics and disease severity, the results show that nurses’ strikes increase in-hospital mortality by 19.4% and 30-day readmission by 6.5% for patients admitted during a strike, with little change in patient demographics, disease severity or treatment intensity. This study provides some of the first analytical evidence on the effects of health care strikes on patients, and suggests that hospitals functioning during nurses’ strikes are doing so at a lower quality of patient care.

So when nurses strike, the patients who show up at the hospital are more likely to die there and also are more likely to be readmitted to the hospital within 30 days. The obvious concern with this analysis is that the nursing strike might affect the kinds of patients that show up to be treated. If only the sickest patients brave the hospital when nurses strike, their outcomes will be worse whether or not the nurses are there. In other words, the link between nurse strikes and bad outcomes could be spurious.

What I like best about this paper is how Gruber and Kleiner deal with that potential criticism. First, they show that on a range of observable characteristics (types of illness, patient age, percent uninsured, etc.), the patients who come to the hospital during the strikes look a lot like the typical patients. Second, if the relatively healthy patients waited to go to the hospital until after the strike, or went to hospitals in other areas during the strike, there should be evidence in the data, but they don’t find anything.


It's anecdotal, but I can tell you that patients avoid striking hospitals in large numbers. During a recent one-day nursing strike in MN, the area hospital at which I work that was not subject to a nursing strike had a volume increase of over 20%. If the threatened strike had gone on longer, we had planned on increasing staffing dramatically to handle the extra volume.


is there any data on how well the strike was publicized or how obvious it was? I'd be curious to know whether the patients knew there was a strike going on.


My late husband, human resource officer at a hospital, was fond of saying that the CEO could be gone for a month before anyone noticed, but if the janitor was gone for even a day, things began to fall apart. The inference? The people that do the most hands-on work are the most critical. This goes for nurses as opposed to doctors. Hospitals must begin to recognize the critical role that staff nurses play in providing safe, quality patient care. A doctor's order is meaningless unless someone reviews it and implements it


My guess is hospitals with nursing strikes delay or greatly reduce elective surgery, further reducing the pool of relatively healthy patients.


Even if you're correct Frank, that patients respond to the strike by shifting in large numbers to other hospitals, overburdening the hospitals that are not on strike likely decreases the quality of care they can deliver.

Dr J

It is a pity we pay doctors so well and nurses so poorly - shouldn't the market have sorted this out?The next time I hear hospitals complain about a "nursing shortage" I thnk I will vomit, what they really mean is "I cannot find enough nurses who will work for the pay I will give them" - duh, increase the pay, every CEO is a great capitalist until they actually have to pay for the work to be done...


i was actually just on a nurses strike at temple hospital in philly- when the scabs boarded the buses, we chanted: 21 codes... 21 codes...- 'nuff said

Deborah Greymoon

Why do 4 out of the 5 comments here bring up a question that has already been addressed? Why not accept the study and its interpretation for what they really point out: that nurses are the hands-on and therefore direct instruments of patient care?


So you will likely have a better outcome if you go to a hospital with nurses? Noted.

Eric M. Jones

Most doctors and nurses wouldn't rate their effectiveness on "mortality". I sure know my dentist wouldn't. The business of nurses is not primarily to keep people from dying.

Many issues work to complicate medical statistics. Much surgery is elective, and when people are unemployed, they have the time to get the elective surgery-- Often before their medical benefits run out. But this doesn't mean unemployment makes them wind up in surgery. Likewise, extremely good doctors often get the worst cases. This really screws up the statistics.

Drill-Baby-Drill Drill Team

Nurse. I am done with my Bedpan.
Nurse! Its very full. Its hard to keep it upright.


When the people who do 80% work leave , conditions deteriorate ? Who would have thought :D

BTW who won that contest?


Did the study account for the fact that nursing strikes can be date range targeted to periods of time when patients are more ill?

Regionally, hospitals experience higher and lower rates of complications, mortality, extended length of stays and readmissions with seasonal changes. Nursing strikes sometimes hit during these periods to maximize impact if it is a more combative contract dispute.

This may be a regional phenomenon though since I only have experience with the West Coast states of WA, OR, CA, AZ and NV.


Those who criticized this study only did it because never needed a long-term hospitalization. So if you had never been with a nurse, you can not understand his role.
We do have a medicalized health perspective (even worse when your vision is dependent on such crap TV series as "Greys' Anatomy," emergency department "), so it's hard to believe that we need to care primarily, instead of drugs.

Regards from Portugal


When doctors go on strike, mortality goes down. This is interesting because it shows the opposite for nurses.


So patients have worse outcomes when there are no nurses? You needed a study to tell you that?

Tom Renda


Don't patronize a hospital that forces its nurses to strike for higher wages. If you want to live, go to the places that pay nurses higher wages.

(Not sure took a study by two PhD's to figure that one.)


The funny thing is that during the nurses' strike in Minnesota (referenced in comment #1), the union kept saying that they were striking because of patient safety and quality of care. They reassured the public that it was NOT about the money.

They made the claim because one of their big negotiation points was to achieve a minimum nurse-patient ratio. [Those of us more economically minded would say that the purpose of that requirement was increased union membership, not safety, but I digress.]

Of course, in the end, the strike ended when they got a pay raise (but absolutely no concession on nurse-patient ratios).

Now it turns out that not only was it not about the safety (only about the money), but the action they took to get that money actually put more patients at risk. Go figure.

Wonks Anonymous

Actually nurses are pretty well paid, when they have a good strong union.

And the high pay won by the nurses unions tends to increase the quality of people who work in nursing because union hospitals have their pick of bright ambitious nurses who have no desire to lose a well paid job and have to travel the country as scabs.

Which goes a long way to explaining why union nurses are so productive in the first place.

I learned this stuff at Berkeley years ago from Lloyd Ullman. I guess that it is still surprising to the boys from Chicago.

- Wonks Anonymous


Nurses provide the monitoring needed to respond when a patient's condition changes. They are first responders in the ICUs and Recovery Rooms, nurseries, ERs, etc., who by their function of observation and constant assessment determine when subtle changes in fluid balance, blood oxygen level, electrolytes, neurological changes, etc. can portend life altering emergencies.
Minimizing a nurse's role to that of bed pan carrying is obviously speaking from ignorance.