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Diverting patients, retraining doctors: How Kaiser was prepping for a strike

One nurse 'joked' that doctors would have to start administering IVs themselves — but wasn’t aware that some doctors were actually being trained to do so.

Kaiser Permanente sent an email to members last week with an alert and basic guidance. The reason for the email? A looming strike of roughly 32,000 Kaiser Permanente nurses and other health care workers in California, Oregon and Washington that was set to begin this week. 

In the email to patients, Kaiser mentioned the pending strike and said there are “plans in place to ensure you continue to receive high-quality care should a strike happen.” It said select appointments had been changed to virtual visits while other appointments, elective surgeries and procedures had been rescheduled or canceled.

While the strike was averted when a tentative agreement was reached early Saturday, the email to patients provided just a glimpse of how Kaiser was readying for the impending threat of a strike. Unbeknownst to most patients and even some staff members, a lot more was happening behind the scenes, according to three nurses and a doctor who spoke with NBC News. 

“They were doing everything they could to counter the strike so the blow wouldn’t be too severe,” said Semanu Mawugbe, a telemetry nurse in Panorama City.

A Kaiser nurse in California, who asked not to be named for fear of retribution, confirmed that doctors across departments were being asked to “step outside their normal functions” and do both nursing and physician roles in anticipation of the strike. She knew of some doctors who were being trained to use pain pumps and start their own IVs — tasks they wouldn’t normally do. 

This was confirmed by an emergency physician who works at Kaiser in California and also chose to remain anonymous for fear of retribution. The doctor said his hospital was also planning to have nurses’ managers administer select drugs — such as the blood thinner, heparin — which they wouldn’t usually do. At least one department was also planning to have doctors learn how to draw blood and use Pyxis, a commonly-used automated medication dispensing system.

But this training wasn’t being broadly publicized to nursing staff, according to the nurses. Nikki Avey, a Kaiser nurse in San Diego, California, who works in labor and delivery, didn’t even know about it. She said she’d made jokes to some doctors about how they’d have to start administering IVs themselves — but was not aware that some doctors were actually being trained to do so.

For the purposes of this labor dispute, doctors were considered part of management and thus on the other side of the negotiating table from the unions. They were being prepared for the strike in that context, even if they may have personally sympathized with their nursing colleagues.

All four health care workers said they weren't sure how hospitals and doctors would have managed if nurses had gone on strike.

“Doctors I spoke with were frantically beginning to dig into their brains to remember how we do what we do as nurses,” Mawugbe said. “They would have had to do things themselves like transporting patients from the surgical ward to the recovery department.”

Kaiser Permanente’s closed system provides its ​​12.5 million members in the U.S. with insurance, medical care and services like on-site pharmacies. It's unique in that it is a one-stop shop for members’ health care needs. However, that also means that a strike would have had major ramifications for patients on multiple levels. The nurses knew this. They also realized they had public support as health care heroes continuing to deal with the ramifications of the Covid-19 pandemic.

A strike would have had major ramifications for patients on multiple levels.

Avey noted that it is nurses who take care of patients in recovery, teach them how to breastfeed their newborns, and even clean their rooms when they’re discharged. It is also nurses who man the advice hotlines for expectant, often nervous, mothers and conduct home health visits.

“Doctors are already scrambling to take care of the patients we currently have and to be in the clinics we have,” Avey said.

Her unit has 125 nurses, about 20 of whom are “travelers,” nurses who leave their home cities to work at other hospitals on set-term contracts. These travel nurses aren't part of the unions that were involved in these negotiations, so they likely would have kept working. Still, Avey said there wouldn't have been enough of them to keep things running as usual since each 12-hour shift requires about 18-20 nurses. 

Diverting patients was another way Kaiser was attempting to respond to anticipated staffing shortages, according to the nurses and doctor. But even that wasn't a perfect solution. It’s expensive, requires a separate transport team and lots of backend logistics, and didn't work in every situation. For instance, it's more complicated for certain patients, such as mothers in labor, and sometimes there wasn't anywhere else to send people as hospitals across the country continue to struggle with the pandemic and subsequent staffing shortages and overcrowding. 

The unnamed nurse in Southern California said she knew of a patient who was recovering from surgery and had to wait nearly 24 hours in an emergency department before he was finally able to be transferred to another hospital. She also provided an example of one hospital that was trying to retain only 30-50 percent of its regular in-patient services. As the strike deadline neared, it became more common.

“I had to send a pregnant mom to another facility,” Avey said. “We sent patients to outlying facilities. We sent our NICU babies to other hospitals. It’s disappointing. It’s like instead of investing in their patients and nurses, they’d rather send patients out.”

A Kaiser spokesman confirmed that doctors would not participate in strikes and that Kaiser was coordinating with other area hospitals.

“Our plans in each of our markets ensure continuity of care which include sourcing temporary staff and redeploying highly trained and experienced Kaiser Permanente clinical staff, managers, physicians, and administrative staff in accordance with their licensing and qualifications, and the use of outside resources, including community hospitals and retail pharmacies,” the spokesman said in a statement.

Kaiser intended to keep hospitals, emergency and urgent care departments open and noted in the email to patients that operations were continuing to run normally. But a strike would have greatly impacted operations, especially in California where hospitals must legally maintain a ratio of one nurse for every four patients in emergency departments. 

In California, hospitals must legally maintain a ratio of one nurse for every four patients in emergency departments.

"There are ways around the ratio, but the ratio is enforced quite rigorously," said the emergency physician. “It would be very difficult to get to new patients quickly without nurses, especially in emergency situations.”

The nurses were hoping it wouldn't come to a strike and expressed concern about how patient care would suffer if it were to happen. But they were also prepared to go without pay because they felt the changes Kaiser was proposing would place undue strain on their profession and hurt patient care in the long run. Many of the Kaiser employees who were planning to strike also receive their own medical care through Kaiser as patients.

Now, with a tentative agreement reached, the unions achieved one of their key goals as Kaiser backed down from its proposal to institute a two-tier wage and benefit system, which would have created two different pay and benefit structures for existing and future employees.

Under these systems, for the length of a given contract, existing workers are grandfathered in and guaranteed certain benefits and pay rates, while future employees are hired at a lower pay rate and often receive fewer or worse benefits.

The unions representing these Kaiser nurses maintained that this system would create disharmony among coworkers, lead to high turnover and hurt their future bargaining power and membership.

“These were challenging negotiations, but this tentative agreement demonstrates the strength of our Labor Management Partnership and the unique success it can achieve when we work together,” Christian Meisner, senior vice president and chief human resources officer at Kaiser Permanente, said in a statement.

The statement noted that, if ratified, the agreement will have an effective date of October 1, 2021.

“What we won isn’t just for Kaiser or health care, it’s for any other establishment that may propose something that won’t help their employees or their unions,” said Mawugbe. “A two-tier system won’t work. It will always fail.”